Sanket Chauhan

Early complication rates in a single-surgeon series of 2500 robotic-assisted radical prostatectomies: report applying a standardized grading system.

BACKGROUND Perioperative complications following robotic-assisted radical prostatectomy (RARP) have been previously reported in recent series. Few studies, however, have used standardized systems to classify surgical complications, and that inconsistency has hampered accurate comparisons between different series or surgical approaches. OBJECTIVE To assess trends in the incidence and to classify perioperative surgical complications following RARP in 2500 consecutive patients. DESIGN, SETTING, AND PARTICIPANTS We analyzed 2500 patients who underwent RARP for treatment of clinically localized prostate cancer (PCa) from August 2002 to February 2009. Data were prospectively collected in a customized database and retrospectively analyzed. INTERVENTION All patients underwent RARP performed by a single surgeon. MEASUREMENTS The data were collected prospectively in a customized database. Complications were classified using the Clavien grading system. To evaluate trends regarding complications and radiologic anastomotic leaks, we compared eight groups of 300 patients each, categorized according the surgeons experience (number of cases). RESULTS AND LIMITATIONS Our median operative time was 90min (interquartile range [IQR]: 75-100min). The median estimated blood loss was 100ml (IQR:100-150ml). Our conversion rate was 0.08%, comprising two procedures converted to standard laparoscopy due to robot malfunction. One hundred and forty complications were observed in 127 patients (5.08%). The following percentages of patients presented graded complications: grade 1, 2.24%; grade 2, 1.8%; grade 3a, 0.08%; grade 3b, 0.48%; grade 4a, 0.40%. There were no cases of multiple organ dysfunction or death (grades 4b and 5). There were significant decreases in the overall complication rates (p=0.0034) and in the number of anastomotic leaks (p<0.001) as the surgeons experience increased. CONCLUSIONS RARP is a safe option for treatment of clinically localized PCa, presenting low complication rates in experienced hands. Although the robotic system provides the surgeon with enhanced vision and dexterity, proficiency is only accomplished with consistent surgical volume; complication rates demonstrated a tendency to decrease as the surgeons experience increased.

Robotic-assisted radical prostatectomy: a review of current outcomes

With the widespread diffusion of the screening for prostate cancer, the disease has been diagnosed more commonly in the organ‐confined stage, and in younger and healthier men. For these patients, radical prostatectomy (RP) is still the standard treatment. In an effort to decrease the morbidity associated with open RP, minimally invasive approaches have been described, including robotic‐assisted RP (RALP). Almost one decade after the introduction of RALP, large and mature series have now been reported. We reviewed the outcomes of the largest series of RALP published recently. We searched Medline for reports published between 2006 and 2009, to identify articles describing intraoperative data, surgical complications, oncological outcomes, continence and potency rates after RALP. Relevant articles were selected and the outcomes evaluated.

Continence, potency and oncological outcomes after robotic-assisted radical prostatectomy: early trifecta results of a high-volume surgeon

Study Type – Therapy (case series)
Level of Evidence 4

Incidence of lymphoceles after robot-assisted pelvic lymph node dissection.

Study Type – Therapy (case series)

Anatomic Grading of Nerve Sparing During Robot-Assisted Radical Prostatectomy

BACKGROUND Because of the lack of intraoperative visual cues, the amount of nerve sparing (NS) intended by the surgeon does not always correspond to what is actually performed during surgery. OBJECTIVE Describe a standardized NS grading system based on intraoperative visual cues. DESIGN, SETTING, AND PARTICIPANTS A total of 133 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) by a single surgeon were evaluated. The surgeon intraoperatively graded the NS independently for either side as follows: 1=no NS; 2=<50% NS; 3=50% NS; 4=75% NS; 5= ≥ 95% NS. SURGICAL PROCEDURE RARP; detailed description of a five-point NS grading system. MEASUREMENTS The area of residual nerve tissue on prostatectomy specimens was compared with the intraoperative NS score (NSS). The rate of positive surgical margins (PSMs) according to the NSS is also reported. RESULTS AND LIMITATIONS In all, 52.6% of operated sides (140 of 266 sides) had NSS 5, 30.1% (80 of 266) had NSS 4, 2.3% (6 of 266) had NSS 3, 13.2% (35 of 266) had NSS 2, and 1.9% (5 of 266) had NSS 1. The area of residual nerve tissue was significantly different among the different NSSs: median area (interquartile range) for NSS 5: 0.5 (0-2) mm(2); for NSS 4: 3 (0-8) mm(2); for NSS 3: 13 (7-23) mm(2); for NSS 2: 14 (8-24) mm(2); and for NSS 1: 57 (56-165) mm(2) (p<0.001). Overall, 9.02% of the patients (12 of 133 patients) had a PSM, with 8.3% (9 of 108) for pT2 and 12% (3 of 25) for pT3. Side-specific PSMs according to NSS were 3.6% (5 of 140) for NSS 5, 7.5% (6 of 80) for NSS 4, 16.7% (1 of 6) for NSS 3, 5.7% (2 of 35) for NSS 2, and 0% (0 of 5) for NSS 1. A limitation of our study is that the key anatomic landmarks are not recognizable in every case, and this technique might not be easy to perform during the early learning curve. CONCLUSIONS We believe that the visual cues exposed in this article will help surgeons achieve more consistent NS during RARP.

Factors Affecting Return of Continence 3 Months After Robot-Assisted Radical Prostatectomy: Analysis From a Large, Prospective Data by a Single Surgeon

PURPOSE In this study we identified preoperative or intraoperative factors responsible for the early return of continence after robot-assisted radical prostatectomy using data from a high volume center. MATERIALS AND METHODS Data from 1,299 patients who underwent robot-assisted radical prostatectomy performed by a single surgeon from January 2008 to June 2010 were collected prospectively and analyzed retrospectively. Patients were categorized according to whether they regained continence (no pad and no urinary leakage) within 3 months and variables were then compared. A self-administered validated questionnaire (Expanded Prostate Cancer Index Composite) was used for assessment of continence status and time to recovery. RESULTS Within 3 months after surgery 86.3% of patients (1,121/1,299) had recovered continence. Multivariable Cox regression analysis revealed that only age (p <0.001, hazard ratio 0.98, 95% CI 0.97-0.99) and performance of a nerve sparing procedure were independent predictors. After adjusting for age, the hazard ratio was 1.61 (95% CI 1.25-2.07, p <0.001) for partial nerve sparing and 1.44 (1.13-1.83, p = 0.003) for bilateral nerve sparing compared to the nonnerve sparing group. Median time (95% CI) to the recovery of continence was prolonged in the nonnerve sparing group compared to nerve sparing counterparts at 6 (5.12-6.88), 4 (3.60-4.40) and 5 weeks (4.70-5.30) in the nonnerve sparing, partial nerve sparing and bilateral nerve sparing groups, respectively, with log rank p <0.01. CONCLUSIONS Findings from our analysis indicate that the likelihood of postoperative urinary control was significantly higher in younger patients and when a nerve sparing procedure was performed.

Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis

Study Type – Therapy (case series)

Predictive Factors for Positive Surgical Margins and Their Locations After Robot-Assisted Laparoscopic Radical Prostatectomy

BACKGROUND Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP). OBJECTIVE We sought to identify predictive factors for PSMs and their locations after RARP. DESIGN, SETTING, AND PARTICIPANTS We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009. INTERVENTION All patients underwent RARP performed by a single surgeon with previous experience of >1500 cases. MEASUREMENTS Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra- and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade. RESULTS AND LIMITATIONS In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio [OR]: 10.7; 95% confidence interval [CI], 2.6-43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9-4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis (p<0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9-4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2-34.5; p=0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor (OR: 1.1; 95% CI, 1.0-1.3; p=0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series. CONCLUSIONS Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs.

The Role of the Prostatic Vasculature as a Landmark for Nerve Sparing During Robot-Assisted Radical Prostatectomy

BACKGROUND Macroscopic landmarks are lacking to identify the cavernosal nerves (CNs) during radical prostatectomy. The prostatic and capsular arteries run along the lateral border of the prostate and could help identify the location of the CNs during robot-assisted radical prostatectomy (RARP). OBJECTIVE Describe the visual cues that have helped us achieve consistent nerve sparing (NS) during RARP, placing special emphasis on the usefulness of the prostatic vasculature (PV). DESIGN, SETTING, AND PARTICIPANTS Retrospective video analysis of 133 consecutive patients who underwent RARP in a single institution between January and February 2011. SURGICAL PROCEDURE NS was performed using a retrograde, antegrade, or combined approach. MEASUREMENTS A landmark artery (LA) was identified running on the lateral border of the prostate corresponding to either a prostatic or capsular artery. NS was classified as either medial or lateral to the LA. The area of residual nerve tissue on surgical specimens was measured to compare the amount of NS between the groups. RESULTS AND LIMITATIONS We could identify an LA in 73.3% (195 of 266) of the operated sides. The area of residual nerve tissue was significantly different whether the NS was performed medial (between the LA and the prostate) or lateral to the LA (between the LA and pelvic side wall): median (interquartile range) of 0 (0-3) mm2 versus14 (9-25) mm2; p<0.001, respectively. CONCLUSIONS The PV is an identifiable landmark during NS. Fine tailoring on the medial border of an LA can consistently result in a complete or almost complete NS, whereas performing the NS on its lateral border results in several degrees of incomplete NS.

Critical review of ' pentafecta ' outcomes after robot-assisted laparoscopic prostatectomy in high-volume centres

Whats known on the subject? and What does the study add?