Daniel Eun, MD discusses the advantages and disadvantages of Robotic Retzius Sparing Simple Prostatectomy when compared to Holmium Laser Enucleation of the Prostate (HoLEP)
Okay. Hi everybody. I'm really enjoying this meeting. I don't know what you guys, but uh, I just wanted to say thank you to our meeting organizers. They just did such a good job in putting a great program together. So, um thank you guys. So I'm going to talk on point counterpoint. And and they gave me a simple prostatectomy. But you know what I really wanted to do. I thought it would be more valuable to talk about the way that we do it in our experience because this is um this is a evolved technique. And so um, what I want to do was I wanted to set it up in a way where I can kind of compare it to what else is out there? Endoscopic lee, which would be holed up. So that's kind of the way this this talk has been structured. Um so here are my disclosures. Uh huh. And my other second disclosure is that I am like all in 100% robotic surgeon. So, I mean everything does look like a nail to me. All right. And so, um you know, somebody like kevin who's like very multifaceted and he has lots of different skill sets and you can call on a lot of different options, you know? Um sometimes I wish I had some of that because it's really interesting with a lot of these new um endoscopic techniques that are coming through the pipeline and seeing what you can do with it. You know, for me, it's just like bang everything is a nail. And that's the way I but you know, I'll show you my experience with with this because I feel like we come across a really nice technique here that I'd like to share. So two years ago I did a live simple and uh I really cut down this uh to about 2.5 minutes or so just to recap kind of how we do it. So I do a midline opens astronomy. So as soon as you doc you're you're a robot, you're going straight to the bladder wall and just unzipping it big. So you can see uh through there's my Trigana ridge, there's my us. I start at six o'clock, you get into the kind of the medium low plane and you let that false playing lead you right into the adenoma. You know during a radical you would re correct back out to the capture plane. But here you let this lead you down into the adenoma plane and this is the easiest place to start off with. And um and and so you try to go as post nearly as possible until you get to maybe around uh the apex and then you start to turn your corners. And sometimes you get bleeding at five and seven o'clock. And uh if I buzz it once or twice and um and it doesn't uh it keeps bleeding then you should just just get a future and and and stitch that. But um so when you start to come around and really I think the most important thing I'll say about this operation is that you've got to really find what I call the butt cheek plane where you get the adenoma and you see the groove come back down to the anti r. Common. Sure if if you look here you can see the midline anterior commission and you got to see that because that tells you that anti really on the prostate, you're on the adenoma plane. And if you hug that plane then you will come down onto the apex of the adenoma and not go into the sphincter. And so if you see where we're gonna end up cutting onto the ureter urethra we are a mile away from this finger. Right? And so there's no issue or worry here that we're gonna injure the continent's mechanism here. So here are the prostates out and I speed it up and here we're gonna do the national usually start at four o'clock I use a 12 inch 30 V. Lock. I take two bites on the bladder and you just crank this thing down and we've done 400 plus grand glands. And I heard some things yesterday about worried about bladder neck contractors and it may not reach down. Look it always reaches down. We've never had one bladder contraction were about close to 200 if not 200 cases in. We have good three year follow up on 150 patient that we just when I went through on our data, it's not yet published. I'll go over some of the slides with you. But here is a full 360 degree your filial to your field anastomosis. It's we try to make it watertight. I uh put ivy extension tubing into the dead space where we just took the adenoma out. We dump a syringe of flow seal in there and then we close this thing into layers. Now, if you close this back wall of the bladder properly, The area that you operate on is an extra perennial dissection. So if it bleeds, it's not gonna bleed out. If it leaks, who really cares? Right. This was a case that we did in about 70 some minutes. Uh this is the urine and the recovery is the actual patient two hours later. And I started to send some of these patients home on the same day now. Right. And over the years we started this in about 2013. Actually started up by accident because I was I was trying to go to next because I um I was actually trying to do diverticular to me first and I looked at that prostate, looking back at me and I said, I bet you I can take that prostate out from this view. And so that's how I kind of stumbled on this technique. And then I said I bet you I could put that in as most together. And it happened to work. And then we started down this road and started doing more of them and then realized the patients really do well with this procedure. So well I robotic simple prospect me for many reasons the same thing as radical prostatectomy. Right. You get good visualization focused use of katerina, meow perineum uh and all the goodies that come along with that. But also you're able to concomitant treatment treatment of other bladder issues. Like you know in some cases we've taken out 1235 diverticular economies insisted the thought to me. Um you know The less complications, more video. I'll go over that in the slides short length this day, average days like 1 1.4 days for this procedure. Um And so when I look at pros and cons I would say you know we especially compared to the open there's a lot less bleeding but it's it's two sets of bleeding, right? One is inter operative bleeding and we can address that robotically. And then there's postoperative bleeding which is the material and the clots in the C. B. I. And all that. And I feel like running in an osmosis really has addressed that problem. And we see that reflective in our low transfusion rates. Uh You know there's also access and learning curve. I think that especially in the U. S. There's like a robot or two or three and even small hospitals rural E. Um And so the access is there. We have a significant number of surgeons that spent a lot of time and effort and and learning how to use this machine and learning this anatomy. So there's a natural inclination to want to apply this to your practice instead of sending it to somebody who does and endoscopic approach. And I don't think it's a bad thing. Um You know I'll go over my results with uh with uh urinary continence uh showing R. I. P. S. S. Catherine free rates are very low. I think we've had one person that has gone back to. I see I see um the ability to concomitant surgeries and even a radical prostatectomy uh if you find this in our prostate cancer is is also nice about this approach because the critical planes on a radical prostatectomy has not been violated when you do this approach. And so I I can show you guys some video later on if you guys are interested in that. Um and then low complication rate. The cons on this. You know it requires robotic acid training if you don't have that and you're out of luck. Um abdominal based operation. You know you are going through the belly. And so we've had a couple cases where we've had a complex abdomen and we've had some issues. And so it is uh I think one of the things that you have to talk to your patients about it's different than an endoscopic uh Trans original technique. Um as far as catherization, I think it's fair to say this at least in my hands we keep the Catherine longer for about a week. But it's also because my patients come from an hour and a half to two hours away and I don't want to screw the referring neurologist by taking it out early and having them have a problem and having them deal with it. So I just leave it for a week and then pull it out at that time. I think billing is a problem in the US right now and hopefully that will change as the eu a um kind of indications on robotic simple prospect and he has recently switched and then the overall cost, you know, comparatively to a trans urethral procedure is probably more expensive. Uh this example of uh I don't really understand the thought process, but this was radiated by uh by a urologist in the Philadelphia area. It's a 400 Grand Gland. Right? So you know, you know exactly, it's gonna have this guy, he's gonna go into retention. Right? And so he shows up in my office because you cannot get a scope into the bladder because this thing is so big. And so it's an example of one of the extremes of of where robotic simple really excels. And so when you look at the literature and you look at what the The best data that I see for open is a 10 year series National impinge sample, 35,000 patients and almost a 30% complication rate was mostly related to bleeding. So it just it just goes to show you that bleeding with an open was very very significant. Now with whole lab, the transfusion rates are low. It's about look at the literature about about you know .8-5%. It's really hard to judge actually bl because you're running fluid. But um you know how often is C. B. I utilize what the transfusion rate is indicative of. But you know I think it's easy to agree that a trans urethral approach and a and a and a whole up uh in specific has lower blood loss rates. Um And um and when you look at a multi institutional experience with robotic simple. Now this study it was a little bit of a dirty population because they mixed two thirds lap and one third robotic. But here, you know you can see in a robotic series there's uh in these guys hands multiple institutions involved 3.5%. So I think that's very respectable. And what I would say not surprising Um looking at our specific uh three year outcomes. So we looked at average mean follow up of uh three years for our 1st 150 consecutive cases since 2013. And you can see here that are estimated blood loss was are just under 370 300 ccs. Our continuous bladder irrigation rate was 1 3 Percent and our postoperative transfusion three was 2%. Um This is a study that Alex Montri had uh produced from a single institution where they looked at their whole up in robotic surgery and uh experience. And as you go through the different papers that are out there and they're um they all have kind of criticisms about shortcomings. But when you look at the whole lepine robotic surgery uh experiences out there, I think it's safe to say that they are both good procedures right. They both get the job done when it comes to taking care of the problem. Bph and urinary retention. Um They have good improvements in I. P. S. S. Post void residual um You know operatively could argue my operative times a little bit longer but honestly we have a lot of resident fellow involvement in these cases. I let them go for a while before I take over. Uh And so I've let that that time run um Hold up. I think you get shorter capitalization time and potentially shorter length to stay. I think it's easy to say that we look at our uh our series the preoperative glance eyes. I mean we this was a study where we showed less than 150 g and greater than 100 50 g. You can see there are significant prostate size on here. But you know in this group you can see that we have a dramatic reduction and postoperative uh uh urinary scores. I think some of my slides fell off the bottom, probably due to formatting issues. So I apologize about that. I think this is also shows it very well here. What's really interesting about this is that, so we saw it out to really a report like a better quality. Try to be very diligent with our follow up and try to report on what's actually happening to these guys. And, you know, because we are realigning the urinary tract. I think that the fundamentally what happens here is that there's a lot less irritation mixed. You're mixing with that raw bed, right? You're you're you're excluding that area because of that. We're seeing a lot less irritated voiding symptoms. You can see here in our second column at two weeks post op, you can see your almost immediately, you're seeing a dramatic reduction in IPs. S And quality of life scores, and then a sustained drop in these measures as we go out to 36 months. I think I'm over time. So I gotta hurry here. So hold up outcomes. The other thing I like to say about holdup because although it's a very good procedure, there are some issues with it, right? And and and low percentages, um, Urinary stricture rates at one year, it's been reported around 1.3% 6% bladder, that contractual rate 1% in continents, right? I will offer a whole up to all of my patients and tell them I'll send them out of town. I mean, out of our institution to uh neighboring institution that does hold up. And but I'll say the one difference is that we don't have any stricture or incontinence rates. And I'll tell you these guys, they don't care about the bleed. They don't care. The only thing they care about is, You know how to minimize the risk of having a stricture, bladder, neck contracture or incontinence. And so um a lot of these patients, very, very few of them leave our practice to go elsewhere. You know, it's interesting when you look at the whole of experience. This is what's um you know, been reported. But on another paper from the same series, what you see is greater than five years out. There's a 5% stress urinary incontinence rate and there's a 6% bladder neck contracture rate. And although our follow was only up to three years, we have not seen any of is uh these occurrences. And so, you know, if you look at our series are, we were operating on bigger prostates are mean prostate size was 100 and 40 for most of the other series are especially the whole up is around 100 grand glands um are preoperative, fully Catherine dependency rate was very high, 64%. And the people that fail trans urethral procedures were 15%. So what I'm trying to basically say here is that we were operating on a very complicated group of patients more so than what's generally out there in the literature. And yet when you look at that you see are stress urinary incontinence rate, 0% bladder, neck, contractor 0%. Re operation rate for Bph 0% and a major uh complication rate. Craving greater than two is 3%. So this is kind of the view I need and you just speed up so um you can see that um That's that's the green line is where you're trying to follow. And I think that's one of the reasons why we have very good continents results. Secondary procedure is also very easily doable. This is a patient that had about 1000 stones in his bladder. He was in stone urinary retention. The worst part about this case was picking out 1000 stones out of this guy's bladder. And lastly, I'd say just access and training. You know, I made that point earlier robotically. There's a lot of robots out there. There's a lot of trained and mature surgeons that are able to do this operation. I think we're holed up has failed is that you don't see a lot of adoption and for whatever reason, whether that's training, whether that's learning curve, you whether that's access to instrumentation. Uh we've just not seen it. Um you know, been shown a lot of love by the urologist in this country. So summary slide, why do it accessible technology maturity, all sets anastomosis uh gives you rapid improvement of irritated, uh symptoms less than 3% transfusion rate less than 3% C. B. We end with 18 french to a Catherine. We do not do see beyond our patients. Uh uh We have not seen strictures, contractors, incontinence and honestly we're not limited by size. The bigger the better because it's closer to you. Uh accommodate procedures are are good to do with the robot. And then we have a very low serious complication rates. Thank you. Sorry for going over.