Paradigm Shift from Open Surgery to Minimally Invasive Surgery in Three Approaches for Radical Prostatectomy: Comparing Outcomes and Learning Curves

Objective: Radical prostatectomy (RP) can be performed by several approaches, such as open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic prostatectomy (RALP). This study investigated and shared the differences in the surgical techniques, learning curves, and outcomes of each approach of RP. Materials and Methods: The data of patients who received RP given by one of the authors between January 2002 to June 2016 were retrospectively reviewed. We compared perioperative and postoperative outcomes among approaches, searched for predictors of a positive surgical margin (PSM), and assess the learning curves of the two minimally invasive approaches. Results: 527 patients underwent RP during January 2002 to June 2016 including 42 RRP, 198 LRP, and 327 RALP. RALP had the highest negative surgical margin (68.8%) and lowest multifocal positive surgical margin (10.7%). PSM predictors were the Gleason score and pathological T staging. The learning curve showed that RALP needed one-hundred-cases experience to achieve the lowest PSM rate and 200 cases to master bleeding control. In the first 100 cases in each group, the PSM rate in LRP was lower than in RALP. Conclusion: Minimally invasive approach in radical prostatectomy showed significant improvements over RRP, especially the RALP approach. RALP would take a surgeon 100 and 200 cases to reach the plateau on the learning curve for achieving the desired oncologic and perioperative outcome efficiencies, respectively. However, LRP and RRP are still feasible in a service setting and for training purposes

Role of preoperative magnetic resonance imaging on the surgical outcomes of radical prostatectomy: Does preoperative tumor recognition reduce the positive surgical margin in a specific location? Experience from a Thailand prostate cancer specialized center

Objective: Multiparametric magnetic resonance imaging (MRI) has become the standard of care for the diagnosis of prostate cancer patients. This study aimed to evaluate the influence of preoperative MRI on the positive surgical margin (PSM) rates. Methods: We retrospectively reviewed 1070 prostate cancer patients treated with radical prostatectomy (RP) at Siriraj Hospital between January 2013 and September 2019. PSM rates were compared between those with and without preoperative MRI. PSM locations were analyzed. Results: In total, 322 (30.1%) patients underwent MRI before RP. PSM most frequently occurred at the apex (33.2%), followed by posterior (13.5%), bladder neck (12.7%), anterior (10.7%), posterolateral (9.9%), and lateral (2.3%) positions. In preoperative MRI, PSM was significantly lowered at the posterior surface (9.0% vs. 15.4%, p=0.01) and in the subgroup of urologists with less than 100 RP experiences (32% vs. 51%, odds ratio=0.51, p<0.05). Blood loss was also significantly decreased when a preoperative image was obtained (200 mL vs. 250 mL, p=0.02). Multivariate analysis revealed that only preoperative MRI status was associated with overall PSM and PSM at the prostatic apex. Neither the surgical approach, the neurovascular bundle sparing technique, nor the perioperative blood loss was associated with PSM. Conclusion: MRI is associated with less overall PSM, PSM at apex, and blood loss during RP. Additionally, preoperative MRI has shown promise in lowering the PSM rate among urologists who are in the early stages of performing RP