Robot-assisted Extraperitoneal Laparoscopic Radical Prostatectomy


effect on the recovery of potency, including patient age, type and quality of nerve-sparing and use of medications. Another challenge is that the assessment of post-operative potency is not standardised, including unvalidated questionnaires and open interviews. Reports for RALP included in this review gave the variable mean potency rates reported in Table 3.10,12,16,17


intrafascial procedure, were 60% at three months.17


Comparison with Laparoscopic Radical Prostatectomy


A European institution reported its experience comparing RP using a pure laparoscopic technique versus a RALP technique with regard to pre-operative, intra-operative and post-operative parameters.11 This match-paired study included 133 consecutive patients who underwent extraperitoneal RALP and compared them with 133 patients treated with a pure extraperitoneal LRP approach.


demonstrated that extraperitoneal LRP is equivalent to RALP in the hands of skilled laparoscopic urological surgeons with respect to operative time, operative blood loss, hospital stay, length of bladder catheterisation and PSM rate. The two groups were statistically similar with respect to age, BMI, PSA, Gleason score and clinical stage. No statistical differences were observed in operative time, estimated blood loss, hospital stay or bladder catheterisation between the two groups. The transfusion rate was 3.0 and 9.8% for LRP and RALP, respectively (p=0.03).11


The study11


There is a suggestion that previous experience of laparoscopy might actually result in a longer learning curve for RALP than for those with open RP experience.30


learning curves for RALP, of up to 200 cases.31


Other studies have shown much longer While uncertainty


surrounds the duration of the learning curves for RALP, it is critical that centres starting a programme do so with supervision and structured support.


Conversion from RALP to LRP


was necessary in four cases. None of the LRP cases required conversion to an open technique. The rate of major complications was 6.0 versus 6.8% (p=0.80).11


The overall PSM rate was 15.8 and 19.5% for LRP and RALP, respectively (p=0.43) (see Table 4).11


It has also been demonstrated that operating room occupational times are equivalent during pure retroperitoneal LRP and RLRP. For a trained team performing four procedures per week, the use of the robot for LRP with no lymph-node dissection decreases actual operative time at the expense of an increase in installation time compared with pure laparoscopy.24


Learning Curve


There are no randomised data, but one real benefit of RALP would be a reduction in the oncological learning curve compared with LRP. Case report series suggest that this is the case despite the variation in how learning curves are reported; however, most include operating time, blood loss and PSM rates.


The learning curve for RALP is associated with the use of innovative technology, loss of tactile feedback and an entirely novel surgical view. It has been suggested that there are two learning curves in RALP: first, to perform the procedure safely and with clear margins; and second, to perform nerve-sparing procedures. Menon et al.,26 Ahlering et al.27


and Artibani et al.28


with RALP for experienced open RP surgeons is at least 20 cases, simply to perform the operation safely. The same authors27,29


also


showed that surgeons with previous experience of open RP have similar complication rates after 20 cases of RALP to a laparoscopic surgeon after 100 cases of LRP. These results suggest that the


EUROPEAN UROLOGICAL REVIEW


Learning curves have been reported for open RP, LRP and RALP. A recent review of LRP showed that the benefit of greater surgeon experience in reducing cancer risk continued up to 750 cases, which suggests that the learning curve for LRP is greater than that for open RP.25


Close mentoring by an experienced team is beneficial when starting to perform RALP. Kaul et al.32


reported on a two-person mentoring


team (with experience of over 1,000 RALPs) training the console surgeon and the assistant for five cases after the entire surgical team had undergone one week of intensive training. This was followed by a period of mentoring by an experienced laparoscopic surgeon for a further 40 cases. This approach has led to satisfactory outcomes, and such approaches should be used by centres implementing RALP. The optimal duration of this mentoring period is not clear; Menon was proctored for the first 100 cases that he performed. A structured approach when starting this technique should include mentoring by experienced RALP surgeons for as long as is necessary to pass through the ‘learning curve’ in order to offer patients the best possible oncological and functional outcomes.


A standardised programme for the implementation of RALP has not yet been developed. There has been concern that initial outcomes have not been as good as they should have been because of inadequate mentoring. Ideally, large-volume centres would provide a ‘mentoring team’ for new RALP centres, with an appropriately targeted mentoring period depending on each surgeon’s competence.


Comparison of Transperitoneal and Extraperitoneal Approaches


reported that the learning curve


RALP can be performed via an extra- or intraperitoneal approach. The extraperitoneal approach has similar advantages to extraperitoneal open RP (avoidance of potential bowel injury or complications related to an intraperitoneal urine leak)33 small working space.


but the potential disadvantage of a


Two reports in the current literature have compared the two approaches. In the first, 55 patients underwent a RALP: 21 were performed using an intraperitoneal approach (group 1) and 34 were performed using an extraperitoneal approach (group 2). Median


17


Table 4: Montsouris Experience Comparing Robotic-assisted Laparoscopic Prostatectomy versus Laparoscopic Radical Prostatectomy


RALP The potency rates, according to the


Median operative time (minutes)


Blood loss (ml)


Transfusion rate (%) Complications rate (%)


Positive surgical margins (%)


(n=133) 166


(90–300) 609


(100–3,000) 9.8


19.4 19.5


LRP


(n=133) 160


(90–270) 512


(70–1,800) 3


9.1 15.8 p NS 0.07


0.02 0.01 0.42


LRP = laparoscopic radical prostatectomy; NS = not significant; RALP = robotic-assisted laparoscopic radical prostatectomy.


learning curve for RALP is shorter than that for LRP, at least with regard to complications.


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