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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 05-November-2010, Vol 123 No 1325

Robot-assisted laparoscopic prostatectomy: a 2010 update
James B Duthie, Joanna E Pickford, Peter J Gilling
Abstract
Aim To build on the previous article and further explore the safety and efficacy of robotic-assisted laparoscopic prostatectomy (RALP) in the first 100 cases from a single institution in New Zealand.
Method A prospective database was created to monitor perioperative and postoperative outcomes of men undergoing RALP for clinically localised carcinoma of the prostate.
Results The first 100 cases were followed prospectively with a mean follow-up of 13.9 months. There were no conversions to open surgery, or re-operations. Average blood loss was 281 ml, and there was only one blood transfusion. Mean hospital stay was 1.1 nights. Mean console time improved from 251.4 minutes over the first 10 cases to 104.6 minutes over the last 10. The overall positive margin rate was 18%. The positive margin rate from pT2 tumours was 8%. The majority of patients had well-differentiated, organ-confined disease. Postoperatively, five have a detectable PSA level. 68% use no incontinence pads at 12 months. At one year, 12% of the men who were previously fully potent have achieved full potency again without assistance
Conclusion The results further support RALP as a safe, effective, and well tolerated procedure for the management of carcinoma of the prostate. The early local experience compares favourably with other published early series.

Robotic-Assisted Laparoscopic Prostatectomy (RALP) is increasingly popular as the mode of surgical management of early prostate cancer worldwide. Shorter hospital stay and earlier return to activities make RALP attractive as a treatment option. This paper reports on the first 100 RALP cases performed at Tauranga, New Zealand, adding more cases and longer follow-up to previously published data on the first 30 cases.1
RALP is now the most common modality of radical treatment for organ-confined prostate cancer in the US, with 80% of cases this year expected to be treated with RALP. The first RALP was performed on 3 September 2007 at Grace Hospital in Tauranga. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) is a master-slave tele-manipulative device controlled by a surgeon sitting at a console, controlling a laparoscopic camera and three operative arms through the use of two hand controls (Figure 1). RALP is at present an uncommon but increasing treatment in New Zealand.
The previously published data reported a single surgeon experience with his first 30 cases.1 The data compared favourably with published international data on learning curves for RALP in terms of intra-operative complications, cancer clearance, analgesia requirements, and time to discharge. The present study provides additional data up to the first 100 cases, with longer follow up.

Methods

Prospective data were obtained on the first 100 consecutive patients undergoing RALP by a single surgeon (PJG) at our institution. Preoperative data—including presenting prostate-specific antigen (PSA), clinical stage, and biopsy histology—were obtained, as well as erectile function questionnaires (Sexual Health Inventory Male score) with Normal being a score >21, Quality of Life (QOL score), and urinary function including daily pad usage. Perioperative data including total theatre and actual robot (console) operating time, blood loss, surgical technique, postoperative analgesia requirements, length of hospital stay, and surgical complications were collected. Serial PSAs, erectile function, continence, and quality of life continue to be measured at 3, 6, 12, and 24 months. The surgical technique was subtly modified and developed over the series, but remains largely unchanged from the description in the previous paper. The technique is based on that pioneered by Menon and modified by Patel.2,3

Results

The cases were performed between September 2007 and December 2009. Patient characteristics are described in Table 1. Follow-up data ranges from 3 to 24 months, with the mean being 13.9 months. All but one patient had clinically organ-confined disease (T1 or T2). A single patient clinically had T3 disease and was treated as part of a multi-modal protocol. Transrectal biopsy showed moderately well differentiated cancer in nearly all patients (from Gleason Grade 3+3 to 4+3); however, five patients had a secondary Gleason grade of 5.
Operative time—Operative times are described in Table 1. The mean total theatre time for the first 10 cases was 341.5 minutes, with a mean console time of 251.4 minutes. The last 10 cases had a total theatre time of 177.3 minutes, with a mean console time of 104.6 minutes. Average blood loss was 281 ml (range <50 ml–2000 ml).
Postoperative—The mean hospital stay was 1.1 nights, 29 patients only stayed overnight. Twenty-one patients required only paracetamol for analgesia; most required only a modest dose of tramadol (average 163 mg) or non-steroidal anti-inflammatory in addition to this. Seven patients required IV morphine, with an average of 7 mg used.
Perioperative morbidity—Three patients had more than 1 L estimated blood loss, of these one lost approximately 2 L. One patient (1%) required a blood transfusion. Five patients had hospital stays of 3 nights, and four exceeded 3 nights; one due to an acute anxiety episode, and one with significant bladder spasm and penile tip pain. One patient developed a urinoma due to vesico-urethral anastamotic leak, which was managed conservatively with an extended period of catheterisation. One patient experienced a postoperative ileus.
Table 1. Average operating times
Quartile
Total Theatre Time
Console Time
First 25 patients
Second 25 patients
Third 25 patients
Fourth 25 patients
273
238
192
190
206
166
120
121
Figure 1. The robotic theatre
Pathology—There was generally good agreement between TRUS biopsy grading and final pathology. The overall positive margin rate was 18%, but only eight patients with positive surgical margins in the absence of extracapsular spread (pT2) on final pathology. Only one of these was in the last 25 patients, and this patient had less than 1 mm involved at the surgical margin.
Functional outcomes—The mean preoperative SHIM score was measured in 87 patients, and was found to have a mean of 19.9. Only 47 were fully potent (SHIM score >21) at baseline. Figure 2 shows SHIM scores increasing with time postoperatively, but at present only 66 patients have been followed up to 12 months. The mean score of these patients is 8.7. Of the fully potent men, 38 have been followed up at 1 year and 12% are fully potent without medical assistance Of the 20 patients followed up to 24 months, the overall mean is 9.3. Mean AUA score at 12 months is 4.6.
The mean preoperative QOL score was 1.6, of the 69 patients followed up to 12 months the mean is again 1.6. Figure 3 shows that mean pad usage was 0.02 preoperatively, 1.8 at 3 months, and 0.5 for the 75 patients with 12 months follow up. 52 patients (68%) use no pads at 12 months.
Figure 2. SHIM score
Figure 3. Number of pads used per day
PSA—Follow up PSA levels at three months have been measured in 96 of the patients, with 94.8% recording undetectable levels. Of the five patients with a detectable PSA, three had pT3 disease, and one had a PSA level that continued to drop to a level below 0.2 ng/ml at 24 months. Only 44 have a 12 month postoperative level, of these three are greater than 0.2 ng/ml.

Discussion

This series compares favourably with published international data in terms of safety and efficacy.4,5 A relatively short learning curve is suggested by the rapid improvement in operative time and low positive margins rates observed over the series. That the console time reached a plateau at the third quartile further supports this theory. The hypotheses that RALP provides effective oncological outcomes with the benefits of reduced blood loss and perioperative pain are supported.
Perioperative morbidity is low, and again comparable to published series. Operative and total theatre times rapidly improved, and are by the end of the series comparable to conventional radical retropubic prostatectomy in many centres, and superior to laparoscopic prostatectomy5. Both erectile function recovery and post-operative continence in this series are good, particularly given the short follow up, as continence may improve up to a year, and erectile function up to two years post-operatively.
Further analysis of preoperatively potent patients (SHIM scores >21) will be performed at the two year mark to further assess this, but early data is satisfactory. Little long term PSA data has been recorded so far, but is so far encouraging and is in line with what is expected following Open Prostatectomy in a similar group. RALP has been demonstrated to have advantages over other techniques for organ confined prostate cancer, and has a growing role in the management of prostate cancer in New Zealand.
Competing interests: None.
Author information: James B Duthie, Trainee Registrar, Department of Urology; Joanna E Pickford, Registered Nurse, Department of Urology; Peter J Gilling, Consultant Urologist, Department of Urology and Head of Bay of Plenty Clinical School; Tauranga Hospital, Tauranga, Bay of Plenty
Correspondence: Peter J Gilling FRACS, Consultant Urologist, Promed Urology, PO Box 56, Tauranga 3140, New Zealand. Fax. +64 (0)7 5784717; email: Peter@promed.co.nz
References:
  1. Wilson L, Pickford J, Gilling P. Robot-assisted laparoscopic radical prostatectomy (RALP)—a new surgical treatment for cancer of the prostate. N Z Med J. 2008;121(1287):32–38. http://www.nzma.org.nz/journal/121-1287/3422/content.pdf
  2. Menon M, Tewari A, Peabody JO, et al. Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases. Urol Clin North Am. 2004;31(4):701–17.
  3. Patel VR, Palmer KJ, Coughlin G, Samavedi S. Robot-assisted laparoscopic radical prostatectomy: perioperative outcomes of 1500 cases. J Endourol. 2008;22(10):2299–305.
  4. Menon M, Tewari A, Baize B, et al. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy: the Vattikuti Urology Institute experience. Urology. 2002;60(5):864–8.
  5. Touijer K, Eastham JA, Secin FP, et al. Comprehensive prospective comparative analysis of outcomes between open and laparoscopic radical prostatectomy conducted in 2003 to 2005. J Urol. 2008;179 (5):1811–7.
     
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