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The Posterior Surgical Approach to Robotic-Assisted Laparoscopic Radical Prostatectomy is Efficacious and Facilitates Dissection of Large Glands
Michael Maddox, MD, Sammy Elsamra, MD, Eugene Cone, AB, Joseph Renzulli, III, MD, Gyan Pareek, MD.
Brown University, Providence, RI, USA.

BACKGROUND:
Despite the abundant data on outcomes following robotic assisted laparoscopic radical prostatectomy (RALRP), no study has compared outcomes between an anterior versus posterior approach. We postulated that a posterior approach may facilitate dissection and lead to improved outcomes in patients with larger prostate glands.
METHODS:
After IRB approval, 404 patients underwent RALRP between 2007 and 2011 by two surgeons at our institution. Of these, 187 patients underwent RALRP utilizing a posterior surgical approach while 217 patients were approached anteriorly. Retrospective review of preoperative, intraoperative, and perioperative characteristics and outcomes were compared between the two cohorts utilizing two sample t-tests and two proportion z-tests to calculate statistical significance.
RESULTS:
There were no significant differences in age, BMI, prostate volume, or PSA of the two cohorts. Pathology was similar although there was a significantly increased proportion of Gleason 9 disease in the anterior approach group. Intraoperative and perioperative outcomes including console time, transfusion rate, positive margins, and complication rates were compared. There was no difference observed in outcomes or console time between the two approaches. However, when console time was stratified for prostate volume, a shorter operative time was seen in the highest quartile for prostate volume with the posterior approach (185.7 minutes versus 168.8 minutes, p=0.049).
CONCLUSIONS:
Despite the widespread application of RALRP, there is no literature addressing which surgical approach is most advantageous. Our data suggests that the posterior approach offers shorter operative times in patients with large prostate glands while overall outcomes remain the same between the two approaches.


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