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| Intermediate-term oncological and functional outcomes in prostate cancer patients treated with perineal robot-assisted radical prostatectomy: A single center analysis |
Umberto Carbonara*( ),Giuseppe Lippolis,Luciano Rella,Paolo Minafra,Giuseppe Guglielmi,Antonio Vitarelli,Giuseppe Lucarelli,Pasquale Ditonno
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| Department of Emergency and Organ Transplantation, Urology Unit, Aldo Moro University, Bari, Italy |
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Abstract Objective: In the last 10 years, robotic platforms allowed to resume of some alternative surgical approaches, including perineal robot-assisted radical prostatectomy (p-RARP). Herein, we present in detail the oncological and functional outcomes of patients who underwent p-RARP with a median follow-up of 30 months. Methods: Patients presenting low- or intermediate-risk prostate cancer and prostate volume up to 60 mL who underwent p-RARP between November 2018 and November 2022 were selected. Baseline, intraoperative, pathological, and postoperative data were collected and then analyzed. Results: Thirty-seven p-RARP cases were included. Such patients presented mean age of 62 years and a mean Charlson comorbidity index of 4. Body mass index of ≥25 kg/m2 was reported by 24 (64.9%) patients, as well as 7 (18.9%) patients reported a past surgical history. Mean prostate volume and median prostate-specific antigen were 41 mL and 6.2 ng/mL, respectively. The median operative time was 242 min. The positive surgical margin rate was 45.9%. In terms of postoperative complications, 10 patients reported complications with any grade; however, a single case (2.7%) of major (Clavien-Dindo grade ≥3) complication was observed. No patient with biochemical recurrence or distant metastasis was reported at 2 years of follow-up. Recovery of continence rates were 67.6%, 75.7%, and 92.9%, at 6 months, 12 months, and 24 months after surgery, respectively. Conclusion: p-RARP is a challenging but safe minimally invasive approach for selected patients with prostate cancer suitable for radical prostatectomy, showing outstanding functional recovery. Despite positive surgical margin rates being relatively high, no cases of biochemical recurrence or distant metastasis were reported after a median follow-up of 30 months.
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Received: 10 November 2022
Available online: 20 October 2023
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Corresponding Authors:
*E-mail address: u.carbonara@gmail.com (U. Carbonara).
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| Characteristic | Description | | Suitable candidate | - Small or medium prostate weight (≤60 mL) | | - Low- or intermediate-risk prostate cancer | | - BMI>30 kg/m2 | | - Medium-severe comorbidities | | - Previous renal transplant recipients | | - Prior mesh repair of inguinal hernia | | - Prior abdominal surgery | | Unsuitable candidate | - High-risk prostate cancer | | - >5% of Briganti's nomogram |
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Suitable candidates for perineal robot-assisted radical prostatectomy at Bari University Hospital (Bari, Italy) between November 2018 and November 2022.
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Perineal region illustrations. (A) Perineal region—can be described as a diamond shape delimited, anteriorly by the inferior margin of pubic symphysis (a), posteriorly by the tip of the coccyx (b), anterolaterally by the inferior margin of ischiopubic rami and ischial tuberosities (c), and posterolaterally by the sacrotuberous ligaments (d); (B) Skin incision. The black dished line is a semicircular landmark draw between the ischial tuberosities, 2 cm above the anus. A line of about 7 cm is measured as a chord of the previous line (black line). The red dashed line shows the skin incision.
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Intraoperative illustrations. (A) The retrograde dissection of the posterior surface of the prostate gland in the nerve-sparing approach; (B) Identification and dissection of lateral aspects of prostate gland; (C) Identification and dissection of seminal vesicles; (D) Incision of the membranous urethra; (E) Vesicourethral anastomosis.
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| Demographic and staging characteristics | Value | | Age, year | 62±5 | | BMI | | <25 kg/m2 | 13 (35.1) | | 25-30 kg/m2 | 14 (37.8) | | >30 kg/m2 | 10 (27.0) | | ASA score | | 1 | 6 (16.2) | | 2 | 22 (59.5) | | 3 | 9 (24.3) | | CCI | 4±1 | | Overall past surgical history | 7 (18.9) | | Abdominal surgery | 4 (10.8) | | Kidney transplant | 1 (2.7) | | Hernia repair | 1 (2.7) | | Other | 1 (2.7) | | PSA, ng/mL | 6.2 (4.8-7.6) | | Prostate volume, mL | 41±6 | | Clinical T stage | | T1c | 32 (86.5) | | T2 | 5 (13.5) | | Biopsy ISUP grade group | | 1 | 21 (56.8) | | 2 | 13 (35.1) | | 3 | 3 (8.1) | | Presence of 3rd lobe | 5 (13.5) | | Preoperative IIEF-5 | 17 (12-23) |
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Demographic and staging characteristics of patients undergoing p-RARP (n=37).
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| Characteristic | Value | | Operative outcomes | | Operative time, min | 242 (202-282) | | Estimated blood loss, mL | 250 (150-350) | | Anesthesia | | General | 9 (24.3) | | Spinal | 3 (8.1) | | Combined | 25 (67.6) | | Nerve-sparing technique | | Unilateral | 14 (37.8) | | Bilateral | 17 (45.9) | | No | 6 (16.2) | | Intraoperative opioid use | 2 (5.4) | | Intraoperative complication | 5 (13.5) | | Postoperative outcomes | | Overall postoperative complication | 10 (27.0) | | Major postoperative complication | 1 (2.7) | | Postoperative opioid use | 2 (5.4) | | Length of drain, day | 1±1 | | Catheter removal time, day | 7±3 | | Length of stay, day | 3±1 | | Follow-up, month | 30 (18-42) | | Readmission | 1 (2.7) | | Pathological outcomes | | Final ISUP grade group | | 1 | 16 (43.2) | | 2 | 13 (35.1) | | 3 | 5 (13.5) | | 4 | 1 (2.7) | | 5 | 2 (5.4) | | Pathological T stage | | 2 | 24 (64.9) | | 3a | 13 (35.1) | | Overall PSM | 17 (45.9) | | Focal | 11 (29.7) | | Non-focal | 6 (16.2) | | PSM location | | Anterior surface | 6 (35.3) | | Apex | 3 (17.6) | | Posterolateral surface | 6 (35.3) | | Base | 2 (11.8) | | Concordance of PSM and site of index lesion at mpMRI | | Yes | 7 (41.2) | | No | 6 (35.3) | | Unknown | 4 (23.5) | | LVI | 4 (10.8) |
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Operative, postoperative, and histopathological outcomes of patients undergoing perineal robot-assisted radical prostatectomy (n=37).
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| Oncological and functional outcomes | Value | | PSA, ng/mL | | Postop 6 mo | 0.02 (0.01-0.03) | | Postop 12 mo | 0.04 (0.03-0.05) | | Postop 24 mo | 0.04 (0.02-0.06) | | BCR at 24 moa,b | 0 (0) | | Metastasis at 24 moa | 0 (0) | | Recovery of erectile function (according to IIEF-5)c | | Postop 6 mo | 24 (64.9) | | Postop 12 mo | 29 (78.4) | | Postop 24 moa | 23 (82.1) | | Recovery of continenced | | Postop 6 mo | 25 (67.6) | | Postop 12 mo | 28 (75.7) | | Postop 24 moa | 26 (92.9) |
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Oncological and functional outcomes after perineal robot-assisted radical prostatectomy.
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| Study | Robotic platform | n | F/U, month | Prostate volume, mL | OPT, min | Nerve-sparing, % | LOS, day | Catheterization time, day | PSM, % | Continence, % | Major complication, % | | Tu?cu et al. 2020 [11] | Xi? | 95 | 13 | 52 | 140 | 100 | 1 | 7 | 8 | 91a | 11 | | Lenfant et al. 2021 [25] | Sp? | 26 | 12.4 | 30 | 255 | 62.5 | 1 | 11 | 65.4 | 80.1a | 23 | | Current | Xi? | 37 | 30 | 42 | 252 | 83.7 | 2 | 9 | 47.3 | 92b | 2.7 |
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Previous studies of perineal robot-assisted radical prostatectomy with more than 20 patients.
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