Peri-operative safety and outcomes in Robotic Assisted Laparoscopic Prostatectomy: A New England experience with 332 cases

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Background:
Open radical prostatectomy has evolved over the past two decades with excellent perioperative and long-term outcomes, however robotic assisted laparoscopic prostatectomy (RALP) is being increasingly utilized. There is limited data regarding subsequent improvement beyond an initial learning experience.
Methods:
Data regarding all consecutive men undergoing RALP were collected prospectively and included preoperative evaluation (Age, Body Mass Index, D’Amico risk profile, comorbidities, and prior abdominal surgeries) and perioperative outcomes (operative time, estimated blood loss [EBL], change in pre vs. recovery room hematocrit [HCT], transfusions, length of stay (LOS), pathologic features). We used the Clavien classification to characterize RALP complications: (I) deviation from clinical pathway, (II) medical management, (III) procedural intervention, (IV) critical care/mortality. To assess ongoing learning curve effects beyond fellowship training, we stratified the study group into 3 equal, consecutive groups.
Results:
We identifed 332 men with an overall mean age of 58.8 years and body mass index of 27.3 kg/m². 30.1% of men underwent prior herniorraphies or intra-abdominal surgeries (Table). Furthemore, D’Amico Risk Classification of baseline tumor characteristics revealed that 57.2%, 37.3%, and 5.4% were low, intermediate, and high risk, respectively. Perioperatively, operative time, EBL, HCT change, and LOS improved with experience. Mean operative times decreased from 225 to 155 minutes (p<0.001), LOS decreased from 1.6 to 1.1 days (p=0.003) and EBL decreased from 269 to 187 cc (p<0.001).There were 0 vs. 4 (1.2%) intra vs. postoperative blood transfusions for cardiac indications. Complications by Clavien Classification decreased significantly with experience (p= 0.016 ).

Table (1)	First 110	Second 111	Third 111	Average	P value
Age	58.4	57.2	60.2	58.8	0.35
BMI	29.1	28.8	28.2	28.7	0.26
Operative Time (min)	225	190	155	190	<0.001
EBL (cc)	269	222	187	226	<0.001
HCT change (preop-postop) (dg/mL)	7.5	8.1	4.2	5.4	0.02
Transfusion (n)	2	1	1	-	1.2%
Hospital Stay (Days)	1.6	1.3	1.1	1.3	0.003
Complications - Clavien Classification (%)
Type I - (Pathway deviation)	10	6	7
Type II - (Medical therapy)	4	1	1
Type III - (Intervention)	6	1	0
Type IV - (Critical Care)	1	0	0		0.016
Positive Margin (%)	16.4	9.0	14.4	13.3	0.23

Conclusions:
Open radical prostatectomy has developed into a procedure with minimal mortality and excellent oncologic outcomes over the past two decades. Few centers have published similar experience in robotic prostatectomy. Our series of 332 patients divided into three cohorts shows low mortality and morbidity in the perioperative period particularly with respect to blood transfusions and length of stay. The results confirm there are continued learning curve benefits well beyond the first 100 cases.

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