not logged in

European Urology

Journal Article Page

Jump to

European Urology

Volume 62, issue 1, pages e1-e30, July 2012

Prostate Cancer

Reply from Authors re: Quoc-Dien Trinh, Khurshid R. Ghani, Mani Menon. Robot-assisted Radical Prostatectomy: Ready To Be Counted? Eur Urol 2012;62:16–8: Walking the Tightrope: Balancing Cancer Control, Urinary Continence, and Sexual Function—A Programmatic Evolution

Ashutosh Tewari a lowast , Anthony Pham a, Abhishek Srivastava a, Robert Leung a, Prasanna Sooriakumaran a b, Dan Bloch c, Usha Seshadri-Kreaden d, April E. Hebert d and Peter Wiklund b

Published online 27 April 2012, pages 18 - 19

Full Text Full-Text PDF (277 KB) Create Platinum Slide Series

Refers to article:

Positive Surgical Margin and Perioperative Complication Rates of Primary Surgical Treatments for Prostate Cancer: A Systematic Review and Meta-Analysis Comparing Retropubic, Laparoscopic, and Robotic Prostatectomy

Ashutosh Tewari, Prasanna Sooriakumaran, Daniel A. Bloch, Usha Seshadri-Kreaden, April E. Hebert and Peter Wiklund

Accepted 14 February 2012

July 2012 (Vol. 62, Issue 1, pages 1 - 15)

Abstract Full Text Full-Text PDF (752 KB)

Refers to article:

Robot-assisted Radical Prostatectomy: Ready To Be Counted?

Quoc-Dien Trinh, Khurshid R. Ghani and Mani Menon

July 2012 (Vol. 62, Issue 1, pages 16 - 18)

Full Text Full-Text PDF (110 KB)

Article Outline

Thanks for the opportunity to respond to the editorial comments presented by Trinh et al. [1]. We appreciate the thoughts on the methodology of meta-analysis. This methodology is robust and gives us a good idea about outcomes in terms of margin rates and perioperative complications. While Trinh et al. correctly point out that our paper demonstrates that margin rates are comparable between open and robotic assisted radical prostatectomy (RARP), our paper also demonstrates that the laparoscopic approach results in an increased risk for positive margins when compared to RARP. It also shows that in terms of perioperative complications, RARP is the safest among these approaches [2].

One thing that is difficult to show using a meta-analytic approach is the impact of innovations and refinements that have occurred in robotic surgery since its inception. In addition to achieving negative margins and reduced surgical complications, RARP seeks to achieve the postoperative goals of continence and return of sexual function. It is in the pursuit of these trifecta goals for prostatectomy that RARP can have the greatest impact. For example, in our own surgical cohort, we have been able to bring incremental improvements to the procedure over the years to achieve negative margin rates, urinary continence, and return of sexual function in patients who had good baseline sexual function (International Index of Erectile Function >21) and were candidates for good nerve sparing (grade 1) [2] in ranges >90% in all domains. By relating these trends with our published literature, it can be seen that these innovations have affected outcomes and reflect the process of learning a complex procedure such as radical prostatectomy (Fig. 1[3], [4], [5], [6], [7], [8], [9], [10], [11], [12], and [13]).

gr1

Fig. 1 (a) Key innovations and concepts published by the Tewari research group beginning in 2005 to the present [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], and [13] correlated to (b) rates of trifecta goals (negative margins, sexual function, continence) for robotic assisted radical prostatectomy performed by the Tewari surgical group in a similar time period.IIEF = International Index of Erectile Function; MPM = multiphoton microscopy; MRI = magnetic resonance imaging; RALP = robot-assisted laparoscopic prostatectomy.

Initially, we worked on detailed trizonal neural architecture and adopted an athermal technique for nerve sparing [10]. Later on, the development of techniques such as total reconstruction of the vesico-urethral junction has proven to be a safe and effective way to achieve an early return of continence with significant gains when compared to the previous gold standard of no or partial reconstruction [3]. The incorporation of visual cues in surgery has yielded improvements in negative margins, allowing experienced surgeons to make informed intraoperative oncologic decisions [9]. Through adopting a risk-stratified approach to nerve-sparing RARP, we have been able to balance the risk of positive margins with preserving urinary and sexual function, achieving the successful outcomes seen today [4] and [8]. With these progressive innovations, RARP has seen greater success in achieving optimal outcomes in all areas of the trifecta goals—negative margins, urinary continence, and return to sexual function—as more and more patients are being treated at our surgical center.

Similar developments and refinements are occurring at other programs [14], [15], and [16]. It would be great to pool the data for similar incremental improvements from multiple institutions and look across the board at the field of innovations in an effort to determine their relationship with improved trifecta outcomes. This is a challenge to tackle in future reviews.

Conflicts of interest

The authors have nothing to disclose.

References

  • [1] Q.-D. Trinh, K.R. Ghani, M. Menon. Robot-assisted radical prostatectomy: ready to be counted?. Eur Urol. 2012;62:16-18 Abstract, Full-text, PDF, Crossref.
  • [2] A. Tewari, P. Sooriakumaran, D.A. Bloch, U. Seshadri-Kreaden, A.E. Hebert, P. Wiklund. Positive surgical margin and perioperative complication rates of primary surgical treatments for prostate cancer: a systematic review and meta-analysis comparing retropubic, laparoscopic, and robotic prostatectomy. Eur Urol. 2012;62:1-15
  • [3] A.K. Tewari, A. Srivastava, M.W. Huang, et al. Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP). BJU Int. 2011;108:984-992 Crossref.
  • [4] A. Tewari, S. Grover, P. Sooriakumaran, et al. Nerve sparing can preserve orgasmic function in most men after robotic-assisted laparoscopic radical prostatectomy. BJU Int. 2012;109:596-602 Crossref.
  • [5] A. Tewari, A. Srivastava, P. Sooriakumaran, S. Grover, P. Dorsey, R. Leung. Technique of traction-free nerve-sparing robotic prostatectomy: delicate tissue handling by real-time penile oxygen monitoring. Int J Impot Res. 2012;24:11-19 Crossref.
  • [6] R. Yadav, S. Mukherjee, M. Hermen, G. Tan, F.R. Maxfield, W.W. Webb, et al. Multiphoton microscopy of prostate and periprostatic neural tissue: a promising imaging technique for improving nerve-sparing prostatectomy. J Endourol. 2009;23:861-867 Crossref.
  • [7] L. Nguyen, J. Jhaveri, A. Tewari. Surgical technique to overcome anatomical shortcoming: balancing post-prostatectomy continence outcomes of urethral sphincter lengths on preoperative magnetic resonance imaging. J Urol. 2008;179:1907-1911 Crossref.
  • [8] A.K. Tewari, N.D. Patel, R.A. Leung, et al. Visual cues as a surrogate for tactile feedback during robotic-assisted laparoscopic prostatectomy: posterolateral margin rates in 1340 consecutive patients. BJU Int. 2010;106:528-536 Crossref.
  • [9] A. Tewari, J. Jhaveri, S. Rao, et al. Total reconstruction of the vesico-urethral junction. BJU Int. 2008;101:871-877 Crossref.
  • [10] A. Tewari, S. Rao, J.I. Martinez-Salamanca, et al. Cancer control and the preservation of neurovascular tissue: how to meet competing goals during robotic radical prostatectomy. BJU Int. 2008;101:1013-1018 Crossref.
  • [11] A.K. Tewari, S.R. Rao. Anatomical foundations and surgical manoeuvres for precise identification of the prostatovesical junction during robotic radical prostatectomy. BJU Int. 2006;98:833-837 Crossref.
  • [12] A. Takenaka, R.A. Leung, M. Fujisawa, A.K. Tewari. Anatomy of autonomic nerve component in the male pelvis: the new concept from a perspective for robotic nerve sparing radical prostatectomy. World J Urol. 2006;24:136-143 Crossref.
  • [13] A. Tewari, A. Takenaka, E. Mtui, et al. The proximal neurovascular plate and the tri-zonal neural architecture around the prostate gland: importance in the athermal robotic technique of nerve-sparing prostatectomy. BJU Int. 2006;98:314-323 Crossref.
  • [14] J.D. Sammon, F. Muhletaler, J.O. Peabody, M. Diaz-Insua, R. Satyanaryana, M. Menon. Long-term functional urinary outcomes comparing single- vs double-layer urethrovesical anastomosis: two-year follow-up of a two-group parallel randomized controlled trial. Urology. 2010;76:1102-1107 Crossref.
  • [15] R.F. Coelho, S. Chauhan, A. Sivaraman, et al. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis. BJU Int. 2012;109:426-433 Crossref.
  • [16] S. Beck, D. Skarecky, K. Osann, R. Juarez, T.E. Ahlering. Transverse versus vertical camera port incision in robotic radical prostatectomy: effect on incisional hernias and cosmesis. Urology. 2011;78:586-590 Crossref.
return to article outline

Footnotes

a Institute of Prostate Cancer and LeFrak Center for Robotic Surgery, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA

b Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna, Sweden

c Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA

d Department of Clinical Affairs, Intuitive Surgical Inc., Sunnyvale, CA, USA

lowast Corresponding author. 525 East 68th Street, New York, NY 10065, USA. Tel. +1 212 746 5638; Fax: +1 212 746 9842.

Recommend this article

Currently this article has a rating of 0. Please log in to recommend it.

Article tools

Elsevier Copyright © Elsevier B.V. All rights reserved