(PRASS) In Robotic Assisted Laparoscopic Radical Prostatectomy

Robotic radical prostatectomy has become the "Gold Standard" treatment for localized prostate cancer. The introduction of robotic surgery to the treatment of prostate cancer has reduced the surgical morbidity of radical prostatectomy but until recently early post prostatectomy urinary incontinence was a major cause of morbidity from radical prostatectomy. Efforts have been made to develop techniques to hasten return of urinary control. Several authors have recently demonstrated improved early continence with either an anterior, posterior or combined reconstruction of the urethral-pelvic attachments. In this study, we compare 3-month urinary function and continence data on a series of prostate cancer patients who underwent robotic prostatectomy with posterior reconstruction and anterior suspension with single anastomotic suture (PRASS).

A prospective cohort of fifty prostate cancer patients underwent robotic prostatectomy with a PRASS reconstruction and were compared to 50 control prostate cancer patients who underwent standard robotic prostatectomy. Urinary Continence was defined as use of zero to 1 urinary pad and was evaluated using the EPIC-26 questionnaire. A weighted summary score was created and group differences were compared using repeated measures analysis of variance model.

After adjusting for age, baseline urinary symptom sexual function score, which were found to correlate with continence, prostate cancer patients who underwent the PRASS reconstruction had significantly improved urinary control at 3 months compared with the control group; 90.9% of the patients in the PRASS group wearing 0-1 pads per day vs. 48.2% in the control group (p=0.014). 20.6% of the patients undergoing the standard prostatectomy and 42% of the patients undergoing the PRASS procedure were totally pad-free (p=0.042).

The PRASS technique for reconstruction during robotic prostatectomy resulted in a statistically significant improvement in urinary control 3 months post-operatively. The PRASS reconstruction is technically straightforward and requires no additional sutures, thus providing a simple technique that should be easily learned and easily adaptable to other robotic surgeons.

Improving Outcomes for Robotic Prostate Surgery

Experience counts! There is more and more scientific evidence that patient outcomes for prostate cancer surgery are directly related to the experience of the surgeon. A recent survey of 72 prostate cancer surgeons demonstrated that the risk for cancer recurrence was reduced by 40% if the surgeon had performed more than 250 open radical prostatectomies. It has also been shown that complications are less in the hands of experienced surgeons. Robotic surgery is equally challenging to master and it has been demonstrated that the "learning curve" for robotic prostatectomy is a minimum of 250 cases. It has also been shown that experience is not the only determinant of surgical outcome since not all "high volume" surgeons achieve equally good results. Thus, when choosing a robotic surgeon it is not only important to ask about experience, but one should also ask about results.

Dr. Ornstein tracts his results carefully in order to help him continually improve his techniques so that he can provide his patients the best opportunity for successful outcomes.

In last 100 robotic prostate cancer surgeries performed by Dr. Ornstein the average total surgical time was 179 minutes (137 minutes of robotic consul time), the average blood loss was 74 cc and no patient required a blood transfusion. A surgical drain was not used in any of these cases and 99% stayed in the hospital less than 24 hours (1 patient stayed 2 days). There was only 1 complication; a small rectal tear that was repaired robotically without consequence. No patient required readmission for any reason, and the foley catheter was removed within 10 days of surgery for all patients. Most importantly the cancer was successfully removed with negative surgical margins in 91% of cases (i.e. overall positive surgical margin rate was 9%). For patients with prostate cancer that had not invaded beyond the prostatic capsule (stage pT2) the positive surgical margin rate was 3.7%.

Dr. Ornstein continuously reviews his results and modifies his technique when he feels that his outcomes can be improved. For example in his first 216 cases the overall positive surgical margin rate was 14.8%, and 5.4% for pT2 cancers. After reviewing multiple videos of prior cases and modifying his technique he was able to lower his positive margin rate to 9% overall and 3.7% for pT2 cancers.

Another example of where a modification in surgical technique has directly resulted in improved outcomes relates to urinary control. For many robotic surgeons, including Dr. Ornstein, their early experience with robotic prostatectomy was associated with good outcomes in regards to continence, but for many patients it took as long as 1 year for urinary control to recover. Dr. Ornstein recognized that this delay in regaining urinary control negatively impacted his patient's quality of life so he sought out to modify his surgical technique to hasten recovery of urinary control. To this effect he developed a technical modification that he has termed the PRASS the technique. This technique is simple to perform, requires only 1 additional suture and takes less than 5 minutes to perform. By incorporating the PRASS technique during robotic prostate surgery (robotic prostatectomy), Dr. Ornstein has improved his 3 month continence rate (1 or fewer pads) from 43 to 91%.

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