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Background: Single-port robot-assisted simple prostatectomy is a minimally invasive alternative for patients with large benign prostatic hyperplasia with severe symptoms and/or failure of medical treatment. In recent literature, the rate of incidental prostate cancer after simple prostatectomy ranges from 1.8% to 13.0%. Our objective is to report the rate of incidental prostate cancer after single-port robot-assisted simple prostatectomy and to compare our findings to other approaches., Methods: A Single-Port Advanced Research Consortium [SPARC] multi-institutional retrospective analysis of all initial consecutive single-port robot-assisted simple prostatectomy cases performed from 2019 to 2023 by eleven surgeons from six centers. Our primary outcome was the rate of incidental prostate cancer in adenoma specimens. We used descriptive statistics to analyze the data., Results: A total of 235 cases were performed successfully without conversions or additional ports. Eleven patients (4.6%) were found to have incidental prostate cancer on pathological analysis. The median percentage of tissue involved by the tumor was 5%. The overall rate of clinically significant prostate cancer was 2.1%. Most cases were Gleason Grade Group 1 (55%). Those with Grade Group ≤3 were subsequently managed with active surveillance with a median follow-up of 17 months. A patient with Gleason Grade Group 4 underwent an uncomplicated multi-port robot-assisted radical prostatectomy with satisfactory functional and oncological outcomes., Conclusions: Initial multi-institutional experience with single-port robot-assisted simple prostatectomy showed an incidental prostate cancer rate of 4.6%, comparable to MP, laparoscopic, and open techniques.

Importance: Planning complex operations such as robotic-assisted laparoscopic radical prostatectomy (RALP) requires surgeons to review 2-dimensional magnetic resonance imaging (MRI) scans to understand 3-dimensional (3D) patient anatomy. Three-dimensional digital models for planning RALP may allow better understanding of patient anatomy and may lead to better patient outcomes, although data are currently limited., Objective: To determine surgical outcomes after RALP when surgeons reviewed 3D digital models during operative planning., Design, Setting, and Participants: This study was a planned secondary analysis of a multicenter, single-blind, randomized clinical trial conducted at 6 large teaching hospitals in the US. The study was conducted between January 1, 2019, and December 31, 2022, and included patients undergoing RALP. Patients were assessed and recruited at the time of surgical consultation. Final data analysis was conducted between August and December 2023., Intervention: Patients were randomized to either a control group undergoing usual preoperative planning with prostate biopsy results and multiparametric MRI only or to an intervention group in which imaging and biopsy results were supplemented with a 3D digital model. This model was viewed on the surgeon's mobile phone in 3D format and picture-in-picture on the robotic console screen., Main Outcomes and Measures: The primary outcome measure for the overall study was oncologic outcomes after RALP, measured as prostate-specific antigen (PSA) detectability. Secondary outcomes were sexual function and urinary function, measured with Sexual Health Inventory for Men (SHIM) scores and rates of urinary incontinence, respectively, as well as use of salvage or adjuvant radiation therapy (RT) or androgen deprivation therapy (ADT). Trifecta outcomes were defined as undetectable PSA without RT or ADT, SHIM score categorically the same or greater than preoperatively, and complete continence. Univariate analysis was performed to compare outcomes between groups., Results: This trial included 92 patients undergoing RALP (51 in the control group and 41 in the intervention group). Their mean (SD) age was 62 (7.4) years; 10 patients (10.9%) were Black and 67 (72.8%) were White. At 18 months postsurgery, the intervention group had lower rates of biochemical recurrence (PSA level >0.1 ng/mL, 0 vs 7 [17.9%]; absolute difference, 17.9% [95% CI, 1.8% to 31.8%]; P = .01) and were significantly less likely to undergo adjuvant or salvage RT (1 [3.1%] vs 12 [31.6%]; absolute difference, 28.5% [95% CI, 10.1% to 46.7%]; P = .002) compared with the control group. Sexual function at 18 months postsurgery was significantly better in the intervention group (mean [SD] SHIM score, 16.8 [8.7] vs 9.8 [7.7]; absolute difference, 7.0 [95% CI, 2.6 to 11.4]; P = .002) and urinary function was unchanged (total continence, 22 [78.6%] vs 29 [80.6%]; absolute difference, 2.0% [95% CI, -17.9% to 21.9%]; P = .84) compared with the control group. Trifecta outcomes were achieved for 12 (48.0%) patients in the intervention group and 3 patients (10.0%) in the control group (absolute difference, 38.0% [95% CI, 14.4% to 61.6%]; P = .002)., Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, patients whose surgical planning of RALP involved 3D digital models had better oncologic and functional outcomes. Further work should assess the effect of 3D models in a broader set of patients, physicians, and hospital settings., Trial Registration: ClinicalTrials.gov Identifier: NCT03943368.

Objective: To evaluate the perioperative complications of single-port robot-assisted radical prostatectomy (SP-RARP)., Patients and Methods: A retrospective review was performed on the prospectively maintained, Institutional Review Board-approved, multi-institutional Single-Port Advanced Research Consortium (SPARC) database. A total of 1103 patients were identified who underwent three different approaches of SP-RARP between 2019 and 2022 using the purpose-built SP robotic platform. In addition to baseline clinical, perioperative outcomes, this study comprehensively analysed for any evidence of intraoperative complication, as well as postoperative complication and readmission within 90 days of the respective surgery., Results: Of the 244, 712, and 147 patients who underwent transperitoneal, extraperitoneal, and transvesical SP-RARP, respectively, intraoperative complications were noted in five patients (0.4%), all of which occurred during the transperitoneal approach. Two patients had bowel serosal tears, two had posterior button-holing of the bladder necessitating repair, and one patient had an obturator nerve injury. Postoperative complications were noted in 143 patients (13%) with major complications (Clavien-Dindo Grade ≥III) only identified in 3.7% of the total cohort. The most common complications were lymphocele (3.9%), acute urinary retention (2%), and urinary tract infection (1.9%). The 90-day re-admission rate was 3.9%., Conclusion: The SP-RARP is a safe and effective procedure with low complication and readmission rates regardless of the approach. These results are comparable to current multi-port RARP literature., (© 2023 BJU International.)

Importance: With the current patterns of adoption and use of robotic surgery and improvement in the overall survival of patients with prostate cancer, it is important to evaluate the immediate and long-term cost implications of treatments for patients with prostate cancer., Objective: To compare health care costs and use 1 year after open radical prostatectomy (ORP) vs robotic-assisted radical prostatectomy (RARP)., Design, Setting, and Participants: This retrospective cohort study used a US commercial claims database from January 1, 2013, to December 31, 2018. A total of 11 457 men aged 18 to 64 years who underwent inpatient radical prostatectomy for prostate cancer and were continuously enrolled with medical and prescription drug coverage from 180 days before to 365 days after inpatient prostatectomy were identified. An inverse probability of treatment weighting analysis was performed to examine the differences in costs and use of health care services by surgical modality. Data analysis was conducted from September 2019 to July 2020., Exposures: Type of surgical procedure: ORP vs RARP., Main Outcomes and Measures: Three outcomes within 1 year after the inpatient prostatectomy were investigated: (1) total health care costs, including reimbursement paid by insurers and out of pocket by patients; (2) health care use, including inpatient readmission, emergency department, hospital outpatient, and office visits; and (3) estimated days missed from work due to health care use., Results: Of the 11 457 patients who underwent inpatient prostatectomy, 1604 (14.0%) had ORP and 9853 (86.0%) had RARP and most patients (8467 [73.9%]) were aged 55 to 64 years. Compared with patients who underwent ORP, those who received RARP had a higher cost at the index hospitalization (mean difference, $2367; 95% CI, $1821-$2914; P < .001), but similar total cumulative costs were observed within 180 days (mean difference, $397; 95% CI, -$582 to $1375; P = .43) and 1 year after discharge (-$383; 95% CI, -$1802 to $1037; P = .60). One-year postdischarge health care use was significantly lower in the RARP compared with ORP group for mean numbers of emergency department visits (-0.09 visits; 95% CI, -0.11 to -0.07 visits; P < .001) and hospital outpatient visits (-1.5 visits; -1.63 to -1.36 visits; P < .001). The reduction in use of health care services among patients who underwent RARP translated into additional savings of $2929 (95% CI, $1600-$4257; P < .001) and approximately 1.69 fewer days (95% CI, 1.49-1.89 days; P < .001) missed from work for health care visits., Conclusions and Relevance: Total cumulative cost in this study was similar between ORP and RARP 1 year post discharge; this finding suggests that lower postdischarge health care use after RARP may offset the higher costs during the index hospitalization.

Objectives: Seminal vesicle invasion (SVI) is a risk factor for poor oncologic outcome in patients with prostate cancer. Modifications to the pelvic lymph node dissection (PLND) during radical prostatectomy (RP) have been reported to have a therapeutic benefit. The present study is the first to determine if lymph node yield (LNY) is associated with a lower risk of biochemical recurrence (BCR) for men with SVI., Methods: A total of 220 patients from 2 high-volume institutions who underwent RP without adjuvant treatment between 1990 and 2015 and had prostate cancer with SVI (i.e., pT3b) were identified, and 21 patients did not undergo lymph node dissection. BCR was defined as a postoperative PSA>0.2ng/mL, or use of salvage androgen deprivation therapy (ADT) or radiation. Multivariable Cox proportional hazards models were used to determine whether LNY was predictive of BCR, controlling for PSA, pathologic Gleason Score, pathologic lymph node status, NCCN risk category, etc. The Kaplan-Meier method was used to determine 3-year freedom from BCR., Results: Median number of lymph nodes sampled were 7 (IQR: 3-12; range: 0-35) and 90.5% underwent PLND. The estimated 3-year BCR rate was 43.9%. Results from multivariable analysis demonstrated that LNY was not significantly associated with risk of BCR overall (HR = 1.00, 95% CI: 0.98-1.03; P = 0.848) for pN0 (HR = 0.99, 95% CI: 0.97-1.03; P = 0.916) or pN1 patients (HR = 0.96, 95% CI: 0.88-1.06; P = 0.468). Overall, PSA (HR = 1.02, P<0.001) and biopsy Gleason sum ≥ 8 (HR = 1.81, P = 0.001) were associated with an increased risk of BCR, and increasing LNY increased the likelihood of detecting>2 positive lymph nodes (OR = 1.27, 95% CI: 1.06-1.65, P = 0.023)., Conclusion: Seminal vesicle invasion is associated with an increased risk of BCR at 3 years, primarily due to pathologic Gleason score and PSA. Although greater lymph node yield is diagnostic and facilitates more accurate pathologic staging, our data do not show a therapeutic benefit in reducing BCR., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Men with pathologic evidence of seminal vesicle invasion (SVI) at radical prostatectomy (RP) have higher rates of biochemical recurrence (BCR) and mortality. Adjuvant radiotherapy (XRT) has been shown to increase freedom from BCR, but its impact on overall survival is controversial and it may represent overtreatment for some. The present study, therefore, sought to identify men with SVI at higher risk for BCR after RP in the absence of adjuvant XRT., Methods: We identified 180 patients in our institutional database who underwent RP from 1990 to 2011 who had pT3bN0-1 disease. The Kaplan-Meier method was used to estimate freedom from BCR for the overall cohort and substratified by Gleason score, PSA, surgical margin status, and lymph node positivity. Cox Proportional Hazards models were used to determine demographic and histopathological factors predictive of BCR. Time-dependent ROC curve analysis was conducted to assess the ability of the UCSF-CAPRA score to predict BCR., Results: Median age was 64 years, and 52.8% of patients were preoperative D'Amico high risk. At RP, 41.4% had a positive surgical margin (PSM), and 12.2% had positive lymph nodes (LN). The most common sites of PSM were the peripheral zone (56.8%) and the apex (32.4%). Positive bladder neck margin (HR = 7.01, P = 0.035) and PSA 10-20 versus ≤10 (HR = 1.63, P = 0.047) predicted higher BCR in multivariable analyses. Median follow-up was 26 months, and 2-, 3-, and 5-year BCR-free rates were 56.1%, 49.0%, and 39.5%. Log rank tests showed that freedom from BCR was significantly less for Gleason 9-10, PSA >20, PSM, and N1 patients. The area under curve (AUC) for CAPRA in predicting BCR was 0.713 at 2 years, 0.692 at 3 years, and 0.641 at 5 years. Increasing CAPRA score was associated with an increased risk of BCR (HR = 1.33, P < 0.001)., Conclusions: pT3b prostate cancer is a heterogeneous disease commonly associated with several high-risk features. Stratifying men with SVI by prognostic features (i.e., Gleason, PSA, node status, surgical margin status) and using these features to augment the CAPRA score will improve identification of those at higher risk for BCR that should be strongly considered for adjuvant XRT., (© 2015 Wiley Periodicals, Inc.)

Introduction: The significance of a "close" but negative surgical margin after radical prostatectomy (RP) is controversial. We evaluated the effect of a close surgical margin (CSM) on biochemical recurrence (BCR) compared to a negative margin after RP., Materials and Methods: Pathologic records of men who underwent RP from 2005-2011 were retrospectively reviewed. Margin status was classified as "positive" (PSM), "negative" (NSM), or "close" (<1mm from margin). BCR was defined as 2 consecutive postoperative prostate specific antigen measurements >0.2ng/ml. Probability of BCR was estimated using the Kaplan-Meier method and stratified by margin status. Univariable and multivariable Cox proportional hazards models were used to determine whether close margin status was associated with an increased rate of BCR., Results: A total of 609 consecutive patients underwent RP (93% robotic) and had complete pathologic data. A total of 126 (20.7%) had PSM, 453 (74.4%) had NSM, and 30 (4.9%) had CSM (mean<0.44mm). The 3-year BCR-free survival for patients with CSM was similar to those with PSM (70.4% vs. 74.5%, log rank P = 0.66) and significantly worse than those with NSM (90%, log rank P<0.001). On multivariable regression, positive margin status (HR = 3.26, P<0.001) was significantly associated with a higher risk of BCR, along with close margins (HR = 2.7, P = 0.04)., Conclusions: BCR for patients with CSM at RP is tantamount to PSM patients. CSM <1mm should be explicitly noted on pathology reports. Patients with this finding should be followed up closely and offered adjuvant therapy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased., Methods: We retrospectively reviewed 4,610 patients undergoing radical prostatectomy between 1990 and 2011. Patients were stratified by biopsy Gleason score and PSA value. For each stratification, χ2 analysis was used to determine the smallest 15-day multiple of surgical delay (e.g., 15, 30, 45…180 days) for which adverse pathologic outcomes were significantly more likely after the time interval than before. Adverse outcomes were defined as positive surgical margins, upgrading from biopsy, upstaging, seminal vesicle invasion, or positive lymph nodes., Results: Two thousand two hundred twelve patients met inclusion criteria. Median delay was 64 days (mean 76, SD 47). One thousand six hundred seventy-five (75.7%), 537 (24.3%), and 60 (2.7%) patients had delays of <=90, >90, and >180 days, respectively. Twenty-six percent were upgraded on final pathology and 23% were upstaged. The positive surgical margin rate was 24.2% and the positive lymph node rate was 1.1%. Significant increases in the proportion of adverse pathological outcomes were found beyond 75 days in the overall cohort (P = 0.03), 150 days for patients with Gleason <=6, and PSA 0-10 (P = 0.038), 60 days for patients with Gleason 7 and PSA >20 (P = 0.032), and 30 days for patients with Gleason 8-10 and PSA 11-20 (0.041)., Conclusion: In low-risk disease, there is a considerable but not unlimited surgical delay which will not adversely impact the rate of adverse pathologic features found. In higher risk disease, this time period is considerably shorter., (© 2015 Wiley Periodicals, Inc.)

Objective: To evaluate how a genomic classifier (GC) that predicts the risk of metastasis after prostatectomy would impact adjuvant treatment recommendations made by radiation oncologists and urologists. The 2 specialties often disagree about postprostatectomy adjuvant treatment recommendations., Materials and Methods: Twenty-six radiation oncologists and 20 urologists with genitourinary oncology expertise reviewed de-identified clinical results from 11 patients after radical prostatectomy and made adjuvant treatment recommendations. The same cases were later randomized and reassigned, and treatment recommendations were made using the clinical information and GC test results together., Results: Using clinical information alone, observation was recommended in 42% of decisions made by urologists vs 23% by radiation oncologists (P < .0001). The GC test results altered 35% and 45% of treatment recommendations made by radiation oncologists and urologists, respectively. Multivariate analysis showed GC risk was the strongest factor influencing treatment recommendations by both specialties, with an adjusted odds ratio of 4.17 (95% confidence interval [CI], 2.26-7.70) and 6.51 (95% CI, 4.29-9.88) for radiation oncologists and urologists, respectively. GC results indicating high metastatic risk resulted in intensification of treatment, whereas low metastatic risk resulted in less aggressive recommendations. The GC results increased interdisciplinary agreement in treatment recommendations, as the odds of a recommendation for adjuvant treatment by urologists vs radiation oncologists increased from 0.27 (95% CI, 0.17-0.44) to 0.46 (95% CI, 0.29-0.75) after results of the GC test were available., Conclusion: The GC test significantly influenced adjuvant postprostatectomy treatment recommendations, reduced disagreement between radiation oncologists and urologists, and has the potential to enhance personalization of postprostatectomy care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction and Objectives: Radical prostatectomy (RP) is associated with a high risk of intraoperative blood loss and subsequent blood transfusions. The shift in surgical technique from open radical prostatectomy (ORP) to robot-assisted radical prostatectomy (RARP) has resulted in lower operative blood loss, and reduced the need for transfusions. We analyzed the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database to compare real-world, contemporary trends in utilization and timing of blood transfusion following ORP and RARP., Methods: We identified men undergoing both RARP and ORP and then queried for patients who received a blood transfusion in the perioperative period. The outcomes of interest were need and timing of perioperative blood transfusion (PBT), which was categorized into early (postoperative day [POD] ≤1) or late (POD ≥2). Logistic regression analysis was used to identify variables associated with the need and timing for PBT., Results: A total of 16,144 men who underwent RP were identified from 2007 to 2012. The overall PBT rate was 3.1%. Highest rate of transfusions occurred on day of surgery for patients undergoing ORP, and first POD for patients undergoing RARP. On multivariate analysis significant predictors of blood transfusion included history of bleeding disorder (OR: 2.8, p=0.002), preoperative dyspnea (odds ratio [OR]: 1.7, p=0.03), starting hematocrit <42% (OR: 1.9, p<0.001), open approach (OR: 0.09, p<0.001), year of surgery (OR: 0.5, p<0.001), resident involvement (OR: 1.6, p=0.003), and operative time (OR: 4.4, p<0.001). The only predictor of receiving a blood transfusion on POD 2 or later was having the procedure performed through a robot-assisted approach (OR: 3.7, p<0.001)., Conclusions: In this study we found that the rate of perioperative transfusions is lower than previously published. A clear separation in timing of transfusion exists based on the utilized surgical approach. It is prudent that surgeons performing RARP be aware of the low, but present risk of a delayed blood transfusion.

Purpose: While robot-assisted radical prostatectomy (RARP) is associated with shortened convalescence and decreased blood loss over open prostatectomy, little objective data is available regarding postoperative pain/discomfort and use of analgesic medications after RARP. We sought to examine these parameters in a contemporary cohort., Patients and Methods: From 2011 to 2013, patients undergoing RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while the patient recovered in the hospital. After discharge, the patients were asked to fill out a daily questionnaire regarding their pain parameters and self-report opiate usage. All questionnaires were based on the Wong-Baker FACES pain rating scale (0-10). Opiate dosages were converted to the approximate oral morphine sulfate equivalent dose (MSE)., Results: A total of 60 patients, mean age 61 years, were enrolled in the study, underwent RARP, and completed follow-up questionnaires. None had a history of chronic narcotic use. Intraoperative opiate use was 94.1 mg MSE. There were 73.3% who received immediate postoperative ketorolac. After RARP, the main source of pain/discomfort was abdominal/incisional, followed by urethral catheter-related, penile, and bladder spasm-related discomfort. Abdominal pain was generally moderate for most patients and decreased significantly after about 4 days. Penile and urethral catheter-related discomfort was mild throughout the study period. Opiate analgesic medication use quickly decreased as the subjective pain scores improved., Conclusions: After RARP, most patients experience mild/moderate abdominal discomfort, which improves steadily over several days. There is also a quick decline in the average opiate pain medication use that corresponds to the subjective improvement in pain symptoms. This information is useful for clinicians counseling patients on the pain associated with RARP and can serve as a reference to compare the convalescence associated with the other options for treatment of patients with localized prostate cancer.

Objective: Robot-assisted radical prostatectomy (RARP) is a minimally invasive alternative to open retropubic radical prostatectomy (RP), and is reported to offer equivalent oncologic outcomes while reducing perioperative morbidity. However, the technique of extirpation can differ based on the usage of thermal energy and coagulation during RARP, which may alter the risk of finding a positive surgical margin (PSM) as cautery may destroy residual cancer cells. We sought to evaluate whether the method of surgery (RP vs RARP) affects the rate of biochemical recurrence (BCR) in patients with PSMs., Materials & Methods: The Columbia University Urologic Oncology Database was reviewed to identify patients who underwent RP and RARP from 2000 to 2010 and had a PSM on final pathology. BCR was defined as a postoperative prostate-specific antigen (PSA) ≥0.2 ng/mL. The Kaplan-Meier analysis was utilized to calculate BCR rates based on the method of surgery. Cox regression analysis was performed to determine if the method of surgery was associated with BCR., Results: We identified 3267 patients who underwent prostatectomy, of which 910 (28%) had a PSM. Of those with a PSM, 337 patients had available follow-up data, including 229 who underwent RP (68%) and 108 who underwent RARP (32%). At a mean follow-up time of 37 months for the RP group, 103 (46%) patients demonstrated BCR; at a mean follow-up time of 44 months for the RARP group, 62 (57%) patients had a BCR (p=0.140). Two-year BCR-free rates for RP vs RARP were 65% and 49%, respectively (log-rank p<0.001). However, after controlling for age, PSA, grade, and year of surgery, the surgical method was not significantly associated with increased risk of BCR (HR 1.25; p=0.29)., Conclusion: Our results confirm the noninferiority of RARP to RP with regard to patients with PSMs. As such, all patients with a PSM at RP are at high risk for BCR and should be followed in the same manner regardless of the surgical approach.

Introduction: Our objective was to determine the impact of race and tumor grade on perioperative leukocytosis on patients undergoing robot-assisted radical prostatectomy (RARP)., Methods: A retrospective review of our urologic oncology database for patients undergoing RARP from August 2002 to July 2011 was conducted. A total of 768 patients were identified with complete data. Demographic data, preoperative prostate specific antigen (PSA), biopsy Gleason score, pathology Gleason score, pathology stage, margin status, and node status were collected. White blood cell (WBC) counts were captured preoperatively, 1 hour postoperatively, and on postoperative day 1. We assessed the differences in leukocyte responses according to the race and Gleason score using ANOVA testing., Results: Preoperative WBC was lowest in black men and comparable between white and Hispanic men. At 1 hour, postoperative WBC remained lowest in Black men (p<0.001). Post-RARP leukocytosis varied significantly depending on the race (p<0.001). At 1 hour, patients with Gleason 8-10 tumors had decreased WBC compared to Gleason 6 patients (p<0.05) despite similar preoperative WBC and Charlson comorbidity index values., Conclusions: We report novel clinical observations that suggest differences in the immune response associated with the race and Gleason grade following RARP. The clinical utility of these findings are yet to be determined.

Introduction: There are many concerns expressed by urologists performed robotic assisted laparoscopic prostatectomy (RALP) regarding management of the dorsal vein complex (DVC). We sought to examine the influence of delayed DVC ligation versus standard DVC ligation on the apical surgical margin status and other key surgical parameters following RALP., Materials and Methods: The Columbia University Urologic Oncology Database was retrospectively reviewed to identify patients who underwent RALP between 2008-2011. Operative records were analyzed to determine whether the DVC was ligated in the 'standard' or 'delayed' manner. The standard group had the DVC ligated prior to the apical dissection; in the delayed group, the DVC was initially transected and subsequently oversewn after completion of the apical dissection. Clinical and pathologic data was retrospectively evaluated and stratified by the type of DVC ligation to compare positive apical margin rates based on DVC-control technique., Results: A total of 244 patients were identified, including 118 in the standard group and 126 in the delayed group. Estimated blood loss (112 mL versus 122 mL), operative time (132 min versus 126 min), and postoperative continence rates (81% versus 84% at 3 months) were similar between the standard and delayed DVC groups (p = NS). Apical margin status was also similar in the two groups, with 3.4% having a positive surgical margin in the standard DVC ligation arm, and 1.6% having a positive margin in the delayed DVC ligation arm (p = 0.43)., Conclusions: Delayed DVC ligation after apical dissection is a safe approach with comparable surgical outcomes during RALP. From a technical standpoint, we feel it allows for improved visualization of the apical dissection and therefore has become standard practice at our institution.

Objectives: To determine the extent of variability in the definitions of the 'trifecta' after radical prostatectomy (undetectable PSA, urinary continence and potency) to be found in the literature. To establish a consensus definition of the trifecta in an effort to standardize criteria and reporting., Materials and Methods: A systematic review of published articles found in the PubMed database for the period from January 2003 to March 2012 was performed. The search queries included the keywords 'radical prostatectomy,' 'prostatectomy outcome,' and 'trifecta'., Results: A total of 86 publications were identified of which 14 were used for analysis. Eight different definitions of biochemical recurrence were reported, the most common definition being PSA ≥0.2 ng/mL. The definition of potency was the most variable. Ten different definitions of potency were found, with the most common being 'having erections sufficient for intercourse with or without a phosphodiesterase-5 inhibitor'. Nine different definitions of continence were found. The most common definition of continence was 'wearing no pads'. Only six of the 14 articles used validated questionnaires in their outcome measures., Conclusions: The definitions of trifecta reported in the literature are highly variable. We propose the following consensus definition based on our analysis: (1) PSA >0.2 ng/mL with confirmatory value; (2) attainment of erections sufficient for intercourse with or without oral pharmacological agents; (3) wearing zero pads. This consensus definition should be considered when designing studies and reporting outcomes of radical prostatectomy., (© 2013 BJU International.)

Introduction: Intraoperative biopsy of the apical margin during radical prostatectomy has been recommended as a way to reduce the positive margin rate at this location. However, the enhanced visibility of the apex during robot-assisted radical prostatectomy (RARP) may obviate this need, allowing for the preservation of maximal urethral length. We assessed pathologic findings of routine apical margin biopsy intraoperative frozen section (IFS) during RARP., Patients and Methods: The Columbia University Robotic Database was retrospectively reviewed to identify men who underwent RARP with biopsy of the apical soft tissue (urethroprostatic junction). Both IFS and permanent section samples were analyzed. The clinical characteristics associated with IFS and permanent section histological findings were assessed., Results: In total, 335 men underwent RARP with apical biopsy from December 2007 to August 2011. Of these, 329 had IFS available for analysis. Median age and prostate-specific antigen level were 60 years (range, 42-78 years) and 5.2 ng/mL (interquartile range, 4.1-6.9 ng/mL), respectively. Of the 329 apical IFS cases, cancer was detected in 9 patients (2.7%), benign prostatic glands in 135 (41%), and nonprostatic tissue in 185 (56.3%). On permanent section, cancer was seen in 9 patients (2.7%), benign prostatic glands in 125 (38%), and nonprostatic tissue in 195 (59.3%). False-positive and false-negative rates of detecting cancer on IFS were 33% (3/9) and 1% (3/320), respectively. The overall positive surgical margin rate was 11%., Conclusions: Cancer is rarely detected by IFS analysis of routine biopsy of the apical margin during RARP. Although routine IFS may not be beneficial for all patients, selective utilization of IFS may be useful in directing apical dissection in men with apical tumors, allowing for the preservation of maximal urethral length.

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Incremental nerve-sparing techniques (NSTs) improve postoperative erectile function after robot-assisted radical prostatectomy (RARP). However, there are no studies to date that histologically confirm the surgeon intended NST. Thus, in the present study, we histologically confirmed that the surgeon performed the nerve preservation as his intended NSTs during RARP. Also, we found that there was more variability in fascia width outcome on the left side compared with the right. Therefore, when performing nerve preservation on the surgeon's non-dominant side, we need to pay more close attention., Objectives: To confirm that the surgeon achieved true intended histological nerve sparing during robot-assisted radical prostatectomy (RARP) by studying RP specimens. To aid the novice robotic surgeon to develop the skills of RARP., Patients and Methods: Between June 2008 and May 2009, 122 consecutive patients underwent RARP by a single surgeon (K.K.B.). The degree of nerve sparing (wide resection [WR], interfascial nerve sparing [ITE-NS], intrafascial nerve sparing [ITR-NS]) on both sides was recorded. The posterior sectors of RP specimens from distal, mid, and proximal parts were evaluated. Fascia width (FW) of each position in RP specimens were compared across nerve-sparing types (NSTs). FW was recorded at 15 ° intervals (3-9 o'clock position), measured as the distance between the outermost prostate gland and surgical margin. The slides were reviewed by an experienced uropathologist who was 'blinded' to the NST., Results: In all, 93 men were included. The overall mean (sd) FW was the greatest in the order of WR, ITE-NS, and ITR-NS, at 2.42 (1.62), 1.71 (1.40) and 1.16 (1.08) mm, respectively (P < 0.001). FW was statistically significantly correlated with the surgical technique used. When the surgeon intended to perform various levels of nerve sparing, these were reflected in the FW. Interestingly, the left-side FW showed more variability than the right side. We suspect that this was a result of the surgeon's right-hand dominance. Erectile function (EF) recovery rate according to NST was 88.9%, 77.3%, 65.6%, 56.3%, and 0% in bilateral ITR-NS, ITR-NS/ITE-NS, bilateral ITE-NS, ITE-NS/WR, and bilateral WR, respectively. To further validate and confirm these preliminary findings, additional studies involving multicentre cohorts would be required., Conclusions: The surgeon intended dissection and FW correlate, with ITR-NS providing the narrowest FW and the EF recovery rate was the highest in bilateral ITR-NS. There was more variability in FW outcome on the left side than the right. The novice robotic surgeon should consider this variability when performing RARP. It may have implications for technique improvement on nerve preservation for EF., (© 2012 BJU International.)

Background and Purpose: The da Vinci Surgical System (dVSS) has been reported to eliminate innate hand dominance of the surgeon. There are no studies to date, however, that specifically address whether the dVSS has its own inherent "handedness" resulting from the fixed left-right preference of specific instrument docking and assistant positioning. We identified the pelvic lymph node (LN) and neurovascular bundle (NVB) dissections as well as positive surgical margin rates as procedure points during robot-assisted radical prostatectomy (RARP) that could be influenced by laterality and sought to illustrate left-right consistency., Patients and Methods: Patients who underwent RARP by a single right-handed surgeon (KKB) between 2008 and 2010 were identified. Surgeon instrument preference and port placement were consistent across all cases. Pathologic LN yield was stratified by the intended limits of dissection (limited or extended) and laterality. In addition, fascial widths (FW) were prospectively measured for 93 consecutive patients, a narrower FW indicating a more precise intended NVB dissection. The pathologists were blinded to intended dissections., Results: A total of 340 limited, 11 bilateral extended, 11 right extended, and 5 left extended LN dissections were performed. For patients undergoing limited LN dissection, the mean LN yield was greater on the right compared with the left (3.26 vs 2.76, P=0.010). This difference was not seen in the extended LN dissection (P=0.96). Average FW was narrower on the right surgical margin compared with the left (1.99 vs 2.64 mm, P<0.001)., Conclusions: Our findings suggest that a greater number of LNs and a closer NVB dissection are achieved on the right compared with the left using the dVSS during RARP. This can be attributed to surgeon handedness, robotic instrument laterality, or assistant instrument laterality. Surgeon awareness of these potential differences is important for the preoperative planning before RARP.

Introduction: Bioimpedance spectroscopy (BIS) is a novel, precise quantification of body composition (BC) using low electrical currents through tissue. Accurate BC quantification may better predict postoperative outcomes. We compared BIS-BC and body mass index (BMI) for correlation with post-surgical outcomes in robotic assisted radical prostatectomy (RARP) patients., Materials and Methods: Preoperative BIS-BC and BMI analyses were conducted on men with biopsy-proven prostate cancer undergoing RARP. Height, weight, percentage and fat mass (PFM, FM), percentage and fat-free mass (PFFM, FFM), percentage and total body water (PTBW, TBW), and percentage and intracellular/extracellular water (PICW, PECW, ICW, ECW) were obtained using the ImpediMed SFB7 Device (San Diego, CA, USA). Preoperative PSA, biopsy and pathologic Gleason scores, prostate volume, percentage tumor volume, margin status, operative time, estimated blood loss (EBL) and pathologic stage were recorded. Spearman's rank correlation was estimated to evaluate the association between BIS-BC results, BMI, and post-surgical outcomes., Results: Between April 2009 and August 2010, 63 men had been enrolled in this ongoing study. Fourteen were of normal weight (18.5 kg/m2-24.9 kg/m2), 33 were overweight (25 kg/m2-29.9 kg/m2) and 16 were obese (BMI ≥ 30 kg/m2). Mean age was 60.7 years, mean preoperative PSA was 7.4 ng/mL, and median Gleason was 7. BMI correlated with FFM (p = 0.002), FM (p = 0.01), and PTBW (p = 0.02). FM correlated with preoperative PSA (p = 0.01). PFFM (p = 0.03), PFM (p = 0.03) and PTBW (p = 0.04) correlated with % tumor volume. ICW (p = 0.01) and TBW (p = 0.009) correlated with EBL. BMI (p = 0.04), PECW (p = 0.04), FM (p = 0.05), and PICW (p = 0.03) correlated with pathologic tumor stage., Conclusions: BMI correlates with BIS-BC FFM, FM and PTBW. PFFM, PFM and PTBW correlated with % tumor volume. ICW and TBW correlated with EBL. BMI, PECW, FM, and PICW correlated with pathologic tumor stage. BIS-BC metrics may be helpful in predicting post-RARP outcomes. Further study is required to validate these predictions.

Objective: •To determine the relationship between statin use and biochemical recurrence (BCR) following radical prostatectomy (RP)., Patients and Methods: •A retrospective analysis was performed on 3198 RP patients between 1990 and 2008. •Exclusion criteria were neo-adjuvant or adjuvant therapy, follow-up <2 years, and insufficient pathological or prostate-specific antigen (PSA) data. •Statin use was determined from the patient's record. Clinical and pathological variables were compared between statin users and non-users. •Kaplan-Meier and multivariate Cox regression analyses were performed to determine the effect of statin use on BCR., Results: •A total of 1261 patients fit criteria for analysis. There were 281 (22%) statin users. Mean age was 60 years and median follow-up was 36 months (mean 43 months). •Statin users had a lower median preoperative PSA (6.4) compared with non-users (7.1) (P < 0.05). In all, 80% of statin users had a pathological Gleason sum ≥7 compared with 67% of non-users (P < 0.05). •On multivariate analysis, statin use was an independent predictor of BCR (hazard ratio 1.54, P < 0.05). Statin users had a lower 5-year BCR-free survival compared with non-users (75% vs 84%, P < 0.05)., Conclusions: •Statin users are at an increased risk for BCR following RP. This finding may be due to the reduction in preoperative PSA potentially delaying diagnosis and/or masking aggressive disease. •Further studies are necessary to elucidate the impact of statin medications following prostate cancer therapy., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Background and Purpose: In addition to their lipid lowering effects, HMG-CoA reductase inhibitors (statins) have been shown to exert antithrombotic effects through downregulation of the coagulation cascade. Because statin use is widespread, it is important to understand the impact of these drugs on blood loss (BL) during surgery. We studied the impact of statin use on BL during robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP)., Patients and Methods: A retrospective review was conducted of a database approved by the Institutional Review Board for patients who underwent RARP or ORP at a single academic institution. Patients were categorized as statin-users or statin-naïve at the time of surgery. Patient demographic information was recorded as was perioperative data, including preoperative and postoperative hematocrit (Hct) value. BL was defined as % Hct change presurgery vs postsurgery. In addition, the outcome of ≥10% drop in Hct was studied. The t test and chi-square analysis were used to compare variables across statin use groups. Univariate and multivariable logistic regression analyses were used to identify factors that impacted BL., Results: From 1987 to 2010, 3578 patients underwent prostatectomy for prostate cancer (RARP=945 and ORP=2633). Of these, 676 men were identified as statin-users and 2902 as statin-naïve. Mean patient age was 60.2±7.0 years. Statin-users were found to be older (P<0.001), have lower mean preoperative prostate-specific antigen (PSA) levels (P=0.002), and have higher pathologic Gleason sum scores (P<0.001). For ORP, statin use was associated with increased BL with Hct % change of 20.7% for users vs18.6% for nonusers, (P<0.001). For RARP, no significant change in Hct was seen with statin use with % changes of 12.6% and 12.5%, respectively (P=0.9). When controlling for age, Gleason sum, surgeon, date of surgery and PSA level, statin use was associated with increased BL (P=0.04)., Conclusion: Even when controlling for age, Gleason sum, surgeon, date of surgery, and PSA, statin use is associated with increased BL during RP. This information may impact preoperative planning and patient counseling for men who are taking statins while preparing for RP.

Background and Purpose: With widespread implementation of posterior rhabdosphincter reconstruction (RSR) followed by urethrovesical anastomosis (UVA), reconstruction has become a significant portion of robot-assisted laparoscopic prostatectomy (RALP). Successful anastomosis can be measured by time for reconstruction and the absence of urinary leak. We prospectively evaluated the experience of a single surgeon (KKB) in using the V-Loc™ wound closure device for the posterior RSR and UVA, and compared it with a standard reconstruction and anastomosis., Patients and Methods: A total of 84 patients divided into two groups underwent RALP, undergoing RSR and UVA using a Van Velthoven technique with the V-Loc or with a standard 3-0 monofilament suture. The primary end point was the time to complete RSR, UVA, and the total reconstruction. As a secondary end point, the clinical evidence of an anastomotic leak was also documented., Results: The mean RSR, UVA, and total times were 9, 18, and 27 minutes for the control group, and 6, 12 and 18 minutes for the V-Loc group, respectively. The time differences between the two groups for RSR, UVA, and total time were 3 minutes (P<0.01), 6 minutes (P<0.01), and 9 minutes (P<0.001), respectively. There was no clinical evidence of anastomotic leak in either group. Continence recovery was equivalent between the groups at 6 weeks and 6 months. At a 9-month follow-up, no patients in either group had a clinical UVA stricture necessitating intervention., Conclusions: The V-Loc suture is associated with a significantly shorter time for the RSR and UVA compared with the traditional suture and is not associated with a higher incidence of clinical urinary leak; however, a larger randomized study with long-term follow-up is necessary to confirm these results.

Introduction: Neurovascular bundle preservation generally results in good postoperative sexual function after radical prostatectomy. However, erectile function (EF) after radical prostatectomy is still a significant concern. The same surgical technique often results in different EF outcomes., Aim: We evaluated factors that correlate with recovery of EF within 1 year after robotic-assisted laparoscopic radical prostatectomy (RALP)., Methods: From January 2008 to May 2009, 145 consecutive patients underwent RALP by one surgeon. Patients were followed postoperatively at 3-month intervals and assessed for EF recovery, defined as an erection sufficient for penetrative intercourse with satisfaction. Baseline demographics, medical comorbidities, degree of nerve sparing, and perioperative and postoperative variables were recorded. Univariate and multivariate analyses were used to determine factors associated with EF recovery., Main Outcome Measures: Postoperative sexual outcomes were attained prospectively via our erectile state questionnaire., Results: Complete follow-up EF data were available on 89 men. Within 1-year follow-up, 56 men (62.9%) recovered EF and 33 men (37.1%) did not. In univariate logistic regression analysis, race (black), diabetes mellitus, hyperlipidemia, and clinical T2 carcinoma of the prostate were associated with diminished EF. Higher-preoperative Sexual Health Inventory for Men score and incremental nerve sparing (enhanced lateral prostatic fascia sparing) were associated with higher odds of recovering potency. In multivariate analysis, hyperlipidemia was primary comorbidity associated with diminished EF, and bilateral nerve sparing with a minimum unilateral-enhanced status was the impacting factor for EF recovery within 1 year after surgery., Conclusions: Bilateral nerve preservation with a minimum unilateral-enhanced status is associated with improved recovery of EF, and hyperlipidemia is a significant negative predictive factor of postoperative EF recovery within 1 year following RALP. Therefore, it is important to control hyperlipidemia as well as to use the proper surgical technique in maximizing EF recovery within 1 year after radical prostatectomy., (© 2011 International Society for Sexual Medicine.)

Objectives: • Gleason sum from prostate biopsy (bGS) is an important tool in classifying severity of disease, ultimately influencing clinical management. • Commonly, pathology specimens are re-evaluated internally prior to surgery. • We evaluate agreement of bGS with prostatectomy Gleason sum (pGS) and the impact of re-grading on prediction of true underlying tumor architecture., Materials and Methods: • Retrospective analysis of men who underwent robotic-assisted radical prostatectomy (RARP) by two surgeons from 2005-2009. Initial transrectal ultrasound (TRUS) biopsy demonstrated carcinoma at an outside lab. Specimens were re-evaluated by our GU pathologists prior to surgery. Biopsy data were correlated with pGS. • Kappa (κ) statistics for agreement and linear regression analyses were used for categorical variables. Coefficient of concordance was used for continuous variables., Results: • 100 patients had 331 positive biopsies. Agreement (κ) for bGS between outside labs and our pathologists was 0.55 (p < 0.001). • Internal read was twice as likely to upgrade vs. downgrade outside bGS (23% vs. 11%). • When re-evaluation resulted in a change in bGS, agreement with pGS was κ= 0.29, vs. κ=-0.04 for agreement of initial (outside) bGS with pGS. • When no change was made to bGS, agreement with pGS was κ= 0.40 (p < 0.001)., Conclusion: • Good reproducibility seen between outside labs and our institution on bGS. Internal pathology re-reads correlated better with pGS than original community bGS. When re-reads result in a change in bGS, there is a marked improvement in prediction of underlying tumor architecture confirming the value of re-evaluating all external biopsies prior to definitive surgery., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Introduction: Carbon dioxide (CO(2)) lasers deliver energy with minimal thermal spread to tissues during dissection. Excess thermal spread during dissection of the neurovascular bundle (NVB) can affect potency in men after robot-assisted radical prostatectomy (RARP). We report on a novel delivery mechanism for CO(2) laser energy through a flexible fiber to enhance accuracy of NVB dissection during RARP., Materials: A feasibility study of the OmniGuide BeamPath URO-LG CO(2) laser fiber for NVB dissection was performed on 10 patients with primary Gleason 3 T1c prostate cancer during RARP. Bilateral lateral fascial antegrade nerve sparing was performed. We evaluated fiber performance, safety, and efficacy., Results: The fiber was inserted through the 12-mm assistant's port and easily manipulated by robotic instruments. Once pedicles were clipped and dissected, the laser fiber was effective in establishing planes of dissection between prostatic capsule and NVB. The endoscopically discernable thermal laser footprint was small, with minimal thermal spread during nerve sparing, meticulous dissection of NVB, and fascial layer identification. Although the laser did provide extremely accurate dissection, it was unable to serve as an adequate means of larger vessel coagulation., Conclusions: The flexible CO(2) laser fiber was easily manipulated. Identification of fascial layers during nerve sparing was facilitated with the fiber. Long-term follow-up is necessary to determine efficacy of this technology versus conventional techniques on the NVB. Larger studies are currently in progress to determine if use of the flexible CO(2) laser fiber results in improvements in functional outcomes with regard to return of sexual potency after RARP.

Background and Purpose: Studies of radical prostatectomy (RP) suggest that higher lymph node yield (LNY) improves tumor staging. Robot-assisted radical prostatectomy (RARP) is becoming increasingly popular, yet LNY data are not well reported. We compare LNY from contemporary open RP (ORP) with RARP at an academic center., Patients and Methods: A retrospective study was conducted of an Urologic Oncology Database. Between January 2005 and November 2009, 217 men underwent ORP with pelvic lymph node dissection (PLND); 99 underwent RARP with PLND by a single surgeon during the same period. Men were stratified according to the D'Amico risk criteria. For intermediate and high-risk disease, an extended PLND was performed. Patient demographic, operative, and pathologic variables were measured, and LNY was compared across groups., Results: No significant differences were seen between groups for race, body mass index, preoperative prostate-specific antigen level or biopsy Gleason score. Patients were younger for RARP vs ORP (P = 0.003) and had higher clinical tumor stage (P = 0.02). Operative time was longer (P = 0.03) and estimated blood loss was greater (P < 0.001) in the ORP group. Overall, only a borderline significant difference was seen in LNY between ORP and RARP (7.49 vs 6.35 nodes, respectively, P = 0.06). No difference was seen for intermediate and high-risk patients, with 7.7 vs 6.8 nodes for ORP and RARP, respectively (P = 0.27). The lymph node metastasis rate was 6.3%, with more positive nodes detected during ORP vs RARP: 19/217 (8.8%) vs 1/99 (1.0%), P = 0.009., Conclusions: No significant differences were seen in LNY during RARP and ORP for intermediate and high-risk men. For experienced surgeons, RARP can achieve equivalent LNY as ORP. A future study with a larger sample size is necessary to make a definitive statement of equivalence.

Objective: We sought to identify predictors of early urinary continence after robot-assisted prostatectomy (RARP) in men who underwent a posterior rhabdosphincter reconstruction., Materials and Methods: A prospective analysis was performed in 107 consecutive men who underwent RARP by a single surgeon in an academic center. Men were excluded if they received adjuvant radiation therapy (7 men), were lost to follow up (4), or did not have a posterior rhabdosphincter reconstruction (8 men). Eighty-eight men received a posterior rhabdosphincter reconstruction and were followed in this study. Patient demographic and postoperative urinary control was recorded at interval follow up visits by the physician and research staff. Level of comorbidity was measured with the Charlson Comorbidity Index (CACI). Preoperative urinary function was measured using the International Prostate Symptom Score (IPSS). Continence was defined as men using zero pads per day., Results: Eighty-eight men with a mean age of 59.2 years (43.1-77.6) were followed for a median of 7.6 (range 1.5-16.7) months. The median preoperative PSA and IPSS was 5.0 ng/mL (range 0.95 ng/mL-23 ng/mL) and 8 (range 0-30), respectively. Overall, 91% of the men achieved continence with a median time to continence of 2.3 months. Of those, 50% achieved continence by 6 weeks. Men continent at 6 weeks were significantly younger, had lower IPSS scores, and less comorbidities (p = 0.01). Age (OR = 0.91, p < 0.01) and higher IPSS scores (OR = 0.28, p = 0.03) were associated with decreased odds of achieving continence at 6 weeks. The presence of coexisting disease was not predictive of continence return. After adjusting for comorbidity, body mass index (BMI), nerve sparing, and IPSS score, only age remained as an independent predictor of early continence (OR = 0.90, p = 0.04)., Conclusions: In conclusion, we found that increased age and increased lower urinary tract symptom (LUTS) severity are associated with decreased odds of achieving continence 6 weeks after RARP. Patient age remains the strongest predictor of early return of continence in a multivariate model. These factors should be used in counseling prior to surgery to meet realistic patient expectations.

Objectives: To determine whether the decreased short-term morbidity associated with minimally invasive surgery (MIS) has resulted in an alteration in the disease-specific risk profile of prostatectomy patients. MIS in many fields has resulted in an expansion in the pool of patients willing to undergo surgery., Methods: The Columbia Urologic Oncology Database was queried, and 1751 patients undergoing radical prostatectomy between 2000 and 2007 were identified. The cohort was divided into 2 groups: patients who received surgery before or after the initiation of robotic-assisted laparoscopic radical prostatectomy (RALRP) at our institution (from 2003 onward). Age at surgery, Kattan Nomogram (KN) score, prostate-specific antigen (PSA), Gleason score sum, and tumor stage were compared using unpaired t tests with Welch correction and Mann-Whitney tests., Results: A total of 663 patients underwent prostatectomy from 2000 to 2002 ("pre-MIS era"), and 1088 patients had surgery in 2003 or later ("MIS era"), of which 519 and 569 underwent RALRP and open prostatectomy, respectively. There was no significant difference between the 2 eras regarding age, Kattan Nomogram score, or tumor stage. However, there was a significant difference in preoperative PSA (P = .01) and Gleason sum (P = .0002). In a comparison of the pre-MIS era with RALRP patients, only PSA differed significantly (P = .0002)., Conclusions: The advent of MIS for prostate cancer did not significantly alter the characteristics of patients undergoing prostatectomy at our institution. Although advancements in surgical techniques may improve clinical outcomes, this study does not suggest a consequential effect on the risk stratification of patients choosing surgery for prostate cancer., (2010 Elsevier Inc. All rights reserved.)

Study Type: Therapy (case series)., Level of Evidence: 4., Objective: To evaluate factors that affect compliance in men who enroll in a phosphodiesterase type 5 inhibitor (PDE5I) protocol after nerve-sparing robot-assisted prostatectomy (RAP), and report on short-term outcomes, as PDE5Is may help restore erectile function after RAP and patient adherence to the regimen is a factor that potentially can affect outcome., Patient and Methods: We prospectively followed 77 men who had nerve-sparing RAP and enrolled in a postoperative penile rehabilitation protocol. The men received either sildenafil citrate or tadalafil three times weekly. The minimum follow-up was 8 weeks. Potency was defined as erection adequate for penetration and complete intercourse. Compliance was defined as men adhering to the regimen for > or =2 months., Results: The mean age of the cohort was 57.8 years and the median follow-up was 8 months. In all, 32% of the men discontinued the therapy <2 months after RAP and were deemed noncompliant with an additional 39% discontinuing therapy by 6 months, with the high cost of medication being the primary reason (65%). Long-term compliance and preoperative erectile dysfunction were independent predictors of potency return after adjusting for age and nerve sparing., Conclusions: The high cost of medication remains a significant barrier to maintaining therapy. Noncompliance to PDE5I therapy in a tertiary care centre was much higher than reported in clinical trial settings. With longer-term follow-up, we need to further define the factors that improve overall recovery of sexual function after RAP.

Objectives: To assess patients who had radical prostatectomy (RP) and pelvic lymph node dissection (PLND) for pT2-4 N0M0 prostate cancer, to determine if LN yield affects the risk of biochemical failure (BCF), as the extent of PLND at the time of RP has become increasingly uncertain with the decreasing trend in tumour stage., Patients and Methods: We reviewed the Columbia University Urologic Oncology Database for patients with pT2-4 N0M0 prostate cancer treated with RP from 1990 to 2005. Exclusion criteria included <12 months of follow-up, incomplete clinical and pathological data, and neoadjuvant androgen-deprivation therapy (ADT) or immediate adjuvant ADT or external beam radiotherapy. Unadjusted and adjusted models were used to determine the ability of clinical and pathological variables to predict BCF., Results: The final dataset included 964 patients, with a mean age of 60.5 years and median preoperative prostate-specific antigen (PSA) level of 6.2 ng/mL. The median (range) LN yield was 7 (1-42) and the median follow-up 59 (12-190) months. In the unadjusted and adjusted models, preoperative PSA, pathological Gleason score, pathological stage, surgical margin status and year of surgery were significant predictors of BCF. The LN group was not a significant predictor of BCF in both the unadjusted and adjusted model (P = 0.759 and 0.408, respectively). When patients were stratified into high- and low-risk groups, LN yield remained an insignificant predictor of BCF., Conclusion: A higher LN yield at the time of RP does not increase the chance of cure for patients with pT2-4N0M0 prostate cancer. This lack of a survival advantage holds true for patients with high-risk disease.

Objectives: To examine by race how frequently the data after radical prostatectomy translates into a substantial change in prognosis. Many nomograms exist to predict the survival outcomes using the pretreatment clinical parameters and post-treatment pathologic parameters. Race might be an important factor affecting their predictive ability., Methods: Kattan nomograms were used to calculate the pretreatment and post-radical prostatectomy 5-year progression-free probability for each patient. The difference between the nomogram scores was used to divide the patients into 3 groups. A decrease in probability of >or=15 percentage points was classified as a significant increase in the probability of recurrence, an increase of >or=15 points was classified as a significant decrease in the probability of recurrence, and an absolute change of <15 points was considered no significant change., Results: The data from 1709 (132 black and 1577 white) men were analyzed. Among the black men, 26.5% had an increase in the probability of recurrence, 57.6% had no change, and 15.9% had a decrease in the probability of recurrence. Among the white men, 13.8% had an increase in the probability of recurrence, 64.5% had no change, and 21.7% had a decrease in the probability of recurrence. Black men were twice as likely to have a significant increase in the probability of recurrence postoperatively compared with white men after adjusting for preoperative prostate-specific antigen level, clinical stage, and biopsy Gleason sum (odds ratio 2.0, 95% confidence interval 1.3-3.1, P = .002)., Conclusions: These data could assist clinicians when counseling black men regarding their treatment options according to their preoperative risk profile.

Objective: To evaluate the safety and feasibility of robotic-assisted radical cystoprostatectomy (RRCP) in a salvage setting for patients with a history of radiation and chemotherapy treatment, complex pelvic anatomy, and significant comorbidities., Materials and Methods: Over a 5 month period, six patients who met these criteria underwent RRCP for urothelial carcinoma. Two of the patients had major cardiovascular disease and were previously denied an open procedure subsequently underwent chemotherapy with external beam radiation protocol. One patient had brachytherapy for prior prostate cancer, and three additional patients had neoadjuvant chemotherapy with large diverticula, measuring up to 12 cm in size. Data was collected on patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes., Results: The mean age was 70.4 years (range 53-84 years) with an average BMI of 25.8 (23.33-28.37). All patients were male. All six RRCPs were completed without intraoperative complications or open conversion. The estimated blood loss was 296 cc (150 cc-500 cc). Four patients had pathologic pT3a disease, one patient had pT4a, and one patient had pT1 urethral squamous cell carcinoma. Four of the patients had positive nodes. All six patients had negative surgical margins. The patients were discharged within a mean of 12 days (range 7-28 days)., Conclusions: Robot-assisted radical cystoprostatectomy is a minimally invasive option in men with complex surgical anatomy and multiple comorbidities. Short term follow up indicates good clinical and pathologic outcome and physiologic benefit of minimally invasive surgery. However a larger cohort with long term follow up is needed to assess the oncologic efficacy of RRCP.

Background: Robotic-assisted radical prostatectomy (RAP) is the dominant minimally invasive surgical treatment for patients with localized prostate cancer. Only a few large series have been published to date, with few long-term data available. The current study presents what to the authors' knowledge is the largest series of patients undergoing RAP with the longest follow-up to data available to date. Using a continuous quality improvement initiative, several technical refinements were adopted, evaluating the impact of this on patient outcome., Methods: Over a 6-year period, 2766 consecutive men underwent RAP at the study institution. Data were collected prospectively including demographic, surgical, oncologic, and functional outcomes with up to 5-year follow-up. The first 200 and most recent 200 patients were compared to determine the impact of experience and quality improvement for patients., Results: The mean age of the patients was 60.2 years and the mean prostate-specific antigen (PSA) level at time of diagnosis was 6.43 ng/mL; 42.4% and 64.2% of patients, respectively, had a biopsy and pathologic Gleason sum of >/=7. The mean surgical and console time was 154 minutes and 116 minutes, respectively. Estimated blood loss was 100 mL; 96.7% of patients were discharged within 24 hours of surgery. At a median follow-up of 22 months, 7.3% of men had a PSA recurrence. The 5-year actuarial biochemical free survival rate was 84%., Conclusions: To the authors' knowledge, the current study is the first report of 5-year outcomes in men undergoing RAP. These data demonstrate that RAP can be performed with favorable outcomes while minimizing complications. As experience increases, further improvements in clinicopathologic and functional parameters are achieved.

Objective: Several investigators have noted that previous inguinal hernia repair with or without the use of prosthetic mesh might be a relative contraindication for open or laparoscopic radical prostatectomy due to the presence of adhesions and the difficulty of tissue dissection. We aimed to evaluate the impact of previous hernia repair on the performance and feasibility of robotic prostatectomy., Materials and Methods: We performed a retrospective analysis of 354 patients who underwent robotic prostatectomy at our institution. The three patient groups were: 292 patients who had no prior hernia repair (group 1), 50 patients who had prior inguinal herniorrhaphy without the use of prosthetic mesh (group 2), and 12 patients who had prior inguinal herniorrhaphy with the use of prosthetic mesh. We compared operative time (surgeon console time), estimated blood loss, and operative complications (bladder, bowel, and/or vascular injuries) in the three groups., Results: Patients with no prior herniorrhaphy (group 1), prior herniorrhaphy without mesh (group 2), and prior herniorrhaphy with mesh (group 3), had similar mean operating times (126.9 minutes, 129.3 minutes and 145.6 minutes, respectively) and similar mean estimated blood loss (152.5 ml, 140.6 ml, and 141.6 ml, respectively) during radical prostatectomy. However, compared to the group of patients who had no prior hernia repair, the group who had prior herniorrhaphy with the use of mesh had a significantly longer mean console operating time (145.6 versus 126.9 minutes, p = .012)., Conclusion: Previous hernia surgery, with or without the use of prosthetic mesh, did not represent a significant barrier to the performance of transperitoneal robotic prostatectomy.

Objectives: Contemporary techniques of radical prostatectomy achieve excellent oncologic outcomes; erectile dysfunction is the most common adverse effect. We have modified our technique of robotic radical prostatectomy (Vattikuti Institute prostatectomy [VIP]) in an attempt to minimize decrease of erectile function while maintaining the excellent oncologic outcomes achieved by the radical retropubic prostatectomy. We present our current technique of VIP with preservation of the lateral prostatic fascia ("veil of Aphrodite")., Methods: A total of 2652 patients with localized carcinoma prostate underwent VIP. The salient features of our current technique are early transection of the bladder neck, preservation of the prostatic fascia, and control of the dorsal vein complex after dissection of the prostatic apex. Oncologic and functional outcomes were obtained through a questionnaire collected by a third party not involved in patient care., Results: Complete follow-up information was obtained in 1142 patients with a minimum follow-up of 12 mo (range: 12-66 mo; median: 36 mo). The actuarial 5-yr biochemical recurrence rate was 8.4% and the actual biochemical recurrence rate was 2.3%. Median duration of incontinence was 4 wk; 0.8% patients had total incontinence at 12 mo. The intercourse rate was 93% in men with no preoperative erectile dysfunction undergoing veil nerve-sparing surgery, although only 51% returned to baseline function., Conclusions: VIP with veil nerve sparing offers oncologic and continence results that are comparable to the results of conventional nerve-sparing radical prostatectomy. Early potency results are encouraging.

Robotic radical prostatectomy is increasingly becoming a popular surgical treatment modality for men with clinically localized prostate cancer. Establishing a robotic prostatectomy program is a tremendous undertaking for any institution requiring both financial support and a dedicated operating room team. A structured approach to learning robotics is paramount in order to successfully start a program while optimizing the learning curve to master the technique and minimize peri-operative complications. We describe our own experience in establishing a robotics program to accomplish a safe and effective operation. In addition, we describe the steps utilized in order to teach our structured approach to other practitioners and institutions around the world. Robotic surgery can be taught to experienced open, as well as, laparoscopic surgeons, and incorporated into residency and fellowship training using this structured approach to learning.