"Robotic fatigue?" - The impact of case order on positive surgical margins in robotic-assisted laparoscopic prostatectomy.

Multiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially.

A multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM.

Overall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P= 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR 0.761.231.97, P= 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion.

Case sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients.

Urologic oncology. 2020 Nov 04 [Epub ahead of print]

Laura Bukavina, Kirtishri Mishra, Amr Mahran, Austin Fernstrum, Al Ray, Sarah Markt, Fredrick Schumacher, Britt Conroy, Robert Abouassaly, Gregory MacLennan, Garrett Smith, Elizabeth Ferry, Daniel Wong, Yair Lotan, Hemant Chaparala, David Sharp, Kareem Alazem, Alireza Moinzadeh, Brittany Adamic, Gregory Zagaja, Puneet Kang, Holly Lawry, Benjamin Lee, Adam Calaway, Lee Ponsky

Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH., Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH., Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH., Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH; Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH., Cleveland Clinic Foundation, Lerner College of Medicine, Cleveland, OH; Louis Stokes Cleveland VA Medical Center, Cleveland, OH., Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH., Department of Urology, State University of New York (SUNY) Upstate Medical University, Syracuse, NY., Department of Urology, University of Texas Southwestern Medical Center (UTSW), Dallas, TX., Ohio State University Wexner Medical Center, Columbus, OH., Lahey Hospital and Medical Center, Urology Institute, Burlington, MA., Department of Urology, University of Chicago, Chicago, IL., Northeast Ohio Medical University (NEOMED), Rootstown, OH., Department of Urology, University of Arizona College of Medicine, Tucson, AZ., Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH. Electronic address: .