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European UrologyVolume 62, issue 1, pages e1-e30, July 2012
Reply from Authors re: Quoc-Dien Trinh, Khurshid R. Ghani, Mani Menon. Robot-assisted Radical Prostatectomy: Ready To Be Counted? Eur Urol 2012;62:16–8: Walking the Tightrope: Balancing Cancer Control, Urinary Continence, and Sexual Function—A Programmatic Evolution
Published online 27 April 2012, pages 18 - 19
Refers to article:
Positive Surgical Margin and Perioperative Complication Rates of Primary Surgical Treatments for Prostate Cancer: A Systematic Review and Meta-Analysis Comparing Retropubic, Laparoscopic, and Robotic Prostatectomy
Accepted 14 February 2012
July 2012 (Vol. 62, Issue 1, pages 1 - 15)
Refers to article:
Robot-assisted Radical Prostatectomy: Ready To Be Counted?
July 2012 (Vol. 62, Issue 1, pages 16 - 18)
Thanks for the opportunity to respond to the editorial comments presented by Trinh et al. . We appreciate the thoughts on the methodology of meta-analysis. This methodology is robust and gives us a good idea about outcomes in terms of margin rates and perioperative complications. While Trinh et al. correctly point out that our paper demonstrates that margin rates are comparable between open and robotic assisted radical prostatectomy (RARP), our paper also demonstrates that the laparoscopic approach results in an increased risk for positive margins when compared to RARP. It also shows that in terms of perioperative complications, RARP is the safest among these approaches .
One thing that is difficult to show using a meta-analytic approach is the impact of innovations and refinements that have occurred in robotic surgery since its inception. In addition to achieving negative margins and reduced surgical complications, RARP seeks to achieve the postoperative goals of continence and return of sexual function. It is in the pursuit of these trifecta goals for prostatectomy that RARP can have the greatest impact. For example, in our own surgical cohort, we have been able to bring incremental improvements to the procedure over the years to achieve negative margin rates, urinary continence, and return of sexual function in patients who had good baseline sexual function (International Index of Erectile Function >21) and were candidates for good nerve sparing (grade 1)  in ranges >90% in all domains. By relating these trends with our published literature, it can be seen that these innovations have affected outcomes and reflect the process of learning a complex procedure such as radical prostatectomy (Fig. 1, , , , , , , , , , and ).
Initially, we worked on detailed trizonal neural architecture and adopted an athermal technique for nerve sparing . Later on, the development of techniques such as total reconstruction of the vesico-urethral junction has proven to be a safe and effective way to achieve an early return of continence with significant gains when compared to the previous gold standard of no or partial reconstruction . The incorporation of visual cues in surgery has yielded improvements in negative margins, allowing experienced surgeons to make informed intraoperative oncologic decisions . Through adopting a risk-stratified approach to nerve-sparing RARP, we have been able to balance the risk of positive margins with preserving urinary and sexual function, achieving the successful outcomes seen today  and . With these progressive innovations, RARP has seen greater success in achieving optimal outcomes in all areas of the trifecta goals—negative margins, urinary continence, and return to sexual function—as more and more patients are being treated at our surgical center.
Similar developments and refinements are occurring at other programs , , and . It would be great to pool the data for similar incremental improvements from multiple institutions and look across the board at the field of innovations in an effort to determine their relationship with improved trifecta outcomes. This is a challenge to tackle in future reviews.
Conflicts of interest
The authors have nothing to disclose.
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a Institute of Prostate Cancer and LeFrak Center for Robotic Surgery, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY, USA
b Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna, Sweden
c Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA
d Department of Clinical Affairs, Intuitive Surgical Inc., Sunnyvale, CA, USA
© 2012 Published by Elsevier B.V.
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