NSAUA 2018: Have the Limits of Robot-Assisted Radical Prostatectomy Been Reached?

Toronto, Ontario (UroToday.com) Jean Joseph, MD gave an overview of robotic radical prostatectomy on all its aspects, including its usage in high-risk disease, costs, and comparison to open procedures. Later on in his talk, he focused on the cutting edge of robotic surgery nowadays, and what type of procedure the robot can be used for today and in the future.  

The first robotic-assisted radical prostatectomy was published in 2001.1 Since then, almost 20 years of technology has evolved, and there have been many developments in the field. It is now possible to perform robotic radical prostatectomy and extended pelvic lymph node dissection in patients with locally advanced prostate cancer, with satisfactory results.2  A recent retrospective study of 94 patients with stage T3 or higher disease was recently published.2 All patients underwent robotic radical prostatectomy with extended pelvic lymph node dissection with extrafascial dissection. The results demonstrated positive surgical margins in 30% of patients and continence rates of 60% at one-year. Approximately 20% received adjuvant radiotherapy, 19% received hormonal therapy, 21 patients had a biochemical recurrence (BCR), and three patients had a complete response. The 3- year BCR free survival was 63%. This study demonstrated that the predictors of BCR included high pathologic stage, higher Gleason score, and the presence of positive surgical margins.2 The authors concluded that in these high-risk patients, robotic radical prostatectomy is safe and effective with 2/3 of the patients being free of recurrence at 3 years.

There is also published data on the costs associated with robotic radical prostatectomy. In a retrospective multicenter study using the Premier database, the authors analyzed 291,015 men who underwent robotic radical prostatectomy between 2003 and 2013 performed by 667 surgeons, in 197 hospitals. In this study, the 90-day direct hospital costs were assessed.3 The mean cost of the procedure was 11,880 USD ranging between 2,837 USD and 25,906 USD. In a high-volume hospital, the costs were usually lower with the highest costs prevalent in northeast and west coast urban areas of the USA.

Data comparing robotic to open prostatectomy has been published as well.4 In a study comparing the outcomes and costs of these two modalities, a total of 629,593 patients were analyzed at 449 hospitals from 2003 and 2013 (from the Premier database). The outcomes assessed included 90-day postoperative complications, blood transfusion rate, operative time, length of hospital stay, and direct hospital costs. This study showed the significant increase of the utilization of robotic procedures over the last decade. From 2008 to 2015, the utilization of the robotic procedure increased from 36.1% to a staggering 86%! The robotic procedure was demonstrated to have a significantly higher 90-day direct hospital costs compared to open surgery. Despite higher costs, there was a significantly lower morbidity rate associated with the robotic procedure, with lower 90-day postoperative complication rate, and lower transfusion rates. This study also showed lower costs of the robotic procedure in high-volume hospitals.

Summarizing the data, Dr. Joseph stated the robotic radical prostatectomy has demonstrated good results on the trifecta outcomes:

  • - Cancer control >90% at one year following surgery
  • - Continence rates > 90% with one pad or less per day reported at one year following surgery
  • - Erectile function reported as 60% of the men managing to have sexual intercourse at one year following surgery.
The postoperative erectile function is the only outcome of the trifecta that needs to improve significantly, according to Dr. Joseph. The reported sexual function following robotic radical prostatectomy varies considerably in different studies and is between 20% and 90%.  Various factors affect this specific outcome, including the level of dissection, patient baseline function, use of phosphodiesterase type 5 inhibitor (PDE5I), and whether the measurement was subjective or objective.5 There have been many potential techniques to try and improve the nerve-sparing performed and the final outcome of the erectile function. These include antegrade vs. retrograde dissection vs. combined approach, using athermal techniques, and minimizing the role of traction.

Next, Dr. Joseph discussed some of the advancements in robotic prostatectomy and what is the cutting edge of this surgery nowadays. He described the great leap forward taken with simulated prostatectomy, using 3d printing and hydrogel injection molding technology. This is enabling full procedural simulation for novice surgeons. This includes various incorporated metrics to measure performance and improve the learning curve of the surgeon.

The next advancement discussed was the usage of the new robot with the single port, which has received the approval of the FDA recently (Figure 1).

UroToday NSAUA2018 Da Vinchi single port robotic system
Figure 1- Da Vinci single port robotic system:

This novel single-port robot uses a single 2.5 cm incision with a large cannula to accommodate all instruments through one single small hole. There have been experimental cadaveric attempts to use this robotic system for perineal radical prostatectomy and even perform pelvic lymph node dissection through the perineum. There have also been experiments to perform a transvesical (through the bladder) prostatectomy. Dr. Joseph also mentioned the ability to perform an extraprostatic simple prostatectomy for benign prostatic hyperplasia, ureteral reimplantation, transvesical partial cystectomy, and all forms of bladder surgery.

In summary, the current and future technological advancements have reset the limits and standards of robotic surgery, and have pushed them far than ever imagined. Therefore, Dr. Joseph concluded his excellent talk with a quote of Albert Einstein: “Once we accept our limits, we go beyond them.”


Presented by: Jean Joseph, MD, MBA, W.W. Scott Professor and Chairman Departement of Urology, Professor of Oncology, University of Rochester 

References: 
1. Binder J, et al. BJU Int 2001
2. Gandaglia G et al. Eur Urol 2017
3. Cole AP et al. J Urol 2016
4. Leow JJ et al. Eur Urol  2016
5. Ficarra V Eur Urol 2007

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, @GoldbergHanan at the 70th Northeastern Section of the American Urological Association (NSAUA) - October 11-13, 2018 - Fairmont Royal York Toronto, ON Canada
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