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| Experience of one single surgeon with the first 500 robot-assisted laparoscopic prostatectomy cases in mainland China |
Huan Chen,Bijun Lian,Zhenyang Dong,Yan Wang,Min Qu,Feng Zhu,Yinghao Sun,Xu Gao( )
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| Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China |
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Abstract Objectives: To summarize the experience of the first 500 robot-assisted laparoscopic radical prostatectomy (RALP) cases by one surgeon and analyze the influencing factors of functional and oncological outcomes.
Methods: Between April 2012 and October 2017, 500 patients who underwent RALP were included and divided sequentially into five equal groups. Patients’ preoperative, perioperative and postoperative outcomes were analyzed and evaluated, and the Kruskal-Wallis test was used to analyze and compare the effect of surgeon experience by case.
Results: There is a statistically significant reduction in operative time, intraoperative estimated blood loss and postoperative hospital stay time (all p<0.001) with the increased experience. The results show that experience was the most important influencing factor in both operative time and blood loss. Pelvic lymph node dissection (PLND) might increase the operative time. The total positive surgical margin (PSM) rate was 21.8%. The PSM rate in pT3 tumors was significantly higher than that in pT2 tumors (12.0% vs. 37.1%, p<0.001). The 5-year biochemical recurrence (BCR)-free rate was 70.8%. The results of Cox regression showed that preoperative prostate-specific antigen (PSA), postoperative Gleason score (GS), and pathologic T stage were independent risk factors for BCR.
Conclusion: After approximately 200 cases, the surgeon reached a plateau for RALP, but the outcomes could still improve after more cases. The surgeon's experience was the most important influencing factor for both operative time and blood loss. PSM rate was mainly determined by tumor stage rather than by operation experience.
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Received: 08 April 2019
Available online: 23 December 2019
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Corresponding Authors:
Xu Gao
E-mail: gaoxu.changhai@foxmail.com
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| Clinical data | Group 1 | Group 2 | Group 3 | Group 4 | Group 5 | p-Value | Overall | | 1-100 | 101-200 | 201-300 | 301-400 | 401-500 | | Age, mean±SD, year | 67.4±6.85 | 66.5±6.57 | 66.2±6.30 | 66.7±6.45 | 66.7±7.75 | 0.788b | 66.7 (6.79) | | BMI, mean±SD, kg/m2 | 24.0±2.90 | 24.4±2.70 | 24.6±2.83 | 24.1±2.41 | 24.6±3.20 | 0.502c | 24.3 (2.82) | | Preoperative PSA, n (%) | | | | | | 0.342d | | | <4.0 | 4 (4.0) | 2 (2.0) | 1 (1.0) | 1 (1.0) | 2 (2.0) | | 10 (2.0) | | 4.0-9.9 | 35 (35.0) | 34 (34.0) | 27 (27.0) | 32 (32.0) | 31 (31.0) | | 159 (31.8) | | 10.0-19.9 | 31 (31.0) | 31 (31.0) | 33 (33.0) | 33 (33.0) | 32 (32.0) | | 160 (32.0) | | >19.9 | 30 (30.0) | 33 (33.0) | 39 (39.0) | 34 (34.0) | 35 (35.0) | | 171 (34.2) | | Clinical stage, n (%) | | | | | | 0.005d | | | T1 | 30 (30) | 37 (37) | 63 (63) | 40 (40) | 24 (24) | | 194 (38.8) | | T2 | 61 (61) | 54 (54) | 23 (23) | 41 (41) | 54 (54) | | 23 (46.6) | | T2a | 31 (31.0) | 32 (32.0) | 12 (12.0) | 19 (19.0) | 13 (13.0) | | 107 (21.4) | | T2b | 30 (30.0) | 21 (21.0) | 2 (2.0) | 6 (6.0) | 11 (11.0) | | 70 (14.0) | | T2c | 0 (0.0) | 1 (1.0) | 9 (9.0) | 16 (16.0) | 30 (30.0) | | 56 (11.2) | | T3 and T4a | 9 (9.0) | 9 (9.0) | 14 (14.0) | 19 (19.0) | 22 (22.0) | | 73 (14.6) | | GS, n (%) | | | | | | 0.633d | | | <7 | 21 (21.0) | 33 (33.0) | 30 (30.0) | 24 (24.0) | 21 (21.0) | | 129 (25.8) | | =7 | 45 (45.0) | 38 (38.0) | 26 (26.0) | 35 (35.0) | 44 (44.0) | | 188 (37.6) | | >7 | 34 (34.0) | 29 (29.0) | 44 (44.0) | 41 (41.0) | 35 (35.0) | | 183 (36.6) | | D'Amico risk group, n(%) | | | | | | 0.084d | | | Low | 12 (13.0) | 10 (10.0) | 14 (14.0) | 12 (12.0) | 10 (10.0) | | 58 (11.8) | | Intermediate | 31 (33.0) | 38 (38.0) | 22 (22.0) | 26 (27.0) | 22 (22.0) | | 139 (28.4) | | High | 57 (54.0) | 52 (52.0) | 64 (64.0) | 62 (61.0) | 68 (68.0) | | 303 (59.8) |
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Preoperative characteristics for each group and overall.
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| Characteristics | Group 1 | Group 2 | Group 3 | Group 4 | Group 5 | p-Value | Overall | | 1-100 | 101-200 | 201-300 | 301-400 | 401-500 | 500 | | Operative time, median (IQR), min | 165 (140-198.75) | 130 (110-150) | 110 (100-123.75) | 105 (90-130) | 90 (75-105) | <0.001a | 120 (100-150) | | Blood loss, median (IQR), mL | 200 (105-300) | 200 (100-200) | 100 (70-187.5) | 100 (100-200) | 100 (50-128.75) | <0.001a | 100 (100-200) | | Postoperative hospital stays median (IQR), day | 9 (7-11) | 6 (5-8) | 5 (5-7) | 5 (4-7) | 5 (4-6) | 0.001a | 6 (5-8) | | NVB preserving, n | 1 | 1 | 6 | 26 | 34 | | 68 | | Unilateral | 1 | 0 | 3 | 9 | 11 | | | | Bilateral | 0 | 1 | 3 | 17 | 23 | | | | T2 | 1 | 1 | 6 | 26 | 32 | | | | T3 | 0 | 0 | 0 | 0 | 2 | | | | Pathologic stage, n (%) | | | | | | 0.001b | 500 | | pT2 | 75 (75) | 66 (66) | 47 (47) | 58 (58) | 54 (54) | | 300 (60) | | pT3 | 23 (23) | 34 (34) | 53 (53) | 42 (42) | 45 (45) | | 197 (39.4) | | pT4 | 2 (2) | 0 (0) | 0 (0) | 0 (0) | 1 (1) | | 3 (0.6) | | Gleason score, n (%) | | | | | | 0.201b | | | <7 | 20 (20) | 15 (15) | 13 (13) | 15 (15) | 14 (14) | | 77 (15.4) | | =7 | 54 (54) | 64 (64) | 54 (54) | 58 (58) | 51 (51) | | 281 (56.2) | | >7 | 26 (26) | 21 (21) | 33 (33) | 27 (27) | 35 (35) | | 142 (28.4) | | PSM+ n (%) | 23 (23.5) | 24 (24.0) | 29 (29.0) | 18 (18.0) | 15 (15.2) | 0.143b | 109 (21.8) | | pT2 | 13 (17.3) | 9 (13.6) | 5 (10.6) | 5 (8.6) | 4 (7.4) | 0.409b | 36 (12.0) | | pT3 | 10 (43.5) | 15 (44.1) | 24 (45.3) | 13 (31.0) | 11 (24.4) | 0.170b | 73 (37.1) |
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Perioperative characteristics for each group and overall.
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| Covariate | Univariate analysis | Multivariate analysis | | HR (95% CI) | p-Value | HR (95% CI) | p-Value | | Postoperative GS | | =6a | 1 | | 1 | | | >7 | 24.717 (5.827-100.272) | <0.0001 | 11.325 (2.590-49.520) | 0.0013 | | Preoperative PSA | | <10a | 1 | | 1 | | | >20 | 7.004 (3.672-13.359) | <0.0001 | 4.174 (2.077-8.391) | <0.0001 | | Age | | ≤59a | 1 | | | | | 74 | 1.475 (0.638-3.411) | 0.3631 | | | | BMI | | <24a | 1 | | | | | ≥24 | 1.100 (0.671-1.802) | 0.7065 | | | | Pathologic T stage | | <T3aa | 1 | | 1 | | | ≥T3a | 5.802 (3.457-9.739) | <0.0001 | 2.344 (1.226-4.341) | 0.0067 | | Pathologic N stage | | N0a | 1 | | 1 | | | N1 | 6.366 (3.390-11.952) | <0.0001 | 1.756 (0.880-3.502) | 0.1102 | | PSM | | Negativea | | | 1 | | | Positive | 3.967 (2.410-6.528) | <0.0001 | 1.837 (1.052-3.207) | 0.0325 |
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The association of possible risk factors of BCR.
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The learning curve of intraoperative blood loss (A), operative time (B) and postoperative hospital stays (C).
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The continence recovery rate (A) and the biochemical recurrence-free survival rate (B). BCR, biochemical recurrence.
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