Trifecta Outcomes After Robotic-assisted Laparoscopic Prostatectomy

doi:10.1016/j.urology.2009.02.082

Urology

Volume 74, Issue 3, September 2009, Pages 619-623

https://doi.org/10.1016/j.urology.2009.02.082 Get rights and content

Objective

To evaluate the trifecta outcomes following robotic-assisted laparoscopic prostatectomy (RALP) and compare the results applying definitions of continence and potency as reported in the literature vs validated questionnaire. The trifecta rate of achieving continence, potency, and undetectable prostate-specific antigen (PSA) following radical prostatectomy has been estimated to be approximately 60% at 1-2 years in open radical prostatectomy series. The definitions of continence and potency were not standardized, which poses difficulty in comparing published results.

Methods

A prospective, institutional RALP database was analyzed for preoperatively continent and potent men with ≥ 1 year follow-up after bilateral nerve-sparing surgery. Continence and potency were evaluated preoperatively and at 3, 6, 12, and 24 months after surgery by surgeon interview (subjective) and using University of California Los-Angeles Prostate Cancer Index self-administered questionnaire (objective). Biochemical recurrence was defined as a detectable (> 0.05 ng/mL), increasing PSA on 2 consecutive tests.

Results

Among 1362 consecutive RALPs, 380 patients were preoperatively potent and continent underwent surgery with bilateral nerve-sparing technique and had sufficient follow-up. Trifecta rates applying subjective continence and potency definitions were 34%, 52%, 71%, and 76% at 3, 6, 12, and 24 months, respectively. The corresponding trifecta rates using objective continence and potency definitions stood at 16%, 31%, 44%, and 44%. The difference was statistically significant at each time point (P < .0001).

Conclusions

RALP provides trifecta outcome rates comparable to open surgery. The outcome rates vary significantly depending on the tools used for continence and potency evaluation.

Section snippets

Patient Selection

We analyzed the University of Chicago, Section of Urology prospective RALP database for preoperatively continent and potent men who underwent bilateral nerve sparing surgery and had at least 1-year follow-up. The study was approved by the Institutional Review Board.

Data collection included age, body mass index (BMI), comorbidities, preoperative PSA, clinical and pathologic stage, pathologic Gleason score, nerve-sparing technique, surgical margin status, follow-up continence, potency, and PSA

Results

Among the 1362 consecutive RALPs performed at our institution between February 2003 and January 2008, 829 (61%) patients had at least 1-year follow-up. Bilateral nerve sparing was used in 537 of these 829 men (66%). Of the 537 patients, 468 (87%) were preoperatively evaluated with UCLA-PCI questionnaire. Finally, 380 of 468 patients (81%) were found to be preoperatively potent according to the UCLA-PCI questionnaire and thus fit the study criteria. The mean age was 58 years (range 42-76), mean

Comment

In a few series reporting trifecta outcomes after RP (Table 3) the rates are in the range of 20%-76%. The study design and criteria for being BCR-free, continent, and potent lack consistency, thus preventing direct comparison.

Salomon et al¹⁰ reported trifecta rate of 20% in their series of 205 patients 1 year after open, laparoscopic, and perineal prostatectomy. Individually, BCR-free, continence, and potency rates were 85%, 66%, and 33%, respectively. The strength of this study is the use of

Conclusions

We found that RALP provides trifecta outcomes rates comparable to open surgery. There is significant difference in trifecta outcomes depending upon continence and potency definitions and whether functional outcomes evaluation is based on information derived from patient-surgeon encounter or self-administered validated questionnaire. To obtain realistic and comparable trifecta outcomes analysis strict and uniform criteria for postoperative potency and continence should be defined.

References (16)

K.L. Greene et al.
Who is the average patient presenting with prostate cancer?
Urology
(2005)
C.M. Lee et al.
Comparison of late rectal toxicity from conventional versus three-dimensional conformal radiotherapy for prostate cancer: analysis of clinical and dosimetric factors
Urology
(2005)
F.J. Bianco et al.
Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (“trifecta”)
Urology
(2005)
P.M. Pierorazio et al.
Preoperative risk stratification predicts likelihood of concurrent PSA-free survival, continence, and potency (the trifecta analysis) after radical retropubic prostatectomy
Urology
(2007)
L. Salomon et al.
Combined reporting of cancer control and functional results of radical prostatectomy
Eur Urol
(2003)
K.C. Zorn et al.
Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation
Eur Urol
(2007)
M.S. Litwin et al.
Differences in urologist and patient assessments of health related quality of life in men with prostate cancer: results of the CaPSURE database
J Urol
(1998)
F.R. Schroeck et al.
Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy
Eur Urol
(2008)

There are more references available in the full text version of this article.

Cited by (97)

Does Centralization of Radical Prostatectomy Reduce the Incidence of Postoperative Urinary Incontinence?
2023, European Urology Open Science
On the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was gradually increased from 20 per year in 2017, to 50 in 2018 and 100 from 2019 onwards.
To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI).
Patients who underwent RP during 2016–2020 were identified in the claims database of the largest health insurance company in the Netherlands. Incontinence was defined as an insurance claim for ≥1 pads/d.
The relationship between hospital RP volume (HV) and RP-UI was assessed via multivariable analysis adjusted for age, comorbidity, postoperative radiotherapy, and lymph node dissection.
RP-UI incidence nationwide and by RP volume category did not decrease significantly during the study period, and 5-yr RP-UI rates varied greatly among hospitals (19–85%). However, low-volume hospitals (≤120 RPs/yr) had a higher percentage of patients with RP-UI and higher variation in comparison to high-volume hospitals (>120 RPs/yr). In comparison to hospitals with low RP volumes throughout the study period, the risk of RP-UI was 29% lower in hospitals shifting from the low-volume to the high-volume category (>120 RPs/yr) and 52% lower in hospitals with a high RP volume throughout the study period (>120 RPs/yr for 5 yr).
A focus on increasing hospital RP volumes alone does not seem to be sufficient to reduce the incidence of RP-UI, at least in the short term. Measurement of outcomes, preferably per surgeon, and the introduction of quality assurance programs are recommended.
In the Netherlands, centralization of surgery to remove the prostate (RP) because of cancer has not yet improved the occurrence of urinary incontinence (UI) after surgery. Hospitals performing more than 120 RP operations per year had better UI outcomes. However, there was a big difference in UI outcomes between hospitals.
Surgical approach and sexual outcomes after radical prostatectomy
2017, Progres en Urologie
La prostatectomie totale est le traitement chirurgical curatif de référence du cancer de la prostate localisé. Les objectifs sont le contrôle carcinologique, la préservation de la continence et la préservation de la sexualité, l’association des trois constituant le Trifecta.
Les objectifs de ce travail étaient d’étudier, au travers de l’analyse de la littérature, les résultats en termes de fonction sexuelle postopératoire en fonction de la voie d’abord chirurgicale : prostatectomie radicale par laparotomie (PRL), prostatectomie radicale laparoscopique (PRLa) ou prostatectomie radicale laparoscopique robot-assistée (PRLaRA).
Une revue exhaustive, rétrospective de la littérature a été réalisé à l’aide du moteur de recherche Pubmed avec les mots clés suivants : “Prostatic Neoplasms” [Mesh], “Prostatectomy” [Mesh], “Erectile Dysfunction” [Mesh], “Robotics” [Mesh], “Laparoscopy” [Mesh], Nerve sparing.
Les articles sélectionnés étaient les articles en langue anglaise ou française portant sur des études rétrospectives ou prospectives de plus de 200 patients et les essais randomisés et méta-analyses publiés entre 1990 et 2014.
Au total ont été sélectionnés 21 études prospectives (6 articles sur la PRL, 4 sur la PRLa et 11 sur la PRLaRA) et 12 rétrospectives (6 articles sur la PRL, 1 sur la PRLa et 5 sur la PRLaRA), 2 essais randomisés et 3 méta-analyses, de 1992 à 2013. Il n’a pas été identifié de voie d’abord chirurgicale supérieure aux autres en termes de sexualité postopératoire.
Les résultats des différents articles de niveau 1 de preuve scientifique étant relativement discordants, en raison d’une grande hétérogénéité dans l’évaluation de la fonction sexuelle postopératoire.
À l’heure actuelle, à notre connaissance, il n’existe pas parmi la PRL, la PRLa et la PRLaRA, de voie d’abord chirurgicale préférentielle en termes de résultats sur fonction sexuelle postopératoire.
Radical prostatectomy is curative surgical treatment of choice for localized prostate cancer. The objectives are cancer control, preservation of continence and preservation of sexuality, the combination of the three constituting the Trifecta.
The objective of this study was to assess, through the analysis of the literature, the sexual outcomes according to surgical approach: radical prostatectomy by laparotomy (PRL), laparoscopic radical prostatectomy (PRLa) and laparoscopic robot-assisted radical prostatectomy (PRLaRA), when nerve sparing was practiced.
An exhaustive and retrospective review of literature was conducted using the Pubmed search with the following keywords: “Prostatic Neoplasms” [Mesh], “Prostatectomy” [Mesh], “Erectile Dysfunction” [Mesh], “Robotics” [Mesh], “Laparoscopy” [Mesh], Nerve sparing.
The selected articles were prospective or retrospective series including more than 200 patients, randomized trials and meta-analyses published between 1990 and 2014.
A total of 21 prospective studies (6 on PRL, 4 on PRLa and 11 on PRLaRA), 12 retrospective studies (6 on PRL, 1 on PRLa and 5 on PRLaRA), 2 randomized controlled trial and 3 meta-analyses were selected from 1992 to 2013. There was no evidence of the superiority of one surgical approach compared to others in terms of sexuality.
Articles with level 1 of scientific evidence have discordant results, due to heterogeneity in the assessment criteria of postoperative sexual function.
According to our knowledge, there is currently no difference in terms of sexual outcomes between PRL, PRLA and PRLaRA approaches.
Assessing the impact of barbed suture on vesicourethral anastomosis during minimally invasive radical prostatectomy: A systematic review and meta-analysis
2015, Urology
To examine the effectiveness of barbed suture (BS) compared with conventional sutures for vesicourethral anastomosis (VUA) during minimally invasive radical prostatectomy (RP).
Relevant studies comparing the safety and efficacy of BS with conventional sutures during minimally invasive RP were identified through a literature search using MEDLINE, EMBASE, and the Cochrane Library. The outcome measures included baseline characteristics, primary outcomes, and secondary outcomes.
Ten studies (378 cases and 369 controls) were included. No significant differences between the 2 groups were detected in any of the baseline variables except for age (P = .02). The BS group had a shorter operation time (mean difference [MD], 10.54; 95% confidence interval [CI], −14.38 to −6.69; P <.01), a shorter VUA time (MD, −5.35; 95% CI, −7.44 to −3.25; P <.01), and a shorter posterior reconstruction time (MD, −0.56; 95% CI, −1.10 to −0.02; P = .04) than those in the conventional sutures group. No significant differences were detected between the 2 groups in other outcomes of interest. In subgroup and sensitivity analyses, there was no change in the significance of any of the outcomes.
This meta-analysis indicates that VUA using BS as opposed to conventional suture is associated with a shorter operative time, comparable postoperative complication rate, and convenience for manipulation, which is of benefit to the surgeon learning robot-assisted RP and laparoscopic RP. Given that the inherent limitations, future well-designed randomized controlled trials are required to confirm our findings.
Is It Worth Continuing Sexual Rehabilitation after Radical Prostatectomy with Intracavernous Injection of Alprostadil for More than 1 Year?
2015, Sexual Medicine
Intracavernous alprostadil injection (IAI) is a widely used treatment for sexual rehabilitation (SR) after radical prostatectomy (RP). It is unknown whether the continuation of IAI beyond 1 year continues to improve erectile function.
To assess evolution of sexual function in patients using IAI who are nonresponsive to phosphodiesterase type 5 inhibitors (PDE5i) between 12 (M12) and 24 (M24) months after RP.
We retrospectively studied 75 men with a nerve-sparing laparoscopic RP, who had normal preoperative erectile function, and who regularly used IAI for SR for at least 24 months. At M12, no patients had responded to PDE5i.
At 12 and 24 months, sexual function was assessed with the UCLA Prostate Cancer Index (UCLA-PCI), International Index of Erectile Function (IIEF)-15, and erection hardness score (EHS) with and without IAI. We also assessed the satisfaction rate with IAI, injection-related penile pain, and satisfaction of treatment. Statistical analysis was performed by using t-tests for paired data and Spearman's rho correlation coefficients to assess the relationships between scores at M12 and M24.
Improvement of nocturnal erection was noted (UCLA-PCI, question 25); however, no significant difference was found for IIEF-erectile function with (19.60 ± 9.80 vs. 18.07 ± 10.44) and without IAI (4.63 ± 2.93 vs. 4.92 ± 4.15), UCLA-PCI-sexual bother (37.14 ± 21.45 vs. 37.54 ± 19.67), nor the EHS score with (2.97 ± 1.30 vs. 2.57 ± 1.30) and without IAI (0.67 ± 1.11 vs. 0.76 ± 0.10). The rate of satisfaction with treatment decreased over time (66.6% vs. 46.7%, P = 0.013). Improved response to IAI at M12 was not correlated to improvement in spontaneous erections at M24.
The response to IAI remained stable after 2 years of treatment, and no significant improvement of spontaneous erections during intercourse attempts was found between M12 and M24. Patients should be informed of the limited effect of IAI on natural erections after 1 year. Yiou R, Bütow Z, Parisot J, Binhas M, Lingombet O, Augustin D, de la Taille A, and Audureau E. Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year? Sex Med 2015;3:42–48.
Functional results and treatment of functional dysfunctions after radical prostatectomy
2015, Progres en Urologie
Décrire les résultats fonctionnels et la prise en charge des troubles fonctionnels après prostatectomie totale (PT) pour cancer de la prostate (CaP).
Recherche bibliographique à partir de la base de données Medline (National Library of Medicine, outil Pubmed) sélectionnée selon la pertinence scientifique. La recherche par mots-clés a été centrée sur la continence, la puissance sexuelle, les dysérections, la sexualité du couple, l’incontinence urinaire, les traitements de l’incontinence et de la dysérection postopératoires, et le Trifecta.
La PT est une intervention complexe dont le risque carcinologique est mis en balance avec les résultats fonctionnels. L’incontinence urinaire est la plus redoutée des complications de la PT. En dépit de l’évolution constante de la technique, 9 à 16 % des patients continuent de présenter une incontinence après PT (IU-PT). L’IU-PT est la conséquence d’une lésion du sphincter strié urétral et/ou d’une dysfonction vésicale. L’évaluation de la sévérité de l’IU-PT conditionne le choix du traitement chirurgical mais manque encore de standardisation. Elle doit comporter au minimum un test de pesée des protections urinaires et un auto-questionnaire validé. L’implantation d’un sphincter urinaire artificiel AMS 800 reste le traitement de référence pour les IU-PR moyennes à sévères. Le développement de techniques moins invasives comme les bandelettes sous-urétrales ou les ballons Pro-ACT ont apporté des alternatives thérapeutiques pour les formes légères et moyennes d’IU-PR. Les bandelettes sous-urétrales compressives sont considérées comme le traitement de référence des IU-PT non-sévères et sans antécédent de radiothérapie. Le traitement de seconde ligne le mieux approprié n’est pas clairement déterminé. De nouveaux dispositifs médicaux tels les sphincters artificiels et bandelettes ajustables ou des thérapies cellulaires ont été décrits. Conserver une sexualité satisfaisante est une préoccupation importante pour une majorité d’hommes confrontés au diagnostic de CaP et à ces traitements. Il est indispensable d’évaluer la sexualité du couple avant le traitement du CaP afin de délivrer une information complète et d’envisager des solutions thérapeutiques précoces et adaptées à la demande du couple. La rééducation pharmacologique active (injections intracaverneuses ou inhibiteurs de la phosphodiestérase de type 5 [IPDE5] à la demande dans les mois qui suivent l’intervention) ou passive (IPDE5 quotidiens après l’intervention) pourrait permettre d’améliorer la qualité des érections notamment en réponse à la prise d’IPDE5. Des formes de sexualité privilégiant les éléments non altérés de la sexualité (orgasme) peuvent, quand l’érection n’est pas encore récupérée, être une solution alternative permettant au couple de préserver intimité et complicité. Le blocage androgénique est un frein considérable au maintien ou au retour d’une sexualité satisfaisante. Le Trifecta est un outil permettant de présenter les résultats de la PT sous une forme unique : il est de 60 % (contrôle carcinologique, patient continent, ayant des érections) en cas de préservation bilatérale des bandelettes neurovasculaires, quelle que soit la voie d’abord.
La PT est une intervention complexe pour laquelle le risque carcinologique est mis en balance avec les résultats fonctionnels. De nombreux traitements existent pour la prise en charge de l’incontinence et de la dysérection postopératoire. Les troubles fonctionnels après chirurgie doivent être pris en charge pour améliorer la qualité de vie des patients.
To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer.
Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta.
Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9–16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach.
Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.
Age-stratifled potency outcomes of bilateral nerve sparing robotic-assisted radical prostatectomy
2023, Canadian Journal of Urology

View all citing articles on Scopus

View full text

Laparoscopy and RoboticsTrifecta Outcomes After Robotic-assisted Laparoscopic Prostatectomy

Objective

Methods

Results

Conclusions

Section snippets

Patient Selection

Results

Comment

Conclusions

Urology

Urology

Urology

Urology

Eur Urol

Eur Urol

J Urol

Eur Urol

Laparoscopy and Robotics
Trifecta Outcomes After Robotic-assisted Laparoscopic Prostatectomy