Advertisement

Factors Influencing Outcomes After Robotic-Assisted Laparoscopic Radical Prostatectomy: The Search for the Trifecta

  • Rafael Ferreira Coelho
  • Vipul R. Patel
Chapter

Abstract

The three long-term goals of Radical Prostatectomy (RP) are complete removal of the cancer, recovery of urinary continence and recovery of sexual potency. However, these individual outcomes are not necessarily independent of each other, i.e., improvement in one outcome may come at the expense of the other two outcomes. Therefore, assessing individual results after RP may not truly inform the patient regarding what to expect in terms of overall cancer control and quality of life after surgery. This has led to the concept of reporting the likelihood of achieving the three outcomes concurrently after RP: the so called “trifecta”.Throughout our learning experience, we developed several technical modifications during Robotic-Assisted Radical Prostatectomy (RARP) which presently allow us to perform the procedure with improved functional outcomes while not compromising cancer control; as a result, excellent “trifecta” rates are currently reported in our series. These technical refinements, which will be fully described in this presentation, include the periurethral suspension stitch, athermal seminal vesicle dissection, early retrograde release of the neurovascular bundle, incremental/partial nerve-sparing, athermal apical dissection, transverse bladder neck plication/reconstruction and, finally, modified posterior reconstruction of the rhabdosphincter.Although each specific outcome of RP has been extensively described, few series analyzing the trifecta rates have been previously reported. We have recently reported our early trifecta outcomes after RARP. We evaluated prospectively 404 consecutive patients who were considered potent preoperatively and underwent bilateral full nerve-sparing. Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times (with or without the use of oral PDE-5 inhibitors) and biochemical recurrence (BCR) was defined as two consecutive values of PSA > 0.2 ng/mL after RARP. Results were compared between three age groups (Group 1 ≤ 55 years, Group 2—56 to 65 years and Group 3 > 65 years). The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively, showing that RARP offers excellent short-term trifecta outcomes when performed by an experienced surgeon. No statistically significant difference was found in the continence and BCR-free rates between the three age groups at all postoperative intervals analyzed. Nevertheless, younger patients demonstrated shorter time to achieving the trifecta (group 1, median time 6 weeks vs. group 2, 12 weeks vs. group 3, 24 weeks, log-rank, P<0.001) and higher trifecta rates at 6 weeks (57.7% vs. 41.3% vs. 22.7%;P<0.01), 3 months (72.6% vs. 64.4% vs. 52.7%;P=0.041) and 6 months (85.5% vs. 75.2% vs. 66.6%; P=0.036) after RARP compared to elderly patients. These findings can be attributed to the earlier return of sexual function (group 1, median time 6 weeks vs. group 2, 6 weeks vs. group 3, 24 weeks, log-rank, P<0.01) and higher overall potency rates also reported by younger men at the same intervals after RARP in our series.

Keywords

Prostate cancer Prostatectomy Treatment outcome Robotic Prognosis 

References

  1. 1.
    Hayat HJ, Howlander N, Reichman ME, Edwards BK. Cancer statistics, trends and multiple primary cancer analyses from the Surveillance, Epidemiology and End Results (SEER) Program. Oncologist. 2007;12:20-37.PubMedCrossRefGoogle Scholar
  2. 2.
    Bill-Axelson A, Holmberg L, Ruutu M, et al. Scan­dinavian prostate cancer group study, 4. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2005;12:1977-1984.CrossRefGoogle Scholar
  3. 3.
    Pierorazio PM, Spencer BA, McCann TR, et al. Preoperative risk stratification predicts likelihood of concurrent PSA-free survival, continence, and potency (the trifecta analysis) after radical retropubic prostatectomy. Urology. 2007;70:717-722.PubMedCrossRefGoogle Scholar
  4. 4.
    Salomon L, Saint F, Anastasiadis AG, et al. Combined reporting of cancer control and functional results of radical prostatectomy. Eur Urol. 2003;44:656-660.PubMedCrossRefGoogle Scholar
  5. 5.
    Bianco FJ, Scardino PT, Eastham JA. Radical prostatectomy: longterm cancer control and recovery of sexual and urinary function (“trifecta”). Urology. 2005;66:83-94.PubMedCrossRefGoogle Scholar
  6. 6.
    Eastham JA, Scardino PT, Kattan MW. Predicting an optimal outcome after radical prostatectomy: the trifecta nomogram. J Urol. 2008;179:2207-2210.PubMedCrossRefGoogle Scholar
  7. 7.
    Shikanov SA, Zorn KV, Shalhav AL. Trifecta outcomes after robotic-assisted laparoscopic prostatectomy. Urology. 2009;74(3):619-623.PubMedCrossRefGoogle Scholar
  8. 8.
    Patel VR, Coelho RF, Chauhan S, et al. Continence, potency and oncologic outcomes after robotic-assisted radical prostatectomy: early trifecta results of a high-volume surgeon. BJU Int. 2010;106(5):696-702.PubMedCrossRefGoogle Scholar
  9. 9.
    Pfitzenmaier J, Pahernik S, Tremmel T, Haferkamp A, Buse S, Hohenfellner M. Positive surgical margins after radical prostatectomy: do they have an impact on biochemical or clinical progression? BJU Int. 2008;102(10):1413-1418.PubMedGoogle Scholar
  10. 10.
    Hong YM, Hu JC, Paciorek AT, Knight SJ, Carroll PR. Impact of radical prostatectomy positive surgical margins on fear of cancer recurrence: results from CaPSURE™. Urol Oncol. 2010;28(3):268-273.PubMedCrossRefGoogle Scholar
  11. 11.
    Swindle P, Eastham JA, Ohori M, et al. Do margins matter? The prognostic significance of positive surgical margins in radical prostatectomy specimens. J Urol. 2005;174:903-907.PubMedCrossRefGoogle Scholar
  12. 12.
    Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic, robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55(5):1037-1063.PubMedCrossRefGoogle Scholar
  13. 13.
    Wieder JA, Soloway MS. Incidence, etiology, location, prevention and treatment of positive surgical margins after radical prostatectomy for prostate cancer. J Urol. 1998;160:299-315.PubMedCrossRefGoogle Scholar
  14. 14.
    Brown JA, Garlitz C, Gomella LG, et al. Pathologic comparison of laparoscopic versus open radical retropubic prostatectomy specimens. Urology. 2003;62:481-486.PubMedCrossRefGoogle Scholar
  15. 15.
    Sofer M, Hamilton-Nelson KL, Civantos F, et al. Positive surgical margins after radical retropubic prostatectomy: the influence of site and number on progression. J Urol. 2002;167:2453-2456.PubMedCrossRefGoogle Scholar
  16. 16.
    Smith RC, Partin AW, Epstein JI, et al. Extended follow-up of the influence of wide excision of the neurovascular bundle(s) on prognosis in men with clinically localized prostate cancer and extensive capsular perforation. J Urol. 1996;156:454-458.PubMedCrossRefGoogle Scholar
  17. 17.
    White MA, De Haan AP, Stephens DD, Maatman TK, Maatman TJ. Comparative analysis of surgical margins between radical retropubic prostatectomy and RALP: are patients sacrificed during initiation of robotics program? Urology. 2009;73(3):567-571.PubMedCrossRefGoogle Scholar
  18. 18.
    Atug F, Castle EP, Srivastav SK, Burgess SV, Thomas R, Davis R. Positive surgical margins in robotic-assisted radical prostatectomy: impact of learning curve on oncologic outcomes. Eur Urol. 2006;49(5):866-871; discussion 871-872.PubMedCrossRefGoogle Scholar
  19. 19.
    Patel VR, Palmer KJ, Coughlin G, Samavedi S. Robot-assisted laparoscopic radical prostatectomy: perioperative outcomes of 1500 cases. J Endourol. 2008;22:2299-2305.PubMedCrossRefGoogle Scholar
  20. 20.
    Liss M, Osann K, Ornstein D. Positive surgical margins during robotic radical prostatectomy: a contemporary analysis of risk factors. BJU Int. 2008;102:603-607.PubMedCrossRefGoogle Scholar
  21. 21.
    Villers A, Stamey TA, Yemoto C, Rischmann P, McNeal JE. Modified extrafascial radical retropubic prostatectomy technique decreases frequency of positive surgical margins in T2 cancers <2 cm(3). Eur Urol. 2000;38(1):64-73.PubMedCrossRefGoogle Scholar
  22. 22.
    Potdevin L, Ercolani M, Jeong J, Kim IY. Functional and oncologic outcomes comparing interfascial and intrafascial nerve sparing in robot-assisted laparoscopic radical prostatectomies. J Endourol. 2009;23(9):1479-1484.PubMedCrossRefGoogle Scholar
  23. 23.
    Secin FP, Serio A, Bianco FJ Jr, et al. Preoperative and intraoperative risk factors for side-specific positive surgical margins in laparoscopic radical prostatectomy for prostate cancer. Eur Urol. 2007;51(3):764-771.PubMedCrossRefGoogle Scholar
  24. 24.
    Ward JF, Zincke H, Bergstralh EJ, Slezak JM, Myers RP, Blute ML. The impact of surgical approach (nerve bundle preservation versus wide local excision) on surgical margins and biochemical recurrence following radical prostatectomy. J Urol. 2004;172:1328-1332.PubMedCrossRefGoogle Scholar
  25. 25.
    Patel VR, Palmer KJ, Coughlin G, Samavedi S. Robotic-assisted laparoscopic radical prostatectomy: perioperative outcomes of 1500 cases. J Endourol. 2008;22:1-7.Google Scholar
  26. 26.
    Badani KK, Kaul S, Menon M. Evolution of robotic radical prostatectomy assessment after 2766 procedures. Cancer. 2007;110:1951-1958.PubMedCrossRefGoogle Scholar
  27. 27.
    Tewari A, Jhaveri J, Rao S, et al. Total reconstruction of the vesico-urethral junction. BJU Int. 2008;101(7):871-877.PubMedCrossRefGoogle Scholar
  28. 28.
    Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic, robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55:1037-1063.PubMedCrossRefGoogle Scholar
  29. 29.
    Patel VR, Coelho RF, Palmer KJ, Rocco B. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol. 2009;56(3):472-478.PubMedCrossRefGoogle Scholar
  30. 30.
    Coughlin G, Dangle PP, Patil NN, et al. Surgery Illustrated–focus on details. Modified posterior reconstruction of the rhabdosphincter: application to robotic-assisted laparoscopic prostatectomy. BJU Int. 2008;102(10):1482.PubMedCrossRefGoogle Scholar
  31. 31.
    Walsh PC. Anatomical radical prostatectomy: evolution of the surgical technique. J Urol. 1998;160:2418-2424.PubMedCrossRefGoogle Scholar
  32. 32.
    Rocco F, Carmignani L, Acquati P, et al. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol. 2006;175(6):2201-2206.PubMedCrossRefGoogle Scholar
  33. 33.
    Menon M, Muhletaler F, Campos M, Peabody JO. Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol. 2008;180:1018-1023.PubMedCrossRefGoogle Scholar
  34. 34.
    Ong AM, Su LM, Varkarakis I, et al. Nerve sparing radical prostatectomy: effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model. J Urol. 2004;172(4 Pt 1):1318-1322.PubMedCrossRefGoogle Scholar
  35. 35.
    Ahlering TE, Eichel L, Skarecky D. Evaluation of long-term thermal injury using cautery during nerve sparing robotic prostatectomy. Urology. 2008;72(6):1371-1374.PubMedCrossRefGoogle Scholar
  36. 36.
    Ahlering TE, Eichel L, Chou D, et al. Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation. Urology. 2005;65:994-997.PubMedCrossRefGoogle Scholar
  37. 37.
    Gill IS, Ukimura O, Rubinstein M, et al. Lateral pedicle control during laparoscopic radical prostatectomy: reWned technique. Urology. 2005;65:23-27.PubMedCrossRefGoogle Scholar
  38. 38.
    Coughlin G, Dangle P, Palmer KJ, Samevedi S, Patel VR. Athermal early retrograde release of the neurovascular bundle during nerve-sparing robotic-assisted laparoscopic radical prostatectomy. J Robotic Surg. 2009;3:13-17.CrossRefGoogle Scholar
  39. 39.
    Kalan S, Coughlin G, Palmer KJ, Patel VR. Robot-assisted laparoscopic radical prostatectomy: an athermal anterior approach to the seminal vesicle dissection. J Robotic Surg. 2008;2:223-226.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  • Rafael Ferreira Coelho
    • 1
  • Vipul R. Patel
    • 2
    • 3
    • 4
  1. 1.Global Robotics Institute – UrologyFlorida Hospital Celebration HealthCelebrationUSA
  2. 2.Florida Hospital Global Robotics Institute Florida Hospital Celebration HealthCelebrationUSA
  3. 3.University of Central Florida College of Medicine, Florida Hospital Celebration HealthCelebrationUSA
  4. 4.Florida Hospital Celebration Health Global Robotics InstituteCelebrationUSA

Personalised recommendations