Robotic Prostatectomy Safe for Patients With Glaucoma
June 2, 2011 (Washington DC) — A policy of routinely denying robot-assisted radical prostatectomy (RARP) to prostate cancer patients if they have a history of glaucoma or ocular hypertension may be unnecessary, according to new data released here at the American Urological Association (AUA) 2011 Annual Scientific Meeting.
The results show a complete absence of overt clinical sequelae in patients with these preexisting ocular diseases who underwent RARP when perioperative factors were optimized as much as possible.
"While prostate cancer patients with glaucoma or ocular hypertension are commonly denied RARP because of concern that increased intraocular pressure [IOP] during the procedure may cause blindness, the risk is largely theoretical," Ronney Abaza, MD, director of robotic urologic surgery and codirector of the Center for Advanced Robotic Surgery at the Ohio State University Medical Center and James Cancer Hospital in Columbus, told Medscape Medical News.
"It does not make sense to deprive patients of the benefits of RARP when their resting IOP with proper treatment may be just as good as yours or mine. We routinely send patients to their ophthalmologist preoperatively precisely to ensure that their IOP is well-controlled, and provided that good control is established, there is currently no evidence that these patients are at increased risk of blindness from a transient elevation of IOP compared with other patients," Dr. Abaza said.
He reviewed outcomes in 830 patients in whom he performed RARP over a recent 2.5-year period, 20 of whom had preoperative glaucoma or ocular hypertension. Although only a small number of patients had these ocular diseases, this series is the first to report outcomes with RARP specifically in "this population of patients in whom controversy exists as to whether or not they should undergo the procedure."
Earlier studies have examined IOP measurements in patients without ocular disease, Dr. Abaza noted.
RARP is the most common surgical therapy for prostate cancer in the United States. The procedure requires steep Trendelenburg positioning to allow access to the prostate deep in the pelvis, as well as gravity retraction of the bowels. Because of the typical facial and neck edema experienced by patients in this position and early reports of elevated IOP during the procedure, many surgeons and anesthesiologists have deemed patients with glaucoma or increased IOP ineligible for this treatment.
"Obviously, our results are not definitive, given the small number of patients in our series with these ocular conditions," Dr. Abaza said. "However, at the very least, our data suggest that categorically excluding glaucoma patients from RARP is unwarranted, as our routine involving preoperative ophthalmology clearance, 'reasonable' procedure time, hemostasis adequate to prevent hypotension, and judicious use of intravenous fluids has allowed for safe RARP in this population so far."
The mean operative time, which included lymphadenectomy in all patients, was 153 minutes. Estimated blood loss was 130 mL (range, 50 - 200 cc) for patients with ocular disease and 119 mL (range, 10 - 400 cc) for unaffected patients. Intravenous fluids were routinely restricted to approximately 1 L in all patients to prevent airway edema and ease extubation, as well as to reduce urine in the operative field.
No patient with a history of glaucoma or ocular hypertension experienced any symptomatic changes in vision or other ocular complications.
"We are currently conducting a study to determine whether subclinical ocular changes occur during RARP for more definitive evidence, as clearly some changes can occur without overt symptoms, even in patients without glaucoma or ocular hypertension," Dr. Abaza said. "Until we have evidence that patients with chronically elevated IOP are harmed by the relatively brief rise in IOP associated with RARP, we believe that these patients deserve to obtain the same benefit from RARP as patients without glaucoma or ocular hypertension."
The study received no outside support. Dr. Abaza has disclosed no relevant financial relationships.
American Urological Association (AUA) 2011 Annual Scientific Meeting: Abstract 775. Presented May 16, 2011.
From Reuters Health Information-
Procedures Faster, Outcomes Equal With Da Vinci S Robot
NEW YORK (Reuters Health), Apr 20 -
Using the second-generation version of the da Vinci robot may shorten the time needed to perform robot-assisted laparoscopic prostatectomy (RALP) compared to the older version of the machine, according to a new report.
But perioperative and oncological outcomes were similar for the two versions of the machine, Drs. Ketul Shah and Ronney Abaza of The Ohio State University Medical Center in Columbus found.
"Individual institutions will need to determine whether the time difference warrants the additional cost of newer generation equipment if RALP and similar pelvic procedures predominate," they write in BJU International, online April 16.
The US Food and Drug Administration approved the first da Vinci robotic system in 2000. The robot's maker, Intuitive Surgical of Sunnyvale, California, introduced a new version of the machine, the da Vinci S, in 2006.
The standard system cost $1 million in 2003, while the base cost of the S is roughly $1.5 million. The very latest system, the da Vinci Si, has a list price of $1.65 million. While 65% of radical prostatectomies performed in the US are done with a da Vinci robot, questions remain over whether patient outcomes are any better with robot-assisted compared to open surgery.
To compare the first, standard da Vinci system to the S system, the researchers looked at 100 consecutive procedures performed by Dr. Abaza from February to June 2008. The surgeon alternated between standard and S machines, using the same technique, so 50 patients were treated with the older machine and 50 with the S robot.
The average time for laparoscopic prostatectomy with lymphadenectomy using the first-generation machine was 191 minutes, compared to 169 minutes with the S robot. Mean blood loss was 148.7 milliliters with the standard robot and 131.4 mL with the S robot (P=0.08). There was no significant difference between the two machines in positive margins or mean number of lymph nodes removed.
The time savings were likely due to the greater ease of docking with the S robot, Dr. Shah and Dr. Abaza say. Working with the newer robot also requires fewer arm position changes, they add.
Depending on the surgical volume, the researchers note, RALP can be more cost effective than open surgery; one study found that cost for the two approaches was equivalent if 10 patients were treated with RALP weekly, while 14 patients a week would reduce the per-patient cost to below the cost of open surgery.
"As the impact of the cost of a robot is large, it should be important to hospitals and society to find out whether the increased cost of newer generations of the technology, or incremental improvements in the technology, are worthwhile," they state.
"The vast majority of RALP procedures can apparently be performed with equal outcomes but with the operating time being a little longer for the standard robot," they conclude.