Yen-Chuan Ou1, Chun-Kuang Yang2, Kuangh-Si Chang3, John Wang4, Siu-Wan Hung5, Min-Che Tung6, Ashutosh K Tewari7, Vipul R Patel8. 1. Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C Department of Research, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C ycou228@gmail.com. 2. Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C. 3. Department of Research, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C. 4. Department of Pathology, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C. 5. Department of Radiation, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C. 6. Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan, R.O.C School of Medicine, National Yang-Ming University, Taipei, Taiwan, R.O.C. 7. Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, U.S.A. 8. Global Robotics Institute, Florida Hospital, Orlando, FL, U.S.A.
Abstract
AIM: To report a series of 1,000 patients treated by a single surgeon using robotic-assisted laparoscopic radical prostatectomy (RALP) and to show how to prevent and manage complications of the procedure. PATIENTS AND METHODS: Complication rates were prospectively assessed in a series of 1,000 consecutive patients who underwent RALP (group I, cases 1-200; IIa, 201-400; IIb, 401-600; IIIa, 601-800; and IIIb, 801-1000). Preoperative evaluation focused on patients' history of gout, use of drugs that can influence clotting time, and cardiopulmonary problems. Magnetic resonance imaging (MRI) was routinely performed. Operative difficulty was assessed based on the following variables: neoadjuvant hormonal therapy (NHT), obesity [body mass index (BMI) >30 kg/m(2)], prostate volume >70 g, presence of a large median lobe with intravesical protrusion >1 cm, previous transurethral resection of the prostate, previous pelvic surgery, previous extended pelvic lymph node dissection (EPLND), and salvage robotic radical prostatectomy (SRP). RESULTS: Operative difficulty tended to increase significantly with greater age, higher American Society of Anesthesiologists' anesthetic/surgical risk class scores, increased BMI, and more advanced clinical stage. The number of cases with NHT, obesity, previous pelvic surgery, EPLND, and SRP significantly increased from early to later groups of patients. Conversely, significantly less blood loss occurred in later groups of patients (group I, 179 ml to 97 ml in group IIIb; p<0.001). The need for blood transfusions gradually reduced from 3.5% to 0.5% in groups I and IIIb, respectively (p=0.022). The total complication rate was 6.4% (64/1,000; surgical/medical=5%/1.4%). Complication rates decreased significantly: 12%, 6%, 6%, 4%, and 4% in groups I, IIa, IIb, IIIa, and IIIb, respectively (p=0.003). The most common complications were blood transfusion and bowel problems (11/1,000=1.1%). CONCLUSION: Assessed in terms of groups of 200 cases, the surgeon's learning curve for RALP showed significantly fewer complications even as the operative difficulty of cases increased. The keys to preventing complications were meticulous preoperative evaluation of patients, MRI planning, and a dedicated robotic team for performing RALP. Early diagnosis and management of complications are paramount in patients who present any deviation from the normal postoperative course and clinical care pathway. Copyright
AIM: To report a series of 1,000 patients treated by a single surgeon using robotic-assisted laparoscopic radical prostatectomy (RALP) and to show how to prevent and manage complications of the procedure. PATIENTS AND METHODS: Complication rates were prospectively assessed in a series of 1,000 consecutive patients who underwent RALP (group I, cases 1-200; IIa, 201-400; IIb, 401-600; IIIa, 601-800; and IIIb, 801-1000). Preoperative evaluation focused on patients' history of gout, use of drugs that can influence clotting time, and cardiopulmonary problems. Magnetic resonance imaging (MRI) was routinely performed. Operative difficulty was assessed based on the following variables: neoadjuvant hormonal therapy (NHT), obesity [body mass index (BMI) >30 kg/m(2)], prostate volume >70 g, presence of a large median lobe with intravesical protrusion >1 cm, previous transurethral resection of the prostate, previous pelvic surgery, previous extended pelvic lymph node dissection (EPLND), and salvage robotic radical prostatectomy (SRP). RESULTS: Operative difficulty tended to increase significantly with greater age, higher American Society of Anesthesiologists' anesthetic/surgical risk class scores, increased BMI, and more advanced clinical stage. The number of cases with NHT, obesity, previous pelvic surgery, EPLND, and SRP significantly increased from early to later groups of patients. Conversely, significantly less blood loss occurred in later groups of patients (group I, 179 ml to 97 ml in group IIIb; p<0.001). The need for blood transfusions gradually reduced from 3.5% to 0.5% in groups I and IIIb, respectively (p=0.022). The total complication rate was 6.4% (64/1,000; surgical/medical=5%/1.4%). Complication rates decreased significantly: 12%, 6%, 6%, 4%, and 4% in groups I, IIa, IIb, IIIa, and IIIb, respectively (p=0.003). The most common complications were blood transfusion and bowel problems (11/1,000=1.1%). CONCLUSION: Assessed in terms of groups of 200 cases, the surgeon's learning curve for RALP showed significantly fewer complications even as the operative difficulty of cases increased. The keys to preventing complications were meticulous preoperative evaluation of patients, MRI planning, and a dedicated robotic team for performing RALP. Early diagnosis and management of complications are paramount in patients who present any deviation from the normal postoperative course and clinical care pathway. Copyright
Authors: Marco Cascella; Giuseppe Quarto; Giovanni Grimaldi; Alessandro Izzo; Raffaele Muscariello; Luigi Castaldo; Barbara Di Caprio; Sabrina Bimonte; Paola Del Prete; Arturo Cuomo; Sisto Perdonà Journal: Medicine (Baltimore) Date: 2019-11 Impact factor: 1.817