Robotic Surgery in Urology
observed with this new drainage method. The reported urinary continence rates were excellent in both groups; however, no statistically significant difference between urethral catheter and PST was observed. After six to 12 months of follow-up, no greater incidence of anastomotic strictures was seen.92
These results allow the conclusion that a catheter- less RALP using PST is a feasible and valid approach.
PSMs during radical prostatectomy double the risk of cancer recurrence.93
Conventional apical transection after
The highest risk of encountering PSMs is at the prostatic apex. At this location the prostate merges with the urethral sphincter and the urethra itself; therefore, it is very difficult for surgeons to distinguish these structures.94
ligation of the dorsal venous complex often obscures visualisation of the intersection between prostatic apex and membranous urethra leading to PSM, hence several modifications have been described for apical handling. To avoid PSMs, surgeons can cut far from the prostate into the urethra during radical prostatectomy. However, this approach often leads to intrinsic sphincter damage and subsequently to sphincter insufficiency following radical prostatectomy, resulting in delayed continence or worse. Furthermore, it has been shown that urethral length correlates with early return of urinary continence.95 Thus, Tewari et al. recently published a new surgical technique to lower PSMs during robotic radical prostatectomy without compromising urethral length and subsequently urinary continence.94
Two hundred
and nine consecutive patients undergoing RALP by one surgeon underwent a synchronous (posterior and anterior) urethral transection via a retro-apical approach. The apical margin rates of these 209 patients were compared with those of 1,665 previously operated patients, who received conventional urethral dissection. Interestingly, this retro-apical technique of synchronous urethral dissection showed a statistical significantly lower apical PSM rate than the control group (1.4 versus 4.4%; p=0.04).94
The circumferential view of the prostatic
apex and its surrounding tissue not only optimises urethral preservation but also leads to a significant reduction of apical PSMs.
Many data on the efficacy and post-operative outcomes after RALP are currently available and it seems that RALP is a viable option in the treatment of prostate cancer. However, it has to be stated very clearly that there are also several downsides to the new technique. Ficarra et al.89
Complications were classified using the Clavien grading system. The median operative time was 90 minutes (IQR 75–100 minutes), median estimated blood loss was 100ml (IQR 100–150ml) and the conversion rate was 0.08%. Only two procedures converted to standard LRP due to robotic malfunction. Clavien grade I, II, IIIa, IIIb and IVa complications were seen in 2.24, 1.8, 0.08, 0.48 and 0.40% of patients, respectively. No cases of multiple organ dysfunction or death (Clavien grade IVb or V) were reported. It could be demonstrated clearly that the overall complication rates (p=0.0034) and the number of anastomotic leaks (p
In contrast to these promising results, the questionnaire-based study by Schroeck et al.97
investigated the patient satisfaction and regret following open strategy versus RALP. Interestingly, this group of authors found higher levels of dissatisfaction and regret in patients undergoing RALP versus conventional open RRP on multivariate analysis. The corrected satisfaction rates were 440% higher and the regret rates were 302% lower for men who had undergone open RRP compared with RALP. These results could not be explained by differences in quality of life outcomes, as function and bother scores based on Expanded Prostate Cancer Index Composite (EPIC) were almost identical between the two groups. The authors could not see any precise cause for this result; however, they concluded that patients undergoing RALP potentially had unrealistic expectations of the operation.
Despite the current literature with promising data for the efficacy of RALP, no single study could prove its superiority over conventional RRP. Kang et al.98
recently published a systematic review of
recently published a systematic review of the literature comparing the results of RALP, open retropubic radical prostatectomy (RRP) and conventional laparoscopic radical prostatectomy (LRP). This group of authors showed that with regard to perioperative outcome, LRP and RALP were more time-consuming than RRP, especially in the initial steps of the learning process. However, parameters such as blood loss, transfusion rates, catheterisation time, hospitalisation duration and complication rates all favoured LRP/RALP. Furthermore, the authors concluded that regarding urinary continence and potency rates, LRP/RALP and RRP showed similar results. With regard to the oncological outcome, LRP and RALP were associated with PSM rates similar to those of RRP.89
However, it also has to be mentioned that
the authors showed clearly that the current quality of comparative studies was not satisfying. No statistically significant superiority could be determined for any of the three therapy modalities. Functional outcome data seem to be pretty similar whether for RALP, RRP or conventional LRP.
A recently published paper by Coelho and Patel96 presented data on
complication rates in a single surgeon series of 2,500 patients who underwent RALP for the treatment of localised prostate cancer.
EUROPEAN UROLOGICAL REVIEW
publications on RALP. The aim of the study was to assess the quality of the published evidence on RALP to support the major shift seen in the last couple of years from conventional open radical prostatectomy to the robot-assisted approach. Seventy-five original research publications were included in the systematic review. Fifty-five (73.3%) studies were published between 2005 and 2008, and only 20 studies (26.7%) were published between 2001 and 2004. Case series amounted to almost three-quarters (74.7%) of the published literature, and only two randomised controlled trials (2.7%) could be identified. Furthermore, 12 authors co-wrote almost three-quarters (72%; 54 of 75 patients) of the published studies. The conclusion of the group of authors was that the current published RALP literature is limited to observational studies of mostly low methodological quality.98
RALP has undoubtedly changed the urological world, and many data are currently available on its safety and efficacy. However, little has been published regarding the limitations and complications of RALP. Murphy and co-workers99
focused on the principal downsides of
RALP. They concluded the following disadvantages: •
• •
device failure (0.2–0.4% of cases); assessment of functional outcome (urinary continence and potency rates) is unsatisfactory because of non-standardised assessment methods;
if a standardised reporting system on complications is used, high rates are noted;
long-term oncological data and data on high-risk prostate cancer are limited; although acceptable operative times are reported after 80 cases of experience before a plateau is achieved;
75
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