JSUR Journal

Introduction

Nowadays Robot Assisted Radical Prostatectomy (RARP) is the standard approach in the surgical treatment of localized prostate cancer [1]. With growing surgical experience more patients, who were usually referred to radiation therapy, are being considered for the procedure. Yet plenty of men may have had a previous transurethral resection of the prostate to alleviate preexisting LUTs [2-4]. RARP after TURP necessitates longer operating times, greater blood loss, and results in higher complication rates and worse short-term continence outcomes [5]. Some authors found RARP after foregoing intervention to be combined with inferior oncological and functional results with severe incontinence reaching 25% [6,7]. Leyh-Bannurah et al. reported a compromise to functional long-term outcomes like potency and continence in a large cohort of almost 5000 men [8]. Others found it technically more challenging, but safe and feasible regarding long term functional and oncological results [9,10]. Some even recommended open approach in this group of men [11]. Some restricted it only for experienced surgeons [12]. RARP past TURP is also associated with longer Catheter days [13], Higher PSM, longer OR time and worse continence rates [12]. Generally, the impact of prior TURP on RARP is controversial. We aim in this study to investigate the functional and oncological outcomes in this cohort of men in a tertiary hospital operated by one surgeon.

Methods

All procedures (n=500) were completed transperitoneally with the Da Vinci X^® Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA). All men received pelvic lymphadenectomy as well. No intraabdominal drainage was introduced. Prior to skin incision, intravenous single-shot antibiotics were administered. The Vesicourethral Anastomosis (VUA) was done in a one-layer fashion with a continuous circumferential double-armed barbed suture. In patients were the bladder neck could not be spared, a tennis-racket ventral reconstruction was done. A one layer Rocco stitch was incorporated in the anastomosis in majority of cases. After completion, patients received intraoperatively anastomosis water-tightness test with 200-300 ml sterile water. A transurethral (TUC) and a Suprapubic Catheter (SPC) were inserted in all men. After removing the transurethral catheter on the first postoperative day, patients were permitted to urinate spontaneously on POD 3-4. When the micturition trial was uneventful, the SPC was then removed the day after.

Participants and Methods

Data form 500 sequential patients who underwent Robot Assisted Radical Prostatectomy (RARP) between 04/2019 and 08/2022 by a specialized surgeon were included in this analysis. Of those 500 cases, 34 patients (6,8%) had previous Transurethral Resection of the Prostate (TUR-P) due to Lower Urinary Tract Symptoms (LUTS) prior to RARP. 4 men were incidentally diagnosed by TURP. The rest developed prostate cancer long after TURP with median time interval between the two procedures exceeding 1 year. Due to patient’s uncertainty about the TURP dates, we could not reliably define the exact interval between TURP and RARP. Patients were divided in two groups. Standard RARP (n=466; 93,2%) men and RAPTUR (n=34; 6,8%) men. Preoperative patients´ characteristics and variables like age, American Association of Anesthesiology Morbidity Score (ASA) score, Prostate Volume In Transrectal Ultrasound (TRUS), Body Mass Index (BMI), preoperative Hemoglobin (Hgb), International Prostate Symptom Score (IPSS), International Index of Sexual Function (IIEF), were compared between groups. All postoperative complications within 90 days after the procedure were graded by the Clavien-Dindo Classification [14]. Minor complications are those managed conservatively. Major complications are those necessitating an intervention, intensive care or resulting in organ injury. Those serious complications are considered the primary point of the study. Since the transurethral catheter was removed on surgery’s day or the Postoperative Day One (POD1), Length of suprapubic catheter days was the secondary endpoint. Statistical analysis was performed using SPSS^®v27. Categorical variables were summarized as frequencies (percentage) and continuous variables as mean ± standard deviation and median values. The Kolmogorov-Smirnov one-sample test was used to verify normal distribution. Match pair analysis using independent T-Test for parametric numeric variables and Mann-Whitney U-Test for nonparametric variables were performed. Pearson Chi Square was also used to compare relative frequencies.

Ethics Statement

The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and approved by the ethics committee of the medical association Westfalen-Lippe and Wilhelm’s university of Münster (ethical vote: 2022-585-f-S).

Results

Baseline Parameters

 RAPTUR group received less nerve sparing technique than standard cases (p=0.049). All other variables, with the exception of ASA score, were similar between groups. RAPTUR patients had more concomitant comorbidities than their counterparts (p=0.010). Despite a trend for higher baseline erectile function score in standard RARP patients (mean IIEF-5 score 15.5 vs. 10.3), statistical analysis showed no difference between groups (p=0.655). Details in table 1.

  Table 1: Analysis of demographic, baseline clinical and preoperative characteristics between groups.

Intraoperative Data

There were no statistical differences between groups regarding all intraoperative parameters. Length of hospital stay, catheter days were similar between groups. In both groups  almost 75% of  men  left the hospital without catheter (p=0.694) with a median of hospital stay of 5 days. Furthermore, the number of lymph node dissected (median 18 LN) and rates of positive surgical margins were comparable in both groups (7,1% standard and 8,8% RAPTUR group). Details in Table 2.

   Table 2: Intra- and postoperative data and pathological findings for all groups.

Complications and Readmissions

All minor and major complications plus readmissions were similar between groups (p=0.606, 0.0164 and 0.0398 respectively). In detail vesicourethral anastomosis related complications like Acute Urinary Retention (AUR), Urinary Tract Infections (UTI) or Secondary Vesicourethral Anastomosis Leakage (VUAL), occurred rarely in RAPTUR group. UTI are not primarily anastomoses related. UTI may have accompanied coexisting vesicourethral anastomosis leakage or micturition’s disorders, so that we included them as anastomosis related.  Upper Urinary Tract Obstructions (UUTO) occurred in cases when the ureter ostium was compromised in the anastomosis. Major complications included two lymphoceles which required insertion of a drainage in local anesthesia and one revision due to incisional hernia. Overall only 28/500 (5,6%) patients had to be readmitted after discharge within 90 days after RARP. Despite a trend toward higher incidence in RAPTUR group (8,8% vs. 5,4% in standard group), statistical analysis showed no difference (p=0.398). For more details we refer to table 3.

 Table 3: 90-day complications and Readmissions.

Discussion