Incremental modification of robotic prostatectomy technique can lead to aggregated marginal gains to significantly improve functional outcomes without compromising oncological control

Abstract

Introduction and objectivesSurgeons should aim for continuous quality improvement. The aim of this study was to evaluate the impact of incremental changes to Robot Assisted Radical Prostatectomy (RARP) technique on intra-operative and early post-operative outcomes. Patients and methods All cases of RARP performed by a single surgeon in a tertiary institution over a 2-year period were included in this evaluation. Routine clinical data were collected. Cases were retrospectively allocated to four groups depending on key technical steps (1 = standard anterior approach; 2 = anterior approach with preservation of endopelvic fascia, puboprostatic fascia and urachus; 3 = posterior approach for nerve spare, with preservation of endopelvic fascia, puboprostatic fascia and urachus; 4 = Retzius-sparing posterior approach). Results 187 patients were allocated to groups: 1 = 22, 2 = 53, 3 = 90, 4 = 22. There were no significant differences in preoperative characteristics, except age: 1 = 62.5, 2 = 62, 3 = 62.5, 4 = 58.5 (p = 0.02). Intra-operative differences were found in console time: 1 = 195, 2 = 167, 3 = 195 4 = 136.5 min (p < 0.001); and proportion of non-nerve sparing cases: 1 = 36%, 2 = 17%, 3 = 13%, 4 = 0% (p = 0.044). No significant differences were found in lymph node dissections, blood loss or complications. Post-operatively, no differences were found in length of stay, pathological characteristics, margin status, lymph node yield, complications or PSA levels. Significant differences were seen in pad-free continence at 6 weeks: 1 = 23%, 2 = 23%, 3 = 34%, 4 = 73% (p < 0.01); and social continence (using 1 pad) at 6-weeks: 1 = 59%, 2 = 87%, 3 = 81%, 4 = 95% (p = 0.01). Significant differences in pad-free continence persisted at 12 months: 1 = 63%, 2 = 81%, 3 = 78%, 4 = 100% (p = 0.019). Conclusion Our results suggest that aggregated marginal gains from incremental modification of RARP leads to significantly improved continence outcomes without compromising patient safety or oncological control.

Analysis of the learning curve for Retzius-sparing Robot-assisted radical prostatectomy for a single surgeon

“…The aim of the current study was to describe the characteristics and outcomes of the first 130 RS-RARP cases performed at our institution; and to draw a comparison between the first, second and third groups of this series. The results demonstrate that patient characteristics were broadly representative of patients undergoing RARP at our institution (9,10). The first group of patients were youngest, with the lowest proportion of clinically locally advanced disease and smallest gland size.…”

“…Galfano's group found no difference between their first and second 100 RS-RARP patients (6). Analysis of our institutions first 22 and 70 cases found that that outcomes compared favourably with standard RARP from the start (9,10). The aim of the present study was to build on the understanding of the learning-curve for RS-RARP by describing the characteristics and outcomes of the first 130 RS-RARP cases, with specific comparison between the first, second and third groups of this series.…”

“…Our RS-RARP has been previously described and is very similar to that described by Galfano et al and has previously been described. (6,9) The Da Vinci Si (Intuitive Surgical) was used for all cases.…”

“…First follow up was at 1-week post-op for the removal of catheter, followed by an outpatient follow-up at 6 weeks. PSA levels are done at 6-8 weeks interval from the operation (9,10). assessed by patients reported levels as a percentage of pre-operative levels (100% being similar to their pre-operative erectile function status).…”

“…The superiority of RS-RARP in achieving better functional outcomes earlier has been subsequently validated in several studies compared to the conventional anterior technique (7), however, other studies have found no significant difference in the long-term functional recovery or quality of life outcomes (8). Our own institution has described our early experience of RS-RARP with publication of outcomes compared to a standard RARP approach for the first 22 and 70 cases (9,10).…”