102 Matthew Goland‐Van Ryn,1 Daniel Rosen,1 Thomas Bessede,2 & Ashutosh Tewari1 1 Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA 2 Department of Urology, University of Paris‐Sud, Orsay, France Optimization of the robot‐assisted laparoscopic radical prostatectomy (RALP) principally focuses on three main outcomes: cancer control, continence, and erectile function. Innovations that address these areas have been applied preoperatively, intraoperatively, and postoperatively. Although the primary purpose of RALP is the safe removal of cancer, advances in our understanding of pelvic anatomy have allowed RALP to cause the least amount of collateral damage possible. Furthermore, the innovation of the robot‐assisted technique allows for higher magnification and vision of tissues as well as increased range of motion with which to manipulate them. Consequently, the past two decades have seen several advances in radical prostatectomy technique, including in bladder neck dissection, prostatic nerve sparing, and urethral anastomosis. A delay of six weeks following biopsy has traditionally been recommended to allow inflammation to subside. One single‐surgeon retrospective study showed the surgeon was less able to perform bilateral nerve sparing when the procedure was performed within six weeks compared to waiting the six‐week period, without seeing any differences in operative outcomes [1]. On the other hand, a large retrospective study showed no increase of adverse events or efficacy of surgery when performed prior to the conclusion of the six‐week waiting period [2]. Further studies have shown that a six‐week delay is unlikely to adversely affect patient outcomes. A large retrospective study found that adverse pathological outcomes did not develop by delaying prostatectomy until 150 days after biopsy for patients with Gleason <6 and prostate‐specific antigen (PSA) 0–10, 60 days for patients with Gleason 7 and PSA >20, and 30 days for patients with Gleason 8–10 and PSA 11–20 [3]. Accordingly, given data showing no worse outcomes within six weeks of biopsy and the desire to avoid unnecessary stress and psychological harm to the patient, prostatectomy may be performed as soon as possible following biopsy. As advances in technology have rapidly progressed, utilization of pelvic magnetic resonance imaging (MRI) has taken on an important role in preoperative planning for patient counseling and surgical preparation. If undertaken post‐biopsy, MRI is generally performed 6–8 weeks following biopsy to decrease artifact from hemorrhage [4]. Preoperative MRI, through the use of the Likert scale, can assess for the presence of clinically significant cancer, and can predict both biochemical recurrence and prostate cancer‐specific mortality [5, 6]. Furthermore, information for the surgery itself can be gleaned from the MRI and utilized to predict surgical complexity [7]. The use of MRI preoperatively can also be used by the surgeon to assess the location and involvement of nerves and the likelihood of extracapsular spread and seminal vesicle invasion [4, 8]. This knowledge can then be used to direct intraoperative frozen‐section analysis to reduce the rate of positive surgical margins (PSMs), though recent data suggests this advantage may only appear in cT1 tumors [9, 10]. Figure 102.1 shows a 3 tesla pelvic MRI with a right‐sided lesion abutting the prostatic capsule, providing valuable clinical information about where a wider dissection may be required. Despite the advantages of MRI, it does have certain limitations. The presence of post‐biopsy inflammation can impair interpretation, and the sensitivity and specificity of the MRI is radiologist dependent [4]. The complexity of interpretation of the study strengthens the need for specifically trained radiologists interpreting the MRI. An additional limitation is the significant cost associated with the study, and availability and accessibility of high‐quality MRI machines. Given its multitude of advantages, pelvic MRI has become an important tool for preoperative optimization. Figure 102.1 A 3 T T2 signal MRI showing Prostate Imaging Reporting and Data System (PI‐RADS) 5 lesion abutting the prostatic capsule on the right transition/peripheral zone. Preoperative exercise and increased activity are recommended for several reasons. First, several studies have pointed to increased complications and surgical difficulty in patients with greater body mass index (BMI) [11, 12]. The second reason is the desire to limit venous thromboembolism (VTE) by increasing physical activity and avoiding stasis. Finally, patients with higher baseline activity levels preoperatively have comparatively improved quality of life following radical prostatectomy [13]. Increasing preoperative mobility may also help motivate the postoperative patient to resume normal activities more quickly. Smoking is a demonstrable risk factor for surgical site infections in addition to its other detrimental effects on the body [14, 15]. As a result, cessation counseling should always be provided prior to surgery. Even abstinence of smoking in a current smoker in the perioperative period can lead to decreased risk of infection [15]. There has also been some controversy as to whether smoking cessation has an impact on biochemical recurrence, though the most recent data demonstrate that smoking must be stopped at least 10 years prior to surgery to have an effect on disease recurrence [16]. Preoperatively, it is also important to quantify baseline erectile function status for several reasons. First, quantification of baseline establishes realistic expectations for postoperative potency. A recent study demonstrated that even returning to baseline does not always lead to patient satisfaction, making preoperative counseling vital to postoperative satisfaction [17]. Furthermore, patients undergoing RALP have higher expectations with regards to recovery of erectile function than following an open procedure [18]. Preoperative erectile function can be evaluated at the time of biopsy to avoid the psychogenic influences of the immediate preoperative period [19, 20]. Potency and sexual function can be quantified using one of the many validated questionnaires of sexual health such as the International Index of Erectile Function (IIEF). Postoperative urinary incontinence is a potential outcome following RALP and should be approached proactively. A recent meta‐analysis demonstrated that preoperative pelvic floor muscle exercises (PFME) might shorten time to recovery of continence. The meta‐analysis demonstrated equivalent return to continence at one and six months, but a 36% reduced risk of incontinence at three months with usage of PFME at three months. Most suggested regimens involve physiotherapist guidance beginning 2–6 weeks preoperatively [21]. Yet, several of these studies suffer from biases including improper postoperative comparisons, limited postoperative PFME, or inconsistent continence criteria. Hoping to address this, a prospective randomized clinical trial found reduced risk of incontinence at both one and three months postoperatively for those undergoing 30 days of biweekly therapy [22]. However, in a 180‐patient randomized clinical trial, conflicting results were found showing that three weeks of preoperative therapy had no improvement of continence following prostatectomy [23]. The discrepancy between the studies’ findings may stem from the difference in definition of continence, with the first using patient’s voiding diary and the second using a more stringent definition of 3 consecutive days of 0 g urine loss on a 24‐hour pad. Although the data are not conclusive, many of the studies suggest a potential benefit of preoperative PFME without any significant clinical downside. Though RALP has traditionally involved a mandatory inpatient admission, efforts have been made in recent years to test the feasibility of performing the RALP as an outpatient procedure. Two small studies conducted by experienced surgeons with carefully selected patients showed that >90% of the patients treated by these surgeons were able to undergo outpatient RALP without any observed detriment to surgical outcomes or patient satisfaction [24, 25]. The American Urological Association (AUA) Best Practice guidelines recommend 24 hours of treatment with antibiotics to be started preoperatively for RALP. First‐line therapy involves a first‐ or second‐generation cephalosporin or an aminoglycoside or aztreonam with either metronidazole or clindamycin. Second‐line antibiotics are ampicillin/sulbactam or a fluoroquinolone. A significant though rare source of morbidity and mortality following RALP stems from VTE, a term comprising both deep venous thromboembolism (DVT) and pulmonary embolism (PE). RALP patients are at risk for VTE due to the extended time spent in lithotomy position. Several studies have identified additional common risk factors for VTE including prior VTE diagnosis, smoking, obesity, and extended operating room time and requirement for lymph node dissection. Accordingly, in complex cases expert consultation is warranted. Studies examining the occurrence of VTE postoperatively found 17% prevalence of asymptomatic VTE and 0.5–2% symptomatic VTE. Critically, most symptomatic VTE events occurred following discharge, with peak occurrence occurring 2–4 weeks following surgery [26, 27]. Consequently, patients should be warned about the signs and symptoms of DVT and PE prior to discharge as well as their potentially catastrophic consequences. A 2009 AUA Best Practice Guideline suggests that all patients should have mechanical prophylaxis and patients with multiple risk factors should be treated with both mechanical and pharmacological prophylaxis. This includes both intermittent compression pneumatic boots as well as either low molecular weight heparin (enoxaparin 40 mg subcutaneous daily) or unfractionated heparin (5000 units every 8 hours subcutaneous starting during or after surgery) [28]. The choice of Foley catheter used in the RALP procedure has been shown to have significant postoperative effects. In particular Yee reported decreased stricture rate with the usage of 18 Fr compared to 22 Fr urinary catheters [29]. The extended time spent in Trendelenburg also poses an increased risk for facial edema and corneal abrasions, which can be prevented with the usage of patient safety goggles or other eye protection [30]. Although preoperative considerations are critical to optimize postoperative outcomes, careful and methodical technique within the operating room is also essential in providing patients with the best chance for a full recovery. All possible measures should be taken to maximize oncologic therapy as well as quality‐of‐life measures. As cancer control is the most critical component requiring successful treatment during RALP, it will be discussed throughout the following sections since its impact should be incorporated in all steps of surgery. At each step of RALP there is opportunity to optimize outcomes. This process begins with a thorough knowledge of all steps involved in RALP as well as the relevant pelvic anatomy. Although a detailed overview of surgical steps can be found in preceding chapters, the anatomy of the prostate and its nerve supply warrant additional discussion as their preservation is paramount in achieving rapid return to continence and erectile function. The periprostatic nerve supply has been shown to form a hammock of neurovascular support extending around the base of the prostate and across its posterolateral aspect down to the apex. The hammock is comprised of the proximal neurovascular plate (PNP), predominant neurovascular bundle (PNB), and accessory distal neural pathways (ANP). All of these structures should be preserved to achieve ideal nerve sparing in any patient undergoing RALP, although oncological implications can sometimes make this impossible [31]. The PNP provides a source for integration of neurons surrounding the prostate. It courses lateral to the bladder neck and seminal vesicles before moving posteriorly along the base of the prostate to join the cavernous nerve. The PNB can be found in the lateral pelvic fascia (LPF) and is responsible for the nerve supply of the cavernosal tissue, urethral sphincter, and levator ani. Since the LPF also contains the ANP lateral and posterior to the prostate, additional care should be taken with any manipulation of this region during dissection [31]. Care also needs to be taken during the apical and posterolateral dissection as this is the area most likely to have positive margins during RALP [32, 33]. A specific technique has been described for apical dissection whereby the conventional approach of ligating the dorsal venous complex (DVC) early is avoided as it can be detrimental to visualization. In one series, 209 patients were treated with a synchronous urethral transection through a retroapical approach and compared to 1665 that had previously undergone traditional anterior urethral transection after DVC ligation. The patients who underwent the novel technique had a lower apical PSM rate (1.4% vs. 4.4%; P = 0.04) despite those patient’s having a higher incidence of >pT3a prostate cancer (16% vs. 10%; P = 0.027) [34]. Bladder neck preservation through meticulous dissection of the muscle wall between the bladder and prostate has been shown to improve early return to continence in patients undergoing RALP. One retrospective analysis was completed with 599 patients who underwent RALP and had the level of bladder neck sparing graded from 1–4 with higher numbers denoting more aggressive bladder sparing. There were a higher proportion of patients in groups 3 and 4 compared to groups 1 and 2 who were continent at their three‐month postoperative visit. However, by the 1‐year mark there was no longer any statistically significant difference in continence [35]. A prospective study examined 1067 men who underwent RALP, 791 of whom had bladder‐sparing surgery and 276 of whom did not. The group who underwent bladder neck sparing had less leakage (P = 0.009). Cancer control as defined by positive margins and biochemical recurrence was equivalent between both groups [36]. Nyarangi‐Dix et al. completed a prospective, single‐blinded randomized trial of 208 men who were assigned to either complete bladder neck sparing with urethra–urethral anastomosis or standard RALP. At 3, 6, and 12 months postoperatively patients who underwent bladder neck sparing were shown to have improved continence compared to controls (84.2% vs. 55.3%; 89.5% vs. 74.8%; 94.7% vs. 81.4%, respectively). The men who underwent bladder neck sparing also reported higher quality‐of‐life (QOL) scores at each visit. Furthermore, there was no significant difference between the two groups with positive margins (12.5% vs. 14.7%; P = 0.65) [37]. Bladder neck preservation is a safe technique with regards to oncological outcomes and can facilitate early return to continence. One area of debate during RALP is preservation of puboprostatic ligaments (PPL). Jarow described a reconstruction where the PPL are maintained in normal anatomic position to bolster support of the anterior urethra following radical retropubic prostatectomy (RRP) [38]. An additional study examined postoperative continence in 43 men following RRP where 25 had traditional apical dissection and the remaining 18 had preservation of the PPL. Postoperative questionnaires were completed showing a median time to continence of 6.5 weeks in the ligament‐sparing group versus 12 weeks in the standard dissection group [39]. However, another study examined 149 men who underwent either PPL preservation alone, bladder neck preservation alone, or both and found that those who underwent either bladder neck preservation alone or in conjunction with PPL preservation had an earlier return to continence than those who had PPL suspension alone. This study also showed no significant difference in oncologic outcomes between the above techniques [40]. Figure 102.2 displays an intraoperative visualization of PPL sparing. Figure 102.2 Anterior view of bladder with sparing of puboprostatic ligaments prior to incision of bladder neck. Another technique to preserve anterior attachments and space of Retzius includes a posterior approach to RALP. Galfano et al. completed 200 RALPs with avoidance of the Retzius structures in favor of dissection through the pouch of Douglas. Although this study was an internal comparison designed to assess the learning curve for this surgical approach, it achieved promising results with regard to continence and erectile dysfunction. Continence was achieved immediately in >90% of patients with 1‐year continence rates of 96%. Erectile function had returned after one month in 40% of patients and by 1 year 70–80% of previously potent men had regained erectile function [41]. Further study into the posterior approach is certainly warranted and many robotic surgeons now champion this technique. Sparing of the endopelvic fascia (EPF) is another technique with promising results. Khoder et al. performed 231 RRPs for clinically localized prostate cancer without incision into the EPF and found earlier return to continence and potency with preservation [42]. Stolzenburg et al. performed 150 endoscopic, extraperitoneal radical prostectomies without incision into the EPF with 12‐month continence rates of 94.3%. They describe a method by which the dissection plane is directly on the prostatic capsule, freeing the prostate laterally and preserving the EPF and PPF as well as the neurovascular bundles (NVBs) [43]. Preservation of the EPF should be attempted in patients where oncologic outcomes are not being sacrificed. Another operative technique to improve both time to and overall rate of continence is preservation of urethral and sphincter length (Figure 102.3). Multiple studies have examined the anatomic relationship between urethral length and continence. Paparel et al. examined 64 men who had undergone MRI before and after radical prostatectomy. Postoperative MRI was completed to assess for local recurrence. Increased mean urethral length was shown to have superior continence as graded on a 1–5 scale by patients. In addition, patients with more periurethral fibrosis were found to have worse continence rates [44]. Nguyen et al. described a new technique for anterior and total reconstruction of the urethra and bladder neck. He examined 274 men who had pre‐ and post‐RALP MRI assessing urethral sphincter length found that in those with urethral sphincters >14 mm, 83% had return to continence (no pads or liner for security reasons) and 99% with the total reconstruction [45]. Figure 102.3 Preservation of maximum urethral length in effort to promote postoperative continence. Nerve sparing during RRP has long been an accepted principle for good functional outcomes after surgery. A relatively new technique, however, involves the utilization of frozen sections in the operating room to ensure that oncological outcomes are not compromised with nerve‐sparing technique. The initial study by Schlomm et al. examined 11 069 patients who underwent RRP. During surgery, the entire lateral and rectal border of the prostate specimen was submitted for frozen‐section analysis to determine surgical margin status. Of those patients who underwent NeuroSAFE, 1368 had positive margins, with subsequent negative margins being detected in 86% of those patients upon secondary resection. Overall rate of nerve sparing in these patients was significantly higher at all disease stages than without utilization of NeuroSAFE (97% vs. 81%; P < 0.0001). Furthermore, NeuroSAFE was found to have no increase in rates of biochemical recurrence [46]. Other studies have confirmed the ability of NeuroSAFE to detect positive margins and convert these patients to having negative margins with improved ability to complete appropriate nerve sparing [47]. Furthermore, the NeuroSAFE technique has also been found to be a feasible alternative specifically for RALP [48]. The oncological principles of NeuroSAFE can be augmented through combination with a graded approach to nerve sparing during RALP. A technique for standardized categorization of nerve sparing during RALP has been successfully utilized. Within this categorization, nerve sparing is graded 1–4, where grade 1 requires dissection immediately outside the prostatic capsule medial to the venous plane, grade 2 involves dissection outside the venous layer adjacent to the prostatic capsule (peri‐venous plane), grade 3 includes dissection through the lateral aspect of the LPF with some adipose tissue visualized on the prostate specimen, and grade 4 involves a wide dissection of the LPF and Denonvilliers’ fascia (Figure 102.4). Grade 1 is reserved for patients with minimal risk of extraprostatic extension (EPE), grade 2 for patients with low risk of EPE, grade 3 in patients with moderate risk of EPE since some medial neural trunks are removed, and grade 4 for patients with known EPE. This grading system was retrospectively validated and, when utilized with NeuroSAFE, was able to establish better grades of nerve sparing without any compromise in cancer control [49]. Figure 102.5
Optimizing Outcomes During Laparoscopic and Robot‐assisted Radical Prostatectomy
Introduction
Preoperative optimizations
Preoperative waiting period
Preoperative magnetic resonance imaging
Weight loss counseling and preoperative activity level
Smoking cessation
Erectile function evaluation
Pelvic floor muscle exercises/training
Outpatient versus inpatient procedure
Choice of antibiotics
Venous thromboembolism prophylaxis
Choice of equipment in the operating room and safety precautions
Perioperative optimization
Prostatic anatomy
Bladder neck preservation
Preservation of puboprostatic ligaments
Preservation of endopelvic fascia
Preservation of urethral length
Neurovascular structure‐adjacent frozen‐section examination (NeuroSAFE)
Graded approach to nerve sparing
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