Elsevier

Urology

Volume 64, Issue 6, December 2004, Pages 1224-1228
Urology

Surgical techniques in urology
Robotic radical prostatectomy: A technique to reduce pT2 positive margins

https://doi.org/10.1016/j.urology.2004.08.021Get rights and content

Abstract

Objectives

To describe a technique using the da Vinci robotic system that enhances one’s ability to visualize and dissect the apex and reduce surgical margins. An important outcome of radical prostatectomy is the reduction of iatrogenic positive margins in organ-confined prostate cancer.

Technical considerations

The clinical data of our first 140 consecutive robot-assisted radical prostatectomies were divided into two groups: group 1, cases 1 to 50; and group 2, cases 51 to 140. After reviewing the surgical margin data and appropriate video clips of our initial 50 patients, we altered our technique. Initially, we had used two sutures to control the dorsal venous complex (DVC), one proximally and distally. The prostate was freed, and, finally, the DVC and urethra were divided. However, a bundle of fat obscured the apex, leading to positive apical margins. We developed the following method. First, we removed all of the fat overlying the DVC and prostate. Second, we divided the puboprostatic ligaments and dissected the levator fibers to expose and increase the DVC length fully. Finally, we stapled and divided the DVC using a vascular stapler.

Results

The two groups were clinically comparable. Overall, the pathologic margin rate improved from 36% in group 1 to 16.7% in group 2. In group 1, 9 (27.3%) of 33 pT2 tumors had positive margins versus 3 (4.7%) of 64 pT2 tumors in group 2 (P = 0.003).

Conclusions

The data demonstrate that this change in technique for robotic prostatectomy resulted in a more defined apical dissection and a statistically significant reduction in positive margins in patients with organ-confined disease.

Section snippets

Patients

The alteration in technique started with case 40 and was fully instituted at case 51. Extensive break point analysis was performed that ultimately identified a dramatic change in positive pT2 margins (at the apex) coinciding with our technique change between cases 46 and 50. Therefore, the clinical data collected prospectively from our first 140 consecutive robot-assisted radical prostatectomies was divided into two relevant groups: group 1, cases 1 to 50; and group 2, cases 51 to 140.

Results

The transition in technique was initiated at case 40 and was in full use after case 50 and technically has not changed since. It is important in the process of comparing pathologic margin rates that the groups are reasonably similar. As the data in Table I demonstrate, both groups were well matched for standard clinical data. The clinical stage was nearly identical in the two groups: T1c, 68% versus 69%; T2a, 28% versus 28%; T2b, 2% versus 2%; and T3, 1% versus 1%. The clinical Gleason scores

Comment

Prevention of positive surgical margins is a critical endpoint of radical prostatectomy. A positive margin is well established as an independent risk factor for PSA recurrence after open radical prostatectomy. 2, 3, 9 Possible etiologies for positive margins include inadvertent entry into the prostate (iatrogenic) and cutting across extraprostatic tumor that extends beyond the limits of resection (noniatrogenic). 1 The prostatic apex is generally regarded as the most common site of iatrogenic

Conclusions

The technological advances offered by the da Vinci robotic system have enabled us to visualize and define clearly the apical dissection of the prostate during laparoscopic prostatectomy. This new technology potentially offers surgeons a means to reduce markedly the risk of iatrogenic positive margins in patients with Stage pT2 prostate cancer. However, in our experience, the fibromuscular attachment of the urethra to the apex continues to remain as a potential source of iatrogenic positive

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