WCE 2019: Society of Urologic Robotic Surgeons - Prostate and Bladder Update

Abu Dhabi, United Arab Emirates (UAE) (UroToday.com) The topic of Part II of the Society of Urologic Robotic Surgeons (SURS) was prostate and bladder surgery. Dr. Ali Abdel-Raheem opened the session by discussing robotic radical prostatectomy tips for good functional outcomes. He overviewed preservation techniques and their effects on continence and potency. Preserving the neurovascular bundle is important in this matter. There is landmark vasculature, such as the landmark artery on the lateral border of the prostate (“prostatic or capsular artery”) and veins on the lateral aspect of the prostate. General principles of preservation are cautery-free dissection, pinpointed low-energy cauterization (<30 W), no neurovascular bundle counter-traction, sharp dissection, and negative surgical margins. The Veil of Aphrodite technique of high anterior release and lateral prostatic fascia preservation had promising results in the Vattikuti Institute’s report of their experience.

Dr. Ashutosh Tewari discussed controversies in intermediate-risk prostate cancer. The D’Amico risk category, assessing the 5-year risk of treatment failure based on clinical factors was used until the International Society of Urological Pathology (ISUP) modifier in 2005, which incorporated the Gleason grading system. This risk stratification could be improved. Patients with 4+3 Gleason prostate cancer were followed to develop a model to predict adverse pathology by using radiogenomics, radiomics, MRI-based imagaing, and pathology genomics. He discussed a novel marker determining a “reactive stroma score” that has shown promise.

New developments in robotic radical cystectomy were discussed by Dr. Khurshid Guru. Trends in the past 10 years show that open radical cystectomy is becoming less common in favor of robotic radical cystectomy. He described nerve-sparing techniques in radical cystectomy, including dissecting underneath the prostate to go intrafascial to peel off the layers, similar to concepts that gave rise to the Veil of Aphrodite technique for prostatectomy.

Several presentations discussed single-port surgery, an emerging technique in robotic and laparoscopy surgery. Dr. Abdel Karim described laparoendoscopic single-site surgery (LESS) studies which have shown decreased analgesic requirements in patients undergoing this type of procedure. Their studies also concluded that there is a learning curve of at least 30 cases of LESS before outcomes are similar to that of multiple port surgery. This may be problematic as he reported that surgeons that conduct this procedure perform about 1-5 per year. A competitor of LESS is mini laparoscopy, however, this technique is limited by strength and durability of the instruments, and a reduced field of vision. A prospective randomized control trial found LESS to be superior to mini laparoscopy in analgesic requirements.

On a related note, Dr. Jihad Kaouk discussed single-port robotic prostatectomy. The technology for this procedure was initially very limited in range of motion, but has undergone recent improvements. At his institution, patients are discharged the same day after this procedure very often. This technique is being performed perineally, which is similar to an open prostatectomy but with shorter incisions. The patient is positioned in Trendelenburg, and an incision is made wide enough to insert the port, gas bubble, and tamponade the veins for a bloodless field.

Overall, the session focused on new robotic techniques regarding radical prostatectomy and radical cystectomy, with a heavy emphasis on the potential of single port laparoscopic and robotic surgery.

Presented by: Ali Abdel-Raheem, MD, PhD1, Aashok Hemal, MD2, Ashutosh Tewari, MD3, Khurshid Guru, MD4, Aly Abdel-Karim, MD, MS, PhD5, Jihad Kaouk, MD6, Michael Stifelman, MD7, Daniel Eun, MD8, Craig Rogers, MD9

  1. King Saud Medical City Urology Department
  2. Wake Forest Baptist Health
  3. Icahn School of Medicine at Mount Sinai
  4. Roswell Park Comprehensive Cancer Center
  5. Alexandria University
  6. Cleveland Clinic
  7. Hackensack Meridian Department of Urology
  8. Temple University
  9. Henry Ford Hospital
Written by: Rajiv Karani, Department of Urology, University of California, Irvine, Medical Writer for UroToday.com at the 37th World Congress of Endourology (WCE) – October 29th-November 2nd, Abu Dhabi, United Arab Emirates