Oncology Prostate Cancer
surgery time was significantly shorter with the extraperitoneal compared with the intraperitoneal approach (three hours and 34 minutes versus 4 hours and 1 minute; p=0.017). This was because of the shorter time interval between the skin incision and opening of the endopelvic fascia in the extraperitoneal versus the intraperitoneal approach (55 minutes versus 74 minutes; p
In the second
report, the outcomes from 40 consecutive patients who underwent extraperitoneal RALP were compared with those of 40 consecutive patients who underwent transperitoneal RALP performed by the same team. This study confirmed the previous results, with a longer median operative time for the transperitoneal approach. The complication and PSM rates were similar in both groups.34
These two
reports confirmed that the extraperitoneal approach was feasible with RALP, but that surgeon preference is likely to play a significant role in the approach used.34
Costs
The system itself costs around US$1.5million to install. Without taking into account capital depreciation and the cost of the robot, each RP carries a real excess cost of around US$1,300 owing to the use of disposable instruments. The number of hospitals carrying out RALP worldwide is steadily increasing. In the US, RALP accounts for 70% of all RP cases. In Europe, the use of robots has remained limited until recent years.35
1. 2.
Jemal A, Siegel R, Ward E et al., Cancer statistics, 2006, CA Cancer J Clin, 2006:56:106–30.
Hankey BF, Feuer EJ, Clegg LX, et al., Cancer surveillance series: interpreting trends in prostate cancer—part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates, J Natl Cancer Inst, 1999:91:1017–24.
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Heidenreich A, Aus G, Bolla M, et al., European Association of Urology, EAU guidelines on prostate cancer, Eur Urol, 2008;53(1):68–80.
Schuessler WW, Schulam PG, Clayman RV, et al., Laparoscopic radical prostatectomy: initial short-term experience, Urology, 1997;50:854–7.
5. Guillonneau B, Vallancien G, Laparoscopic radical prostatectomy: the Montsouris experience, J Urol, 2000;163:418–22.
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Abbou CC, Salomon L, Hoznek A, et al., Laparoscopic radical prostatectomy: preliminary results, Urology, 2000;55(5):630–34.
Rassweiler J, Sentker L, Seemann O, et al., Laparoscopic radical prostatectomy with the Heilbronn technique. An analysis of the first 180 cases, J Urol, 2001;166:2101–8.
Eden CG, Cahill D, Vass JA, et al., Laparoscopic radical prostatectomy: the initial UK series, BJU Int, 2002;90: 876–82.
9. Binder J, Kramer W, Robotically-assisted laparoscopic radical prostatectomy, BJU Int, 2001;87:408–10.
10. 11.
Joseph JV, Rosenbaum R, Madeb R, et al., Robotic extraperitoneal radical prostatectomy: an alternative approach, J Urol, 2006;175(3 Pt 1):945–50.
Rozet F, Jaffe J, Braud G, et al., A direct comparison of robotic assisted versus pure laparoscopic radical prostatectomy: a single institution experience, J Urol, 2007;178(2):478–82.
12.
Ploussard G, Xylinas E, Salomon L, et al., Robot-assisted extraperitoneal laparoscopic radical prostatectomy: experience in a high-volume laparoscopy reference centre, BJU Int, 2010;105:1155–60.
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Badani KK, Kaul S, Menon M, Evolution of robotic radical prostatectomy: assessment after 2766 procedures, Cancer, 2007;110:1951–8.
Swindle P, Eastham JA, Ohori M, et al., Do margins matter? The prognostic significance of positive surgical
25. 22. 21. 15. 16. Improvements
As operative techniques continue to improve rates of continence and potency, the robotic system is likely to gain in popularity. In addition, the system itself continues to be updated, with the latest ‘Si system’ including high-definition screens. The loss of tactile feedback remains an issue, and novel engineering approaches are being tested to try to resolve this issue.
This was performed via a single umbilical incision, with all instruments used passing through the single site. This illustrates the shift in surgery over recent years to provide a procedure with optimal oncological and functional outcomes, with a similar cosmetic result to minor surgery.
Conclusion
The lack of randomised trials with this new technology makes assessment difficult. However, there is clear evidence from retrospective studies that extraperitoneal RALP can achieve excellent oncological and functional outcomes. The future of robotic surgery for prostate cancer is exciting and there are likely to be many advances made, including improved outcomes for patients with locally advanced disease. n
margins in radical prostatectomy specimens, J Urol, 2005;174(3):903–7.
Patel VR, Thaly R, Shah K, Robotic radical prostatectomy: outcomes of 500 cases, BJU Int, 2007;99:1109–12.
Madeb R, Golijanin D, Knopf J, et al., Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy, JSLS, 2007;11(3):315–20.
17.
Xylinas E, Ploussard G, Paul A, et al., Intrafascial nerve- sparing laparoscopic robot-assisted extraperitoneal radical prostatectomy: early oncological and functional results, J Endourol, 2010;24(4):577–82.
18. 19.
Tewari A, Jhaveri J, Rao S, et al., Total reconstruction of the vesico-urethral junction, BJU Int, 2008;101:871–7.
Rocco F, Carmignani L, Acquati P, et al., Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy, J Urol, 2006;175:2201–6.
20.
Rocco B, Gregori A, Stener S, et al., Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy, Eur Urol, 2007;51:996–1003.
Coughlin G, Dangle PP, Patil NN, et al., Surgery Illustrated – focus on details. Modified posterior reconstruction of the rhabdosphincter: application to roboticassisted laparoscopic prostatectomy, BJU Int, 2008;102:1482–5.
Patel VR, Coelho RF, Palmer KJ, et al., Periurethral suspension stitch during robotic-assisted laparoscopic radical prostatectomy. Description of the technique and continence outcomes, Eur Urol, 2009;56:472–8.
23.
Menon M, Muhletaler F, Campos M, et al., Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial, J Urol, 2008;180:1018–23.
24.
Ploussard G, Xylinas E, Paul A, et al., Does robotic assistance increased operating room time compared to pure retroperitoneal laparoscopic radical prostatectomy?, J Endourol, 2009;23(6):939–43.
Vickers AJ, Savage CJ, Hruza M, et al., The surgical learning curve for laparoscopic radical prostatectomy: a
29. 30. 31. 32. 27. retrospective cohort study, Lancet Oncol, 2009;10:475–80. 26.
Menon M, Shrivastava A, Tewari A, et al., Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes, J Urol, 2002;168(3):945–9.
Ahlering TE, Skarecky D, Lee D, et al., Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy, J Urol, 2003;170: 1738–41.
28.
Artibani W, Fracalanza S, Cavalleri S, et al., Learning curve and preliminary experience with da Vinci-assisted laparoscopic radical prostatectomy, Urol Int, 2008;80: 237–44.
Menon M, Tewari A, Peabody J, Vattikuti Institute prostatectomy: technique, J Urol, 2003;169:2289–92.
Zorn KC, Orvieto MA, Gong EM, et al., Robotic radical prostatectomy learning curve of a fellowship-trained laparoscopic surgeon, J Endourol, 2007;21:441–7.
Mikhail AA, Orvieto MA, Billatos ES, et al., Robotic- assisted laparoscopic prostatectomy: first 100 patients with one year of follow-up, Urology, 2006;68:1275–9.
Kaul SA, Peabody JO, Shah N, et al., Establishing a robotic prostatectomy programme: the impact of mentoring using a structured approach, BJU Int, 2006;97:1143–4.
33. 34.
Madi R, Daignault S, Wood DP, Extraperitoneal v intraperitoneal robotic prostatectomy: analysis of operative outcomes, J Endourol, 2007;21(12):1553–7.
Atug F, Castle EP, Woods M, et al., Transperitoneal versus extraperitoneal robotic-assisted radical prostatectomy: is one better than the other?, Urology, 2006;68(5):1077–81.
35. 36. 37.
Burgess SV, Atug F, Castle EP, et al., Cost analysis of radical retropubic, perineal, and robotic prostatectomy, J Endourol, 2006;20(10):827–30.
Kaouk JH, Goel RK, Haber GP, et al., Single-port laparoscopic radical prostatectomy, Urology, 2008;72(6): 1190–93.
Barret E, Sanchez-Salas R, Kasraeian A, et al., A transition to laparoendoscopic single-site surgery (LESS) radical prostatectomy: human cadaver experimental and initial clinical experience, J Endourol, 2009;23(1):135–40.
The robotic system has recently been used in conjunction with laparo-endoscopic single-site surgery to perform RP in several institutions.36,37
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