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The practice of radical prostatectomy for treating prostate cancer has evolved remarkably since its general introduction around 1900. Initially described using a perineal approach, the procedure was later popularized using a retropubic one, after it was first described as such in 1948. The open surgical method has now largely been abandoned in favour of the minimally invasive robot-assisted method, which was first described in 2000. Until 1980, the procedure was hazardous, often accompanied by massive blood loss and poor outcomes. For patients in whom surgery is indicated, prostatectomy is increasingly being used as the first step in a multitherapeutic approach in advanced local, and even early metastatic, disease. However, contemporary molecular insights have enabled many men to safely avoid surgical intervention when the disease is phenotypically indolent and use of active surveillance programmes continues to expand worldwide. In 2020, surgery is not recommended in those men with low-grade, low-volume Gleason 6 prostate cancer; previously these men — a large cohort of ~40% of men with newly diagnosed prostate cancer — were offered surgery in large numbers, with little clinical benefit and considerable adverse effects. Radical prostatectomy is appropriate for men with intermediate-risk and high-risk disease (Gleason score 7–9 or Grade Groups 2–5) in whom radical prostatectomy prevents further metastatic seeding of potentially lethal clones of prostate cancer cells. Small series have suggested that it might be appropriate to offer radical prostatectomy to men presenting with small metastatic burden (nodal and or bone) as part of a multimodal therapeutic approach. Furthermore, surgical treatment of prostate cancer has been reported in cohorts of octogenarian men in good health with minimal comorbidities, when 20 years ago such men were rarely treated surgically even when diagnosed with localized high-risk disease. As medical therapies for prostate cancer continue to increase, the use of surgery might seem to be less relevant; however, the changing demographics of prostate cancer means that radical prostatectomy remains an important and useful option in many men, with a changing indication.In this Perspectives, a pioneer in the field of robotic radical prostatectomy describes the history of the technique and changing indications for its use, from an operation once considered useless, to one offered to almost all patients with low-risk disease, to a procedure that now has a role in advanced disease as part of a multimodal approach.

Apical dissection is a crucial step of radical prostatectomy (RP) for postoperative functional outcomes. Robot-assisted laparoscopic RP (RALRP) represents a good visualization for this stage and bleeding during ligation of dorsal vein complex (DVC) is a challenging problem in open RP (ORP). In our study, the results of finger dissection technique in open RP were evaluated and compared with RALRP. We retrospectively reviewed 184 patients who underwent RP for clinically localized prostate cancer. Blunt finger dissection technique performed for ligation of DVC in ORP and patients were divided into two groups according to the surgical method (Group 1:RALRP; Group 2:FD-ORP – Finger dissection-ORP). The primary outcomes were continence status and erectile functions. Ninety-two patients in each group were enrolled in the study. Demographics, operative outcomes, preoperative and postoperative oncological data were also recorded. Demographics and preoperative data were similar. There is no statistically difference between groups in terms of operation time, blood loss, transfusion rates, hospitalization time, and peri- and postoperative complications ( p  > 0.05). Continence rates (82.6% vs. 89.1%, p  = 0.439) and erectile functions (mean IIEF: 10.62 vs. 11.34, p  = 0.107) showed no statistically significant difference between FD-ORP and RALRP in the first year after surgery. Finger dissection of the DVC during ORP is a simple and feasible technique that provides the correct plane on the urethra, resulting in better apical dissection with effective hemostasis. Although it shows similar early functional results as RALRP, more research is needed. These findings suggest that FD-ORP may serve as a viable surgical option in settings where robotic technology is inaccessible.

PurposeThis study is a systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes and the cost of open retropubic radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP).MethodsSummary data was abstracted from 104 original research articles representing 227,400 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE and the Cochrane Library were reviewed in December 2016. A total of 104 publications were selected for inclusion. The primary outcomes were positive surgical margin (PSM) and major complication rate according to Clavien classifications. Secondary outcomes were operative time, length of hospital stay, estimated blood loss, transfusions, conversions, rate of post-operative erectile dysfunction and incontinence and total cost of procedure.ResultsORP had a significantly higher rate than RALP for PSM (OR: 1.18; 95% CI 1.05–1.32; p = 0.004), but the rate of PSM was not significantly different between ORP versus LRP (OR: 1.37; 95% CI 0.88–2.14; p = 0.17) and RALP versus LRP (OR: 0.83; 95% CI 0.40–1.72; p = 0.62). The major Clavien complication rate was significantly different between ORP and RALP (OR: 2.14; 95% CI 1.24–3.68; p = 0.006). Estimated blood loss, transfusions and length of hospital stay were low for RALP, moderate for LRP and high for ORP. The rate of erectile dysfunction (OR: 2.58; 95% CI 1.77–3.75; p < 0.001) and incontinence (OR: 3.57; 95% CI 2.28–5.58; p < 0.001) were significantly lower after RALP than LRP and equivalent for other comparisons. Total cost was highest for RALP, followed by LRP and ORP.ConclusionsFor PSM and peri- and post-operative complications, RALP showed better results than ORP and LRP. In the context of the biases between the studies, one should interpret the results with caution.

PurposeOur study compares perioperative outcomes between two-dimensional (2D) laparoscopic radical prostatectomy (LRP) and the 4th generation three-dimensional/high definition (3DHD) LRP.MethodsRetrospectively acquired data from patients that underwent 2D LRP (n = 75) and 3DHD LRP (n = 75) from March 2013 to October 2015 were evaluated. Procedures were performed by a single surgeon. The extra-peritoneal approach with 5 trocars was utilized. Perioperative outcomes, potency, and continence were compared between groups.ResultsPatient characteristics were similar between the two groups in terms of age (p = 0.44), prostate-specific antigen (PSA) levels (p = 0.34), and Gleason scores (p = 0.14). Body mass index (BMI) was significantly higher in the 3DHD group (p = 0.0036). Postoperatively, no significant differences were observed in Hgb loss (p = 0.50), positive surgical margins (p = 1.00), and post-op Gleason scores (p = 0.30). Significant differences were observed for length of hospital stay (p < 0.001) and Jackson-Pratt (JP) drainage (p < 0.001). Regarding potency, 73.7% and 51.6% of the patients in the 3DHD and 2D groups regained potency at 6 months, respectively (p = 0.0025). Almost 43% of the patients in the 3DHD group regained continence at 1 month while for the 2D groups it was only 17.3% (p = 0.0008).Conclusion3DHD and 2D LRP have resulted in good outcomes in the perioperative periods. Our results show decreased JP drainage, shorter length of hospital stay, earlier return of urinary control, and earlier return of sexual function in the 3DHD LRP group. In lower volume centers where robotics equipment is not feasible due to economic barriers 3DHD can be safely performed as a minimally invasive alternative.

Post-prostatectomy continence status, in addition to lower urinary tract symptoms, is a major concern among patients after robotic-assisted radical prostatectomy (RaRP). In this prospective study, we enrolled patients undergoing RaRP to evaluate subjective urinary symptoms and objective urodynamic parameters before and after surgery. Patients were recruited before RaRP surgery between January 2019 and August 2020. One day before surgery, the participants completed three questionnaires and pressure-flow studies, which were repeated approximately 3 months postoperatively. Of the total 135 patients initially enrolled, 85 (63.0%) completed the entire follow-up period. Three months after RaRP, the International Prostate Symptom Score showed significant increases in storage symptoms. Similar trends were observed in the Urinary Distress Inventory Short Form, and Overactive Bladder Symptom Score questionnaires. More than half of the patients regained continence within 2 months, although 9.6% remained incontinent after 1 year. Postoperative urodynamic studies indicated increased bladder hypersensitivity and significantly decreased detrusor pressure at peak flow. Furthermore, the bladder contractility index and bladder outlet obstruction index were reduced postoperatively. Ten patients (11.8%) developed de novo detrusor overactivity. The multivariate analysis identified age and cross-sectional area of the bladder neck as predictors of immediate continence after RaRP.

This study aimed to evaluate the effect of robotic surgery experience on open radical prostatectomy (ORP) outcomes. We retrospectively reviewed 100 patients who underwent an ORP for clinically localised prostate cancer (PCa) performed by the same experienced surgeon. The groups included the last 50 patients before (Group 1) and the first 50 patients after (Group 2) robotic surgery experience. A detailed history, peroperative, and oncological data were recorded. Continence status and erectile functions were evaluated before surgery and at 1, 3, 6, and 12 months postoperatively by daily pad count and an International Index of Erectile Function (IIEF) short form and were compared between groups. The demographics and preoperative data were similar. The preoperative and postoperative Gleason score was higher in Group 2 ( p  = 0.001, 0.033; respectively). The operation time (200 vs. 115 min), estimated blood loss (400 vs. 200 ml), peroperative transfusion rate (46% vs. 8%), drain removal time (4 vs. 3 days), hospital stay (5 vs. 4 days), and urethral catheter removal time (21 vs. 14 days) were significantly lower in Group 2 ( p  < 0.001). The continence rate was significantly higher in Group 2 in the first month ( p  = 0.027), but no significant difference was found at 3, 6, and 12 months. Erectile functions (mean IIEF: 9.47 vs. 11.18 at 12th month, p  = 0.220) showed no significant difference between the groups in the first year after surgery. In addition to ergonomic benefits, robotic surgery provides a significant surgical procedure experience due to its great visualisation. The most important advantages that robotic surgery adds to our ORP experience were improved early continence; less bleeding and a decreased need for transfusions; and a shorter operation time, hospital stay, and urethral catheter removal time.

Purpose This study aimed to develop a novel model that combines both clinical and image-based parameters to predict early recovery of urinary incontinence after robotic-assisted radical prostatectomy (RARP) more easily and precisely. Materials and methods We retrospectively enrolled data from patients who underwent RARP performed by a single surgeon. Clinical parameters were collected through medical chart review. All patients received cystography one week after RARP to evaluate the anastomosis healing condition. All cystography images were analyzed by a single radiologist who was blinded to the clinical status of the patients. Multivariate analysis was performed to select significant predictors for early post-prostatectomy incontinence (PPI) recovery, defined as being pad-free within four weeks after surgery. Results A total of 293 patients were enrolled in this study. Among them, 26.7% experienced immediate dryness after surgery, while 47.6% achieved being pad-free within one month. The overall continence rate was over 90% six months after surgery. In univariate analysis, factors associated with early PPI recovery were BMI, T stage, NVB preservation, surgical margin status, downward bladder neck, and bladder neck angle on cystography. BMI, NVB preservation, and downward bladder neck remained significant in multivariate analysis (p-values = 0.041, 0.027, and 0.023, respectively). A nomogram model was established based on these three predictors. Conclusion This is the first model to combine preoperative clinical factors, peri-surgical factors, and postoperative image-based factors to predict PPI recovery after RARP. This model can assist clinicians in taking optimal actions for PPI and also reduce patient anxiety.

PurposeTo provide a systematic analysis of the comparative outcomes of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer based on the best currently available evidence.MethodsAn independent systematic review of the literature was performed up to February 2021, using MEDLINE®, EMBASE®, and Web of Science® databases. Preferred reporting items for systematic review and meta-analysis (PRISMA) recommendations were followed to design search strategies, selection criteria, and evidence reports. The quality of the included studies was determined using the Newcastle–Ottawa scale for non-randomized controlled trials. Demographics and clinical characteristics, surgical, pathological, and functional outcomes were collected.ResultsTwenty-six studies were identified. Only 16 “high-quality” (RCTs and Newcastle–Ottawa scale 8–9) studies were included in the meta-analysis. Among the 13,752 patients included, 6135 (44.6%) and 7617 (55.4%) were RARP and LRP, respectively. There was no difference between groups in terms of demographics and clinical characteristics. Overall and major complication (Clavien–Dindo ≥ III) rates were similar in LRP than RARP group. The biochemical recurrence (BCR) rate at 12months was significantly lower for RARP (OR: 0.52; 95% CI 0.43–0.63; p < 0.00001). RARP reported lower urinary incontinence rate at 12months (OR: 0.38; 95% CI 0.18–0.8; p = 0.01). The erectile function recovery rate at 12months was higher for RARP (OR: 2.16; 95% CI 1.23–3.78; p = 0.007).ConclusionCurrent evidence shows that RARP offers favorable outcomes compared with LRP, including higher potency and continence rates, and less likelihood of BCR. An assessment of longer-term outcomes is lacking, and higher cost remains a concern of robotic versus laparoscopic prostate cancer surgery.

Radical prostatectomy and radiotherapy are common first-line treatments for clinically localized prostate cancer. Despite advances in surgical technology and multidisciplinary management, post-prostatectomy urinary incontinence (PPI) remains a common clinical complication. The incidence and duration of PPI are highly heterogeneous, varying considerably between individuals. Post-prostatectomy urinary incontinence may result from a combination of factors, including patient characteristics, lower urinary tract function, and surgical procedures. Physicians often rely on detailed medical history, physical examinations, voiding diaries, pad tests, and questionnaires-based symptoms to identify critical factors and select appropriate treatment options. Post-prostatectomy urinary incontinence treatment can be divided into conservative treatment and surgical interventions, depending on the severity and type of incontinence. Pelvic floor muscle training and lifestyle interventions are commonly conservative strategies. When conservative treatment fails, surgery is frequently recommended, and the artificial urethral sphincter remains the “gold standard” surgical intervention for PPI. This review focuses on the diagnosis and treatment of PPI, based on the most recent clinical research and recommendations of guidelines, including epidemiology and risk factors, diagnostic methods, and treatment strategies, aimed at presenting a comprehensive overview of the latest advances in this field and assisting doctors in providing personalized treatment options for patients with PPI.