Robotic Prostate Surgery
Mr Chris Ogden - The Royal Marsden Hospital
Prostate cancer treatment
Private: 020 7603 6067 | NHS: 020 7808 2076
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ERUS 2019
Mr Christopher Ogden presents to ERUS 2019 his radical perineal insufflated prostatectomy series - the first in Europe and the third series in the world along with Dr Jihad Kaouk, Cleveland Clinic, USA.
Introduction & Objectives
Open perineal prostatectomy (OPP) for decades was a favoured approach for localised prostate cancer surgery. The perineal approach has been largely superseded by the retropubic radical prostatectomy, but OPP still maintains its benefits of avoiding intraperitoneal structures and the abdomen entirely. Urological Professor Jihad Kaouk, Cleveland, USA has pioneered the Robotic Perineal Prostatectomy (RPP) and his expertise shared with our Unit for our first case, has now translated to a series in our Department.
Materials & Methods
Eleven patients were offered RPP with da Vinci surgical system (Intuitive Surgical Inc.) Xi model. Thorough clinic counselling on associated benefits and risks compared to the the traditional retropubic approach was undertaken. Eight patients underwent this procedure and data was retrieved from electronic records.
Results
2/11 patients decided to opt for retropubic prostatecomy. 1/11 patient was advised due to Anaesthetic concerns to have retropubic surgery due to average shorter operative time to completion.
N = 8 RPP
Age = 64.5 (62 - 70)
ECOG 0/1, ASA 2
BMI 27.3 (23 - 31.5)
Mean Perineal dissection, mean = 40min
Mean Console Time = 125min
Estimated blood loss = 180cc (maximum 300)
Mean Length of stay = 2 days (1 -2)
No post-operative opioid requirements
Conclusions Our UK RPP series is the first in Europe and is safe, feasible and can be taught and assimilated into Units. The peritoneum is not encountered and associated surgical and anaesthetic risks are avoided. Previous major abdominal surgery must no longer exclude patients from Robotic Radical Prostatectomy.
Long term BCR free interval at minimum 5 year follow up post RALP in the UK
Intro
RALP has entered its second decade as a well-established method of treatment for localised prostate cancer. The long term outcomes of patients post RALP is still being investigated. There has been 1 other publication with any long term follow up post RALP in the UK with a sample population of 175 patients. We looked at the oncological outcome in terms of the Bio-Chemical Recurrence (BCR) free for the first 500 consecutive patients operated upon by a single surgeon with a minimum follow up of 5 years. We compared the results with currently published data.
Materials and Methods
Patient data was collected retrospectively on all patients who underwent a RALP between 1st Jan 2007 and 31th May 2010. Exclusion criteria used to narrow the patient population were complete lack of follow up PSA data or development of other significantly morbid pathology. For the remaining eligible patients, final T staging and follow up PSA data were tabulated. BCR was defined as a post op PSA of >0.2 ng/ml consistently on 2 or more occasions. Percentage recurrence in various populations were calculated and then compared to currently published data.
Results
One Patient was found to have undiagnosed metastatic disease post-surgery. The remaining patient distribution by final Gleasons and T stage were:
Gleason Grade | Percentage of Patients |
|---|---|
6 | 22 |
7 | 73.5 |
8 | 1.5 |
9 | 2.5 |
Pathalogical T Stage | Percentage |
|---|---|
pT2a | 12 |
pT2b | 2.5 |
pT2c | 61.5 |
pT3a | 16 |
pT3b | 7.5 |
The overall PSM and BCR rates were around 24% and 12%. Distribution of BCR by Gleasons and final pathological T stage were:
Gleasons | BCR (in %) |
|---|---|
6 | 4.5 |
>7 | 14 |
T Stage | BCR (in %) |
|---|---|
T2 | 4.5 |
T3 | 21 |
Conclusions
The reported long term data on BCR by Menon et al, Sukumar et al, Suardi et al and Billia et al suggest 5 year BCR free rates of 86.5%, 90.2%, 86% and 95.4% respectively. These correspond to our rate of 88%. This 5 year data includes data from the surgeons "learning curve", the change form a 3 to a 4 arm system. There have also been many minor modifications in the dissection and reconstruction techniques due better understanding of the relevant anatomy and physiology, the introduction of newer suture materials and haemostatic agent etc.
The outcomes published till date validate the need for proper risk stratification and appropriate management to maximize clinical benefit for patients. The correlation between post op staging and Gleason’s grade with BCR also highlight the need for reassessment post RALP to consider adjuvant therapy especially in high risk populations.
