Overcoming the Challenges of Robot-assisted Radical Prostatectomy

M A Goldstraw; B J Challacombe; K Patil; P Amoroso; P Dasgupta; R S Kirby

Disclosures

Prostate Cancer Prostatic Dis. 2012;15(1):1-7. 

In This Article

Abstract and Introduction

Abstract

Robot-assisted radical prostatectomy (RARP) is the most commonly performed robotic procedure worldwide and is firmly established as a standard treatment option for localised prostate cancer. Part of the explanation for the rapid uptake of RARP is the reported gentler learning curve compared with the challenges of laparoscopic radical prostatectomy (LRP). However, robotic surgery is still fraught with potential difficulties and avoiding complications while on the steepest part of the learning curve is critical. Furthermore, as surgeons progress there is a tendency to take on increasingly complex cases, including patients with difficult anatomy and prior surgery, and these cases present a unique challenge. Significant intra-abdominal adhesions may be identified following open surgery, or dense periprostatic inflammation may be encountered following TURP; large prostate gland size and median lobes may alter bladder neck anatomy, making difficult subsequent urethro-vesical anastomosis. Even experienced robotic surgeons will be challenged by salvage RARP. Approaching these problems in a structured manner allows many of the problems to be overcome. We discuss some of the specific techniques to deal with these potential difficulties and highlight ways to avoid making serious mistakes.

Introduction

Robot-assisted radical prostatectomy (RARP) is the most commonly performed robotic procedure worldwide and is firmly established as a standard treatment option for localised prostate cancer. Although preliminary data appear to show some advantages over open prostatectomy with reduced blood loss, decreased pain and early mobilisation, there is no definitive data proving advantages over laparoscopic radical prostatectomy (LRP). Part of the explanation for the rapid uptake of RARP is the reported gentler learning curve compared with the challenges of LRP. Despite this, starting a robotic programme can be a daunting prospect and the surgery is still fraught with potential difficulties.

As with open surgery, there is a strong correlation between surgeon experience and good clinical outcomes, particularly the critical 'trifecta' of surgical margins, potency and continence.[1] It is vital that the acquisition of experience does not come at the expense of clinical outcomes. Furthermore, as surgeons progress through the learning curve (LC), there is a tendency to take on increasingly complex cases including patients with more difficult anatomy and prior surgery. These cases present additional challenges and avoiding complications, while on the steepest part of the learning curve is critical. We discuss these potential difficulties and highlight ways to avoid making serious mistakes.

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