Robotic radical prostatectomy: a step by step approach (SIU 2011)
- uploaded: Jul 22, 2011
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Institution:San Giovanni Hospital, Rome, Italy
Aim of this study is to describe operative details of robotic radical prostatectomy and to evaluate perioperative and short-term functional and oncological outcome of the first 112 cases with a minimum follow up of 6 months.
One-hundred and twelve consecutive patients underwent robotic radical prostatectomy over a 24-month period. Two surgeons performed all the procedures. The senior surgeon proctored the junior surgeon after the first 50 cases utilizing a step-by-step approach. The first 20 procedures were performed via a five port extraperitoneal approach, whereas the remaining were performed via a six port transperitoneal approach. Perioperative data and functional and pathological results were prospectively collected. Perioperative outcome measures included: operative time, estimated blood loss, transfusion rate, perioperative complication rate according to modified Clavien system, median hospital stay, mean catheterization time. Pathologic outcome measures encompassed positive surgical margin rate and biochemical recurrence free survival (PSA < 0.2). Perioperative and pathologic outcomes were also analyzed using prostate weight as a continuous variable by multivariate regression. Return of continence was evaluated at 6 months (continent 0 pads; incontinent 1 or more pads). Return of potency was evaluated at 6 months with IIEF-5 scores in 54 patients who underwent a nerve-sparing procedure (mean age 61 years; range 47 - 67).
Mean age was 64.2 years. Mean body mass index (BMI) was 26.6. Median preoperative PSA level was 7.6 ng/ml. Mean operative time was 168 minutes. Mean estimated blood loss was 180 cc. Blood transfusion was needed in 3 patients. Median hospital stay was 4 days, mean catheterization time was 8.4 days. Clavien Grade III complication rate was 2.6 % (two rectal injuries, one anastomotic stricture). Positive surgical margin rate was 13.8 % for pT2 disease and 25 % for pT3 disease. Mean prostate weight was 53 g. No correlation between prostate weight, perioperative outcomes and positive margins was found at the multivariate regression analysis (P > 0,5). Overall biochemical recurrence free survival is 95% at mean follow up of 8.9 months. Complete continence (pad free) at 6 months was achieved in 87.5 % of patients. At six months 56% of 54 evaluated patients with nerve-sparing were potent (IIEF-5 > 21) with the use of oral medications.
Robotic radical prostatectomy has a low perioperative complication rate and acceptable pathologic outcomes even during proctoring. Two surgeons accomplished their learning curve within 100 cases without posing outcomes at risk. Perioperative and pathologic outcomes seem to be unrelated to prostate weight. After this initial experience, robotic radical prostatectomy has replaced at our institution our previous standards of open and laparoscopic radical prostatectomy.
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