A Role for Laparoscopy in the Age of Robotics: A Retrospective Cohort Study of Perioperative Outcomes Between 2D Laparoscopic Radical Prostatectomy vs 3DHD Laparoscopic Radical Prostatectomy - Beyond the Abstract
The first three generations of 3D visual systems were limited by reduced resolution, dimmer illumination, blurred peripheral display, or the use of bulky helmets, which resulted in symptoms of ocular fatigue, headache, nausea, and increased surgeon fatigue. The first robot-assisted radical prostatectomy using the da Vinci system was performed in 2001. With a learning curve of 10–20 cases and comfortable 3D vision, a growing number of radical prostatectomies were performed with the robotic-assisted approach, supplanting ORP as the most common radical prostatectomy alternative. The 4th generation laparoscopic 3DHD visual system ameliorated the previously described limitations of the older 3D laparoscopic visual systems with the use of film-type patterned technology. The glasses are light, comfortable, and do not impair vision upon looking away from the screen. RARP is not feasible in low-volume centers due to economic barriers. The study compares 4th generation 3DHD and 2D LRP techniques to assess 3DHD LRP safety and discusses it as a minimally invasive alternative to the expensive RARP in low-volume centers. With RARP popularity increasing, the findings are relevant not only to urologists in medium or low-volume centers but also to healthcare providers overall when considering economic factors.
Retrospectively acquired data from 150 Hispanic patients that underwent prostatectomy surgery from March 2013 to October 2015 were evaluated. 150 patients were stratified into two groups. 75 patients to the group who underwent 2D LRP and 75 patients who underwent 4th gen 3DHD LRP. Nerve-sparing was attempted in all patients. No significant differences were detected between study groups in terms of age, preoperative PSA level, and preoperative biopsy Gleason scores. However, body mass index (BMI) was significantly higher in the 3D LRP group. The series resulted in decreased JP drainage, shorter length of hospital stay, earlier return of continence, and earlier return of potency in the 3DHD LRP group. No significant differences were observed in Hgb loss, positive surgical margins, and post-op Gleason scores. Regarding complications, the most common Grade 1 complications were anastomotic leaks, detected on JP output. None of the patients required prolonged catheterization due to persistent anastomotic leakage. In terms of Grade 2 complications, one patient in the 2D LRP group (1%) presented with deep vein thrombosis (DVT) 3 weeks after the procedure. Regarding Grade 3 complications, no rectal or urethral injuries were reported.
The superior findings in the 4th generation 3DHD LRP are attributed to superb visualization with the reticulating scope and the three-dimensional reconstruction of the target region which greatly facilitates the accuracy of surgical manipulation and the estimate of anatomic depth. This proves useful during the nerve-sparing dissection, urethra-vesicular anastomosis, and allows for greater sphincter-saving and reduced trauma. We found that performing the dissection with the reticulating scope and the articulating scissors allowed us to reach the neurovascular bundle from different angles, allowed for careful mucosal apposition, eversion of the bladder neck mucosa, proper handling of the tissue, and easy access to the posterior prostatic surface which cannot be accomplished with the rigid 2D scope.
As with all new technologies, our collective goal as physicians is to improve upon existing standards of care and advance our specialty. As managed care becomes more prevalent, urologists must critically evaluate the economic aspect and patient satisfaction with urological practice patterns. Data from the nationwide inpatient sample reported in 2009 that 61% of prostatectomies were RARP. In recent years RARP has replaced ORP as the most common surgical approach to prostate cancer despite the lack of evidence demonstrating superior oncologic or functional outcomes. With RARP popularity increasing, our findings are important not only to urologists but also to healthcare providers when considering economic issues in centers that do not have the volume to make robotics use sustainable.
Written by: Andrew Engel-Rodriguez, Isabel Ruiz-Irizarry, Natalie Engel-Rodriguez, Carmen Ortiz-Sánchez, Jarline Encarnación-Medina, Gilberto Ruiz-Deya
St. Luke's Episcopal Hospital, Ponce, PR, USA., Department of Basic Sciences, Ponce Research Institute, Ponce Health Sciences University, Ponce, PR, USA., St. Luke's Episcopal Hospital, Ponce, PR, USA.
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