Platinum Priority – Prostate CancerEditorial by Manfred P. Wirth and Michael Froehner on pp. 953–954 of this issueEarly Complication Rates in a Single-Surgeon Series of 2500 Robotic-Assisted Radical Prostatectomies: Report Applying a Standardized Grading System
Introduction
Data from the Surveillance, Epidemiology and End Results registry indicate that the incidence of prostate cancer (PCa) in men under 50 has risen steadily over the past 10 yr, with an annual percent increase of 9.5% [1]. In addition, with the widespread diffusion of prostate-specific antigen (PSA) testing, PCa is frequently diagnosed in younger and healthier men with organ-confined disease. Consequently, patients desire to undergo definitive treatment with short recovery time and low complication rates while maintaining their baseline quality of life.
Since Reiner and Walsh [2] first introduced the anatomic nerve-sparing technique for radical retropubic prostatectomy (RRP), this procedure has become the gold standard and the most widespread treatment for clinically localized PCa, providing excellent cancer control in most patients with clinically localized disease [3]. However, although several modifications have been added to the original technique and most urologic surgeons are now familiar with the procedure, RRP still has an inherent morbidity.
In an effort to further decrease the morbidity of RRP, a laparoscopic minimally invasive surgical approach to treating PCa was first described by Schuessler and colleagues [4] in 1997. Although cancer cure with laparoscopic radical prostatectomy (LRP) was deemed comparable to open surgery, the technical demands of the surgery and the protracted learning curve has prevented the widespread adoption of LRP by most urologic surgeons. The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has been introduced to the field of urologic surgery and, with the advantages of three-dimensional vision, 7 degrees of freedom, and magnification, has raised new hopes of reducing both the morbidity and the learning curve of minimally invasive prostatectomy [5]. But as expected, the introduction of any innovative technology or surgical procedure is associated with an initial learning curve and with the potential of eliciting new risks and surgical complications [6].
Perioperative complications following robotic-assisted radical prostatectomy (RARP) have been previously reported in some recent series. Few studies, however, have used standardized systems to classify surgical complications, and that inconsistency has hampered accurate comparisons between different series or surgical approaches. Based on these limitations, Clavien and colleagues proposed a grading system for surgical complications in 1992 and modified it in 2004 [7]. The Clavien grading system is a simple, objective, and reproducible approach for comprehensive surgical outcomes assessment and has been applied more frequently in recent publications reporting complications after RRP, LRP, and RARP.
In this study we analyzed early surgical complications in a single-surgeon series of 2500 consecutive RARPs. Complications were classified according to the modified Clavien grading system, and trends in the incidence of morbidities according to the surgeon’s experience were analyzed.
Section snippets
Materials and methods
We analyzed 2500 consecutive patients who underwent RARP for treatment of clinically localized PCa. All of the procedures were performed by a single surgeon (VRP) from August 2002 to February 2009. After institutional review board approval, data were prospectively collected in a customized database and retrospectively analyzed. Complications were classified in our database according to the modified Clavien grading system (Table 1) [7].
Early surgical outcomes
Patient characteristics are presented in Table 2.
The median follow-up of our cohort was of 25 mo (IQR:10–35 mo). Median operative time was 90 min (IQR: 75–100 min), and the median estimated blood loss was 100 ml (IQR:100–150 ml). Bilateral PLND was performed in 44.5% of our patients. Our conversion rate was 0.08%, comprising two procedures converted to standard laparoscopy due to robot malfunction. No cases were converted to open surgery. In our series, 95% of patients were discharged home on
Discussion
Direct comparisons among RRP, LRP, and RARP complication rates are difficult due to variations in the definition and classification of complications in the series currently published in the literature. Donat [12] recently analyzed the quality of complication reporting in the urologic literature. A total of 109 studies reporting outcomes after urologic surgery were analyzed. Of the 36 studies reporting complication severity, only 7 (19%) used a numeric grading system; 29 studies (81%) used a
Conclusions
RARP is a safe option for treatment of clinically localized PCa, presenting low complication rates in experienced hands. Although the robotic system provides the surgeon with enhanced vision and dexterity, proficiency is only accomplished with consistent surgical volume; complication rates demonstrated a tendency to decrease as the surgeon’s experience increased. The use of standardized classification systems to analyze surgical complications will allow proper comparisons among different
References (30)
- et al.
An anatomical approach to the surgical management of the dorsal vein and Santorini’s plexus during radical retropubic surgery
J Urol
(1979) - et al.
Laparoscopic radical prostatectomy: initial short-term experience
Urology
(1997) - et al.
The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study
Lancet Oncol
(2009) - et al.
Periurethral suspension stitch during robotic-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes
Eur Urol
(2009) Standards for surgical complication reporting in urologic oncology: time for a change
Urology
(2007)- et al.
Operative details and oncological and functional outcome of robotic-assisted laparoscopic radical prostatectomy: 400 cases with a minimum of 12 months follow-up
Eur Urol
(2009) - et al.
Prospective evaluation with standardised criteria for postoperative complications after robotic-assisted laparoscopic radical prostatectomy
Eur Urol
(2010) - et al.
Classification and trends of perioperative morbidities following laparoscopic radical prostatectomy
J Urol
(2005) - et al.
Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial
J Urol
(2008) - et al.
Perioperative complications of laparoscopic and robotic assisted laparoscopic radical prostatectomy
J Urol
(2006)
Robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of 184 cases
Eur Urol
A direct comparison of robotic assisted versus pure laparoscopic radical prostatectomy: a single institution experience
J Urol
Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy
J Urol
Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies
Eur Urol
Cancer statistics, trends and multiple primary cancer analyses from the Surveillance, Epidemiology and End Results (SEER) program
Oncologist
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