AUA 2017: Panel Discussion: 'The Uber Prostatectomist: Why Did You Do That and What Can You Prove?' 

Boston, MA ( A panel of expert prostatectomist were task to discuss the most important topics associated with procedure and future directions to improve the surgery. The session is started by Dr. Menon who discussed the results of the CONSORT trial. The trial is a randomized controlled trial which looked to assess key differences between the standard robotic prostatectomy approach (VIP) and the emerging Retzious sparing posterior approach. The trial randomized a total of 120 patients with intermediate risk prostate cancer. The patients where closely followed in regards to continence, potency and biochemical recurrence rates. Patients undergoing the posterior approach regain continence much faster than the standard group, but the difference in continence rates disappeared at 3 months. There was no difference is potency or biochemical recurrence rates. Margin rates where not reported in the presentation but Dr. Menon states that the difference was not statistically significant. Complication rates were equal in both groups but there is a higher risk of ureteral injury with the posterior approach due to the proximity of the dissection to the distal ureter.

Dr. Wiklund followed presenting the results of the LAPRO study. The LAPRO study is a prospective trial which assess the functional and oncological outcomes 4000 patients who underwent prostatectomy via a robotic or open approach. All surgeons included in the study were required to have performed at least 100 cases in order to enroll patients. Of the 4000 patients, 3000 underwent a robotic procedure and 1000 an open prostatectomy. Patient reported data was collected before and at 3, 12 and 24 months after surgery. A standardized documentation was required for all procedures.

There was no difference in overall continence rates between the two procedures. When assessing continence rates by specific surgeon, open surgeons had the best continence rates of the group. On retrospective evaluation of the surgical technique this select group of surgeons were performing aggressive urethral sparing procedures which likely contributed to their improved continence rates. When the patients were stratified by D’Amico risk group open surgeons were able to achieve better continence rates, likely to due to more aggressive apical dissection that was aided by tactile feedback. Likewise there was no overall difference in potency rates between the two procedures. Potency rates within individual surgeons were more widely distributed than continence rates, which is suspected to be due to greater variability in nerve sparing technique and layer dissection. As with continence rates, high risk patients had better potency rates following an open procedure.

In regards to oncological outcomes there was no difference in biochemical recurrence rates between the two groups. The overall margin rate was also equivalent but marked differences were noted when patients were stratified by risk group. Margin rates were higher in patients with low risk prostate cancer undergoing a robotic procedure likely due to an aggressive nerve sparing technique. Interestingly, the opposite was seen in high risk patients, with a higher margin rate observed in open cases. The likely reason behind this phenomenon is the overconfidence of the open surgeon to perform a closer apical dissection compared to robotic surgeons who lack tactile feedback.

Dr. Costello presented is view on the state of RARP by discussing the history of prostatectomy. Early prostatectomists followed the Halstedian view of cancer treatment by performing wide local excision without specific regard to functional outcomes. In the PSA era, however, curative treatment for prostate cancer (PC) is expected, and therefore quality of life outcomes have become paramount. For example, in 1977, radical prostatectomy required a 3-week hospital stay, had major blood loss, and expected near total incontinence and ED. Compare that to today’s expectations! Dr. Costello’s view is that contemporary robotic surgery incorporates better anatomical insights and improved standardization, all of which has led to improved continence and potency.

There are some known factors that optimize continence such as age, radiation, pelvic floor training, center volume, and meticulous apical dissection. A wide host of other surgical manipulations and thoughts exist that purport to also improve functional outcomes; but Dr. Costello poignantly calls out the reality that there is no evidence behind most of those manipulations. For example, it is unclear if nerve sparing actually leads to improved continence. Likewise, seminal vesical tip sparing has an unclear anatomic basis for working and newer evidence shows it doesn’t make any difference in functional outcome.

He presented a compelling view that meticulous apical dissection is paramount to continence preservation. We now have an improved understanding of urethral striated sphincter anatomy. This rhabdosphincter can easily be damaged during apical dissection and sphincter fibers should be recognized and separated from the apex/urethra early. Innervation of the rhabdosphincter comes from the pudendal nerve and should enter separately, but branches can still be injured as they enter the rhabdosphincter if the surgeon dissects too distally.

In conclusion, surgical technique at the apex appears to be one of the central factors to optimizing continence. He presented data that supports this hypothesis. Realistically, the adoption of robotic assistance has allowed for the feedback and insight needed to disseminate these improved techniques and reduce surgeon variability, which continues to be one of the most predictive factors affecting postoperative functional outcomes.

Presenters: John Davis, MD; Mani Menon, MD; Peter Wiklund, MD; Anthony Costello

Written By: Shreyas Joshi, M.D. & Andres Correa, Fox Chase Cancer Center, Philadelphia, PA
Twitter: @ssjoshimd

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA