Hariharan Palayapalayam Ganapathi

Technical Modifications for Salvage and Complex Radical Prostatectomy

Robotic radical prostatectomy is a procedure that has evolved considerably in the last 15 years as one of the main treatments for localized prostate cancer. Published literature currently describes in detail the procedure and outcomes. However, as widespread as it may be, we believe that certain technical modifications have greatly improved our technique, hence improving early and medium-term outcomes. After having performed close to 10,000 cases (single surgeon series—VP), our technique has evolved significantly, including several refinements to reduce patient morbidity and further improve the functional outcomes. In the present manuscript, we perform a detailed description of our surgical technique of Robotic-Assisted Laparoscopic Radical Prostatectomy and provide practical recommendations based on available reports and personal experience.

Nerve wrapping with biomaterials during radical prostatectomy to improve potency recovery

leak after pelvic lymphadenectomy, preventing symptomatic lymphocele. The incidence of symptomatic lymphocele is ~2.5% in those undergoing RARP and extended pelvic lymph node dissection, as most lymphoceles are asymptomatic, but those that present late may be more at risk of infection in people with diabetes [6]. Another aspect that a small randomized controlled trial will not evaluate is the impact of the very occasional disaster, such as significant anastomotic disruption by a pelvic haematoma or a postoperative haemorrhage, and how that might be adverted by prior placement of a pelvic drain.

Nerve-sparing in salvage robot-assisted prostatectomy: surgical technique, oncological and functional outcomes at a single high-volume institution

To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preservation during salvage robot‐assisted radical prostatectomy (RARP).

MP93-12 PROSTATE CANCER IN MEN YOUNGER THAN 55: RATES OF FUNCTIONAL RECOVERY POST-ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY

return of urinary continence, and recovery of sexual function that constitute the RARP 00trifecta00. A method to quantifying RARP outcome was developed in Europe that classifies survival (S), continence (C), and potency (P). The SCP mimics the TNM system used for staging. We sought to validate SCP in a large cohort of Americans followed for more than 5 years after RARP. METHODS: A retrospective review of prospectively collected data from 800 men who underwent RARP from Jan 2006 to Dec 2011 was performed. Total of 637 men were used for analysis after applying inclusion and exclusion criteria. NCCN biochemical failure was used as a proxy for oncologic outcome (S). The UCLA-Prostate Cancer Index Urinary Function and Sexual Function Questionnaires were used to evaluate continence (C) and potency (P), respectively. Continence was refined further by querying medical records for use of a security pad. RESULTS: The 5and 10-year biochemical progression-free survival rates were 93% (95% CI: 0.90-0.95) and 73% (95% CI: 0.67-0.79), respectively. At last follow up, 502 (79%) patients used no pads (C0), 70 (11%) patients used one security pad (C1), 63 (9.8%) patients used one or more pads routinely (C2), and 2 (0.2%) patients were incontinent before RARP (Cx). Of the 522 (82%) patients who had bilateral nerve-sparing RARP, 128 (24.5%) patients were fully potent without use of aids (P0), 74 (14.2%) patients were potent with PDE-5 inhibitor (P1), 320 (61.3%) patients experienced erectile dysfunction (P2). 115 (18%) patients were impotent preoperatively or did not undergo bilateral nerve sparing (Px). In patients preoperatively continent and potent who underwent bilateral nerve preservation and did not require adjuvant radiation therapy, oncologic and functional perfection (S0C0P0) was achieved in 58 (45%) patients. Oncologic and continence perfection (S0C0) was achieved in 92 (80%) of patients for whom potency was not recoverable (Px). CONCLUSIONS: SCP classification offers a tool for objective assessment of oncologic and functional outcome after RARP.

V8-09 ROBOT ASSISTED RADICAL PROSTATECTOMY FOR PROSTATES OVER 100 GRAMS: TECHNIQUE AND OUTCOMES

previously reported Milan vas deferens sling technique by adding reinforcement of under-anastomosis layers during robot-assisted radical prostatectomy, which significantly accelerates early recovery of postoperative urinary continence in cases without nerve-sparing. METHODS: Modified sling technique; Sling suture was made from autologous vas deferens. After putting the vas deferens sling on the sub-urethral perirectal fat, three independent layers were constructed below the urethrovesical anastomosis, and a single anterior layer was made. Then, both ends of the sling were transfixed to Cooper ligaments bilaterally with adequate sling suspension. Between October 2015 and July 2016, consecutive 35 patients who underwent robotassisted radical prostatectomy without nerve-sparing at our institution with a single surgeon were investigated. The patients were classified into two groups: 15 using the sling technique (sling group) and 20 using the non-sling technique with simple posterior reconstruction (nonsling group). Urinary continence defined as 0 or safety 1 pad use daily was compared between the groups. RESULTS: Patients’ characteristics were comparable between the groups. Urinary continence rate significantly improved in the sling group (60.0%, p1⁄40.0365) as compared to the nonsling group (25.0%) at 1 month despite no difference at 3 months (86.7% in the sling group vs. 65.0% in the nonsling group, p1⁄40.1467) postoperatively. Postoperative complications related to sling procedure were not detected. CONCLUSIONS: Despite a small sample size in the singleinstitution study, this sling technique may improve early urinary continence recovery after robot-assisted radical prostatectomy even without nerve-sparing. A larger study is needed to confirm its efficacy.

MP100-15 LONG TERM ONCOLOGICAL OUTCOMES FOLLOWING RADIO FREQUENCY ABLATION OF RENAL MASS

effective, and non-invasive tissue ablation modality. Previous studies have shown that HIFU delivered laparoscopically can be used to ablate kidney tumors, potentially enabling a lower morbidity treatment with faster recovery time as compared to partial nephrectomy procedures. Challenges remain, however, including ensuring full tissue necrosis and consistent energy coupling to the target volume. The objective of this study was to evaluate whether a newly developed laparoscopic HIFU probe is able to address these challenges. METHODS: A laparoscopic porcine kidney model was used to investigate the safety and efficacy of the new 15mm HIFU probe. Under ultrasound guidance, kidneys of 12 pigs were targeted and ablated with HIFU, creating on average 2 ablation zones per kidney of varying sizes and locations in order to quantify the probe0s ability to deliver HIFU to any location on the kidney. Efficacy was evaluated via the analysis of ablation volume histology slides, real-time ultrasound images collected during HIFU delivery, and MRI and ultrasound contrast images. Safety was evaluated by surviving a subgroup of the animals (2w). Grosspathological data, sonication parameters, and workflow feedback was also collected during the study. RESULTS: Repeatable lesions could be created at a rate of 0.48cm/min and average energy densities of 584cal/cm. Histological evaluation indicated contiguous ablated volumes using these delivery parameters, extending from the transducer0s focal zone to the kidney surface, with a maximum treatment depth of 27mm. Ablated target volumes ranged from 5.1cm to 24.5cm. CONCLUSIONS: The results confirm the ability of the new probe to deliver HIFU in a consistent and reliable manner. Initial dose requirements for ablating tissue at various depths were also determined. Workflow feedback has resulted in additional system user interface improvements, with all of these results paving the way for a future clinical study.

MP93-06 TECHNICAL FACTORS PREVENTING FULL NERVE SPARING DURING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY IN PATIENTS THAT ARE CANDIDATES FOR FULL NERVE SPARING

RESULTS: The recovery of incontinence was similar to the two groups at 6 and 12 months after the surgery. However, patients underwent RARP restored the continence sooner than those in the LRP group in 1 and 3 months after the surgery (P <0.001 and 0.001) (Fig.1). For the multivariable analysis, the type of RP procedure was a uniquely meaningful contributing factor (P 1⁄4 0.001, HR 1⁄4 1.925; 95% CI 1⁄4 1.299e2.851). In the case of urinary function, the RARP groups showed a better IPSS score than LRP groups at the 1-, 3-, and 6-month visits, respectively (P 1⁄4 0.008, 0.026, 0.001), (Fig.2) and the RARP groups early improved compared with LRP groups at the 3-month visit in the case of erectile function (P 1⁄4 0.018) (Fig.3). CONCLUSIONS: The RARP tended toward getting back the urinary continence earlier than the LRP. In addition, urinary and erectile function recovered more quickly in the RARP group than in the LRP group.

PD51-06 SALVAGE ROBOT ASSISTED RADICAL PROSTATECTOMY AFTER PRIMARY RADIATION OR ABLATION TREATMENT: WHAT HAVE WE LEARNED? ASSESSING THE LEARNING CURVE IN TERMS OF MORBIDITY, ONCOLOGICAL AND FUNCTIONAL OUTCOMES.

RESULTS: On IVA adjusting for socio-demographic, facilityand tumor-specific covariates, RP was associated with lower overall mortality compared to RT+ADT (hazard ratio (HR) 0.52; 95% CI, 0.470.57; p<0.001) in the overall analysis, in patients with age 1⁄465 years with CCI 0 (HR 0.48; p<0.001), in patients >65 years with CCI 0 (0.53; p<0.001), those receiving RT with neoadjuvant (HR 0.52; p<0.001) or adjuvant ADT (HR 0.47; p<0.001), or treated with high dose (1⁄475.6 Gy) RT (HR 0.54; p<0.001). While the survival outcomes for patients treated with RT (+/-ADT) in the RCTs were not statistically different from similarly treated and appropriately selected patients within the NCDB, RP was associated with greater overall mortality-free survival than any of the arms represented in the RCTs. CONCLUSIONS: Our results suggest that in patients with clinically high-risk PCa, primary RP is associated with greater overall mortality-free survival than primary RT+ADT in patients with clinically high-risk PCa, regardless of baseline characteristics. These findings, in lieu of a randomized trial, can guide the clinicians to carefully choose the primary modality of treatment for patients with high-risk PCa.

MP97-02 ROBOTIC ASSISTED RADICAL PROSTATECTOMY IN METABOLIC SYNDROME PATIENTS. STRATIFICATION BY NUMBER OF METABOLIC RISK FACTORS.

INTRODUCTION AND OBJECTIVES: The optimal treatment for high-risk prostate cancer (Pca) remains to be established. We previously reported favorable biochemical recurrence-free survival (BRFS) for highrisk Pca patients treated with neoadjuvant therapy comprising a luteinizing hormone-releasing hormone (LHRH) agonist plus low-dose estramustine (EMP) (LHRH agonist + EMP) prior to radical prostatectomy (RP) (Koie T et al. Int J Clin Oncol 2015). In the present study, we evaluated the efficacy of neoadjuvant therapy comprising a LHRH antagonist plus low-dose EMP (LHRH antagonist + EMP) in patients with high-risk Pca. METHODS: Between September 2005 and March 2016, we identified 406 high-risk Pca patients of whom 136 received neoadjuvant LHRH antagonist + EMP and 270 received LHRH agonist + EMP before RP. We retrospectively evaluated the clinical and pathological covariates between the two groups. The primary endpoint was the rate of pathological 1⁄4T2 status, and the secondary endpoint was BRFS. RESULTS: The rates of pathological1⁄4T2 status were 80.2% and 61.5% in the LHRH antagonist + EMP and LHRH agonist + EMP groups, respectively (P < 0.001). The 2-year BRFS rates were 97.8% and 87.8% in the LHRH antagonist + EMP and LHRH agonist + EMP groups, respectively (P 1⁄4 0.027). Multivariate analysis revealed that biopsy Gleason score, LHRH antagonist + EMP, and clinical T stage were independent predictors of pathological 1⁄4T2 status in surgical specimens. CONCLUSIONS: Our findings suggest that neoadjuvant LHRH antagonist + EMP followed byRPmay improve the pathological outcomes and reduce the risk of biochemical recurrence in patients with high-risk Pca. Further prospective studies to confirm these findings are warranted. Source of Funding: none

Surgical Robotics: Past, Present and Future

The evolution of robots in surgical practice is an intriguing story that spans cultures, continents and centuries. The idea of reproducing himself with the use of a mechanical robot has been in man’s imagination in the last 3000 years. However, the use of robots in medicine has only 30 years of history. Surgery has traditionally required larger incisions to allow the surgeon to introduce his hands into the body and to allow sufficient light to see the structures being operated on. Surgeon directly touched and felt the tissues and moved the tip of the instruments. However, innovations have radically changed the performance of surgical procedures in operating room by digitization, miniaturization, improved optics, novel imaging techniques, and computerized information systems. These surgical procedures can be done by manipulating instruments from outside the patient, by looking at displays of direct electronic images of the target organs on the monitor. The robot completes the transition to the Information Age. The surgeon is immersed in this computer-generated environment (called “virtual reality,” term coined by Jaron Lanier, 1986) and sends electronic signals from the joysticks of the console to the tip of the instruments, which mimic the surgeon’s hand movements [1].