RALP may offer improved margins, ease of transition

Atlanta-Positive surgical margin rates decrease as experience with robot-assisted laparoscopic prostatectomy (RALP) increases. In addition, formal laparoscopic training may not be necessary for optimizing some outcomes with the robotic procedure, according to the findings of two new studies presented here at the AUA annual meeting.

Surgical specimens from 366 patients were evaluated. Specimens were immersed in ink and assessed by histologic evaluation of 5-mm incremental step sections. A positive margin was defined as the presence of any tumor cells that reached the inked margin or that were located at the site of a capsular incision, even if a negative margin was observed on subsequent excision.

"Achieving expertise with RALP re-quires acquisition of a different skill set for surgeons primarily acquainted with open surgical approaches," Dr. Herrell and his colleagues wrote.

They also suggested that early outcomes with RALP produced more positive margins than radical retropubic prostatectomy does, although this was not statistically significant. However, after the initial patient groups, positive margin rates for the robot-assisted procedure were lower than were those for the traditional retropubic procedure.

Dr. Herrell told Urology Times that measures of other outcomes, such as sexual function and continence, are still pending.

"We have not seen an advantage with RALP outcomes in terms of length of stay or reduction in pain, although we have seen a slight advantage in terms of blood loss," he said.

A second study, presented by David P. Wood, Jr, MD, professor of urology at the University of Michigan, Ann Arbor, sought to determine the importance of laparoscopy and oncology training in outcomes with RALP using the daVinci robot.

Dr. Wood and colleagues evaluated the initial experience of three urologists with the robotic procedure. One was a fellowship-trained oncologist with limited laparoscopic experience; another was fellowship-trained in minimally invasive urology, but had limited experience with radical retropubic prostatectomy since residency; and the third urologist had combined fellowship training in oncology and minimally invasive surgery.

Pathologic, intraoperative, and postoperative outcomes from each surgeon's first 10 RALP procedures were compared. Patient characteristics were similar among the three surgeons' cases.

Training makes the difference

The fellowship-trained laparoscopist had a higher median operative time and more blood loss than did both the surgeon with combined training and the oncology-trained urologist for the 10 cases. Operative times were 389 minutes, 266 minutes, and 248 minutes for the laparoscopist, oncologist, and combined-training surgeon, respectively (p<.001); blood loss was 375 mL, 132 mL, and 175 mL, respectively (p=.004). Average length of patient hospital stay was 2 days for the laparoscopist compared with 1 day for each of the other two surgeons.

Conversion to open prostatectomy, positive surgical margins (focal)/extraprostatic extension, and urine leak/bladder neck contracture were comparable among the three surgeons.

"These findings indicate that surgeons who are comfortable performing an open prostatectomy will learn robotic prostatectomy relatively quickly, even if they have rudimentary laparoscopic skills," Dr. Wood told Urology Times.