Srinivas Samavedi

Robot-Assisted Laparoscopic Radical Prostatectomy: Perioperative Outcomes of 1500 Cases

BACKGROUND Robot-assisted laparoscopic radical prostatectomy (RALP) is an evolving minimally invasive treatment of for localized prostate cancer. We present our experience of 1500 consecutive cases with an analysis of perioperative outcomes. PATIENTS AND METHODS Fifteen hundred consecutive RALPs were performed by a single surgeon (VRP). Following Institutional Review Board approval, clinical coordinators performed prospective intraoperative and postoperative data collection. Functional outcomes were assessed using validated self-administered questionnaires. RESULTS Mean OR time from skin incision to fascial closure (the time that the surgeon was present) was 105 minutes (55-300). Mean EBL was 111 cc (50-500). Ninety-seven percent of patients were discharged home on postoperative day 1. The overall complication rate was 4.3% with no mortalities. The positive margin rate (PMR) was 9.3% overall. PMR was 4% for pT2, 34% for T3 and 40% for pathologic stage T4. CONCLUSIONS Our initial series represents one of the largest published series for perioperative outcomes of robotic assisted prostatectomy. Our data demonstrates the feasibility, safety and efficacy of the procedure.

Dehydrated Human Amnion/Chorion Membrane Allograft Nerve Wrap Around the Prostatic Neurovascular Bundle Accelerates Early Return to Continence and Potency Following Robot-assisted Radical Prostatectomy: Propensity Score–matched Analysis

We present a propensity-matched analysis of patients undergoing placement of dehydrated human amnion/chorion membrane (dHACM) around the neurovascular bundle (NVB) during nerve-sparing (NS) robot-assisted laparoscopic prostatectomy (RARP). From March 2013 to July 2014, 58 patients who were preoperatively potent (Sexual Health Inventory for Men [SHIM] score >19) and continent (no pads) underwent full NS RARP. Postoperative outcomes were analyzed between propensity-matched graft and no-graft groups, including time to return to continence, potency, and biochemical recurrence. dHACM use was not associated with increased operative time or blood loss or negative oncologic outcomes (p>0.500). Continence at 8 wk returned in 81.0% of the dHACM group and 74.1% of the no-dHACM group (p=0.373). Mean time to continence was enhanced in group 1 patients (1.21 mo) versus (1.83 mo; p=0.033). Potency at 8 wk returned in 65.5% of the dHACM patients and 51.7% of the no-dHACM group (p=0.132). Mean time to potency was enhanced in group 1, (1.34 mo), compared to group 2 (3.39 mo; p=0.007). Graft placement enhanced mean time to continence and potency. Postoperative SHIM scores were higher in the dHACM group at maximal follow-up (mean score 16.2 vs 9.1). dHACM allograft use appears to hasten the early return of continence and potency in patients following RARP.

Continence outcomes of robot-assisted radical prostatectomy in patients with adverse urinary continence risk factors

To analyse the continence outcomes of robot‐assisted radical prostatectomy (RARP) in suboptimal patients that have challenging continence recovery factors such as enlarged prostates, elderly patients, higher body mass index (BMI), salvage prostatectomy, and bladder neck procedures before RARP.

Age stratified comparative analysis of perioperative, functional and oncologic outcomes in patients after robot assisted radical prostatectomy – A propensity score matched study

INTRODUCTION AND OBJECTIVES Our goal was to evaluate the perioperative, functional and intermediate term oncological outcomes of robot assisted radical prostatectomy (RARP) in patients ≥ 70 years. MATERIALS AND METHODS The study population (N = 3241) consisted of consecutive patients who underwent RARP for localized prostate cancer by a single surgeon (VP) from January 2008 through February 2012. A query of our Institutional Review Board approved registry identified 400 men ≥ 70 years of age, with good functional status (Charlson co-morbidity index < 3). These patients were propensity score matched to younger patients. Perioperative and postoperative functional and oncologic outcomes for the two groups were compared. RESULTS Full nerve sparing as well as the ease of nerve sparing were similar in 2 groups. Intra-operative complications were comparable. Postoperative complication occurrence rates were similar. At mean follow up of 34.1 months and 37.2 months respectively in younger and older patients, the continence rate was comparable in 2 groups (91.3% and 87.3%).Average time to continence and potency were similar in 2 groups. A greater proportion of younger patients became potent than elderly (52.3% vs 33.5%,p < 0.001).The biochemical recurrence (BCR) rate was comparable in 2 groups (7.8% vs 8.3%; p = 0.79). The mean time to BCR was also comparable in 2 groups (16 months vs 22.6 months; p = 0.07). CONCLUSIONS In appropriately selected patients (minimal comorbidities with CCI ≤ 2, life expectancy >10 years, localized prostate cancer) RARP is a reasonable option in patients ≥ 7 0 years and provides comparable perioperative, functional and intermediate term oncologic outcomes as compared to younger patients.

Perioperative and early oncological outcomes after robot-assisted radical prostatectomy (RARP) in morbidly obese patients: a propensity score-matched study.

To evaluate the perioperative and pathological outcomes associated with robot‐assisted radical prostatectomy (RARP) in morbidly obese men.

Overall rate, location, and predictive factors for positive surgical margins after robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer.

We report the overall rate, locations and predictive factors of positive surgical margins (PSMs) in 271 patients with high-risk prostate cancer. Between April 2008 and October 2011, we prospectively collected data from patients classified as D′Amico high-risk who underwent robot-assisted laparoscopic radical prostatectomy. Overall rate and location of PSMs were reported. Stepwise logistic regression models were fitted to assess predictive factors of PSM. The overall rate of PSMs was 25.1% (68 of 271 patients). Of these PSM, 38.2% (26 of 68) were posterolateral (PL), 26.5% (18 of 68) multifocal, 16.2% (11 of 68) in the apex, 14.7% (10 of 68) in the bladder neck, and 4.4% (3/68) in other locations. The PSM rate of patients with pathological stage pT2 was 8.6% (12 of 140), 26.6% (17 of 64) of pT3a, 53.3% (32/60) of pT3b, and 100% (7 of 7) of pT4. In a logistic regression model including pre-, intra-, and post-operative parameters, body mass index (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.01-1.19, P= 0.029), pathological stage (pT3b or higher vs pT2; OR: 5.14; 95% CI: 1.92-13.78; P = 0.001) and percentage of the tumor (OR: 46.71; 95% CI: 6.37-342.57; P< 0.001) were independent predictive factors for PSMs. The most common location of PSMs in patients at high-risk was the PL aspect, which reflects the reported tumor aggressiveness. The only significant predictive factors of PSMs were pathological outcomes, such as percentage of the tumor in the specimen and pathological stage.

Current status of various neurovascular bundle-sparing techniques in robot-assisted radical prostatectomy

Nerve-sparing procedures during robot-assisted radical prostatectomy (RARP) have demonstrated improved postoperative functional outcomes. This article provides an overview of clinically applied prostatic neuro-anatomy, various techniques of nerve sparing (NS), and recent innovations in NS and potency outcomes of NS RARP. We retrieved and reviewed all listed publications within PubMed using keywords: nerve sparing, robotic radical prostatectomy, prostate cancer, outcomes, pelvic neuroanatomy and potency. Studies reporting potency outcomes of NS RARP (comparative and non-comparative) were analysed using the Delphi method with an expert panel of urological robotic surgeons. Herein, we outline the published techniques of NS during RARP. Potency and continence outcomes of individual series are discussed in light of the evidence provided by case series and published trials. The potency outcomes of various comparative and non-comparative series of NS RARP have also been mentioned. There are numerous NS techniques reported for RARP. Each method is complimented with benefits and constrained by idiosyncratic caveats, and thus, careful patient selection, a wise intraoperative clinical judgment and tailored approach for each patient is required, when decision for nerve sparing is made. Further large prospective multi-institutional randomized controlled trials are required to evaluate potency and continence outcomes of these techniques, using a rigid standard patient selection criteria and definition of potency are warranted in the new era of functional outcome-driven research.

Does Surgeon Subjective Nerve Sparing Score Predict Recovery Time of Erectile Function Following Robot-Assisted Radical Prostatectomy?

INTRODUCTION During robot-assisted radical prostatectomy (RARP), the quality of nerve sparing (NS) was usually classified by laterality of NS (none, unilateral, and bilateral) or degree of NS (none, partial, and full). Recently, side-specific NS have been more frequently performed, but previous NS grading system might not reflect the differential NS in each side. AIM Herein, we assessed whether a subjective NS score (NSS) incorporating both degree of NS and NS laterality can predict the time to potency recovery following RARP. METHODS Data were analyzed from 1,898 patients who had left and right neurovascular bundle sparing quality scores and at least one year of follow-up after RARP was performed between January 2008 and October 2011. MAIN OUTCOME MEASURES Cox proportional hazard method analyses were used to determine predictive factors for early recovery. Multivariate linear regression models were used to assess subjective NSS in an effort to predict time to potency recovery. Subjective NSSs were compared to a model based on the three grades according to laterality and degree. RESULTS Time to potency recovery showed a statistically significant difference in favor of higher NSS by the Cox proportional hazard regression analysis (NSS 0 vs. NSS 5-6, 7-8, and 9-10; P < 0.01). The regression model indicated that the statistical significance of the subjective NSS covering the differential NS is not different from that of the conventional three-grade scales, while it has a higher R(2). The regression equation with subjective NSS was as follows: Log (Time) = 5.163 - (0.035 × SHIM Score) + 0.028 Age - (0.101 × Subjective NSS). CONCLUSION The subjective NSS can reflect NS degree for each side based on the visual cues. Regression model can be used to help inform the patient about the time to postoperative potency regain, which is an important patient concern following RARP.

Handling difficult anastomosis. Tips and tricks in obese patients and narrow pelvis

Vesico-urethral anastomosis (VUA) is a technically challenging step in robotic-assisted laparoscopic prostatectomy (RALP) in obese individuals. We describe technical modifications to facilitate VUA encountered in obese individuals and in patients with a narrow pelvis. A Pubmed literature search was performed between 2000 and 2012 to review all articles related to RALP, obesity and VUA for evaluation of technique, complications and outcomes of VUA in obese individuals. In addition to the technical modifications described in the literature, we describe our own experience to encounter the technical challenges induced by obesity and narrow pelvis. In obese patients, technical modifications like use of air seal trocar technology, steep Trendlenburg positioning, bariatric trocars, alterations in trocar placement, barbed suture and use of modified posterior reconstruction facilitate VUA in robotic-assisted radical prostatectomy. The dexterity of the robot and the technical modifications help to perform the VUA in challenging patients with lesser difficulty. The experience of the surgeon is a critical factor in outcomes in these technically challenging patients, and obese individuals are best avoided during the initial phase of the learning curve.

Proposal of a method to assess and report the extent of residual neurovascular tissue present in radical prostatectomy specimens

To propose a method to assess and report the amount of neurovascular tissue present in radical prostatectomy (RP) specimens.