8 Surgical outcome of robot-assisted radical prostatectomy after a training program in a high-volume robotic centre

posters / european urology supplements 10 (2011) 531–556

6 The impact of body mass index on surgical, oncologic and functional outcomes of patients undergoing robotic-assisted radical prostatectomy V. Zugor1 , A.P. Labanaris1 , J.H. Witt1 . 1 Department of Urology and Pediatric Urology – Prostate Center Northwest, St. Antonius Medical Center, Gronau, Germany Introduction and Objectives: Patients with a high body mass index (BMI) undergoing robot-assisted laparoscopic radical prostatectomy (RALP) can pose increased challenges even to experienced RALP operators. The objective of this study is to assess the impact of BMI on surgical, oncologic and functional outcomes in patients undergoing RALP. Material and Methods: The records of N = 2,000 men who underwent RALP at a certified robotic institute from February 2006 to April 2010 were retrospectively reviewed. The patients were categorized into 3 groups (normal, overweight and obese) according to their BMI (18.5 to 24.9, 25–29.9 and >29.9). A comparison was performed among these patient cohorts. The parameters analyzed included: age, body-mass index (BMI), prostate size, PSA values, bilateral neurovascular bundle (NVB) preservation, Gleason score, pathologic stage, positive surgical margins, percentage of prostate cancer (PCa) found in the prostate specimen, estimated blood loss, minor (Clavien’s grade I–IIIa) and major complications (Clavien’s grade IIIb-IVa), skinto-skin operative time, continence (defined as no pad use) and potency (defined as erections sufficient for penetration with or without phosphodiesterase inhibitors) in 12 months. Results: The clinicopathological characteristics of the patients are listed in the Table. A statistical difference of the parameters analyzed was only observed in operative time (p < 0.05). Interestingly, obese patients exhibited a slight but insignificant tendency for a positive surgical margin status (p = 0.18). There was no significant difference regarding functional outcomes. At 12 months, 92.1%/91.9%/90.6% were continent and 66.8%/ 67.1%/65.9% of preoperative potent patients who underwent NVB preservation were potent. Conclusions: Although the operative time of patients undergoing RALP is affected by BMI, the surgical, oncologic and functional outcomes remain unaffected. Interestingly, in this study, obese patients exhibited a slight but insignificant tendency for a positive surgical margin status. Parameters

Normal

Overweight

Obese

Patients Age (median)

N = 488 (24.4%) 64 y 23.1 kg/m2

N = 1,173 (58.7%) 64 y 26.7 kg/m2

N = 339 (16.9%) 63 y 32.8 kg/m2

53.9 g 10.1% 66.1%

54.2 g 10.3 ng/ml 65.3%

55.7 g 10.9 ng/ml 65.2%

39.1% 50.1% 10.8%

42.5% 47.4% 10.1%

39.2% 50.2% 10.6%

74.7% 25.3% 15.2% 8.7% 138 ml 140 min 11.9% 1.3%

73.7% 26.3% 15.8% 7.9% 157 ml 152 min 10.9% 1.2%

71.5% 28.5% 17.9% 13.5% 179 ml 169 min 12.5% 1.4%

BMI (median) Prostate size (median) PSA (median) NVB preservation Gleason score <7 =7 >7 Stage Confined disease Extraprostatic extension % of tumor in specimen Positive margins Blood loss (median) Operative time (median) Minor complications Major complications

7 Secondary partial rupture of the vesicourethral anastomosis following robotic prostatectomy. Diagnosis, therapy and functional outcomes V. Zugor1 , A.P. Labanaris1 , A. Abdulhak1 , J.H. Witt1 . 1 Department of Urology and Pediatric Urology – Prostate Center Northwest, St. Antonius Medical Center, Gronau, Germany Introduction and Objectives: Secondary partial rupture of the vesicourethral anastomosis (SPROVA) following robot-assisted laparoscopic radical prostatectomy (RALP) is a rare complication that requires immediate diagnosis and management. The

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objective of this study is to demonstrate our experience with this rare complication focusing on its diagnosis, therapy as well as functional outcomes in such patients. Material and Methods: The records of N = 2,000 men who underwent RALP from February 2006 to April 2010 were retrospectively reviewed. A total of N = 10 patients (0.5%) were identified as having SPROVA after RALP. Prior to primary catheter removal all patients had undergone a cystogram which was none pathologic in all cases. The parameters analyzed included: symptoms, laboratory findings, radiological examinations, age, body-mass index (BMI), prostate weight, PSA values, bilateral neurovascular bundle (NVB) preservation, intraoperative complications, bladder neck reconstruction, length of catheterisation, continence (defined as no pad use), potency (defined as erections sufficient for penetration with or without phosphodiesterase inhibitors) and presence of biochemical progression. Results: All symptoms of the patients involved in this series were noted the first day after catheter removal. N = 4 patients (40%) exhibited peritonitis-like symptoms, with an increase of creatinine levels (2.15 mg/dl), CRP levels (198.7 mg/l) and leukocytosis (median 14.2 Th/cu). N = 4 patients (40%) exhibited lower abdomen discomfort with an increase only of CRP levels (226.2 mg/l) and N = 2 patients (20%) exhibited urinary retention without any pathological laboratory findings. A new catheter was inserted in the bladder of all patients and a new cystogram was performed exhibiting the presence of a SPROVA. After a median of 2.5 days all patients were asymptomatic and after a median of 8.8 days all laboratory findings were non pathologic. The median patient age was 65.1 years (51–74), median BMI 26.1 kg/m2 (21–28 kg/m2 ) and median prostate weight 94 gr. (35–204 g). The median PSA value was 12.7 ng/ml (1.5–48 ng/ml) and bilateral NVB preservation was performed in N = 6 patients (60). No intraoperative complications were evident. A bladder neck reconstruction was performed in N = 3 patients (30%), the median length of catheterization prior to the SPROVA was 5 days and after its diagnosis was 9.9 days (7–31). After a median follow up of 21.6 months (36–10), N = 9 (90%) were continent (0 Pads/d), N = 1 (10%) had mild incontinence (1–2 Pads/d) and N = 5 from the N = 6 patients who underwent bilateral NVB preservation were potent (83.3%). Conclusions: Peritonitis-like symptoms, lower abdomen discomfort, urinary retention and pathological laboratory findings, especially increased CRP levels, following catheter removal are strong indications for the presence of SPROVA in patients following RALP. A conservative approach seems to solve this life threatening condition without compromising the long term functional results in these patients. 8 Surgical outcome of robot-assisted radical prostatectomy after a training program in a high-volume robotic centre N. Lumen1 , V. Fonteyne2 , G. De Meerleer2 , G. Villeirs3 , B. De Troyer1 , W. Oosterlinck1 , A. Mottrie4 . 1 Dept. of Urology, Ghent University Hospital, Ghent, Belgium; 2 Dept. of Radiotherapy, Ghent University Hospital, Ghent, Belgium; 3 Dept. of Radiology, Ghent University Hospital, Ghent, Belgium; 4 Dept. of Urology, O.L.V. Clinic, Aalst, Belgium Introduction and Objectives: Robot-assist radical prostatectomy (RARP) is an excellent technique in the treatment of prostate cancer but requires substantial surgical skills. A training program that allows the beginning robot-surgeon to obtain these skills can overcome the problem of a learning curve. This report aims to evaluate the usefulness of such a training program in the early experience of a young urologist. Material and Methods: Before starting RARP, a young urologist followed a 6-month training program at a high-volume robotic centre. During the first 2 months, he was trained in the basic

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posters / european urology supplements 10 (2011) 531–556

principles of robotic surgery: patient’s positioning, trocar placement, installing of the robot and assisting at the table. Thereafter, he was allowed to take place after the robot console and began the procedure under strict supervision. Only when he was able to perform a surgical step in a sufficient manner, he was allowed to continue with the next step in the procedure. During this period, he had also the possibility to train his surgical skills on a robot console in a dry lab on surgical models. After this fellowship program, he started to perform RARP himself. The surgical outcome of the first 35 RARPs (August 2009–April 2011) are evaluated and compared with a cohort of 35 open radical prostatectomies performed by senior urologists familiar with this procedure in the same centre during the same period. Surgical outcome included operation time (skin-to-skin), blood loss (decline of haemoglobin level on the first postoperative day), duration of hospital stay, duration of catheterisation period, complications and positive surgical margin rate. Details on tumour and patient’s characteristics and operative technique are shown in Table 1. Table 1. Tumor and patient characteristics and operation details

Tumor characteristics Stage (n) T1–T2 T3 Grade (n) Gleason < 7 Gleason = 7 Gleason > 7 Operation details Lymph node dissection (n) Nerve sparing (n) no unilateral bilateral Patient characteristics PSA (ng/ml), mean±SD Age (years), mean±SD Prostate volume (ml), mean±SD Follow-up (months), mean±SD

Robot

Open

p-value

25 10

24 11

1

17 14 4

7 20 8

0.04

19

25

0.22

5 18 12

13 10 12

0.054

9.4±5.3 63.2±5.9 39.9±16.2 7.1±5.4

11.4±7.3 60.8±7 39.3±16.1 13±8.8

0.18 0.13 0.88 0.0012

Table 2. Surgical outcome Outcome

Robot

Open, mean±SD

p-value

Operation time (min), mean±SD Decline Hb (g/dl), mean±SD Hospital stay (days), mean±SD Catheter duration (days), mean±SD Overall complications (n) Complications requiring surgical intervention (n) Positive surgical margin (n)

221±54 2.21±1.09 6.9±2.2 8.1±4.3 4 1

203±50 3.65±1.28 7.4±3.2 14.7±5.9 8 4

0.16 <0.0001 0.39 <0.0001 0.34 0.35

1

12

0.0021

Results (Table 2): The two groups only differed significantly in tumor grade (more aggressive tumours in the open group) and follow-up duration (longer in the open group). The operation time and hospital stay was similar. Catheterisation duration was significantly shorter in the robot group. The blood loss was significantly more in the open group. There were 4 complications in the robot group: one pelvic hematoma compressing the ureters with postrenal insufficiency as a consequence requiring laparoscopic drainage. The 3 other complications were lymphocele requiring prolonged maintenance of the drain, early urinary retention requiring re-insertion of the urinary catheter and postoperative fever. In the open group, 8 complications were observed. There was one peroperative rectal injury which was closed primarily. Three patients developed an anastomotic stricture and were treated with internal urethrotomy. One patient developed a recto-urethral fistula which needed surgical revision with contemporary colostomy. Other complications were early urinary retention in 2 patients requiring re-insertion of the urinary catheter and lymphoedema in one patient. Only one patient had a positive surgical margin in the robot group versus 12 patients in the open group (p = 0.0021).

Conclusions: These data (non-matched cases) indicate that a well balanced training program in a high volume robotic centre can overcome the problem of the learning curve. RARP was associated with significantly less positive surgical margins, shorter catheterisation duration and less blood loss compared to open radical prostatectomy. 9 Intra- and postoperative serum creatinine kinase and position damages in patients undergoing robot assisted radical prostatectomy during and after the learning curve G.B. Di Pierro1 , V. Rafeld2 , H. Danuser2 , A. Mattei2 . 1 Department of Urology, ‘Sapienza’ University, Rome, Italy; 2 Klinik f¨ ur Urologie, Luzerner Kantonsspital, Luzern, Switzerland Introduction and Objective: During robot assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND) patients are in extreme Trendelenburg position. This might cause position damages. Serum creatinine kinase is the most sensitive parameter signalizing rhabdomyolysis. We investigated the serum creatinine kinase concentration ([CK]) before and after RARP and PLND as indicator of position damages in and after the learning curve. Furthermore, we investigated the relation between serum-[CK] as well as position damages and surgical experience. Methods: The first 120 consecutive pts after introducing RARP at our institution were enrolled: Group 1 included the first 60 pts (considered as learning curve) and Group 2 the following 60 pts. We compared operative time, length of Trendelenburg position, intra-, pre- and post-operative serum-[CK], serum creatinine, position damages and hospital stay. Position damages were defined in 3 degrees (Degree I: red skin disappearing by investigators finger pressure, spontaneous healing within 3 days; Degree II: red skin not disappearing by investigators finger pressure, healing within 10 days under local therapies; Degree III: evident skin lesion, healing within 3 months under local and systemic therapies.) Table 1. Patient characteristics Age, yr, median (IQR*) PSA level, ng/ml, median (IQR*) D’Amico risk group Low Intermediate High BMI, median (IQR*) ASA score 1 2 3 Tumor stage, n. (%) ≤pT2 pT3 pT4 Lymph node status pN+, n. (%)

Group 1 n = 60

Group 2 n = 60

p value

63 (58–66) 8.21 (5.61–11.50)

65 (61–68) 7.95 (6.04–13.00)

0.1539 0.4221 0.6682

9 (15%) 40 (67%) 11 (18%) 26.3 (24.8–26.5)

4 (7%) 41 (68%) 15 (25%) 26.1 (24.1–29.1)

13 (22%) 44 (73%) 3 (5%)

9 (15%) 47 (78%) 4 (7%)

53 (88%) 6 (10%) 1 (2%)

43 (71%) 15 (25%) 2 (4%)

7 (12)

7 (12)

0.9614 0.3464

<0.05

-

*IQR = Interquartile range.

Table 2. Intra- and post-operative data

Operative time (min), median (range) Trendelenburg time (min), median (range) Position damages, n. (%) Degree I II III Serum [CK] values (IU), median (range) Time preoperatively 6 h post-op 18 h post-op Hospitalization time, days (range)

Group 1 n = 60

Group 2 n = 60

p value

315 (290–475) 280 (170–470)

240 (150–465) 220 (140–440)

<0.05 <0.05

16 (76%) 2 (10%) 3 (14%)

18 (86%) 3 (4%) 0 (0%)

0.6374

81.5 (39–437) 613 (95–18,229) 880 (186–19,513) 7 (4–20)

50 (29–172) 318 (61–2,646) 527 (61–5,889) 7 (5–12)

0.1160 <0.05 <0.05 0.6782

Results: The two groups were comparable for all preoperative parameters (Table 1). Operative and Trendelenburg time as well as postoperative serum-[CK] were significantly lower for pts of Group 2 (Table 2). Position damages Degree I and II were equally present in both groups. In Group 2 there was no position damage Degree III. No patient even with high serum [CK] developed renal failure. Serum-[CK] elevation was