Robotic radical prostatectomy shows good oncologic, functional outcomes

Berlin—Robot-assisted laparoscopic radical prostatectomy provides very promising functional and oncologic results, and may very well be the future in minimally invasive techniques in the treatment of localized prostate cancer, according to Belgian researchers who reported their study findings at the European Association of Urology annual congress here.

Peter Van Migem, MD, of the department of urology at Onze-Lieve-Vrouw Hospital in Aalst, Belgium, and colleagues conducted a retrospective study on 184 patients who had clinically organ-confined prostate cancer (≤cT2c disease), performing a radical prostatectomy using the robot-assisted laparoscopic technique. The mean follow-up of all patients in the study was 6.8 months.

The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) with three arms was used in the series. One of the benefits of this system is that it offers more natural handling as well as a 3D view, according to Dr. Van Migem.

"In our study, special attention was given to perform a meticulous interfascial nerve-sparing procedure, when indicated, as well as to perform a complete circular dissection of the periurethral tissue before the dissection of the urethra. This was important, as it may reduce the rate of the positive surgical margins and gain urethral length. Also, when making the vesicourethral anastomosis, we used a running suture with a Monocryl 2-0, according to the technique of Van Velthoven," he said.

Low positive margin rate
Despite the relatively modest size of the series and short follow-up time of 6.8 months, the initial oncologic results are excellent and very promising, Dr. Van Migem reported. Results show an overall positive surgical margin rate of 15.7% (29 of 184 patients) and a 2.8% margin rate in patients wtith pT2 tumors.

In terms of functional outcomes, 95% of patients were completely continent or wore one safety liner, and the potency rate was as high as 84%. Continence was defined as the use of no pad or only a safety pad for occasional loss of drops of urine.

Dr. Van Migem said that because of the robot technique used, the anastomosis was made easier and better, making an early catheter removal possible, approximately 6 days post-procedure. No major postoperative complications were seen.

"We noticed that the time to full continence seemed to be shorter in the bilateral nerve-sparing group, which is difficult to explain. In the group that had the bilateral nerve-sparing procedure, almost 50% were continent in the first 4 weeks post-procedure. This was different from the non-nerve-sparing group, where almost 40% needed over 3 months to become completely continent," Dr. Van Migem said.

Dr. Van Migem noted that Alex Mottrie, MD, the study's first author, had conducted approximately 75 classic laparoscopic radical prostatectomies before starting on the robotic method. EAU session co-moderator Richard Gaston, MD, asked whether Dr. Mottrie still uses conventional laparoscopy or if he only uses robotic surgery to perform radical prostatectomy and other urologic procedures.

"Currently, we perform all radical nephrectomies via classic laparoscopy," Dr. Van Migem explained. "Pyeloplasties are also done laparoscopically via a transperitoneal or retroperitoneal approach. We have done laparoscopic cystectomies and cysto-prostatectomies for a long time now, but we are now moving on to the robotic surgery more and more. It also seems that the pyeloplasties are going in that direction, as well. I think that once you start using the robotic technique, you will very quickly become comfortable with this technique."

Robot-assisted radical prostatectomy is the next step in the evolution of minimally invasive techniques in the treatment of prostate cancer, according to Dr. Van Migem. He admitted that it may be a bit early to draw hard conclusions from this relatively short-term study and that a longer follow-up of the data and larger, prospective studies are needed.