V O L U M E 6 8 . N. 5 . O T T O B R E 2 0 1 3 MINERVA CHIR 2013;68:499-512 Robot assisted laparoscopic prostatectomy in 2013 A. ALI, D. P. NGUYEN, A. TEWARI Robot assisted laparoscopic prostatectomy has surpassed open radical prostatectomy as the most common surgical approach for radical prostatectomy in the United States. In this article we briefly describe the evolution of this minimally invasive technique. The current diagnostic approaches of multiparametric magnetic resonance imaging and fusion biopsy used in preoperative workup of the patients are discussed, followed by a description of risk stratified athermal nerve sparing approach with total anatomical reconstruction. Finally we present a critical appraisal of the published oncological, continence and potency outcomes. Key words: Prostatectomy - Robotics - Prostatic neoplasms. P rostate cancer (PC) is the most common non-cutaneous malignancy among men in Western countries. An estimated 30,000 will die of the disease in the United States and 70,000 in Europe in 2013.1, 2 Widespread use of prostate specific antigen (PSA) as a biomarker for prediction of PC has led to a dramatic shift towards early detection of organ-confined disease in a younger patient population.3, 4 For those patients with clinically organ-confined disease, radical prostatectomy (RP) remains a commonly used Corresponding author: Dr. A. Tewari, MD, M. Ch, Center for Prostate Cancer, Weill Cornell Medical College and New York Presbyterian Hospital, Lefrak Center of Robotic Surgery, NYPH, Weill Cornell Medical College, New York Presbyterian Hospital, 525 East 68th Street, Starr 900, New York, NY 10021, USA. E-mail: [email protected] Vol. 68 - No. 5 Center for Prostate Cancer Lefrak Center of Robotic Surgery Department of Urology Weill Cornell Medical College New York Presbyterian Hospital New York, NY, USA treatment modality, and may be the preferred option based on individual patient’s cancer risk, age and comorbidities.5 It offers excellent cancer control with disease specific survival rates of 93% to 95% after 15 years of follow-up.6 Early on RP was not considered the firstline of localized PC management due to the dreaded complications of incontinence and erectile dysfunction. A better understanding of the pelvic anatomy as well as important advances in surgical technique over a century after the first radical perineal prostatectomy was performed by Young in 1904 7 have led to its current widespread acceptance. The retropubic approach for RP which allowed access to pelvic lymph nodes for tumor staging was described by Millin in 1947.8 Later, anatomical studies in 1980’s led to the development of modified radical retropubic prostatectomy which integrated better understanding of DVC(Dorsal Venous Complex),9 neurovascular bundles (NVBs) 10 and urinary sphincter.11 The incorporation of these new anatomical findings to surgical tech- MINERVA CHIRURGICA 499 ALI ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 nique decreased intraoperative blood loss, preserved potency and decreased urinary incontinence.12, 13 The first laparoscopic RP was performed in 1991 by Schuessler.14 Over the next decade, advancement in optics, digital imaging and software led to further refinement of laparoscopic technique.15, 16 The next major advancement was with the development of da Vinci Surgical system (Intuitive Surgical®, Mountain View, California). The first robot assisted laparoscopic prostatectomy (RALP) using this robotic interface was performed in May 2000 by Binder and Kramer.17 The first generation da Vinci ® Surgical system had three robotic arms, two for instruments and one for endoscope. Using this masterslave surgical system, surgeons were able to view the surgical field three dimensionally in 10X magnification using stereo-endoscope lens and camera. Moreover, surgical instrument tips had a 360° range of movement. In the United States, RALP was pioneered and established as treatment for patients with PC at Vattikuti Urology Institute.18, 19 By 2008, more than 60% of radical prostatectomies in the USA were RALP.20 We herein review the current surgical management of PC with emphasis on RALP. We offer a detailed description of our RALP technique including individualized NS and the addition of dynamic detrusor cuff trigonoplasty. Finally, complications, outcomes and economics of RALP are discussed. Indications for RALP A complete medical history and physical examination including DRE along with serum PSA are done as part of PC screening. In case of an elevated serum PSA level, a transrectal ultrasound (TRUS) guided prostate needle biopsy can be done to exclude or confirm PC. Indications for RALP are identical to those for open RP and include patients with biopsy proven, clinically localized PC without clinical or radiographic evidence of metastasis who have consented to the procedure. Patients with severe cardiopulmonary disease unable to tolerate gen- 500 eral anesthesia and those with uncorrected bleeding diatheses are not candidates for RALP Preoperative workup: current approaches Two MRI-based imaging techniques are used in our institution in order to optimize surgical planning and tune the procedure to each individual patient’s unique requirement based on preoperative disease characteristics. Targeted fusion biopsy In place of standard TRUS guided biopsy fusion biopsy may be done. Three techniques of fusion have been described: Cognitive fusion, In-Bore MRI-MRI Fusion and MRI-TRUS Fusion. Cognitive fusion simply requires the TRUS operator to target areas where previously reviewed MRI demonstrated significant lesions. This technique however quick and easy is subject to human error. In-Bore MRI-MRI fusion is performed within the MRI tube. It fuses a previous MRI with a synchronous MRI for biopsy needle localization. This technique requires two MRI sessions and is thus time consuming and more expensive. Finally, MRI-TRUS fusion is done in two steps: first a multiparametric endorectal MRI is done; the studies are then loaded onto a software on which the radiologist marks the prostate gland and the regions of interest for biopsy in different slices and views of the MRI, known as segmentation (Figure 1). This information is then loaded on to a device which then fuses the segmented MRI with real-time ultrasound to create a threedimensional real-time reconstruction of the prostate on which the aiming and tracking of biopsy site is done (Figure 2). This technique can be done in an outpatient setting under local anesthesia within a few minutes. Currently five devices approved by the Food and Drug Administration (FDA) are available for MRI-TRUS fusion biopsy. For instance, the Artemis device (Eigen, Grass MINERVA CHIRURGICA October 2013 ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 ALI A B C D Figure 1.—From top left clockwise. A) Axial T2 weighted 3T MRI with endorectal coil showing two regions of interests (Red high suspicion, Green Low suspicion); B) coronal section interpolated image based on the axial section; C) it shows a 3D rendering of the prostate after segmentation in light brown color, regions of interests in red and green; D) axial diffusion weighted imaging showing the marked regions (Red region of interest has an ADC value of 784). Figure 2.—MRI-TRUS Fusion with planned targets. MRI on the top left quadrant with the planned target. Bottom right quadrant showing 3D view of the region of interest with planned target site. Vol. 68 - No. 5 MINERVA CHIRURGICA 501 ALI ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 Valley, California, USA) has a mechanical arm and is capable of tracking and recording biopsy locations with three dimensional ultrasound and fusion of real-time ultrasound with MRI. An initial study using the Artemis at UCLA in 171 patients who underwent prostate biopsies using the Artemis platform investigated 106 patients under active surveillance for confirmed PC and 65 patients with increasing PSA, prior negative conventional biopsy.21 PC was detected in 53% of all men. MR-TRUS fusion biopsy based targeted cores had higher yield of 21% as compared to 7% for systemic biopsy cores. Moreover, a higher number of Gleason 7 cores (36% vs. 24%) were detected. Multiparametric endorectal MRI The use of MRI for the diagnosis and staging of PC has increased over the past 5 years. The ideal 3T (Tesla) mp-eMRI comprises of T1 and T2 weighted images (T2WI) for demonstrating high signal blood product and demonstrating the anatomy, respectively, as well as functional imaging which includes diffusion weighted (DW) imaging, dynamic contrast enhanced (DCE) imaging and magnetic resonance spectroscopic imaging (MRSI) with the use of pelvic phased-array coil along with an endorectal coil on a high field-strength A magnet. To obtain sub millimeter-resolution which are necessary for local staging, T2 weighted images acquired should have thickness of 3 mm with a 14 cm field of view.22 PC foci commonly demonstrate decreased signal intensity relative to the highsignal intensity normal peripheral zone on T2 weighted images.23 For the detection of PC the sensitivity of MRI ranges from 60 to 96%, but has poor specificity.24 However, to detect EPE or seminal vesicle (SV) invasion the sensitivity and specificity of MRI is 73% to 80% and 97-100% respectively (Figure 3).25 DW-MRI allows the mapping of diffusion of water molecules within tissue. Apparent diffusion coefficient (ADC) is helpful in differentiating between low, intermediate and high risk Gleason scores.26 DW-MRI along with T2 weighted imaging has 89% sensitivity and 91% specificity for detection of PC.27 DCE-MRI assesses the micro vascular changes such as blood flow, density and capillary perfusion for detection of malignant PC lesions. This is done by dynamically running a T1-weighted sequence after intravenous administration of gadolinium chelate. MRSI assess the relative citrate and choline concentrations which are overlaid on T2 images. The addition of these functional scans significantly improves detection of peripheral zone lesions when compared to T2WI alone.28, 29 Barentsz et al. described a standardized interpretation and reporting guidelines for B C Figure 3.—3T MP-MRI and histopathology of a patient with extra prostatic extension who received grade 4 nerve sparing and had negative surgical margins. A) T2W axial view showing a hypointense lesion in the left peripheral zone marked by arrows; B) corresponding DWI ADC map showing restricted diffusion with an ADC value of 435 marked by red outline; C) Corresponding T2W coronal view showing the same lesion marked by arrows in the left peripheral zoneextending from apex to base. 502 MINERVA CHIRURGICA October 2013 ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 mp-eMRI known as PI-RADS(Prostate Imaging Reporting and Data System) which could lead to broader and more reliable adoption of mp-eMRI.30 At our institution 3T mp-eMRI findings are used to improve surgical management and optimize the functional outcomes in individual patients based on their own unique disease and anatomical characteristics. The information retrieved from 3T mpeMRI helps in making informed decisions during surgery for achieving negative surgical margins and preserving periprostatic tissue and nerves which control continence and sexual functions.31 RALP: Surgical technique Positioning Once the patient has been put under general anesthesia, he is placed in steep trendelenburg position with arms tucked and padded on the side and legs securely abducted on a split leg table. The stomach and bladder are decompressed by placement of orogastric tube and urethral catheter under aseptic precautions. Port placement A pneumoperitoneum is created by insufflation using a Veress needle inserted infraumbilically. Once adequate insufflation is done, a 12 mm trocar is placed supraumbilically or at umbilicus for the placement of stereoscopic-endoscope. A total of five trocars, three for robotic arms and two for assistants are placed. Two 8mm pararectal trocars are placed on the right and left side for second and third robotic arms. Another 8 mm trocar is placed in the left lumbar region for the second and third robotic arms. Additionally, two trocars of 12 mm and 5 mm for assistant ports are placed on the patient’s right side. Once the placement of trocars is done, the da Vinci robot is moved into position between the patient’s legs and the arms of the robot are brought above the patient and docked. Vol. 68 - No. 5 ALI Surgical procedure The transperitoneal anterior approach for RALP is as here described. Dropping the bladder Once intra-abdominal access is gained a careful inspection is carried out, urachus and medial umbilical ligaments are identified and adhesions are lysed if present. A wide inverted U-shaped incision is made starting lateral to the left medial umbilical ligament and extending anteromedially dividing the urachus in the midline to the right medial umbilical ligament using monopolar cautery. This U-shaped incision is then extended bilaterally to the vas deferens (VD). The retropubic space is then developed by blunt dissection within the space of Retzius. This exposes pubis, endopelvic fascia, bladder, puboprostatic ligaments and prostate. Athermal dissection is then carried out within the periprostatic space between the endopelvic fascia and lateral prostatic fascia (LPF). During development of the retropubic space and incision of the endopelvic fascia, we proceed distally and medially. Meticulous dissection is performed to minimize disruption of the puboprostatic ligaments and arcus tendineus until the urethra is exposed and there is a clear space for the placement of the dorsal venous stitch. The arcus tendineus and puboprostatic ligaments are used later in the anterior reconstruction. Bladder neck dissection Using a 30° downward angle lens for visualization, the prostate is held on either side using blunt robotic instruments and pulled proximally until there is a sudden feeling of “giving way” at the junction with collapsed bladder. This technique enables relatively easy identification of the prostatovesical junction (PVJ) and this techniques is known as “bimanual bladder neck pinch”.32 Once the PVJ is identified, the bladder neck is incised in the midline using Maryland bipolar MINERVA CHIRURGICA 503 ALI ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 forceps and hot shears. Dissection is carried out until the Foley catheter is identified, the tip is identified and the catheter is grasped by the left-side assistant with firm anterior traction. The dissection then proceeds laterally. With traction on the shaft of the catheter, the exact location for the posterior incision becomes visible and the mucosa of the posterior bladder neck is now incised precisely. After dissection through the mucosa, the retrotrigonal fibromuscular layer is identified.33 Dissection then proceeds athermally to preserve the neural hammock surrounding the prostate and the trigonal nerves until the shiny white surface of the VD is seen. Athermal dissection of SV and VD The SV and VD are identified and dissected athermally, the ends are clipped and cut. The cut ends are then lifted by the fourth arm of the robot to develop a plane between the SV and the surrounding fascia, arteries entering into the SV are identified. These are cut using clips and sharp dissection. Every attempt is made to preserve the NVB which are present lateral to the SV. Both the SV and VD are then pulled upward. In patients who are appropriate candidates for nerve sparing, an intracompartmental SV dissection is performed.34 Risk stratified grades of NS Nerve sparing has been found to be independently associated with post-operative recovery of erectile function.35 Different variations of NS technique have been described in the literature. Use of cautery-free NS which significantly improved return of sexual function was reported by Ahlering et al.36 The “Veil of Aphrodite” technique in which dissection of the prostatic fasica is carried to the prostatic surface, and periprostatic tissue is released in a relatively avascular plane was described by Menon et al.37 A clipless antegrade nerve sparing technique was described by Chien et al.38 Our risk stratified approach to athermal, traction free NS during RALP is based on the patient’s preoperative findings which pre- 504 dict ipsilateral EPE. This preoperative decision making model incorporates serum PSA level, clinical stage, biopsy Gleason score and MRI findings and strives to achieve the competing goals of cancer clearance and preservation of continence and potency by varying degress of preservation of the nerve fibers in different fascial planes (Figure 4).31 These degrees of preservation are described as follows: —— Grade 1 NS: The Denonvilliers’ fascia and the LPF are incised just outside the prostatic capsule to preserve the neural hammock. We also describe this as medial venous plane for complete hammock preservation. This is the greatest degree of NS possible, and we perform this procedure for patients with no-to-minimal risk of EPE. —— Grade 2 NS: The Denonvilliers’ fascia (leaving deeper layers on the rectum) and LPF are incised just outside the layer of veins of the prostate capsule. This allows the preservation of most large neural trunks and ganglia and is used for patients at low risk of EPE. —— Grade 3 NS (partial/incremental): Incision is made through the outer compartment of the LPF (leaving some yellow adipose and neural tissue on the specimen), excising all layers of Denonvilliers’ fascia. This is performed for patients with moderate risk of EPE because some of the medial trunks are sacrificed, whereas the lateral trunks are preserved. Figure 4.—Risk stratification algorithm for nerve sparing. PSA levels in nanograms per milliliter. Risk grade 1: All criteria should be met; Risk grade 2-4 any two criteria or magnetic resonance imaging findings. If MRI findings are not available, only clinical criteria are used. EPE: extra prostatic extension; eMRI: endorectal magnetic resonance imaging; PSA: prostate specific antigen. MINERVA CHIRURGICA October 2013 ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 —— Grade 4 NS (non-NS): These patients have high risk of EPE and are not candidates for NS. In such cases, we perform a wide excision of the LPF and Denonvilliers’ fascia containing most of the peri-prostatic neurovascular tissue. In selected patients, we attempt nerve advancement of the identifiable ends of the NVB. These planes are developed athermally by sharp and blunt dissection, proceeding distally toward the apex and laterally on both sides. At the lateral attachments, the perforating arteries enter into the prostatic capsule. They are sharply cut after being secured by clips and the plane is created between the capsule and the medial aspect of the pedicular vessels.39-41 Circumapical dissection of the urethra As the prostatic apex is a frequent site of positive surgical margin (PSM), extra care has to be taken during apical dissection. Once the prostate is mobilized, it is lifted anteriorly and a plane is developed along the posterior surface of the prostate. At this time the a few layers of Denonvillers fascia and the rectourethralis muscle covers the posterior prostatic apex. Once the prostate is lifted anteriorly, blunt dissection is carried out to develop a distinct plane between the prostatic apex and the urethra. To gain an A ALI additional 1-2 mm of ventral membranous urethral length prior to transection of the urethra posteriorly, it is swept away from the apex. Once transected the foley catheter is seen and then the transection of the urethra is completed circumferentially via the retroapical approach.42 The DVC is ligated using CT-1 needle and 0-polyglactin suture. Once the prostate is free, lymph node dissection is done and the specimen is bagged (Figure 5). Dynamic detrusor cuff trigonoplasty The anterior bladder is held using the 4th arm of the robot and the bladder opening, mucosa and uretric orifices are identified. The posterior extent of the bladder opening is closed using a “tennis racquet” stich with a 4-0 Biosin suture. The mucosa is then everted using the same suture and the posterior gap is covered using a flap of detrusor muscle and approximated in the midline using a 3-0 V-Lock suture to support the bladder neck creating a detrusor cuff. This posterior reinforcement is based on the principles of Pagano (Figure 6).43 Posterior reconstruction Using a few shallow bites from the posterior aspect of the Denonviller’s fascia, the B Figure 5.—Circum-apical dissection. A) Shows the posterior aspect of the prostate gland and a good length of membranous urethra is clearly visible; C) Shows the Foley catheter tip being pulled from the transected urethra posteriorly. P: prostate; U: membranous urethra Vol. 68 - No. 5 MINERVA CHIRURGICA 505 ALI ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 A B Figure 6.—Dynamic detrusor cuff trigonoplasty. A) The posterior flap of detrusor is clearly seen. A running suture is passed to approximate the flaps medially; B) the posterior detrusor flap is approximated using a running suture cuffing the bladder neck. suture is then passed through the retrotrigonal layer and cinched down. The shallow bites are taken to avoid injury to the underlying nervous tissue. Anastomosis and anterior repair Using a V-lock suture, a two layer anastomosis is completed by synchronized pull and push technique to cinche the retrotrigonal layer close to rectourethralis.44 A secure water tight anastomosis is created by mucosa-mucosal, tension-free approximation and avoidance of neurovascular bundles. The previously preserved arcus tendinius are sutured to the detrusor muscle using a single-knotted suture for the anterior reconstruction.45 This helps in positioning and stabilizing the vesico-urethral junction. Supra pubic catheter placement The bladder is filled with 180mL of water and a suprapubic catheter is then inserted into. The placement of a supra pubic catheter helps in elevation of the bladder to its normal preoperative position and also serves as a urinary diversion route in cases which a catheter is not used.46 Finally, reperitonization is done to restore preoperative anatomy (Figure 7). 506 Postoperative management A suprapubic catheter, bulb drain, and occasionally a Foley catheter are left in place. Parentral narcotics are used for postoperative pain management. Early ambulation is encouraged to prevent deep venous thrombosis. The patient is started on a clear liquid diet and advanced as tolerated. Once the patient has been taught catheter care, is ambulatory and tolerating oral pain medication, he is discharged. Patient returns one week after surgery for catheter removal. Patients then begin Kegel exercises. Complications Perioperative complication rate after RALP ranged from 2.5 to 26% of all cases and include was follows.47 Hemorrhage Most studies show that for laparoscopic RP and RALP blood loss is about 50-200 mL during the procedure and blood transfusion rates of 2% or less have been reported.48 This limited blood loss is due to the tamponade effect of the pneumoperitoneum and possibly due to improved visualization. MINERVA CHIRURGICA October 2013 ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 A ALI B Figure 7.—Suprapubic catheter placement. A) Supra pubic catheter is inserted through the anterior abdominal wall and the bladder is held in position for receiving the supra pubic catheter; B) Supra pubic catheter inserted into the bladder. A: anterior abdominal wall; PB: pubic bone; SPC: suprapubic catheter; B: bladder. Excessive bleeding is most often due to injury to the DVC. Rarely the superior epigastric artery can be injured during trocar insertion. During the procedure increasing the pneumoperitoneum pressure can help in controlling minor bleeding. Rectal injury Intraoperative rectal injury occurs in 0.7% to 2.4% cases undergoing RALP and can be usually managed successfully without open conversion.49, 50 Large prostates, inflammation and scarred tissue between the anterior rectal wall and the Denonvillier’s fascia are the major causes of rectal injuries. These injuries may occur during dissection of the posterior prostate plane or the SV, and some cases may occur at the prostatic apex when dissecting the neurovascular bundles or during separation of prostatic apex. tion. Large prostates or median lobes and history of prostatitis are known risk factors for ureteral injury.52 Anastomotic stricture The incidence of anastomotic stricture following RALP ranges from less than 2% to 14.0% and depends on the surgical technique.53, 54 Its occurrence depends mainly on the surgical technique and surgeon experience. Other risk factors include patient age, obesity, smoking, diabetes mellitus, hypertension, coronary artery disease, postoperative bleeding and previous history of transurethral resection of the prostate.55 For patients who develop a postoperative anastomotic stricture, the treatment options include transurethral anastomotic dilation or incision and intermittent selfdilation. Ureter injury Outcomes Ureteral injuries occur in lower than 0.5% of all cases. Most of cases are detected postoperatively because of urinary leakage intra- or retroperitoneally.51 Urinary leakage can be easily diagnosed by contrastenhanced computed tomography. Ureteral injuries usually happen during extended lymphadenectomy or bladder neck dissec- Vol. 68 - No. 5 Oncological outcomes Surgical margins In a meta-analysis with data abstracted from 400 original research articles representing 167 184 open RP, 57 303 laparo- MINERVA CHIRURGICA 507 ALI ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 15.60% 16 months 294 Murphy (US), 2009 70 400 19.20% 22 months 395 Shikanov (US), 2009 71 1362 19.50% 24 months 380 Carlucci (US), 2009 72 700 11.90% 12 months 309 1100 10.64% 18 months 404 Patel (US), 2010 73 Sharma (UK), 2011 74 500 24% 12 months 500 Xylinas (F), 2011 75 540 30% 24 months 500 Kim (SK), 2011 76 528 27.10% 12 months 495 Tewari (US), 2013 77 2536 Samadi (US), 2013 78 1436 8.50% >12 months 1335 18% 12 months 1105 Potency rate 294 Defination of potency Krambeck (US), 2009 69 Continence rate, % 1142 Defination of continence 36 months Follow up method - Patients evaluated 2652 FU Menon (US),2007 68 PSM Author Total cases Table I.—Comparative positive surgical margins, continence rates and potency rates reported in various studies following RALP. Self administered, validated Self administered, validated Self administered, validated Self administered, validated Self administered, validated Self administered, validated Self administered, validated Self administered, validated Physicians interview Self administered, validated Self administered, validated No pad or 1 pad/day No pad or security pad No pad or security pad No pad 95.20% ESI 93% 91.9% ESI 70% 91.4% SHIM≥21 62% 80% ESI 69% No pad or security pad No pad 94% ESI 83% 97.90% ESI 96.60% No pad or security pad No leak no pad 91% IIEF-6≥16 75% 88% ESI 63% No pad 95% ESI 84% No pad 98% ESI 92.40% No pad or security pad 93% SHIM≥16 84% PSM: positive surgical margin; FU: follow-up period scopic RP, and 62 389 RALP patients (total: 286 876), RALP was found at least equivalent to open RP or laparoscopic RP in terms of margin rates. The overall PSM rates were 24.2% for open RP patients and 16.2% for RALP patients; pT2 PSM rates were 16.6% for open RP patients and 10.7% for RALP patients; pT3 PSM rates were 42.6% for open RP, 39.7% for laparoscopic RP, and 37.2% for RALP (Table I). Intraoperative real time transrectal ultrasound (US) and surgical loupes are new technical adjuncts that have been recently reported as a dissection guide to reduce margin positivity during RP.56 Biochemical Recurrence The American Urological Association defines BCR as an initial serum PSA value equal to or higher than 0.2 ng/mL followed by a subsequent confirmatory level of PSA 508 of >0.2 ng/mL.57 The European Association of Urology defines it as PSA values >0.2 ng/ mL, confirmed by two consecutive measurements.58 BCR is positively associated with the PSM, tumor stage and Gleason score. PSA elevations developed within the first 2 years following surgery are more often associated with distant recurrences. Masterson et al., in a retrospective review of 357 open RP patients and 669 RALP patients who underwent surgery between 1999 and 2010 were compared for biochemical recurrence-free survival rates according to surgical approach, no differences were seen at 24 or 60 months postoperatively between open RP patients (87% and 71%, respectively) and RALP patients (87% and 73%, respectively)[59]. Similarly, Magheli et al., evaluated 522 patients undergoing RALP with open RP patients; short-term followup yielded BCR rates of 93% for open and 94% for RALP.60 MINERVA CHIRURGICA October 2013 ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 Functional outcomes Urinary continence Urinary incontinence after radical prostatectomy is caused due to damage to the urinary sphincter and alterations in the pelvic floor musculature. Less often, unstable detrusor muscle can induce urgency incontinence; while post-operative anastomotic stricture and/or low- compliance bladder can induce overflow incontinence. Various surgical techniques such as 1) optimizing preservation of urethral rhabdosphincter length, without affecting the positive surgical margin rate;42 2) total reconstruction of the vesico-urethral junction;45 3) preservation of puboprostatic ligaments and arcus tendineus. Incising the puboprostatic ligaments just proximal to the prostate apex, and careful dissection in that plane is used so as to avoid detaching the urethral rhabdosphincter from its anterolateral ligamentous attachments;61 4) periurethral retropubic suspension stitch;62 and 5) nerve sparing 63 are known to improve urinary continence outcomes. Erectile dysfunction Postoperative potency rates ranging from 3.4% to 96.6% have been reported. These rates are largely dependent on the type of nerve sparing done and the surgical technique.64 For patients with postoperative erectile dysfunction, the choices of treatment include phosphodiestrase type 5 inhibitors, intraurethral or intracavernosal vasodilators vacuum erection devices, and penile prosthesis. Economics The increased costs associated with RALP remain a matter of debate. Bolenz et al. reported in an analysis of 262 RALP, 220 laparoscopic RP and 161 open RP that the median direct cost was higher for RALP than for open RP (RALP: $6,52 [interquartile range (IQR): $6,283-$7,369]; open RP: Vol. 68 - No. 5 ALI $4437 [IQR: $3,989–$5,141]; P<0.001).65 The main differences were in surgical supply cost (RALP, $2015; ORP, $185) and operating room (OR) cost (RALP, $2798; ORP, $1611; P<0.001). Lotan et al. found that RRP was the most cost-effective approach with a cost advantage of $487 and $1726 over LP and RALP, respectively.66 This large difference in RRP and RAP costs was due to a cost of $857 per case for robot purchase and maintenance, and the high cost of $1705 for equipment per case. Moreover, introduction of robotics has resulted in 35.3% of the hospitals that owned a robot performing 85% of all RPs, with 9% of very high volume hospitals performing 57% of all RPs.67 Cost benefits which are gained as a result of shorter OR times, less blood loss and need for transfusions, shorter hospital stays, less use of pain medication, and earlier return to work after a shorter convalescence following RALP need to be factored in future studies. Conclusions More than a decade after its introduction RALP has been shown to be a viable option for patients with clinically localized PC. The current literature shows that RALP has overtaken open RP as the primary surgical approach in PC management. Future studies with longer patients’ follow-up will address oncological outcomes such as disease-specific and overall mortality after RALP. Furthermore, open questions regarding the economics of RALP remain. More importantly, the patient’s perspective has to be kept in mind, avoiding hype, portraying realistic outcomes data so as to avoid post procedure dissatisfaction and regret. Riassunto Prostatectomia laparoscopica robotica nel 2013 La prostatectomia laparoscopica robotica ha superato la prostatectomia radicale a cielo aperto quale approccio chirurgico più diffuso per la prostatectomia radicale negli Stati Uniti. Nel presente articolo MINERVA CHIRURGICA 509 ALI ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 descriviamo brevemente l’evoluzione di questa tecnica mininvasiva. Vengono discussi gli attuali approcci diagnostici di imaging a risonanza magnetica multiparametrico e biopsia con fusione utilizzati nell’iter diagnostico preoperatorio del paziente, seguiti da una descrizione dell’approccio atermico di preservazione del nervo con stratificazione del rischio e ricostruzione anatomica totale. Infine, presentiamo una valutazione critica degli esiti pubblicati relativi a oncologia, continenza e potenza. Parole chiave: Prostatectomia - Robotica - Tumori prostatici. References 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. Cancer J Clin 2013;63:11-30. 2. Malvezzi M, Bertuccio P, Levi F, La Vecchia C, Negri E. European cancer mortality predictions for the year 2013. Ann Oncol 2013;24:792-800. 3. Jemal A, Ward E, Thun M. Declining death rates reflect progress against cancer. PLoS One 2010: 5:e9584. 4. Jang TL, Yossepowitch O, Bianco F, Scardino PT. Low risk prostate cancer in men under age 65: the case for definitive treatment. Urol Oncol 2007;25:510. 5. Cooperberg MR, Vickers AJ, Broering JM, Carroll PR. Comparative risk adjusted mortality outcomes after primary surgery, radiotherapy, or androgen deprivation therapy for localized prostate cancer. Cancer 2010;116:5226-34. 6. Bill-Axelson A, Holmberg L, Ruutu M, Garmo H, Stark JR, Busch C et al. Radical prostatectomy versus watchful waiting in early prostate cancer. New Engl J Med 2011;364:1708-17. 7. Young HH. The early diagnosis and radical cure of carcinoma of the prostate: being a study of 40 cases and presentation of a radical operation which was carried out in four cases. Johns Hopkins Hosp Bull 1905;16:315-21. 8. Millin T. Retropubic Urinary Surgery: E. & S. Livingstone; 1947. 9. Reiner WG, Walsh PC. An anatomical approach to the surgical management of the dorsal vein and Santorini’s plexus during radical retropubic surgery. J Urol 1979;121:198 10. Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol 1982;128:492. 11. Oelrich TM, Department of Anatomy MSI, The University of Michigan, Ann Arbor MI 48109. The urethral sphincter muscle in the male. Am J Anatomy 1980;158:229-46. 12. Walsh PC. Radical prostatectomy for localized prostate cancer provides durable cancer control with excellent quality of life: a structured debate. J Urol 2000;163:1802. 13. Nielsen ME, Schaeffer EM, Marschke P, Walsh PC. High anterior release of the levator fascia improves sexual function following open radical retropubic prostatectomy. J Urol 2008;180:2557-64. 14. Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial shortterm experience. Urology 1997;50:854-7. 15. Abbou CC, Salomon L, Hoznek A, Antiphon P, Cicco A, Saint F et al. Laparoscopic radical prostatectomy: preliminary results. Urology 2000;55:630-3. 510 16. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol 2000;163:1643-9. 17. Binder J, Department of Urology and Paediatric Urology UH, Johann‐Wolfgang‐Goethe University, Frankfurt am Main, Germany, Kramer W, Department of Urology and Paediatric Urology UH, Johann‐Wolfgang‐Goethe University, Frankfurt am Main, Germany. Robotically‐assisted laparoscopic radical prostatectomy. BJU Int 2001;87:408-10. 18. Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO et al. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol 2002;168:945-9. 19. Tewari A, Peabody J, Sarle R, Balakrishnan G, Hemal A, Shrivastava A et al. Technique of da vinci robot-assisted anatomic radical prostatectomy. Urology 2002: 60:569-72 20. Trinh QD, Sammon J, Sun M, Ravi P, Ghani KR, Bianchi M et al. Perioperative outcomes of robotassisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol 2012;61:679-85. 21. Sonn GA, Natarajan S, Margolis DJA, MacAiran M, Lieu P, Huang J et al. Targeted biopsy in the detection of prostate cancer using an office based magnetic resonance ultrasound fusion device. The J Urol 2013;189:86-91. 22. Hricak H, White S, Vigneron D, Kurhanewicz J, Kosco A, Levin D et al. Carcinoma of the prostate gland: MR imaging with pelvic phased-array coils versus integrated endorectal--pelvic phased-array coils. Radiology 1994;193:703-9. 23. Schnall MD, Pollack HM. Magnetic resonance imaging of the prostate gland. Urol Radiol 1990: 12:109-14. 24. Kirkham APS, Emberton M, Allen C. How good is MRI at detecting and characterising cancer within the prostate? Eur Urol 2006;50:1163-75. 25. Heijmink SW, Ftterer JJ, Hambrock T, Takahashi S, Scheenen TW, Huisman HJ et al. Prostate Cancer: Body-Array versus Endorectal Coil MR Imaging at 3 T—Comparison of Image Quality, Localization, and Staging Performance1. Radiology 2007;244:184-95. 26. Morgan VA, Riches SF, Thomas K, Vanas N, Parker C, Giles S et al. Diffusion-weighted magnetic resonance imaging for monitoring prostate cancer progression in patients managed by active surveillance. Br J Radiol 2011;84:31-7. 27. Giannarini G, Petralia G, Thoeny HC. Potential and limitations of diffusion-weighted magnetic resonance imaging in kidney, prostate, and bladder cancer including pelvic lymph node staging: a critical analysis of the literature. Eur Urol 2012;61:326-40. 28. Turkbey B, Pinto PA, Mani H, Bernardo M, Pang Y, McKinney Y et al. �� Prostate Cancer: Value of Multiparametric MR Imaging at 3 T for Detection—Histopathologifc Correlation 1. Radiology 2010;255:8999. 29. Turkbey B, Mani H, Shah V, Rastinehad AR, Bernardo M, Pohida T et al. Multiparametric 3T prostate magnetic resonance imaging to detect cancer: histopathological correlation using prostatectomy specimens processed in customized magnetic resonance imaging based molds. J Urol 2011;186:1818-24. 30. Barentsz JO, Richenberg J, Clements R, Choyke P, Verma S, Villeirs G et al. ESUR prostate MR guidelines 2012. Eur Radiol 2012;22:746-57. 31. Tewari AK, Srivastava A, Huang MW, Robinson BD, Shevchuk MM, Durand M et al. Anatomical grades of nerve sparing: a risk stratified approach to neural MINERVA CHIRURGICA October 2013 ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY IN 2013 hammock sparing during robot assisted radical prostatectomy (RARP). BJU Int 2011;108:984-92. 32. Tewari AK, Rao SR. Anatomical foundations and surgical manoeuvres for precise identification of the prostatovesical junction during robotic radical prostatectomy. BJU Int 2006;98:833-7. 33. Tewari A, El Hakim A, Rao S, Raman JD. Identification of the retrotrigonal layer as a key anatomical landmark during robotically assisted radical prostatectomy. BJU Int 2006;98:829-32. 34. Srivastava A, Grover S, Sooriakumaran P, Tan G, Takenaka A, Tewari AK. Neuroanatomic basis for traction-free preservation of the neural hammock during athermal robotic radical prostatectomy. Curr Opin Urol 2011;21:49. 35. Rabbani F, Stapleton AMF, Kattan MW, Wheeler TM, Scardino PT. Factors predicting recovery of erections after radical prostatectomy. J Urol 2000;164:1929-34. 36. Ahlering TE, Skarecky D, Borin J. Impact of cautery versus cautery-free preservation of neurovascular bundles on early return of potency. J Endourol 2006;20:586-9. 37. Menon M, Shrivastava A, Kaul S, Badani KK, Fumo M, Bhandari M et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51:648-58. 38. Chien GW, Mikhail AA, Orvieto MA, Zagaja GP, Sokoloff MH, Brendler CB et al. Modified clipless antegrade nerve preservation in robotic-assisted laparoscopic radical prostatectomy with validated sexual function evaluation. Urology 2005;66:419. 39. Tewari A, Takenaka A, Mtui E, Horninger W, Peschel R, Bartsch G et al. The proximal neurovascular plate and the tri zonal neural architecture around the prostate gland: importance in the athermal robotic technique of nerve sparing prostatectomy. BJU Int 2006;98:314-23. 40. Tewari A, Rao S, Martinez-Salamanca JI, Leung R, Ramanathan R, Mandhani A et al. Cancer control and the preservation of neurovascular tissue: how to meet competing goals during robotic radical prostatectomy. BJU Int 2008;101:1013-8. 41. Tewari A, Tan G, Dorsey P. Optimizing erectogenic outcomes during athermal robotic prostatectomy: a risk-stratified tri-zonal approach. Urol Times Clin Edition 2008;3:s4-12. 42. Tewari AK, Srivastava A, Mudaliar K, Tan GY, Grover S, El Douaihy Y et al. Anatomical �� retro apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy. BJU Int 2010;106:1364-73. 43. Pagano F, Prayer Galetti T, d’Arrigo L, Altavilla G, Gardiman M, Zattoni F. Radical surgery for clinically confined prostate cancer. Ann New York Acad Sci 1996;784:85-92. 44. Tewari AK, Srivastava A, Sooriakumaran P, Slevin A, Grover S, Waldman O et al. Use �� of a novel absorbable barbed plastic surgical suture enables a “selfcinching” technique of vesicourethral anastomosis during robot-assisted prostatectomy and improves anastomotic times. J Endourol 2010;24:1645-50. 45. Tewari A, Jhaveri J, Rao S, Yadav R, Bartsch G, Te A et al. Total reconstruction of the vesico urethral junction. BJU Int 2008;101:871-7. 46. Tewari A, Rao S, Mandhani A. Catheter less robotic radical prostatectomy using a custom made synchronous anastomotic splint and vesical urinary diversion device: report of the initial series and perioperative outcomes. BJU Int 2008;102:1000-4. 47. Sanchez-Salas R, Flamand V, Cathelineau X. Prevent- Vol. 68 - No. 5 ALI ing Complications in Robotic Prostatic Surgery. Eur Urol Suppl 2010;9:388-93. 48. Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M et al. Retropubic, laparoscopic, and robotassisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol 2009;55:1037-63. 49. Guillonneau B, Gupta R, El Fettouh H, Cathelineau X, Baumert H, Vallancien G. Laparoscopic management of rectal injury during laparoscopic radical prostatectomy. J Urol 2003;169:1694-6. 50. Yee DS, Ornstein DK. Repair of rectal injury during robotic-assisted laparoscopic prostatectomy. Urology 2008;72:428-31. 51. Carlsson S, Nilsson AE, Schumacher MC, Jonsson MN, Volz DS, Steineck G et al. �� Surgery-related complications in 1253 robot-assisted and 485 open retropubic radical prostatectomies at the Karolinska University Hospital, Sweden. Urology 2010;75:1092-7. 52. Crisci A, Young MD, Murphy BC, Paulson DF, Dahm P. Ureteral reimplantation for inadvertent ureteral injury during radicalperineal prostatectomy. Urology 2003;62:941. 53. Msezane LP, Reynolds WS, Gofrit ON, Shalhav AL, Zagaja GP, Zorn KC. Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of incidence, risk factors, and impact on urinary function. J Endourol 2008;22:377-84. 54. Buckley JC. Complications after radical prostatectomy: anastomotic stricture and rectourethral fistula. Curr Opin Urol 2011;21:461. 55. Sandhu JS, Gotto GT, Herran LA, Scardino PT, Eastham JA, Rabbani F. Age, obesity, medical comorbidities and surgical technique are predictive of symptomatic anastomotic strictures after contemporary radical prostatectomy. J Urol 2011;185:2148-52. 56. Magera Jr JS, Inman BA, Slezak JM, Bagniewski SM, Sebo TJ, Myers RP. Increased optical magnification from 2.5 to 4.3 with technical modification lowers the positive margin rate in open radical retropubic prostatectomy. J Urol 2008;179:130-5. 57. Greene KL, Albertsen PC, Babaian RJ, Carter HB, Gann PH, Han M et al. Prostate specific antigen best practice statement: 2009 update. J Urol 2009;182:2232. 58. Heidenreich A, Bolla M, Joniau S. EAU guidelines on prostate cancer, 2011 [Internet]. Available at http:// www uroweb org/gls/pdf/08% 20Prostate% 20Cancer_LR% 20March% 2013th [cited 2013, Mar 20]. 59. Masterson TA, Cheng L, Boris RS, Koch MO. Open vs. robotic-assisted radical prostatectomy: A single surgeon and pathologist comparison of pathologic and oncologic outcomes. Urol Oncol Seminars 2012 [Epub ahead of print]. 60. Magheli A, Gonzalgo ML, Su LM, Guzzo TJ, Netto G, Humphreys EB et al. Impact of surgical technique (open vs. laparoscopic vs. robotic assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching. BJU Int 2011;107:1956-62. 61. Tewari AK, Bigelow K, Rao S, Takenaka A, El-Tabi N, Te A et al. Anatomic restoration technique of continence mechanism and preservation of puboprostatic collar: a novel modification to achieve early urinary continence in men undergoing robotic prostatectomy. Urology 2007;69:726-31. 62. Patel VR, Coelho RF, Palmer KJ, Rocco B. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol 2009;56:472-8. 63. Srivastava A, Chopra S, Pham A, Sooriakumaran P, Durand M, Chughtai B et al. Effect of a risk-stratified MINERVA CHIRURGICA 511 This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. 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Rapid communication: early potency outcomes with cautery-free neurovascular bundle preservation with robotic laparoscopic radical prostatectomy. J Endourol 2005;19:715-8. 65. Bolenz C, Gupta A, Hotze T, Ho �� R, Cadeddu JA, Roe�� comparison of robotic, laparohrborn CG et al. Cost scopic, and open radical prostatectomy for prostate cancer. Eur Urol 2010;57:453. 66. Lotan Y, Cadeddu JA, Gettman MT. The new economics of radical prostatectomy: cost comparison of open, laparoscopic and robot assisted techniques. J Urol 2004;172:1431-5. 67. Stitzenberg KB, Wong YN, Nielsen ME, Egleston BL, Uzzo RG. Trends in radical prostatectomy: centralization, robotics, and access to urologic cancer care. Cancer 2012;118:54-62. 68. Menon M, Shrivastava A, Kaul S, Badani KK, Fumo M, Bhandari M et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51:648-57; discussion 57-8. 69. Krambeck AE, DiMarco DS, Rangel LJ, Bergstralh EJ, Myers RP, Blute ML et al. Radical prostatectomy for prostatic adenocarcinoma: a matched comparison of open retropubic and robot assisted techniques. BJU Int 2009;103:448-53. 70. Murphy DG, Kerger M, Crowe H, Peters JS, Costello AJ. Operative details and oncological and functional outcome of robotic-assisted laparoscopic radical prostatectomy: 400 cases with a minimum of 12 months follow-up. Eur Urol 2009;55:1358-67. 71. Shikanov SA, Zorn KC, Zagaja GP, Shalhav AL. Trifecta outcomes after robotic-assisted laparoscopic prostatectomy. Urology 2009;74:619-23. 72. Carlucci JR, Nabizada-Pace F, Samadi DB. Robotassisted laparoscopic radical prostatectomy: technique and outcomes of 700 cases. Int J Biomed Sci 2009;5:201-8. 512 73. Patel VR, Coelho RF, Chauhan S, Orvieto MA, Palmer KJ, Rocco B et al. Continence, potency and oncological outcomes after robotic assisted radical prostatectomy: early trifecta results of a high volume surgeon. BJU Int 2010;106:696-702. 74. Sharma NL, Papadopoulos A, Lee D, McLoughlin J, Vowler SL, Baumert H et al. First 500 cases of robotic assisted laparoscopic radical prostatectomy from a single UK centre: learning curves of two surgeons. BJU Int 2011;108:739-47. 75. Xylinas E, Durand X, Ploussard G, Campeggi A, Allory Y, Vordos D et al. Evaluation of combined oncologic and functional outcomes after roboticassisted laparoscopic extraperitoneal radical prostatectomy: trifecta rate of achieving continence, potency and cancer control. Urol Oncol 2013;31:99103. 76. Kim SC, Song C, Kim W, Kang T, Park J, Jeong IG et al. Factors determining functional outcomes after radical prostatectomy: robot-assisted versus retropubic. Eur Urol 2011;60:413-9. 77. Tewari AK, Ali A, Metgud S, Theckumparampil N, Srivastava A, Khani F et al. Functional outcomes following robotic prostatectomy using athermal, traction free risk-stratified grades of nerve sparing. World J Urol 2013;31:471-80. 78. Lavery HJ, Levinson AW, Brajtbord JS, Samadi DB. Candidacy for active surveillance may be associated with improved functional outcomes after prostatectomy. Urol Oncol 2013;31:187-92. Conflicts of interest.—Dr. Ashutosh Tewari discloses that he is the principal investigator on research grants from Intuitive Surgical, Inc. (Sunnyvale, California, USA) and Boston Scientific Corporation; he is a non-compensated director of Prostate Cancer Institute (Pune, India) and Global Prostate Cancer Research Foundation; he has received research funding from, The LeFrak Family Foundation, Mr. and Mrs. Paul Kanavos, Craig Effron & Company, Charles Evans Foundation and Christian and Heidi Lange Family Foundation. MINERVA CHIRURGICA October 2013