Joseph Tortora

Does Prior Abdominal Surgery Influence Outcomes or Complications of Robotic-assisted Laparoscopic Radical Prostatectomy?

OBJECTIVES To determine whether robotic-assisted laparoscopic radical prostatectomy (RALP) in patients with prior abdominal surgery is associated with increased operating times, positive surgical margins, or complications. METHODS An institutional review board-approved retrospective review of a prospective, prostatectomy database was performed. Patients undergoing surgery between January 1, 2004, and February 29, 2008 were included. Transition from open retropubic prostatectomy to RALP took place through 2004, at which point all surgical candidates were offered RALP, regardless of prior surgical history. Learning curves from all surgeons were included. Patients with prior abdominal surgery were compared with those patients without prior surgery with respect to total operating time, robotic-assist time, surgical margin positivity, and rate of complications. RESULTS A total of 1083 patients underwent RALP between January 1, 2004, and February 29, 2008, at our institution; of these, 839 had sufficient data available for analysis. In all, 251 (29.9%) patients had prior abdominal surgery, whereas 588 (70.1%) had no prior abdominal surgery. Total operating times were 209 and 204 minutes (P = .20), robotic console times were 165 and 163 minutes (P = .59), and surgical margin positivity was 21.1% and 27.2% (P = .08) for patients with and without prior abdominal surgery, respectively. The incidence of complications was 14.3% and 17.3% for patients with and without prior abdominal surgery (P = .33). CONCLUSIONS Prior abdominal surgery was not associated with a statistically significant increase in overall operating time, robotic assist time, margin positivity, or incidence of complications in patients undergoing RALP. Robotic prostatectomy can be safely and satisfactorily performed in patients who have had a wide variety of prior abdominal surgery types.

Prostate Cancer Biochemical Recurrence Rates After Robotic-Assisted Laparoscopic Radical Prostatectomy

Negative surgical margins for prostate cancer patients undergoing robotic-assisted laparoscopic radical prostatectomy result in lower biochemical recurrence rates for low and intermediate risk groups.

Does Heparin Prophylaxis Reduce the Risk of Venous Thromboembolism in Patients Undergoing Robot-Assisted Prostatectomy?

BACKGROUND AND PURPOSE Venous thromboembolism (VTE) is a major complication of urologic surgery. Data are limited regarding the benefits of heparin prophylaxis for patients undergoing minimally invasive urologic surgery. The American Urological Association recommends sequential compression devices (SCDs) for urologic laparoscopic and robot-assisted procedures but provides no clear recommendations for the use of pharmacologic prophylaxis. We compare the rates of postoperative VTE in two groups of patients undergoing robot-assisted prostatectomy (RP) by two surgeons-one who consistently used heparin with SCDs (group 1) and the other who used SCDs alone (group 2) for prophylaxis. PATIENTS AND METHODS An Institutional Review Board approved, prospectively managed database was analyzed. Group 1 received SCDs just before induction and 5000 units of heparin subcutaneously just after induction. SCDs were continued postoperatively, and heparin was administered twice a day until discharge. VTE rate, patient age, body mass index (BMI), operative time, lymphocele rate, length of stay (LOS), estimated blood loss (EBL), Gleason score, and pathologic stage were compared. Categorical variables were analyzed with the chi square test of proportions and continuous variables with t test using SPSS v 14 software. RESULTS There were 1486 consecutive patients who underwent RP between August 2007 and December 30, 2011. Of these, 922 patients received heparin/SCDs and 564 received SCDs alone. Age, BMI, EBL, medial LOS, Gleason score, and pathologic stage were the same in the two groups. There was a higher rate of positive nodes in group 2 (1.3% vs 3.5%). There was one lymphocele in each group. Although operative times were longer in group 2 (229 vs 170 min, P<0.001), the incidence of VTE was not statistically different (1.0% vs 0.7%, P=0.78). BMI, operative time, EBL, and the performance of lymph node dissection were not associated with VTE. CONCLUSIONS The risk of VTE in patients undergoing RP is low and not significantly reduced with the administration of prophylactic heparin/SCDs compared with SCDs alone.

National Comprehensive Cancer Network® Favorable Intermediate Risk Prostate Cancer—Is Active Surveillance Appropriate?

Purpose: We compared pathological and biochemical outcomes after radical prostatectomy in patients at favorable intermediate risk who fulfilled current NCCN® (National Comprehensive Cancer Network®) Guidelines® for active surveillance criteria to outcomes in patients who met more traditional criteria for active surveillance. Materials and Methods: We queried our institutional review board approved prostate cancer database for patients who met NCCN criteria for very low risk (T1c, Grade Group 1, 3 or fewer of 12 cores, 50% or less core volume and prostate specific antigen density less than 0.15 ng/ml), low risk (T1‐T2a, Grade Group 1 and prostate specific antigen less than 10 ng/ml) or favorable intermediate risk (major pattern grade 3 and less than 50% positive biopsy cores) and who had 1 intermediate risk factor, including T2b/c, Grade Group 2 or prostate specific antigen 10 to 20 ng/ml. Men at intermediate risk who did not meet favorable criteria were labeled as being at unfavorable intermediate risk. Patients at favorable intermediate risk were compared to those at very low and low risk, and those at unfavorable intermediate risk to identify differences in rates of adverse pathological findings at radical prostatectomy, including Gleason score Grade Group 3–5, nonorgan confined disease or nodal involvement. Time to biochemical recurrence was compared among the groups using Cox regression. Results: A total of 3,686 patients underwent radical prostatectomy between January 1, 2014 and December 31, 2015. Of these men 1,454, 250 and 1,362 fulfilled the criteria for low, favorable intermediate and unfavorable intermediate risk, respectively. The rate of adverse pathological findings in favorable intermediate risk cases was significantly higher than in low risk cases and significantly lower than in unfavorable intermediate risk cases (27.4% vs 14.8% and 48.5%, respectively, each p <0.001). Time to biochemical recurrence differed significantly among the risk groups (p <0.001). Conclusions: Relative to men at low risk those at favorable intermediate risk represent a distinct group. Care should be taken when selecting these patients for active surveillance and monitoring them once they are in an active surveillance program.