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| Journal of the New Zealand Medical Association,
05-November-2010, Vol 123 No 1325
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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.
MethodsProspective 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
ResultsThe 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
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.
DiscussionThis 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:
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