Perioperative and Oncologic Outcomes of Anterior versus Posterior Approach Robot-assisted Laparoscopic Radical Prostatectomy

Abstract

Introduction: Robot-assisted laparoscopic radical prostatectomy is now considered the gold standard treatment of prostate adenocarcinoma in the modern world. There are two approaches to the precise dissection of seminal vesicles (anterior and posterior) during a laparoscopic radical prostatectomy, each of which with unique advantages and disadvantages. Primarily, the authors compared the intraoperative and oncological outcomes of these two approaches. Secondary objective included the establishment of the minimum number of cases before a surgeon can enter the competent phase of the learning curve.

Materials and Methods: Chart review was performed on 111 patients who underwent RALP from 2014-2016 performed by 3 experienced robotic surgeons with interchangeability of role as console operator. Two arms were developed based on the approach of seminal vesicle dissection, that is, anterior and posterior approach. Cumulative summation of the console time was performed to obtain a chart with a) negative slope-learning phase and b) positive slope-competent phase. Patients under the competent phases were included for analysis.

Results: There were no significant differences in age, body mass index, prostate volume, preoperative prostate specific antigen (PSA), gleason score and oncologic risk. Pathology was almost similar in majority of cases under the anterior approach arm being gleason 7 (3+4) and posterior approach arm being gleason 6 (3+3). With a p-value of <0.05, console time was significantly shorter in the posterior approach at 121±25.95 when compared to anterior approach at 148±30.25 minutes. The other perioperative and postoperative outcomes were not significantly different between the groups.

Conclusion: Posterior approach has provided a shorter console time, while the overall oncologic and perioperative outcomes for both approaches were similar. The learning curve for the anterior approach is less steep than that of the posterior approach with only 14 versus 26 consecutive cases, respectively, to be able to competently perform RALP.