INTRODUCTION AND OBJECTIVE:
Robotic-assisted radical prostatectomy (RARP) represents a widely used treatment modality for organ-confined prostate cancer (PCa). However, the surgical outcomes are often suboptimal and the relationship between intra-operative feedback and post-operative results has never been demonstrated. We hypothesized that the retrospective evaluation of the RARP technique may predict post-op outcomes.
A series of consecutive video-recorded RARP for PCa performed by a single surgeon was retrospectively watched by 2 experienced surgeons, blinded to the post-op results. The videos were scored with the PACE (Prostatectomy Assessment and Competence Evaluation) scoring system. Moreover, the urethral stump length (USL) and of the urethral wall thickness (UWT) were assessed. The outcomes of interest were the surgical margins (SM) status, immediate post-op urinary continence (IUC) recovery, defined as the use of no pads 7 days after catheter removal, PO erectile function recovery at 6 months (EF) by means of the Sexual Health Inventary for Men (SHIM) score ≥17 (with or without PDE5-inhibitors) therapy and the incidence of post-op complications. Patients were followed-up at 1 week and at 1 and 6 months after surgery. The association between video scores of each surgical step and the outcomes was performed with uni- and multi-variable logistic regression analyses.
126 patients were analyzed. Median (IQR) age was 63,6 (57.6;68.9) years. Nerve-sparing status was bilateral in 68 (54%), unilateral in 35 (27.8%) and non-NS in 23 (18.3%) patients. IUC was obtained in 84 patients (66.7%). Positive SM were found in 32 cases (25.4%). Post-op complications were seen in 16 pts. (12.7%), the most frequent being vescico-urethral fistulas (3.2%). At univariable logistic regression analyses, the PACE domain “development of posterior anatomical plane” (OR=0.52; p=0.008) and pT stage (OR=2.01; p=0.05) represented significant predictors of positive SM. Age (OR:0.92; p=0.01), NS status (OR:2.46; p=0.002), and UWT score (OR:2.24; p=0.02) were significantly associated with higher IUC rates. Age (OR:0.76; p<0.001), NS status (OR:8.45; p<0.001) and the PACE domain for “neurovascular bundle preservation” (OR:2.88; p<0.001) represented significant predictors of EF recovery. The PACE domain “bladder neck dissection” (OR=0.65; p=0.04), age (OR:1.08; p=0.05) as well as NS status (OR:0.47; p=0.02) represented predictors of post-op complications. Moreover, “bladder neck dissection” (OR=0.45; p=0.02) and UWT (OR=0.23; p=0.03) were significantly related to the development of post-op urinary fistula. Logistic regression multivariable analyses confirmed the associations between each surgical step and the outcomes of interest, after adjusting for patient age, nerve-sparing status and pT stage (all p<0.04).
The evaluation of the surgical technique of RARP may be used to predict post-op outcomes. The study demonstrates a significant contribution of the quality of surgery to the achievement of post-op results.
Source of Funding:
Authors declare no financial support