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The Canadian Journal of Urology Jun 2017We sought to apply the principles of human factors research to robotic-assisted radical prostatectomy to understand where training and integration challenges lead to...
INTRODUCTION
We sought to apply the principles of human factors research to robotic-assisted radical prostatectomy to understand where training and integration challenges lead to suboptimal and inefficient care.
MATERIALS AND METHODS
Thirty-four robotic-assisted radical prostatectomy and bilateral pelvic lymph node dissections over a 20 week period were observed for flow disruptions (FD) - deviations from optimal care that can compromise safety or efficiency. Other variables - physician experience, trainee involvement, robot model (S versus Si), age, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical status - were used to stratify the data and understand the effect of context. Effects were studied across four operative phases - entry to insufflations, robot docking, surgical intervention, and undocking. FDs were classified into one of nine categories.
RESULTS
An average of 9.2 (SD = 3.7) FD/hr were recorded, with the highest rates during robot docking (14.7 [SD = 4.3] FDs/hr). The three most common flow disruptions were disruptions of communication, coordination, and equipment. Physicians with more robotic experience were faster during docking (p < 0.003). Training cases had a greater FD rate (8.5 versus 10.6, p < 0.001), as did the Si model robot (8.2 versus 9.8, p = 0.002). Patient BMI and ASA classification yielded no difference in operative duration, but had phase-specific differences in FD.
CONCLUSIONS
Our data reflects the demands placed on the OR team by the patient, equipment, environment and context of a robotic surgical intervention, and suggests opportunities to enhance safety, quality, efficiency, and learning in robotic surgery.
Topics: Clinical Competence; Communication; Efficiency; Ergonomics; Humans; Lymph Node Excision; Male; Middle Aged; Operative Time; Patient Care Team; Prostatectomy; Robotic Surgical Procedures; Surgical Equipment
PubMed: 28646936
DOI: No ID Found -
Investigative and Clinical Urology May 2022The selection of open prostatectomy (OP) over transurethral laser surgery is controversial for large volume prostates. Thus, we aim to compare the efficacy and safety of... (Meta-Analysis)
Meta-Analysis
Comparison of the efficacy and safety of transurethral laser versus open prostatectomy for patients with large-sized benign prostatic hyperplasia: A meta-analysis of comparative trials.
PURPOSE
The selection of open prostatectomy (OP) over transurethral laser surgery is controversial for large volume prostates. Thus, we aim to compare the efficacy and safety of transurethral laser versus OP, and provide the latest evidence of clinical practice for large-sized benign prostatic hyperplasia (BPH).
MATERIALS AND METHODS
This meta-analysis used Review Manager V5.3 software and the systematic literature search of Cochrane Library, Embase, PubMed, and Web of Science datasets was performed for citations published from 2000 to 2020 that compared transurethral laser with OP for the treatment of large BPH. Variables of interest assessing the two techniques included clinical characteristics, and the perioperation-, effectiveness-, and complication-related outcomes.
RESULTS
The meta-analysis included twelve studies containing 1,514 patients, with 792 laser and 722 OP. The transurethral laser group was associated with shorter hospital stay and catheterization duration, and less hemoglobin decreased in the perioperative variables. There was no significant difference in the international prostate symptom score, post-void residual urine volume, maximum flow rate, and quality of life score. Transurethral laser group had a significantly lower incidence of blood transfusion than OP group (odds ratio, 0.10; 95% confidence interval, 0.05 to 0.19; p<0.001; I²=8%), and no statistical differences were found with respect to the other complications.
CONCLUSIONS
Both OP and transurethral laser prostatectomy are effective and safe treatments for large prostate adenomas. With these advantages of less blood loss and transfusion, and shorter catheterization time and hospital stay, laser may be a better choice for large BPH.
Topics: Humans; Lasers; Male; Prostatectomy; Prostatic Hyperplasia; Quality of Life; Transurethral Resection of Prostate; Treatment Outcome
PubMed: 35437960
DOI: 10.4111/icu.20210281 -
European Review For Medical and... Feb 2015To compare outcomes of open (O-), laparoscopic (L-) and robot-assisted laparoscopic (RAL-) radical prostatectomy (RP) performed by the same surgeon. (Comparative Study)
Comparative Study
Open, laparoscopic and robot-assisted laparoscopic radical prostatectomy: comparative analysis of operative and pathologic outcomes for three techniques with a single surgeon's experience.
OBJECTIVE
To compare outcomes of open (O-), laparoscopic (L-) and robot-assisted laparoscopic (RAL-) radical prostatectomy (RP) performed by the same surgeon.
PATIENTS AND METHODS
From May 1999 to April 2012, 484 RPs were performed by a single surgeon. Patients' data including age, body-mass index, serum prostate specific antigen (PSA) level, Gleason score of prostate biopsy and prostatectomy specimen, preoperative prostate and specimen volumes, clinical and pathologic stages, operation time, estimated blood loss (EBL), catheterization time, blood transfusion rate were recorded. Prospectively collected data was evaluated retrospectively by statistical analyses.
RESULTS
Of 484 radical prostatectomies, ORP (50), LRP (308) and RALRP (79) done by the same surgeon were included into study. Mean ages were 63.8, 62.7 and 60.3 years for ORP, LRP and RALRP respectively. Operation times for ORP, LRP and RALRP were 255, 208 and 242 minutes. EBL and hospitalization time were 602, 526, 234 mL, and 9.1, 3.2, 3.2 days for ORP, LRP and RALRP, respectively. While a significant advantage was found for EBL and complication rates in RALRP and for operation time in LRP, significant disadvantages were found in terms of catheterization time, hospitalization time, decrease in hemoglobin and blood transfusion in ORP. However, preoperative prostate volume and serum PSA level, oncologic outcomes and positive surgical margins were nearly similar in all operative techniques.
CONCLUSIONS
Minimally invasive techniques such as LRP and RALRP are promising techniques with comparable outcomes with ORP. Shorter catheterization time, less blood loss and fewer complication rates can be provided by RALRP.
Topics: Aged; Blood Transfusion; Humans; Laparoscopy; Length of Stay; Male; Middle Aged; Neoplasm Grading; Operative Time; Prostate-Specific Antigen; Prostatectomy; Prostatic Neoplasms; Retrospective Studies; Robotic Surgical Procedures; Surgeons; Treatment Outcome
PubMed: 25753865
DOI: No ID Found -
Asian Journal of Andrology 2021This study aims to investigate whether clinical and biological preoperative characteristics of patients who were to undergo radical prostatectomy were associated with...
This study aims to investigate whether clinical and biological preoperative characteristics of patients who were to undergo radical prostatectomy were associated with impairment in patient-reported quality of life (QoL) and erectile dysfunction immediately before intervention. We evaluated patient-reported outcomes among 1019 patients (out of 1343) of the AndroCan study, willing to score the Aging Male Symptom (AMS) and the International Index of Erectile Function 5-item (IIEF-5) auto-questionnaires. Univariate linear regression and robust multiple regression were used to ascertain the relationship between demographic, clinical, and hormonal parameters and global AMS or IIEF-5 scores. As a result, most patients (85.1') of the Androcan cohort agreed to complete questionnaires. Significantly higher IIEF-5 global scores were found in non-Caucasian and obese patients, with larger waist circumference, metabolic syndrome, diabetes mellitus, cardiovascular disease, hypertension, high blood sugar, concomitant medications, and hypogonadism, while the AMS global score was significantly higher in patients with larger waist circumference, metabolic syndrome, high blood pressure, raised glycemia, and concomitant medication. The IIEF-5 global score was correlated to age, dehydroepiandrosterone (DHEA), fat mass percentage, and androstenediol (D5). The AMS global score was significantly correlated to DHEA, D5, and DHEA sulfate. Finally, the multivariate models showed that QoL and erectile function were significantly affected, before surgery, by symptoms and signs that are usually considered as pertaining to the metabolic syndrome, while sexual hormones are essentially correlated to erectile dysfunction.
Topics: Adult; Aged; Androgens; Erectile Dysfunction; Humans; Male; Metabolic Syndrome; Middle Aged; Preoperative Period; Prostatectomy; Quality of Life; Severity of Illness Index; Surveys and Questionnaires
PubMed: 33762475
DOI: 10.4103/aja.aja_3_21 -
Archivio Italiano Di Urologia,... Dec 2013To reassess the double continence technique for open retropubic radical prostatectomy, proposed by Malizia and employed by Pagano et al., with the "tension free...
Modified radical retropubic prostatectomy: personal technical variation "tension free continuum-urethral anastomosis (T.F.C.U.A)" with optical magnification in the preservation of the bladder neck, and estimation of the urinary continence.
OBJECTIVE
To reassess the double continence technique for open retropubic radical prostatectomy, proposed by Malizia and employed by Pagano et al., with the "tension free continuum-urethral anastomosis" (T.F.C.U.A.) personal modification and the use of image magnification optical systems and appropriate and delicate surgical tools.
MATERIALS AND METHODS
A total of 173 radical retropubic prostatectomies, performed by the same surgeon, were evaluated in terms of early and late continence.
RESULTS
The presence of residual prostate cancer cells within the muscle layer was always excluded by the histopathological examination that also demonstrated that the muscle layer was well represented; satisfactory outcomes were obtained in terms of both early urinary continence (60%) and urinary continence at 6-12 month follow-up (92.4% for the whole series and 97.2% for the last series of patients).
CONCLUSIONS
The "tension free" anastomosis obtained by the suspension of the anterior bladder wall to the the pubis along the median line allowed to achieve satisfactory outcomes in terms of urinary continence, even if these data obviously need to be confirmed by other series and comparative trials.
Topics: Anastomosis, Surgical; Follow-Up Studies; Humans; Male; Organ Sparing Treatments; Prostatectomy; Prostatic Neoplasms; Urethra; Urinary Bladder; Urinary Incontinence
PubMed: 24399116
DOI: 10.4081/aiua.2013.4.170 -
BMC Cancer May 2012Prostate cancer is the most common male cancer in the Western world however there is ongoing debate about the optimal treatment strategy for localised disease. While... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Prostate cancer is the most common male cancer in the Western world however there is ongoing debate about the optimal treatment strategy for localised disease. While surgery remains the most commonly received treatment for localised disease in Australia more recently a robotic approach has emerged as an alternative to open and laparoscopic surgery. However, high level data is not yet available to support this as a superior approach or to guide treatment decision making between the alternatives. This paper presents the design of a randomised trial of Robotic and Open Prostatectomy for men newly diagnosed with localised prostate cancer that seeks to answer this question.
METHODS/DESIGN
200 men per treatment arm (400 men in total) are being recruited after diagnosis and before treatment through a major public hospital outpatient clinic and randomised to 1) Robotic Prostatectomy or 2) Open Prostatectomy. All robotic prostatectomies are being performed by one surgeon and all open prostatectomies are being performed by one other surgeon. Outcomes are being measured pre-operatively and at 6 weeks and 3, 6, 12 and 24 months post-surgery. Oncological outcomes are being related to positive surgical margins, biochemical recurrence +/- the need for further treatment. Non-oncological outcome measures include: pain, physical and mental functioning, fatigue, summary (preference-based utility scores) and domain-specific QoL (urinary incontinence, bowel function and erectile function), cancer specific distress, psychological distress, decision-related distress and time to return to usual activities. Cost modelling of each approach, as well as full economic appraisal, is also being undertaken.
DISCUSSION
The study will provide recommendations about the relative benefits of Robotic and Open Prostatectomy to support informed patient decision making about treatment for localised prostate cancer; and to assist in treatment services planning for this patient group.
TRIAL REGISTRATION
ACTRN12611000661976.
Topics: Adult; Aged; Australia; Humans; Laparoscopy; Male; Middle Aged; Prostate; Prostatectomy; Prostatic Neoplasms; Quality of Life; Robotics; Surveys and Questionnaires; Treatment Outcome
PubMed: 22632109
DOI: 10.1186/1471-2407-12-189 -
Clinical Nutrition ESPEN Feb 2022Many dietary supplements, including omega-3 fatty acids (ω3), are suspected to affect blood coagulation and platelet function. Despite no clinical evidence,... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND AND AIMS
Many dietary supplements, including omega-3 fatty acids (ω3), are suspected to affect blood coagulation and platelet function. Despite no clinical evidence, discontinuation is recommended before radical prostatectomy. However, long-chain ω3 (LCω3) appear beneficial against prostate cancer progression. Here, we aim to determine the effect of LCω3 supplements on perioperative bleeding, hemoglobin, platelets, and postoperative complications after radical prostatectomy.
METHODS
This is a planned exploratory analysis of 130 patients diagnosed with prostate cancer grade group 2 or greater enrolled in a randomized controlled trial (NCT02333435) testing the effects of LCω3, on prostate cancer biological and pathological outcomes at radical prostatectomy as main outcomes. The LCω3 intervention (MAG-EPA 3 g daily) or equivalent placebo was given 4-10 weeks prior to radical prostatectomy. An intention-to-treat analysis approach was used with bi-variate statistical testing of bleeding and complications outcomes. We also estimated the difference between groups using linear regression and non-parametric quantile regression models. All models were adjusted for confounding variables selected on clinical relevance.
RESULTS
We found no clinically significant effect of LCω3 versus placebo on perioperative bleeding, laboratory tests or postoperative complications. In contrast, as expected, we found a significant increase in perioperative bleeding in open retropubic radical prostatectomy compared to robot-assisted radical prostatectomy (adjusted difference 115.8 mL, p = 0.04).
CONCLUSIONS
Our results suggest that ω3 supplements can be safely taken before radical prostatectomy without increasing surgical bleeding risk. These findings are relevant since ω3 may beneficially affect prostate cancer evolution.
Topics: Blood Loss, Surgical; Dietary Supplements; Fatty Acids, Omega-3; Humans; Male; Prostate; Prostatectomy
PubMed: 35063205
DOI: 10.1016/j.clnesp.2021.12.011 -
International Braz J Urol : Official... 2024Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation... (Review)
Review
BACKGROUND AND OBJECTIVE
Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP.
MATERIALS AND METHODS
We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings: Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively.
CONCLUSIONS
Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.
Topics: Humans; Prostatectomy; Male; Salvage Therapy; Prostatic Neoplasms; Robotic Surgical Procedures; Laparoscopy; Neoplasm Recurrence, Local; Treatment Outcome; Postoperative Complications
PubMed: 38701186
DOI: 10.1590/S1677-5538.IBJU.2024.0126 -
Investigative and Clinical Urology Jan 2020Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological... (Review)
Review
Robotic radical prostatectomy (RARP) is a standardized treatment for localized prostate cancer, which provides better functional outcomes and similar oncological outcomes compared to open approaches. Here, we share our experience of 12,000 RARPs by describing the outcomes of the procedure in terms of positive surgical margin (PSM), continence, and potency as well as by presenting our detailed surgical technique with recent modifications. On cancer control, the PSM rates were 5.8% and 26.1% in T2 and T3, respectively. On the premise of not compromising oncologic outcomes, a tailored approach to individual patients is essential. Even if an extracapsular extension is suspected, neurovascular bundle (NVB) tailoring can be applied using an anatomical landmark to preserve maximal nerve tissue with a negative margin. We developed a nomogram as a useful tool for deciding the degree of tailoring. For improvements of functional outcomes, we used athermal retrograde early release with a toggling technique, wherein the nerve dissection from the bottom helps with blood loss and allows for smooth NVB releasing. Additionally, we recently performed a new minimal apical dissection/lateral prostatic fascia preservation technique. As a result, our 1-week continence rate was 37% and the 6-week rate was 77.6%. In addition, the potency rates in our study were 69%, 82%, and 92% at 3 months, 6 months, and 1 year, respectively (preoperative Sexual Health Inventory for Men scores >21 & bilateral full nerve spared).
Topics: Dissection; Erectile Dysfunction; Humans; Male; Margins of Excision; Neoplasm, Residual; Nomograms; Peripheral Nerves; Prostatectomy; Prostatic Neoplasms; Robotic Surgical Procedures; Urinary Incontinence
PubMed: 31942457
DOI: 10.4111/icu.2020.61.1.1 -
Archivio Italiano Di Urologia,... Jun 2020To assess the economic impact of Holmium laser enucleation of prostate (HoLEP) in comparison with transurethral resection of prostate (TURP) and open prostatectomy (OP). (Comparative Study)
Comparative Study
OBJECTIVE
To assess the economic impact of Holmium laser enucleation of prostate (HoLEP) in comparison with transurethral resection of prostate (TURP) and open prostatectomy (OP).
METHODS
Between January 2017 and January 2018, we prospectively enrolled 151 men who underwent HoLEP, TURP or OP at tertiary Italian center, due to bladder outflow obstruction symptoms. Patients with prostate volume ≤ 70 cc and those with prostate volume > 70 cc were scheduled for TURP or HoLEP and OP or HoLEP, respectively. Intraoperative and early post-operative functional outcomes were recorded up to 6 months follow up. Cost analysis was carried out considering direct costs (operating room [OR] utilization costs, nurse, surgeons and anesthesiologists' costs, OR disposable products costs and OR products sterilization costs), indirect costs (hospital stay costs and diagnostics costs) and global costs as sum of both direct and indirect plus general costs related to hospitalization. Cost analysis was performed comparing patients referred to TURP and HoLEP with prostate volume ≤ 70 cc and men underwent OP and HoLEP with prostate volume > 70 cc respectively.
RESULTS
Overall, 53 (35.1%), 51 (33.7%) and 47 (31.1%) were scheduled to HoLEP, TURP and OP, respectively. Both TURP, HoLEP and OP proved to effectively improve urinary symptoms related to BPE. Considering patients with prostate volume ≤ 70 cc, median global cost of HoLEP was similar to median global cost of TURP (2151.69 € vs. 2185.61 €, respectively; p = 0.61). Considering patients with prostate volume > 70 cc, median global cost of HoLEP was found to be significantly lower than median global cost of OP (2174.15 € vs. 4064.97 €, respectively; p ≤ 0.001).
CONCLUSIONS
Global costs of HoLEP are comparable to those of TURP, offering a cost saving of only 11.4 € in favor of HoLEP. Conversely, HoLEP proved to be a strong competitor of OP because of significant global cost sparing amounting to 1890.82 € in favor of HoLEP.
Topics: Aged; Aged, 80 and over; Costs and Cost Analysis; Electrosurgery; Humans; Italy; Lasers, Solid-State; Male; Middle Aged; Prospective Studies; Prostatectomy; Prostatic Hyperplasia; Tertiary Care Centers; Transurethral Resection of Prostate; Urinary Bladder Neck Obstruction
PubMed: 32597105
DOI: 10.4081/aiua.2020.2.82