WCE 2018: Lessons Learned from Open to Laparoscopic to Robotic-Assisted Surgery

Paris, France (UroToday.com) Ali Riza Kural, MD gave a summary regarding the changes in the approach to prostate cancer throughout the years, from diagnosis to treatment. In the past, nearly all patients diagnosed with low risk prostate cancer were offered treatment (radiation or surgery) and were ideal candidates for nerve-sparing radical prostatectomy (RP). Thanks to a series of publications with long-term follow-up evaluating the role of active surveillance, many patients with low risk prostate cancer are now able to avoid radical treatments that are associated with morbidity and a decrease in their quality of life. Patients with intermediate and high risk prostate cancer are still offered radical treatment. However, whereas these patients were once treated mostly with radiation and hormonal therapy, it is now common to initiate therapy with surgery, complemented with multimodal therapy, if necessary. Moreover, in recent years, highly selected patients with oligometastatic disease are treated with RP as well. This would have been considered a complete contraindication to surgery only a few years ago and well illustrates the shift in the urologists’ approach to prostate cancer.

The diagnosis of prostate cancer has been also revolutionized. The state of the art multi-parametric MRI is now considered an essential tool in both diagnoses of prostate cancer and surgical planning. From a finger-guided biopsy through a transrectal ultrasound-guided biopsy, US-MRI fusion biopsy is now considered the most accurate method of diagnosing prostate cancer. This technique not only detects more clinically significant cancers in the setting of first or repeat biopsy, but it also lowers the detection rate of indolent cancers. Precision medicine has recently emerged in prostate cancer and is gradually being used by urologists. Molecular and genetic tests allow for better selection of patients to either active surveillance, repeat biopsy, radical treatment, or adjuvant therapy.

RP was introduced in 1904 by Hugh Hampton Young, using the perineal approach. Four decades later, Terrence Millin developed the retropubic approach. RP , however, was not frequently performed, mainly due to bleeding and adverse effects (erectile dysfunction up to 100%, severe incontinence in 25%). In an attempt to decrease procedure-related morbidity, Patrick Walsh described in 1974 the surgical anatomy of the prostate. This consisted of selective ligation of the dorsal venous complex, description of the pelvic plexus and cavernosal nerves, and the different fascial layers of the pelvis. The introduction of robotic assisted-laparoscopic radical prostatectomy (RALRP) initiated a debate as to whether the minimally invasive procedure is superior to open surgery. Although level I evidence backed by large-scale randomized trial is still lacking, it is generally accepted that RALRP results in lower blood loss, shorter hospitalization, and less anastomotic strictures. The advantages of RALRP are mainly due to 3D magnified view and instruments with a wide range of motion. Dr. Kural’s conclusion of this debate is that it is the surgeon who makes a difference, not the instruments.

Presented by: Ali Riza Kural, MD, Professor,  Urology Department of Acibadem Maslak Hospital, Istanbul, Turkey

Written by Dr. Shlomi Tapiero, medical writer for UroToday.com at the 36th World Congress of Endourology (WCE) and SWL - September 20-23, 2018 Paris, France