Emad Rajih

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

INTRODUCTION We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a time-based benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps. METHODS We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps. RESULTS In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time. CONCLUSIONS Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre

INTRODUCTION The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. METHODS A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. RESULTS Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. CONCLUSIONS Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Perioperative predictors for post-prostatectomy urinary incontinence in prostate cancer patients following robotic-assisted radical prostatectomy: Long-term results of a Canadian prospective cohort

INTRODUCTION We aimed to report the impact of perioperative factors that have not been well-studied on continence recovery following robotic-assisted radical prostatectomy (RARP). METHODS We analyzed data of 322 men with localized prostate cancer who underwent RARP between October 2006 and May 2015 in a single Canadian centre. All patients were assessed at one, three, six, 12, and 24 months after surgery. We evaluated risk factors for post-prostatectomy urinary incontinence from a prospectively collected database in multivariate Cox regression analysis. The primary endpoint was continence, defined as 0 pad usage per day. RESULTS 0-pad continence rates were 126/322 (39%), 187/321 (58%), 222/312 (71%), 238/294 (80%), and 233/257 (91%) at one, three, six, 12, and 24 months, respectively. Bladder neck preservation (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.5-0.99; p=0.04), and prostate size (HR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictors of continence recovery after RARP. Smoking at time of surgery predicted delayed continence recovery on multivariate analysis (HR 1.42; 95% CI 1.01-1.99; p=0.04). Neurovascular bundles preservation was associated with continence recovery after 24 months. No statistically significant correlation was found with other variables, such as age, body mass index, Charlson comorbidity index, preoperative oncological baseline parameters, presence of median lobe, or thermal energy use. CONCLUSIONS Our results confirmed known predictors of postprostatectomy incontinence (PPI), namely bladder neck resection and large prostate volume. Noteworthy, cigarette smoking at the time of RARP was found to be a possible independent risk factor for PPI. This study is hypothesis-generating.

MP02-09 EVALUATION OF SURGICAL OUTCOMES WITH PHOTOSELECTIVE GREENLIGHT XPS LASER VAPORIZATION OF THE PROSTATE IN HIGH MEDICAL RISK MEN WITH BENIGN PROSTATIC ENLARGEMENT: A MULTICENTER STUDY

underexplored. Herein, we describe outcomes of HoLEP in a select cohort of patients with significant LUTS, and known low risk PCa. METHODS: Data were collected retrospectively on patients undergoing HoLEP by a single surgeon. A select group of well informed patients with large symptomatic glands and low risk cancer were carefully counseled that HoLEP was an option to address the obstructive BPH, would unpredictably remove the cancer (all, part, or none), emphasizing they were not undergoing a cancer operation, and that HoLEP would be followed by continued surveillance. Preand postoperative clinical factors, and operative and hospital stay data were collected. RESULTS: In total, 7 men were included. All men had Gleason 3+3 cancer in at most 20% of at most 3 cores on biopsy. Other preop characteristics are described in Table 1. Mean tissue removed was 48.8g. No patients required transfusion or reoperation. Median length of hospital stay was 24.5 hours; median length of catheterization was 19 hours. On final pathology, 3 of 7 of patients had cancer in the specimen, all of which were Gleason 3+3. At f/u, all flow rates improved, PVR improved or remained low, and PSA significantly decreased in all patients (Table 1). No patient have developed stricture, bladder neck contracture, incontinence, or required reoperation. Median f/u time was 4 months (range 4-24 months). Notably, 2 patients had prostate MRI within 2 years of HoLEP, neither of which showed suspicion for PCa. CONCLUSIONS: We have offered HoLEP judiciously to select patients on surveillance for low risk PCa and significant symptomatic BPH, a complex and increasingly common scenario, with acceptable short term outcomes. Further investigations into long-term cancerspecific outcomes, as well as strategies for continued surveillance, will be crucial in order to further evaluate and refine this new approach.

MP93-04 THE RISK OF URINARY RETENTION FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY AND ITS IMPACT ON EARLY CONTINENCE OUTCOMES

INTRODUCTION AND OBJECTIVES: Radical prostatectomy (RP), external-beam radiotherapy (EBRT), and brachytherapy are standard treatments for localized prostate cancer but each may negatively impact bowel function. We sought to develop a nomogram predicting the probability of treatment-related bowel problems using prospective, patient-reported data. METHODS: Patient-reported data on treatment-related bowel problems was obtained from four prospective, longitudinal, healthrelated quality-of-life (HRQOL) protocols comprising 2,668 patients treated between 1999 and 2011 in the United States and Spain. A single HRQOL instrument was not uniformly used for each study, though a similar 5-point scale was used in each protocol to assess bother related to bowel problems. Bowel dysfunction was defined as bowel symptoms identified as a moderate-to-big problem by patients on survey responses before treatment and 2 years post-treatment. Multivariable logistic regression analysis was used to model the clinical information and follow-up data. Internal validation was performed using bootstrapping. RESULTS: Overall, 43 patients (2%) with complete data had bowel dysfunction prior to treatment. The rate of bowel dysfunction at 2 years in patients with no bowel dysfunction pretreatment was 2%, 10%, and 4% for patients treated by RP, EBRT, and brachytherapy, respectively (p<0.001). A nomogram based on pretreatment bowel bother, treatment modality, and race had a concordance index of 0.725 and predictions were well-calibrated with observed outcome on cross-validation. The predictive accuracy was not increased by the inclusion of additional demographic, tumor-related, or treatmentrelated variables, or by the creation of separate treatment-specific models. CONCLUSIONS: A validated nomogram that predicts 2-year probability of bowel dysfunction after treatment for localized prostate cancer has been developed. The nomogram is anticipated to be useful for patient counseling regarding treatment options for localized prostate cancer.

Functional and oncological outcomes of salvage external beam radiotherapy following robot-assisted radical prostatectomy in a Canadian cohort

INTRODUCTION We sought to determine the impact of salvage radio-therapy (SRT) on oncological and functional outcomes of patients with prostate cancer after biochemical recurrence (BCR) following robot-assisted radical prostatectomy (RARP). METHODS Data of 70 patients with prostate cancer treated with SRT after developing BCR were retrospectively analyzed from a prospectively collected RARP database of 740 men. Oncological (prostate-specific antigen [PSA]) and functional (pads/day, International Prostate Symptom Score [IPSS], and Sexual Health Inventory for Men [SHIM]) outcomes were reported at six, 12, and 24 months after RT and adjusted for pre-SRT status. RESULTS Men who underwent SRT had a mean age, PSA, and time from radical prostatectomy (RP) to RT of 61.8 years (60.1-63.6), 0.5 ng/ml (0.2-0.8), and 458 days (307-747), respectively. Freedom from biochemical failure (FFBF) post-SRT, defined as a PSA nadir <0.2 ng/mL, was observed in 89%, 93%, and 81%, at six, 12, and 24 months, respectively. Undetectable PSA was observed in 14%, 35%, and 40% at the same time points, respectively. There was no significant difference in urinary continence post-SRT (p=0.56). Rate of strict continence (0 pads/day) was 71% at 24 months compared to 78% pre-SRT. Mean IPSS at six, 12, and 24 months was 3.4, 3.6, and 3.6, respectively compared to pre-RT score of 3.3 (p=0.61). The mean SHIM score pre-SRT was comparable at all time points following treatment (p=0.86). CONCLUSIONS In this unique Canadian experience, it appears that early SRT is highly effective for the treatment of BCR following RARP with little impact on urinary continence and potency outcomes.