Lessons learned from 12,000 robotic radical prostatectomies: Is the journey as important as the outcome?

Abstract

Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological outcomes compared to open approaches. Here, we share our experience of 12,000 RARPs by describing the outcomes of the procedure in terms of positive surgical margin (PSM), continence, and potency as well as by presenting our detailed surgical technique with recent modifications. On cancer control, the PSM rates were 5.8% and 26.1% in T2 and T3, respectively. On the premise of not compromising oncologic outcomes, a tailored approach to individual patients is essential. Even if an extracapsular extension is suspected, neurovascular bundle (NVB) tailoring can be applied using an anatomical landmark to preserve maximal nerve tissue with a negative margin. We developed a nomogram as a useful tool for deciding the degree of tailoring. For improvements of functional outcomes, we used athermal retrograde early release with a toggling technique, wherein the nerve dissection from the bottom helps with blood loss and allows for smooth NVB releasing. Additionally, we recently performed a new minimal apical dissection/lateral prostatic fascia preservation technique. As a result, our 1-week continence rate was 37% and the 6-week rate was 77.6%. In addition, the potency rates in our study were 69%, 82%, and 92% at 3 months, 6 months, and 1 year, respectively (preoperative Sexual Health Inventory for Men scores >21 & bilateral full nerve spared).

Early outcomes of single‐port robot‐assisted radical prostatectomy: lessons learned from the learning‐curve experience

“…The patients were discharged at an average of 16 h with no readmissions or post-discharge narcotic use. Early oncological and quality of life outcomes were also acceptable and compatible with our multiport experience [4]. After our initial learning curve, we would advise a cautious approach to SP RARP, the technology is quite revolutionary and has the potential to be very effective.…”

“…We characterised the nerve sparing performed as bilateral full nerve sparing (patients who had a nerve preservation of ≥95%) and partial nerve sparing (patients who had 50–95% of nerve preservation) according to our technique classification described previously [4]. Full continence was defined as the use of no pads.…”

Prediction of A Positive Surgical Margin and Biochemical Recurrence After Robot-Assisted Radical Prostatectomy 

“…and less blood loss 19,20 . In our series, the overall PSM rate was 30.1%, which is a higher rate than that reported in high-volume RARP studies, in which the range typically was 10.8-22% 21 . This may be attributable to a much higher percentage (56.6%) of patients in the pT3 stage in our study than in other studies, where the percentage of pT3 stage patients ranged from 9.3 to 37.5% 21 .…”

“…Previous studies have been reported the apex is the most frequent region of PSM in RP specimens 31,41 . This is attributable to the unclear prostate capsular margins, which are di cult to identify in pT2 and pT3 stages 38 . More other studies have reported that apical PSM is correlated with the surgeon's approach and skills rather than the tumor stage 21,26,41 . The surgeon in this study has extensive laparoscopic experience, explaining the relatively low rate of PSM in the apex.…”

Comprehensive approach for preserving cavernous nerves and erectile function after radical prostatectomy in the era of robotic surgery

“…Needless to say, RARP needs to achieve not only cancer control, but also preserve urinary continence and erectile function. 1,2 Therefore, RARP has been considered a challenging operation, even today.…”