Travis Rogers

Safety of Live Robotic Surgery: Results from a Single Institution

BACKGROUND Live surgery events (LSEs) have become one of the most attended activities at surgical meetings and provide a unique opportunity for the audience to observe the decision-making process used by skilled and experienced surgeons in real time. However, there is an ongoing discussion on whether patients treated during LSE are at higher risk of complications. OBJECTIVE To examine LSE outcomes for robot-assisted radical prostatectomy (RARP) and establish patient safety and efficacy. DESIGN, SETTING, AND PARTICIPANTS From January 2008 to April 2016, >9000 patients underwent RARP at our institution, performed by a single surgeon. From this group, 36 patients underwent live RARP surgery (LS group) transmitted via video link from our institution to an external congress. A control group was obtained from our database to compare outcomes between the LS group and patients undergoing RARP under regular circumstances. The data were prospectively collected in a customized database and retrospectively analyzed. INTERVENTION All patients underwent RARP performed by a single surgeon at our institution. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Postoperative outcomes were compared between the LS (n=36) and the control (n=108) groups using Students t test and analysis of variance for continuous variables, and a two-tailed Fishers exact test for categorical variables. Statistical significance was set at p<0.05. RESULTS AND LIMITATIONS There were no significant differences in baseline characteristics (age, body mass index, comorbidities, preoperative Gleason score, Sexual Health Inventory for Men score and American Urological Association symptom score) between the groups. The median console time was shorter for the LS group (73min, interquartile range [IQR] 70-79) than for the control group (78min, IQR 75-87; p=0.0371). No major complications were reported in either group, and only four minor complications were observed in the control group (p=0.2415). After median follow-up of 31 mo (IQR 18-50), only one patient (2.77%) in the LS group experienced biochemical recurrence, compared to four (3.71%) in the control group (p=0.7927). There was no significant difference in continence rates between the LS and control groups (97.22% vs 93.52%; p=0.7768). No differences in potency rate were evident by the end of the follow-up period (LS 69.44%, control group 70.37%; p=0.8432). The retrospective nature, the lack of randomization, and the single-institution experience are limitations of the study. CONCLUSIONS In this series of live transmitted RARPs, perioperative results (oncological and functional outcomes and complications) were similar to those found in daily practice. After careful patient selection, LSEs are safe with minimal patient morbidity in the hands of an experienced surgeon working with a familiar surgical team. Further evaluation of the results from other surgeons at other centers is necessary. PATIENT SUMMARY We investigated the safety of surgeries broadcast live from our institution. We found that outcomes were similar to those for patients undergoing surgery under regular circumstances in terms of the rate of complications and oncological and functional outcomes. We conclude that live transmitted surgery is safe in well-selected patients in the hands of an experienced surgeon.

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.

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].

Robotic Assisted Radical Prostatectomy

Radical prostatectomy is one of the gold standard treatments for clinically localized prostate cancer. Since introduced in 2001 robotic assistance has significantly changed the surgical management of clinically localized prostate cancer. Within a decade, robot assisted laparoscopic radical prostatectomy (RALP) is being utilized worldwide. In the USA, more than 80 % of radical prostatectomies are performed with robot assistance [1]. Several technical modifications evolved with the principle of achieving trifecta. Our group introduced the concept of pentafecta with key components of local tumor control with negative surgical margins, less perioperative morbidity while preserving continence and sexual function [2].