Self-learning in robot-assisted laparoscopic radical prostatectomy. Intraoperative outcomes and initial experience without any assistance from a tutor
The transperitoneal approach remains the most accepted and popular approach in performing robot-assisted laparoscopic radical prostatectomy (RALP) associated with minimal perioperative morbidity and good functional and oncological outcomes (1). Choice of approach should be related on patient characteristics as well as surgeon preference (2). The aim of this paper was to report our initial experience in performing RALP without any assistance from a tutor.
Materials and Methods
From January to December 2016, 36 patients underwent a RALP to our Department of Urology. Of these, 17 patient underwent a RALP using an extraperitoneal approach (Group A) and 19 using a transperitoneal approach (Group B), with a progressive shift from the extraperitoneal to the transperitoneal access. In the first six months of the year only 3 out of 15 patients underwent a transperitoneal RALP. 12 out of 36 patients (33.3%) underwent a simultaneous pelvic lymphadenectomy. Of these, only 2 patients underwent a lymphadenedctomy with an extraperitoneal approach. The da Vinci Xi surgical robotic system was used in all the cases.
All procedures were performed by a single surgical team with a good experience in laparoscopic procedures.
The mean operative time was 191,25±57,26 for Group A and 156,88±28,7 for Group B (p=0,0302).
The mean operative time for docking and for trocar positioning was 38,13±7,72 for Group A and 25,63±5,74 for Group B.
The mean blood losses were similar in the two groups (268,75±161,16 for Group A and 293,75±378,98 for Group B, p=0,8032). In one patient a shift from the extraperitoneal to the transperitoneal approach was needed. In 13 out of 17 patients a small hole in the peritoneum was made during the extraperitoneal approach. The rate of complications was similar in both groups. In the group A, one patient experience a gastric hemorrhage, one patient a leakage from the anastomosis, and one patients experience the dislocation of the urethral catheter because of a bladder anterior wall lesion that was repaired during the procedure.
In the group B, two patients experience a leakage from the anastomosis and one patient a rectal injury that was repaired during the procedure without postoperative sequelae.
The normalization of the intestinal canalization was slightly inferior for the group A but we have not reached the statistical significance (Group A= 2,63±0,72, Group B=3,25±1,19, p=0.0756). The time of dismissal from the hospital was similar in the two groups (Group A=4,94±1,95, Group B=4,69±1,20, p=0,6629)
At the beginning of our learning curve in robotic procedures, without any assistance from a tutor, we were loath to the use of the fourth robotic arm. Despite this only four procedures were performed without the use of the fourth arm. The fourth arm was always placed on the left side of the abdomen (the same side of the bipolar forceps for the right-hander). Moreover, in the first three procedures we used to coagulate the prostatic pedicle with the Caiman instrument. After this first procedures we understood the utility of the fourth arms and we started the coagulation of the prostatic pedicles using the bipolar energy.
In our experience we assisted to a shift from the extraperitoneal to the transperitoneal approach. It is mainly related to the difficulty to introduce the trocar for the Air Seal system and for the bigger work spaces associated with the transperitoneal approach. Moreover in the last six months of the year, we started to perform a lot of “high risk group” radical prostatectomy with the robotic technology. As a consequence the need to perform an extensive lymphadenectomy lead to us to choose a transperitoneal approach.
In our experience we had a shorter operative time in the Group B despite the bigger number of lymphadenectomy performed in this group. It can be related to the use of an easier approach. Moreover in the last six months of the year, the surgical team was at a more advanced point in the learning curve for all steps of the robotic procedures. In conclusion, in the last five procedure in Group B, we used a V-Loc absorbable wound closure devices that helps the surgeon to perform a quicker anastomosis.
In our department less than 1% of laparoscopic radical prostatectomy were performed with the transperitoneal approach. The extraperitoneal approach to RALP was described as a good alternative to the transperitoneal approach with similar intraoperative, postoperative and functional outcomes (3). In our experience the transperitoneal approach is only related to a shorter operative time. In our opinion, surgeons should be familiar with both approaches in order to provide patients with the best care.
1-Patel VR, Thaly R, Shah K.Robotic radical prostatectomy: outcomes of 500 cases. BJU Int. 2007 May;99(5):1109-12.
2- Capello SA, Boczko J, Patel HR, Joseph JV. Randomized comparison of extraperitoneal and transperitoneal access for robot-assisted radicalprostatectomy. J Endourol. 2007 Oct;21(10):1199-202.
3-Akand M, Erdogru T, Avci E, Ates M.Transperitoneal versus extraperitoneal robot-assisted laparoscopic radical prostatectomy: A prospective single surgeon randomized comparative study. Int J Urol. 2015 Oct;22(10):916-21.Argomenti: cancro della prostata