Ali Rıza Kural

Acıbadem University, Maslak Hospital

Urology & Robotic Surgery Department

6th POMERIAN URO-

ONCOLOGY,2013

Is RARP the best available surgical treatment in Prostate Cancer ?

Advantages ?

3-D 10-12x magnified vision on console

Instruments 6 Degree of free movement

Tremor Scaling

Ergonomic for surgeon

First successful RARP program:

Mani Mennon & Vallancien, November 2000, Detroit, USA

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Anatomical Dominance ?

● APAs are dominant blood supply to penis in greater than 50 % of pts (Nehra et al)

● In some patients the only major arterial blood supply

Preservation of APAs :

Does it make any difference??

Rogers et al, Urology, 2004 :

RRP for 2399 pts potent

84 APAs ( 4% )

●APA preservation resulted in;

2 times greater likelihood of potency

50 % decrease in time to the return

of potency

6th POMERIAN URO-

ONCOLOGY,2013

Anatomical Dominance ?

● APAs are dominant blood supply to penis in greater than 50 % of pts (Nehra et al)

● In some patients the only major arterial blood supply

Preservation of APAs :

Does it make any difference??

Rogers et al, Urology, 2004 :

RRP for 2399 pts potent

84 APAs ( 4% )

●APA preservation resulted in;

2 times greater likelihood of potency

50 % decrease in time to the return

of potency

6th POMERIAN URO-

ONCOLOGY,2013

6th POMERIAN URO-

ONCOLOGY,2013

BETTER UNDERSTANDING THE ANATOMY ?

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ONCOLOGY,2013 World J Urology, 2006

Fascial Anatomy ?

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Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy. Tewari et al, BJU Int, 2011

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ONCOLOGY,2013 J Urol, 2008

MORBID OBESITY and ROBOTIC PROSTATECTOMY

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MORBID OBESITY and ROBOTIC PROSTATECTOMY

Mayo Clinic, J Urol, 2008

Group I : 94 pts BMI < 25

Group II : 187 pts BMI 25-30

Group III : 119 pts BMI > 30 EBL is higher and OR Time is longer in Group III

SM + is higher in group III but no statistical difference

CONCLUSION : RARP is a safe method for morbid obese pts

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ONCOLOGY,2013

6th POMERIAN URO-

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EBL is less, blood transfusion is lower, hospital stay is shorter in RARP series.

Eur Urol, 2009

Perioperative results with RARP ?

Oncological results ? 6th POMERIAN URO-

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BJU Int, 2013

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BJU Int, 2013

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* No evidence to suggest that RARP results in worse oncological outcomes, even for patients with high risk cancer. * Enough number of lymph nodes can be removed during RARP. * RARP need not be limited to patients with low to intermediate risk

cancer. It can be safely performed in high risk group as well.

BJU Int, 2013

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184 STUDİES IDENTIFIED BETWEEN 2008 and 2011

( 136 EVALUATING ONLY RARP , 44 COMPARING RARP,RRP/LRP )

129 WERE SELECTED RECORDING ONCOLOGICAL OUTCOMES

47 ABSTRACTS OR MEETING REPORTS,

5 DUPLICATE PUBLICATIONS WERE EXCLUDED

EXCLUSION CRITERIA :

• PAPERS ALREADY INCLUDED IN THE ORIGINAL REVIEW

• SECONDARY ANALYSIS

• PAPERS REPORTING NOT RELEVANT OUTCOMES

• DUPLICATE PUBLICATIONS

• POPULATION BASED STUDIES

• CASE SERIES INCLUDE < 100 CASES

6th POMERIAN URO-

ONCOLOGY,2013

TWO STUDIES PUBLISHED DURING THE REALIZATION

OF THE SYSTEMATIC REVIEW

RARP

Case

series: 34

RARP

Comparative

studies: 24

Studies

comparing RARP

and RRP: 13

Studies

comparing RARP

and LRP: 8

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Vattikuti Institute Prostatectomy: Contemporary Technique and Analysis of Results

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Fig. 2 Cumulative analysis of PSM rates for pT2 tumors after robot-

assisted radical prostatectomy or open radical prostatectomy.

International Journal of Urology ,2013

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ONCOLOGY,2013 International Journal of Urology ,2013

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184 STUDİES IDENTIFIED BETWEEN 2008 and 2011

77 WERE SELECTED REPORTING URINARY CONTINENCE

24 ABSTRACTS OR MEETING REPORTS,

3 DUPLICATE PUBLICATIONS WERE EXCLUDED

- CASE SERIES : 17

- COMPARATIVE STUDIES : 17

- STUDIES COMPARING RARP and RRP : 9

- STUDIES COMPARING RARP and LRP : 8

For the first time, our cumulative analyses showed a statistically

significant advantage in favor of RARP in comparison with both RRP

and LRP in terms of 12-mo urinary continence recovery. However,

multiple design and methodological factors need to be considered in

interpreting these outcomes.

6th POMERIAN URO-

ONCOLOGY,2013

6th POMERIAN URO-

ONCOLOGY,2013

RARP IS THE BEST METHOD IN THE TREATMENT OF LOCALIZED P Ca

Since RARP ……..

Is associated with less blood loss and shorter hospital stay

Oncological results are similar to open RP

Can be performed safely in high risk patients

Is associated with better continence rates at 12 months

Provides better identification and preservation of APAs

Can be safely performed in morbid obese patients

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ONCOLOGY,2013

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THANK YOU

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