Li June Tay

Objectives: To report intraoperative and early postoperative outcomes of posterior approach Robotic Assisted Radical Prostatectomy (RARP) patients and analyse a single‐surgeon learning curve.Patients & Methods: The initial 150 patients undergoing posterior approach RARP by a single surgeon were analysed in three equal cohorts. Initial postoperative follow‐up was for a minimum of 3 months.Results: A total of 150 patients were included. These cases were performed between April 2017 to June 2024. There was no significant difference in pre‐operative patient age, prostate specific antigen (PSA), body mass index (BMI), prostate volume, number of biopsy positive cores, International Society of Urological Pathologists (ISUP) grade group and clinical T‐stage.Intraoperative differences between cohorts were decreasing total operative time (153 min vs 121 min vs 106 min, p < 0.001) and estimated blood loss (296 ml vs 205 ml vs 199 ml, p < 0.001), but no difference in nerve sparing status (p = 0.243).Postoperatively, no difference was found in median length of stay, ISUP grade group, tumour volume, 30‐day readmissions or complications. There were significant differences in overall pathological T stage (p = 0.004) between the cohorts, but not positive margin status, even with T2/T3 disease. There was a significant difference in early continence recovery within the first week (p = 0.022) and at 1 month (0.041) but no difference between overall continence recovery and erectile function recovery.Conclusions: Estimated blood loss and total operative time decreased across the cohorts, despite worsening disease burden. Oncological and functional outcomes are excellent throughout when compared with published literature. The learning curve may be facilitated initially by careful patient selection. Posterior approach RARP could be safely adopted by urologists adept in standard RARP, and structured training may improve the uptake of this technique.

Background: The learning curve for Retzius-sparing robotic radical prostatectomy is not fully understood. Objective: This study attempts to identify the learning curve across the first 130 cases of a single surgeon. Design, Setting and Participants: All Retzius-sparing robotic radical prostatectomy cases performed by a single surgeon at a high-volume tertiary hospital between April 2019 and July 2022 were included. Outcome Measurements and Statistical Analysis: Outcome measures included positive surgical margin rate, complication rates and unplanned readmission to hospital, postoperative urinary continence, erectile function and prostate-specific antigen (PSA) measurement. Cases were divided chronologically into three groups and differences between groups assessed. Results and Limitation: A total of 130 Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) cases were identified. Differences were found between groups in several areas. Positive surgical margin rate fell between Group 1 (30.2%) and Group 3 (9.1%). Safety, postoperative continence, erectile function and PSA remained stable. Median patient age increased between Group 1 (59 years) and Group 3 (66.5 years) ( p = 0.04). Proportion of patients with stage >T2 increased between Group 1 (27.9%) and Group 2 (41.9%) ( p = 0.036). Median console time increased between Group 1 (120 minutes) and Group 2 (150 minutes) ( p = 0.01). Median gland weight increased between Group 1 (28 g) and Group 3 (35.5 g) ( p < 0.001). Conclusions: The positive surgical margin rate improved over the learning curve, despite the complexity of cases increasing, reflected in older patients, larger prostates and higher stage disease. Safety and functional outcomes are excellent throughout. The learning curve might be facilitated by careful case selection favouring smaller prostates with less advanced disease. Patient Summary: We analysed the learning curve for Retzius-sparing robotic radical prostatectomy. Across the first 130 cases, positive surgical margin rate fell; safety and continence remained excellent. Selection of smaller and less advanced cases may facilitate learning. Level of evidence: III

Objectives: The COVID-19 pandemic has led to a long waiting list for elective surgery and increasing bed pressures from acute admissions. This led to widespread cancellations on the day of surgery even for cancer procedures. To address this, all inpatient stay robotic-assisted radical prostatectomy (RARP) cases were managed via our day surgery unit as a 23-hour stay. We report the safety and feasibility of our initial implementation. Methods: A standard operating procedure for admission via the day surgery unit, including a modified enhanced recovery pathway, for patients undergoing RARP with or without pelvic lymph node dissection (PLND) was devised. All pre-operative variables were collected, and all perioperative outcomes analysed. Primary outcomes were number of on the day cancellations, discharge failure as 23-hour stay and 30-day readmissions. Results: Between November 2021 and June 2022, 135 patients underwent RARP with or without PLND via the day surgery unit. Mean patient age was 65 (46–76) years. Mean operative time and estimated blood loss were 153 (67–281) minutes and 197 (50–700) mL, respectively. Concomitant lymph node dissection was performed in 32.7% of cases. No patient required blood transfusion or conversion to open. We had 3 (2.2%) discharge failures, all of which were due to clinical reasons. Our 30-day hospital readmission rate was 3.7%, while another 5.2% attended emergency department and were discharged without admission. Conclusion: Short (23-hour)-stay RARP is safe and feasible and reduces pressure on inpatient beds but requires a multidisciplinary approach and engagement from all stakeholders. Level of evidence: 2

Introduction: The aim of this study was to compare intraoperative and early post-operative outcomes between retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) versus standard approach for RARP (S-RARP). Patients and methods: All RARPs by a single surgeon were included and divided into two groups: (1) standard approach including combined anterior–posterior approach (S-RARP); (2) retzius-sparing posterior approach (RS-RARP). Allocation was based on prostate size and location of index lesion on MRI. Initial post-operative follow-up was at 6 weeks. Results: Overall, 169 RARPs were performed between March 2018 and October 2021: S-RARP = 99 versus RS-RARP = 70. There was no significant difference in pre-operative body mass index (BMI), prostate-specific antigen (PSA), International Society of Urological Pathology (ISUP) grade group and clinical T stage. Intraoperative differences were found in blood loss (300 versus 200 mL, p = 0.008), console time (180 versus 135 minutes, p < 0.001) favouring RS-RARP, with no differences in nerve-spare or lymph node dissection. Post-operatively, no difference was found in ISUP grade, pathological T stage, positive surgical margins, number of lymph nodes sampled, readmissions or complications. Gland size in the RS group was smaller (38 versus 29 g, p = 0.001). Early (6 weeks) post-op follow-up showed a significant difference between groups for both pad-free continence (35% versus 53%, p = 0.011) and social continence (79% versus 89%, p = 0.024), but no difference for erectile function recovery (27% versus 50% of baseline) and post-op PSA levels < 0.1 ng/mL (85% versus 93%). Conclusion: Even early in the learning curve, continence recovery, operative time and blood loss were significantly better for RS-RARP than S-RARP. Margin status and PSA levels are comparable to published literature for both groups. Standardised training in RS-RARP might help to improve the uptake of this novel technique. Level of evidence: 2.

Objectives: To conduct an audit of patients presenting with long‐term urinary catheter ( LTC )‐associated problems to our Emergency Department ( ED ) and to assess the availability of community nursing support for their LTC . We also estimated the cost implication to the health service and the potential solutions to this issue, as although catheter care is provided by community nurses, LTC problems are common presentations to the ED and are often significant burdens to the services. Patients and Methods: A study was carried out of all patients presenting to the ED with a urinary catheter problem, specifically studying LTC s and the reason for presentation, district nurses' involvement, and the intervention received. Results: In all, 78 patients with a urinary catheter problem presented to the ED over a 69‐day period, of whom 59 (68%) had a LTC . In all, 33 patients (42%) attended during normal working hours between 0900 and 1700 h. The mean (range) age was 74 (42–93) years and the duration the LTC had been in situ was 11 (1–120) months. The most common reasons for attendance were blocked catheter (37 patients, 47%) and catheter‐bypass (18, 23%). Only 28 patients (36%) were known to district nursing services, and 14% were referred by a district nurse. Most of the remaining patients self‐referred to the ED . No patient had any documented contact with their general practitioner. In addition, 64 patients (82%) had their catheter issues addressed adequately by ED nurses or doctors, without any urology involvement. Conclusions: The high morbidity of LTC s causes a considerable demand on ED services, and has heavy cost implications to the health system. Most patients had minimal community nurse support, and their catheter problems were easily dealt with by ED nurses and doctors.