Montorsi et al, 201266
Best Practices in Robot-Assisted Radical
Prostatectomy: Recommendations of the Pasadena Consensus Panel |
The following recommendations are made with regard to patient selection and surgical technique:
There are no absolute contraindications to RARP. Obesity, previous abdominal surgery, larger prostate size, and previous radiation are not absolute contraindications for RARP, although such patients may be best operated on by only experienced clinicians. A transperitoneal antegrade surgical approach is the most commonly used. Robotic techniques have changed the understanding of prostate anatomy, thus making obsolete some commonly used terms use as interfascial or intrafascial dissections. The newer concept of incremental nerve-sparing procedures (full, partial, and minimal) should be adopted. Thermal energy should be used judiciously and with low cautery levels. Traction of tissues should also be minimized. Seminal vesicles can be removed either partially or completely during RARP according to the patient's oncologic status. RARP and RRP have equivalent efficacy for performing prostatectomy-related extended PLND. Single running suture is the most frequently used technique to perform the urethrovesical anastomosis. Monofilament is the standard suture. Barbed suture is an acceptable option. The use of medical DVT prophylaxis is optional. If used, clinicians should follow NICE or other national guidelines.
The following recommendations are made with regard to cancer control:
Available data suggest that RARP may also be used in patients with D'Amico high-risk cancers, provided that standard criteria for patient selection, lymph node dissection, and nerve preservation are fulfilled. Positive surgical margin rates after RARP are equivalent to those reported after RRP and LRP. When appropriately performed, RARP is not associated with an increased risk of patients needing adjuvant therapies. Biochemical disease-free survival after RARP seems to be equivalent to other approaches, although existing data are limited. RARP is appropriate for those with high-risk disease; the surgical approach should be determined by the surgeon's experience and expertise.
The following recommendations are made with regard to functional outcomes and complications of RARP:
The definition of surgical complications should be standardized, complications should be assessed in detail from the intraoperative period until at least 3 months postoperatively, and results should be available in most patients. Systematic reviews indicate the potential superiority of RARP for preservation of continence and potency following RP surgery; however, methodological limitations in most studies and the lack of prospective randomized trials need to be considered. Other factors, such as the level of surgeon experience, means of outcome assessment, premorbid function, and postsurgical rehabilitation of the patient, can have a significant impact on functional outcomes. Comparative studies of functional outcomes following RP surgery performed according to best practice guidelines are needed. Postoperative anejaculation and fertility preservation strategies should be discussed with patients, and realistic expectations should be set regarding a return to continence and baseline potency. Although the most appropriate way to report composite outcomes following RP has yet to be standardized, such reporting should take into account baseline patient characteristics, type of surgery, use of adjuvant therapies, and peri- and postoperative complications and sequelae.
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Not reported |
National Institute for Health and Care Excellence (NICE), 201465
Prostate Cancer: Diagnosis and Treatment |
Commissioners of urology services should consider providing robotic surgery to treat localised prostate cancer.
Commissioners should ensure that robotic systems for the surgical treatment of localised prostate cancer are cost effective by basing them in centres that are expected to perform at least 150 robot-assisted laparoscopic radical prostatectomies per year. |
Not reported |
Merseburger et al (European Association of Urology), 201464
Guidelines on Robotic- and Single-Site Surgery in Urologya
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Surgical and oncological outcomes:
Robotic surgery does not improve oncological outcomes in comparison to ORP and LRP; surgical expertise is the crucial factor. Use of the robot is not recommended to improve surgical outcomes. (Grade A recommendation: based on clinical studies of good quality and consistency that addressed the specific recommendations, including at least one randomized controlled trial)
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RARP for localised prostate cancer is now a well-established surgical approach offering similar positive surgical margin rates with ORP and LRP. (Level of evidence 2a: from one well-designed controlled study without randomisation) Long-term PSA-free survival of patients treated with RARP as documented for up to 5 years is comparable with other radical prostatectomy approaches. (Level of evidence 3: from well-designed nonexperimental studies, such as comparative studies, correlation studies and case reports) In the absence of level 1a data and very limited long-term data, a firm conclusion regarding the oncological superiority of the technique over other techniques cannot be drawn. (Level of evidence 2a: from one well-designed controlled study without randomisation) |
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Incontinence:
Potency:
To achieve better early potency results, the use of laparoscopy or robotic techniques are [sic] recommended.* (Grade C recommendation: made despite the absence of directly applicable clinical studies of good quality) To achieve better early potency results, a cautery-free (i.e. athermal) technique during neurovascular bundle dissection is recommended. (Grade A recommendation: based on clinical studies of good quality and consistency that addressed the specific recommendations, including at least one randomised controlled trial)
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RARP for localised prostate cancer is a surgical approach offering high continence rates, at least comparable with ORP and LRP. (Level of evidence 2a: from one well-designed controlled study without randomisation) Experienced robotic surgeons achieve good early continence results. (Level of evidence 3: from well-designed nonexperimental studies, such as comparative studies, correlation studies and case reports) There is a trend towards faster recovery of continence after RARP in comparison to ORP and LRP. (Level of evidence 3: from well-designed nonexperimental studies, such as comparative studies, correlation studies and case reports) Potency assessment after radical prostatectomy has many limitations, which partly explains the wide variation in potency outcomes among different studies. (Level of evidence 2a: from one well-designed controlled study without randomisation) RARP is not inferior to ORP and LRP for potency rates. (Level of evidence 2a: from one well-designed controlled study without randomisation) There is a trend towards faster recovery of potency after robotic assisted laparoscopic radical prostatectomy (RALP) in comparison to ORP and LRP. (Level of evidence 2a-3: from one well-designed controlled study without randomisation; and well-designed nonexperimental studies, such as comparative studies, correlation studies, and case reports)
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Mottet et al (European Association of Urology), 201567
Guidelines on Prostate Cancer |
In patients who are surgical candidates for radical prostatectomy, all approaches (i.e. open, laparoscopic or robotic) are acceptable as no single approach has shown clear superiority in terms of functional or oncological results. (Grade A recommendation: based on clinical studies of good quality and consistency that addressed the specific recommendations, including at least one randomised controlled trial) |
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