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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 30  |  Issue : 3  |  Page : 124-130

Can robot-assisted radical prostatectomy improve functional outcomes compared to laparoscopic radical prostatectomy? Experience at a laparoscopic center


1 Department of Urology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
2 Department of Urology, E-Da Hospital; School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
3 Department of Urology, E-Da Hospital; Department of Health and Beauty, Shu-Zen College of Medicine and Management, I-Shou University, Kaohsiung, Taiwan
4 Department of Urology, E-Da Hospital; Department of Chemical Engineering, Institute of Biotechnology, I-Shou University, Kaohsiung, Taiwan

Date of Submission11-Nov-2018
Date of Decision07-Jan-2019
Date of Acceptance14-Jan-2019
Date of Web Publication20-Jun-2019

Correspondence Address:
Victor C Lin
No. 1, Yida Road, Jiaosu, Yanchao, Kaohsiung 82445
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_134_18

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  Abstract 


Purpose: This study compared the perioperative parameters and early functional outcomes between robot-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP) at a urological laparoscopic center. Materials and Methods: Between January 2006 and May 2017, 242 patients underwent endoscopic radical prostatectomy (LRP for 208 cases; RARP for 34 cases). Patients who were followed up > 12 months were included in the study. Propensity score-matched groups of patients who underwent LRP or RARP were created based on age, body mass index, history of diabetes mellitus, history of smoking, preoperative prostate-specific antigen level, clinical T status, risk group classification, American Society of Anesthesiologists score, and whether the nerve-sparing technique was performed. Results: There were no significant differences in the blood transfusion rate, surgical margin status, length of stay, catheterization time, or days to oral intake for both procedures. Although RARP is more time-consuming, it provided significant benefits regarding the yield of dissected lymph nodes (19 vs. 9; P < 0.001) and early urinary continence recovery (i.e., continence rates after 1 month [56.2% vs. 21.9%; P = 0.006] and after 3 months [84.4% vs. 53.1%; P = 0.001]). No difference was observed for early complications, although the RARP group had more late complications. Conclusion: Our experience indicated that RARP could provide less blood loss and faster recovery of urinary continence and yield more dissected lymph nodes compared to LRP. Further studies are needed to determine whether the long-term clinical, functional, and oncological outcomes are superior.

Keywords: Functional outcomes, laparoscopic, radical prostatectomy, robotic


How to cite this article:
Lu CH, Wu CH, Chen YC, Chen CH, Wu RC, Lee YH, Huang CY, Yu TJ, Lin VC. Can robot-assisted radical prostatectomy improve functional outcomes compared to laparoscopic radical prostatectomy? Experience at a laparoscopic center. Urol Sci 2019;30:124-30

How to cite this URL:
Lu CH, Wu CH, Chen YC, Chen CH, Wu RC, Lee YH, Huang CY, Yu TJ, Lin VC. Can robot-assisted radical prostatectomy improve functional outcomes compared to laparoscopic radical prostatectomy? Experience at a laparoscopic center. Urol Sci [serial online] 2019 [cited 2019 Jul 16];30:124-30. Available from: http://www.e-urol-sci.com/text.asp?2019/30/3/124/260780




  Introduction Top


Although prostate cancer is the most common cancer among men, its cancer-specific mortality rate is relatively low compared to that of other aggressive urological malignancies.[1] Therefore, curing the disease is not the only consideration when treating patients with prostate cancer. For example, increased emphasis has been placed on postoperative quality of life based on functional outcomes such as urinary function and sexual function. As such, treatment must aim to preserve the aforementioned functions and minimize treatment-related morbidity. Radical prostatectomy is the gold standard of treatment for prostate cancer, especially localized and select locally advanced cases that can result in life expectancies of >10 years.[2] Recently, increasing proportions of patients have been able to be treated using minimally invasive and robot-assisted techniques. Compared to open and purely laparoscopic approaches, robot-assisted radical prostatectomy (RARP) has been shown to provide better functional outcomes.[3] Herein, the current study aimed to compare the functional outcomes among patients who were treated for prostate cancer using RARP and those who were treated with laparoscopic radical prostatectomy (LRP) at a urological laparoscopic center.


  Materials and Methods Top


This retrospective study evaluated 255 patients who underwent radical prostatectomy (LRP, 217 cases; RARP, 38 cases) at our center between January 2006 and May 2017. Patients were excluded if they had preoperative lymph node metastasis (5 patients who underwent LRP), a follow-up period <12 months (4 patients who underwent RARP), or incomplete data (4 patients who underwent LRP). Therefore, the present study included 242 patients [Figure 1]. The study protocol was approved by an International Review Board and registered (http://www.edah.org.tw/irb/; EMRP-102-093).
Figure 1: Study flow chart. LRP: Laparoscopic radical prostatectomy; RARP: Robot-assisted radical prostatectomy

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The same surgeon and a dedicated surgical team performed both procedures in our series. Most LRP was performed using an extraperitoneal approach with pelvic lymphadenectomy as previously described.[4] RARP was performed using the da Vinci ® Xi Surgical System and the transperitoneal approach (locally advanced cases) or the extraperitoneal approach (localized cases) depending on whether extended or standard node dissection was chosen. Neurovascular bundle preservation was selected based on the tumor location and invasion depth. Pelvic lymph node dissection (PLND) was performed for all patients. During LRP, the urethrovesical anastomosis was fashioned by six to eight interrupted sutures without significant anterior or posterior repair. During RARP, anterior reconstruction with anchoring the dorsal vein complex on the pubic bone and posterior reconstruction of the rhabdosphincter before the vesicourethral anastomosis was performed to achieve earlier continence recovery. During the postoperative period, the Jackson–Pratt drain was removed if there were no suspicious signs of poor anastomosis healing, and patients were discharged on approximately postoperative day 7 after the Foley catheter was removed with or without postoperative cystogram. To encourage urinary continence rehabilitation, all patients received instructions to perform pelvic floor exercises after catheter removal.

Demographic data including the baseline characteristics, intraoperative findings, postoperative results, and pathological characteristics of the patients were collected prospectively and retrospectively. Operative time was defined as the time from the first incision to closure. Postoperative continence was defined as the use of zero or one safety pad per day. Potency was defined as experiencing a morning erection or being able to achieve vaginal penetration with or without phosphodiesterase type 5 inhibitor treatment. Early complications were defined as those occurring within 1 month after surgery, whereas late complications were defined as those occurring after 1 month postoperatively. All complications were classified based on the Clavien–Dindo system, and detailed methods were described according to the study by Cheng et al. in 2014.[5] All patients were followed up on an outpatient basis to monitor continence, potency, and any complications.

To reduce the influence of potential confounding, we performed 1:1 propensity score matching to create matched RARP and LRP groups. The propensity scores were calculated based on age, body mass index, history of diabetes mellitus, history of smoking, preoperative prostate-specific antigen level, clinical T (cT) status, risk group classification, American Society of Anesthesiologists (ASA) score, and whether a nerve-sparing technique was performed. After matching, continuous variables were compared using the independent t-test and categorical variables were compared using the Chi-square test. The Kaplan–Meier method and log-rank test were used to compare continence recovery rates. All analyses were performed using IBM SPSS software (version 22; IBM Corp., Armonk, NY, USA).


  Results Top


Before propensity score matching, the study included 208 patients who underwent LRP and 34 patients who underwent RARP. No significant intergroup differences were observed in terms of age, body mass index, prostate-specific antigen level, risk group, or ASA score. However, significant differences were observed for clinical T stage (P = 0.023) and nerve-sparing technique (P = 0.002). In the LRP group, 26.4% of the patients were treated using a bilateral nerve-sparing technique, and 25.4% of patients were not treated using a nerve-sparing technique. However in the RARP group, 52.9% of the patients were treated using a bilateral nerve-sparing technique. Before matching, 189 patients (93%) in the LRP group and 32 patients (94%) in the RARP group regained continence within 1 year, with mean times to continence of 76 days and 59 days, respectively. Propensity scoring was used to minimize the differences between these two groups, which resulted in 32 matched pairs of patients who underwent LRP or RARP. These groups did not have any significant differences in terms of their demographic, cancer-related, or preoperative characteristics [Table 1].
Table 1: Baseline clinical characteristics of patients

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No significant differences were observed in the blood transfusion rate, length of stay, catheterization time, and days to starting oral intake. Although RARP is more time-consuming, compared to LRP, it resulted in significantly less blood loss (152 mL vs. 240 mL; P = 0.008) and more dissected lymph nodes (19 vs. 9; P < 0.001) [Table 2]. The RARP group had worse postoperative pathological results than the LRP group, with 12 patients (37.5%) in the RARP group had Gleason scores ≥8 (vs. only 4 patients in the LRP group; P = 0.06). Similarly, 18 patients in the RARP group had pathological stage T3–4 compared to only eight patients in the LRP group (P = 0.03) [Table 2]. Early and late complications are listed in [Table 3]. No significant differences were observed in early complications, although the RARP group had more late complications.
Table 2: Perioperative outcomes and pathological results

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Table 3: Early and late complications

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Seven patients in LRP group and nine patients in RARP group received adjuvant hormone therapy. The reasons for these seven patients in LRP group to receive hormone therapy include positive surgical margins in four patients, extracapsular extension in three, and detectable PSA in five patients respectively. For the nine patients in RARP, the reasons include positive surgical margins in two patients, extracapsular extension in six, and detectable PSA in four patients, respectively. The RARP group had a nonsignificantly inferior surgical margin status, but 11 of 13 patients in the RARP group with positive surgical margins had undetectable prostate-specific antigen (PSA) levels without adjuvant hormone therapy. Meantime to PSA nadir was 112 days in LRP group and 95 days in RARP group (P = 0.520).

Eight patients achieved continence within 2 weeks after RARP. The 14-day continence rate was nonsignificantly higher in the RARP group than in the LRP group (25% vs. 15.6%), and the RARP group had significantly higher continence rates after 1 month (56.2% vs. 21.9%; P = 0.006) and after 3 months (84.4% vs. 53.1%; P < 0.001). However, the difference between these two groups became obscure after 6 months [Figure 2]. No significant differences between the two groups were observed in the preoperative potency rate (P = 0.45) or the postoperative potency rate (P = 1 after 3 months; P = 0.719 after 1 year).
Figure 2: Rates of continence recovery at different time points

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  Discussion Top


In the present study, we use propensity score to control the preoperative variables. Some widely used factors such as age, BMI, PSA, clinical T stage, and nerve-sparing technique were included in our study design. However still, some factors which may affect the perioperative outcomes were not included and analyzed. One of these is the different approach method (transperitoneal vs. retroperitoneal approach). Although short hospital stay and lower complication rate were noted in extraperitoneal approach than transperitoneal approach, no significant difference was noted in 12-month continence and operation time.[6] However, the reason not using it is the way we choose approach methods depends on the extension of pelvic lymph node dissection. The risk of lymph node metastases is associated with PSA and cT stage which were factors to calculate the propensity score. Our result also showed no difference between LRP and RARP group on approach methods after propensity score matched. Another unincluded factor is anastomosis manner. A review article from Kowalewski et al. showed no significant differences in continence rate.[7] Therefore, even though anastomosis manner is an inherent bias in our study and may have an influence on the peri-operative outcomes, we did not include anastomosis manner as a factor. Pelvic floor reconstruction is the other inherent bias not analyzed in our study. Although total pelvic floor reconstruction (posterior and anterior reconstructions) has proved to has better continence rate compared with nontotal pelvic floor reconstruction.[8],[9] It is more challenging to do total pelvic floor reconstruction on LRP than on RARP, and most of the patients received LRP did not get total pelvic floor reconstruction.



About the operation time, our results indicated that RARP is more time-consuming than LRP (377.0 ± 126.1 min vs. 230.8 ± 78.3 min). However, previous studies showed conflict results.[10],[11] These discrepancies may be related to various factors. One potential factor is the learning curve for RARP. Doumerc et al. suggested that 140–170 RARP procedures need to be performed before the surgeon is considered competent.[12] Our center has much less experience with RARP, but the surgeon (VCL) has profound experience in advanced laparoscopic surgery and performed >400 cases of LRP. This may have influenced the surgical time and outcomes. Another factor is that most studies have described similar pathological results for both groups, whereas our RARP group had a higher proportion of pathological stage ≥T3a. Tumors with extracapsular invasion require more extensive lymph node dissection, which increases the number of harvested lymph nodes and prolongs the surgical time. The other factor is a large number of nerve-sparing procedures, which also increase the operative time. However, we attempted to minimize its influence by using propensity score matching.

Previous studies have described varying times for catheterization and length of stay, which may be related to regional health policies. For example, European patients often stay in the hospital until the catheter is removed, whereas American patients are usually discharged within a few days after surgery because of the high cost of staying in the hospital.[10] Furthermore, RARP is associated with a shorter length of stay than open surgery or LRP in the United States,[13] and similar results have been reported in Europe.[10] However, in our experience, both groups had similar lengths of stay, which is likely related to our national health insurance that allows patients to stay in the hospital from the preoperative laboratory testing until the day after catheter removal. Interestingly, we found that RARP was associated with nonsignificantly shorter catheterization times compared to LRP, which has also been previously reported.[10] This may be because LRP is always performed by the same experienced surgeon, thereby expediting the postoperative recovery similar to that of RARP at our hospital.

Positive surgical margins were detected in 13 patients (40%) in our RARP group, which is similar to or higher than the positive surgical margin rates of previous studies that have compared RARP and LRP for pT2 disease.[14],[15] This may be related to the limited number of patients, the higher pathological stage in our RARP group and the bias in pathological interpretation by different pathologists. For example, our RARP group included 18 patients (56%) with pathological stage ≥T3a, but there were only 8 patients (25%) with pathological stage ≥T3a in the LRP group. Even so, 84% of patients in the RARP group with positive surgical margins in our series had nadir PSA levels without adjuvant hormone therapy. Coelho et al. reported that the clinical stage was the only preoperative factor associated with positive surgical margins after RARP and positive surgical margins are known to increase the risk of biochemical recurrence.[16] However, the present study did not experience the local recurrence or metastases in oncological outcomes and it may be due to the short follow-up period for the RARP group. Long follow-up period is necessary to present the fact of oncological results in our series.

In our series, the RARP group had a mean lymph node yield of 19.7, which was higher than that of the LRP group. Standard pelvic node dissection can be easily performed during RARP; however, during LRP, limited pelvic node dissection was adopted due to the technical limitations. Although it is unclear whether PLND during radical prostatectomy provides a therapeutic benefit, and it is known to be associated with poorer intraoperative and perioperative outcomes, PLND may be curative for select patients with limited nodal invasion.[17],[18] The bottom line is that PLND provides staging benefits and should be performed whenever indicated.[18]

Continence is an important issue that is related to the patient's quality of life. However, it can take up to 1–2 years to achieve continence after LRP.[19] Therefore, different strategies have been reported to preserve continence or lead to prompt continence recovery soon after surgery. In our experience, and according to the literature, the LRP and RARP techniques do not involve differences in bladder neck dissection or anastomosis, although RARP may easily reproduce some critical steps for improving the reconstructive steps, including anterior and posterior reconstruction and vesicourethral anastomosis.[19] These benefits are associated with significant improvements in continence recovery. For example, De Carlo et al. compared the continence rates of LRP and RARP after 6 months (63.82% vs. 89.12%) and after 12 months (70.77% vs. 92.78%).[10] Ku et al. also compared LRP and RARP in terms of early continence recovery rates after 1 month (31% vs. 65%) and after 3 months (69% vs. 91%).[20] The present study revealed that, compared to LRP, RARP was associated with slightly better recovery rates after 14 days (15.6% vs. 25.0%; P = 0.324) and significantly better recovery rates after 1 month (21.9% vs. 56.2%; P = 0.006) and after 3 months (53.1% vs. 84.4%; P = 0.001). The difference between these two groups became obscure after 6 months and both groups got excellent continence rate after 12 months, respectively (P = 0.281; P = 0.554).

Many factors influence erectile function after radical prostatectomy, such as age, preoperative erectile function, comorbidity profile, surgical technique, the definition of dysfunction, data collection methods, additional prostate cancer treatments, and the use of erectogenic therapies.[21] Some reports have described significantly better recovery of erectile function in the RARP group,[22],[23],[24] although they noted that the rates of sexual intercourse were not different within 1 year after surgery and only became significantly different at 1 year or later.[22] Berryhill et al. also reviewed the outcomes of RARP and LRP, which revealed 12-month potency rates of 14.3%–97% in the RARP group and 35%–78.9% in the LRP group.[25] Nevertheless, some reports indicated that there is no significant difference between LRP and RARP.[26] We also failed to detect a significant difference in erectile function after 12 months in our series, although this may be attributable to the short follow-up period and the small number of patients.

Cheng et al. reported an overall complication rate of approximately 43% after minimally invasive radical prostatectomy, whereas others reported overall complication rates of 28.5%–57.1% in the LRP group and 5.6%–21.6% in the RARP group.[5] Our RARP group included seven patients who experienced late complications, including two patients with urethral strictures that were successfully treated with a series of urethral sounding and two patients with symptomatic pelvic lymphocele treated with percutaneous drainage without further adverse events. Like other studies described, bladder neck contracture, anterior urethral stricture, and lymphocele were complications which may happen 30 days after the operation. In a study by Liss et al. in 2013, they analyzed the cause and provided various ways in reducing complications. For the urethral stricture, the risk can be statically significant reduced by reducing the size of the Foley catheter to <22Fr.[27] They also found half of the intraoperative/early and 25% of the late complications occurred in the first 200 RARP cases after an experience of 1000 consecutive patients.[27] Another study by Fossati et al. said PLND was associated with a significantly higher risk of lymphocele.[18] Therefore, the reasons for more late complications in the RARP group may be urethral manipulation, extended PLND, and limited experience.[27],[28]

The present study has several strengths. First, it used propensity score matching, which can limit the influence of selection bias. Second, a single experienced surgeon performed LRP and RARP using standardized surgical procedures, and all patients received the same postoperative care and counseling, which may allow for more accurate intergroup comparisons. However, the present study also had several limitations. The follow-up time was short and the sample size was small. In addition, erectile function was not evaluated using the International Index of Erectile Function-5 questionnaire, urinary continence was only evaluated using the pad test, and the International Prostate Symptom Score was not assessed postoperatively. Patients were not classified according to different surgical techniques or to the use of neoadjuvant and adjuvant hormone therapy, which could influence some perioperative factors. Finally, the 1-year follow-up may be sufficient to evaluate perioperative continence outcomes, but it may not be sufficient to detect differences in potency, as some reports have indicated that potency recovery can require >12 months.[10]


  Conclusion Top


If patients cannot afford RARP, then LRP can provide the benefits of minimal invasiveness, good continence recovery, and similar oncological outcomes when performed by an experienced and dedicated surgical team. However, the current study revealed that RARP could prompt better early urinary continence rates after 14 days, 1 month, and 3 months, and it yielded more pelvic nodes than LRP. Although more extensive studies are needed to comprehensively compare LRP and RARP, we believe that these findings provide useful information regarding the relative efficacies (i.e., recovery of urinary continence and urinary and erectile functions) of LRP and RARP for clinically localized or locally advanced prostate cancer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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