Investig Clin Urol.  2020 Jan;61(1):1-10. 10.4111/icu.2020.61.1.1.

Lessons learned from 12,000 robotic radical prostatectomies: Is the journey as important as the outcome?

• Kang SG
• Shim JS
• Onol F
• Bhat KR
• Patel VR

• KMID: 2466786
• DOI: http://doi.org/10.4111/icu.2020.61.1.1

Abstract

Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological outcomes compared to open approaches. Here, we share our experience of 12,000 RARPs by describing the outcomes of the procedure in terms of positive surgical margin (PSM), continence, and potency as well as by presenting our detailed surgical technique with recent modifications. On cancer control, the PSM rates were 5.8% and 26.1% in T2 and T3, respectively. On the premise of not compromising oncologic outcomes, a tailored approach to individual patients is essential. Even if an extracapsular extension is suspected, neurovascular bundle (NVB) tailoring can be applied using an anatomical landmark to preserve maximal nerve tissue with a negative margin. We developed a nomogram as a useful tool for deciding the degree of tailoring. For improvements of functional outcomes, we used athermal retrograde early release with a toggling technique, wherein the nerve dissection from the bottom helps with blood loss and allows for smooth NVB releasing. Additionally, we recently performed a new minimal apical dissection/lateral prostatic fascia preservation technique. As a result, our 1-week continence rate was 37% and the 6-week rate was 77.6%. In addition, the potency rates in our study were 69%, 82%, and 92% at 3 months, 6 months, and 1 year, respectively (preoperative Sexual Health Inventory for Men scores >21 & bilateral full nerve spared).

Keyword

Prostate; Prostatectomy; Prostatic neoplasms; Robotics

MeSH Terms

Fascia
Humans
Male
Nerve Tissue
Nomograms
Prostate
Prostatectomy*
Prostatic Neoplasms
Reproductive Health
Robotics

Figure

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  Fig. 1 Output yielded by the graphical user interface for a 72-year-old patient with T2a clinical stage and a prostate-specific antigen (PSA) level of 3 ng/mL. The left lobe had no positive cores, while the right lobe had three positive cores, all with Gleason score >7. Produced with permission from Vipul R. Patel. ECE, extracapsular extension.

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  Fig. 2 (A) Left. Existing method: a suspension stitch and incised endopelvic fascia were observed. (B) Right. Minimal apical dissection: an intact endopelvic fascia was observed.

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  Fig. 3 Posterior reconstruction (second layer suture). The two-layer reconstruction involved the realignment of the sphincteric muscle to the Denonvillier's fascia, followed by a second suture that fixed the posterior bladder wall to the urethra. Produced with permission from Vipul R. Patel.

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  Fig. 4 Neurovascular bundle (NVB) penetration from the Denonvillier's fascia to the prostatic anterior aspect; the palpating landmark artery on the NVB is clearly observed.

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  Fig. 5 (A) The 30 degrees down view is shown. The left vas deferens is retracted with the fourth arm and the right vas is retracted by the assistant. The dissection plane between the prostate fascia and the neurovascular bundle (NVB) is rarely seen in this view. (B) The 30 degrees up view is shown. In this view, we can easily access the proper plane for interfascial dissection. If the adhesion is not severe, we can see the already penetrated space between the prostatic anterior aspect and Denonvillier's fascia following separation of the NVB.

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  Fig. 6 Neurovascular bundle (NVB) separation. The NVB is completely and easily saved by retrograde early release on the mid-prostate level.

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  Fig. 7 Cross-section of the neurovascular bundle, represented as a histology slide (left) and a diagram (right), demonstrating our graded approach to nervesparing. Several degrees of partial nerve-sparing can be obtained when careful attention is given to the anatomic cues that are discussed. Produced with permission from Sally Shisler. LA, landmark artery.

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