Perioperative, oncological, and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases

Abstract

Background: Robotic-assisted radical prostatectomy (RARP) is being increasingly done in Canada. Despite this, the Canadian literature lacks publications on the oncologic and functional outcomes of RARP. The objective of this study is to report the longest single surgeon experience in the province of Quebec. Methods: We collected prospective data from 250 consecutive patients who underwent RARP by a single fellowship trained surgeon (AEH) from October 2006 to October 2012. Mean followup was 28 months (range: 1-72). The D'Amico risk stratification distribution was 34% in low-risk, 48% in intermediate-risk and 18% in high-risk groups. Results: The mean operation time (±SD) was 194 ± 60.6 minutes, and estimated blood loss 318 ± 179 mL. The transfusion rate was only 0.4%. All procedures were completed robotically. The mean hospital stay was 1.2 days, and 88% of patients were discharged on postoperative day 1. The mean catheterization time was 7 days (range: 6-13). There were 2% major (Clavien III-IV) and 7.2% minor (Clavien I-II) postoperative complications, and no mortalities. On final pathology, 76% of patients were organ-confined and 70% specimen-confined. Pathological Gleason sum ≥7 accounted for 86%. Return of urinary continence (0-pads) at 3, 6, 12, and 24 months was 73.3%, 83.5%, 92.3%, 96.5%, respectively. Potency rate (successful penetration with or without medication) at 6, 12, and 24 months was 49.3%, 85%, and 95.3%, respectively. Operative time and positive surgical margin (PSM) in organ-confined disease (pT2) decreased significantly after 50 cases. Seventeen patients (6.8%) had no undetectable prostate-specific antigen (PSA) at first visit (PSA <0.1 ng/mL). Of remaining 233 patients, biochemical recurrence (PSA >0.2 ng/mL) was 4.7% (11 patients), and another 3.4% (8 patients) received early salvage radiotherapy (rising PSA, but <0.2 ng/mL). No patients with undetectable PSA required salvage treatments within 6 months postoperatively. Conclusions:Our results compare favourably with high-volume RARP programs, despite mainly intermediate-to high-risk disease. Initial learning curve was estimated to be 50 cases. Fellowship training was instrumental in achieving adequate functional and oncological outcomes, while maintaining low complications rate.

Predictors of early continence following robot-assisted radical prostatectomy

“…The surgical technique was performed as previously reported. [7][8][9][10] Both surgeons used the barbed polyglyconate suture (V-Loc-suture, Covidien Inc.) for vesico-urethral anastomosis, 11 which included posterior rhabdo-sphincter reconstruction. 12 …”

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon’s experience

“…5 In a recent report by Al-Hathal and colleagues, the RARP learning curve of a fellowshiptrained surgeon was evaluated at 50 cases after which the positive surgical margin (PSM) rate in organ-confined disease was significantly reduced and the overall operative time (OT) was reduced by an average of 80 minutes. 6 When using oncological outcome to define surgical proficiency, Herrell and colleagues reported a minimum learning curve of 150 cases to reduce the PSM rate after RARP to a level comparable to that obtained by open procedure. 7 Murphy and colleagues also reported a RARP learning curve of >80 cases before a plateau is achieved.…”

Description of the Open Anterograde Anatomic Radical Retropubic Prostatectomy Technique

“…In an extensive literature review, rates of positive surgical margin reached 50% in pT3 [23]. Another related factor is the number of procedures, with less than 50 cases the positive margin occurred in 36.1% in pT2 [24]. Oncological control, as indicated by serum PSA ≤ 0.05, was achieved in all patients within 1 year after surgery, including the patient with advanced stage disease, with tumor extension outside the prostate and lymph node involvement (pT3 N1), which demonstrates the ability of the method to address extra prostatic involvement.…”