Outcomes of Robot-Assisted Radical Prostatectomy in Men after Trans-Urethral Resection of the Prostate: A Matched-Pair Analysis

Outcomes of Robot-Assisted Radical Prostatectomy in Men after Trans-Urethral Resection of the Prostate: A Matched-Pair Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outcomes of Robot-Assisted Radical Prostatectomy in Men after Trans-Urethral Resection of the Prostate: A Matched-Pair Analysis Danny Darlington Carbin, Wissam Abou Chedid, Richard Hindley, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4109598/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Apr, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Prior history of transurethral resection of the prostate (TURP) can complicate Robot-assisted radical prostatectomy (RARP). Very few studies analyse the outcomes of RARP in men with a prior history of TURP. Methods We analysed the oncological and functional outcomes of RARP in post-TURP men from our prospectively maintained database. We included the RARP data from January 2016 to January 2022. Thirty men who had RARP with a prior history of TURP were identified (Group 2). They were matched using R software and propensity score matching to 90 men with no previous TURP (Group-1). The groups were matched for age, body mass index (BMI) and D’Amico risk category in a 1:3 ratio. The two-year oncological and functional outcomes were compared. Results Overall, the study found no significant difference between the groups in the preoperative parameters, such as BMI, age, clinical stage, prostate volume, and D’amico risk grouping. There was no difference in the estimated blood loss. The TURP group had a lower chance of having a nerve spare (p = 0.03). The median console time was longer in the TURP group (140 minutes (120,180) versus 168 (129,190) p = 0.058). The postoperative complications (Clavien-Dindo 3a 2% versus 6.7%) and hospital stay (median of 2 days), positive surgical margins, continence, and biochemical recurrence rates at 3, 12, and 24 months were not statistically different between the groups. Conclusion In high-volume centres, the oncological and continence outcomes of RARP post-TURP are not inferior to that of men without prior TURP. continence robot-assisted radical prostatectomy transurethral resection of the prostate trifecta Introduction Trans-urethral resection of the prostate (TURP) is one of the most common operations performed for Benign Prostatic Hypertrophy (BPH) in the UK.( 1 ) TURP removes the adenomatous tissues of the prostate leaving the peripheral zone. Given the increasing incidence of prostate cancer, it is not uncommon to encounter prostate cancer in the TURP histology or prostate cancer developing in the post-TURP peripheral zone.( 2 ) Definitive treatment for the primary tumour depends on disease and patient factors. Surgical treatment of prostate cancer has seen a significant improvement with the advent of Robot-Assisted Radical Prostatectomy (RARP). However, RARP can be challenging in post-TURP men due to the capsular inflammation and adhesions distorting the peri-prostatic tissue planes. Despite widespread PSA screening, 10% of prostate cancer is detected in TURP specimens, thereby necessitating definitive cancer treatment after TURP.( 3 ) RARP in men with a prior history of TURP poses technical challenges to the surgeon. The difficult planes around the prostate after TURP can make nerve-sparing, bladder neck dissection and the subsequent anastomosis difficult. ( 4 ) However, the three-dimensional vision and precise control of the robot are advantageous in these complex scenarios. RARP after TURP is generally assumed to be associated with poor functional and oncological outcomes.( 5 ) Very few studies in the literature compare the oncological and functional outcomes of RARP in post-TURP men. Most of these are case series or unmatched comparative studies. Therefore, we conducted a matched-pair study to analyse the oncological and continence outcomes of RARP in post-TURP men matched to men with no prior history of TURP. Methods We analysed our prospectively maintained robotic prostatectomy database, which documented preoperative, intraoperative and postoperative data of 1280 men who underwent RARP from January 2012 to January 2022. We excluded the RARPs done in the learning curve phase and included only the RARPs done between January 2016 and January 2022. Men who received neoadjuvant hormone therapy or underwent other BPH surgeries such as Simple prostatectomy, HOLEP, Urolift and Rezum were excluded from the study. Thirty men who had RARP after TURP were identified in this period. A 3:1 Propensity score matching was done using the R software for non-TURP versus TURP men for age at surgery, D’Amico risk category and body mass index (BMI). On propensity score matching, 90 men were selected from the non-TURP group against the 30 men with prior history of TURP. The operative, postoperative, continence and oncological outcomes were compared between the two groups. Data collection: We compared the variables such as age, Gleason grade, prostate volume, console time, blood loss, complications, length of stay, postoperative histology, and status of surgical margins. We followed them up at 3, 12 and 24 months with PSA levels.( 6 ) We defined continence as the usage of zero pads and biochemical recurrence (BCR) was defined as a PSA level of > 0.2 ng/dl and/or the requirement of radiotherapy or hormone therapy on follow-up. Potency rates were not analysed due to incomplete data. All participants consented to the RARP and the principles of Helsinki Declaration, 1964 were adhered to in the study. Surgical methods: All the surgeries were performed by an expert robotic urological surgeon (CE) using the daVinci Xi robot (Intuitive Surgical, Sunnyvale, CA). We did not perform pre-operative cystoscopy or JJ stent insertion routinely. Based on the preoperative risk stratification, the pelvic lymphadenectomy was performed as and when required. The standard six-port robotic radical prostatectomy was performed by the Martini clinic transperitoneal approach. Seminal vesicles were dissected and the bladder was dropped. Post-TURP, the bladder neck was identified by visual cues like the absence of bladder fat, change in the bladder contour and by appreciation of the compressibility using the robotic instruments. Bladder neck dissection was completed, and nerve sparing was done based on the preoperative MRI scan findings and the D’amico risk stratification. Modified Rocco’s stitch was taken, and the vesicourethral anastomosis was completed using double-armed sutures by the Van-Velthoven technique over a catheter.( 7 ) We do not place abdominal drains, and the catheter was removed after 1–2 weeks of the surgery based on the surgeon’s decision. Statistical methods: The data was compiled using MS Excel Office 2021, and the ‘R’ software was used for matching. Descriptive data were presented as percentages for categorical variables and median-interquartile range for continuous data. The Fisher Exact test was used to compare proportions (Categorical variables). Continuous variables were analysed using the Wilcoxon sign rank test. A p value of < 0.05 was considered significant. Results We selected 30 men with a prior history of TURP and matched them 1:3 to 90 men with no previous history of TURP for the analysis. The preperative-data such as BMI, Age, and D’amico risk stratification were matched and hence similar between both the groups. None of them were incontinent or had underlying neurological disorders (like parkinsonism, stroke, etc) pre-operatively. Surprisingly, the prostate volume was not statistically different between the two groups (Table-1). The non-TURP group had a statistically higher chance of undergoing complete nerve preservation than the TURP group (p = 0.03, Table-2). The operative time, blood loss, length of stay and postoperative complications were unremarkable. Final histological staging and positive surgical margins (PSM) were similar (Table-2). On follow-up, both the early (3-month) and late (24-month) continence rates and biochemical recurrence (BCR) rates were not statistically different between the two groups. Table-1 Pre-operative data of the two groups in the study Characteristic N No TURP, N = 90 Prior TURP, N = 30 2 p-value Age at therapy (years) 1 120 67.0 (61.0, 71.0) 66.5 (61.3, 71.0) > 0.90 Age groups 120 > 0.90 74 0 (0%) 0 (0%) BMI 1 120 26.5 (25.0, 30.0) 26.0 (25.0, 30.0) > 0.90 PSA (ng/ml) 1 120 7 ( 5 , 10 ) 6 ( 4 , 8 ) 0.07 Clinical stage 120 > 0.90 cT1-2a 58 (64%) 20 (67%) cT2b 1 (1.1%) 0 (0%) cT2c-4 31 (34%) 10 (33%) Gleason Grade 120 0.50 7 18 (20%) 9 (30%) Prostate volume 1 (cc) 120 41 (31,54) 38 (24,49) 0.12 D'Amico 120 > 0.90 Low 9 (10%) 3 (10%) Intermediate 42 (47%) 14 (47%) High 39 (43%) 13 (43%) 1 Median (IQR); n (%) 2 Wilcoxon rank sum test; Fisher’s exact test Table-2:Peri-operative and follow-up data of the two groups Characteristic N No TURP, N = 90 Prior TURP, N = 30 2 p-value Console time 1 (min) 120 140 (120,180) 168 (129,190) 0.058 Nerve sparing 120 Complete 37 (41.12%) 1 (3.33%) 0.03 Partial 48 (53.33%) 24 (80.00%) None 5 (5.55%) 5 (16.67%) Blood loss 1 (ml) 120 200 (100,200) 150 (100,275) 0.50 Clavien Dindo 120 0.40 0 86 (96%) 28 (93%) 2 2 (2.2%) 0 (0%) 3a 2 (2.2%) 2 (6.7%) Hospital stay 1 (days) 120 2 ( 1 ) 2 (0) 0.90 Pathological staging 120 0.10 ≤pT2a 5 (5.5%) 2 (6.6%) pT2b 2 (2.3%) 0 (0%) pT2c 45 (50%) 17 (56.7%) ≥pT3a 38 (42.2%) 11 (36.7%) Positive surgical margins 120 16 (18%) 5 (17%) 0.90 Continence 3 months 120 88 (98%) 27 (90%) 0.10 Continence 12 months 120 90 (100%) 30 (100%) > 0.90 Continence 24 months 120 90 (100%) 30 (100%) > 0.90 PSA 3 months 120 BCR 10% 7.4% > 0.90 PSA 12 months 120 BCR 21% 11% 0.50 PSA 24 months 120 BCR 28% 25% > 0.90 1 Median (IQR); n (%) 2 Wilcoxon rank sum test; Fisher’s exact test BCR = Biochemical recurrence Discussion We compared the peri-operative, continence and oncological outcomes of RARP between matched men with and without previous history of TURP. The non-TURP group had more complete nerve sparing than the TURP group. The two groups did not statistically differ in the peri-operative, two-year continence and oncological outcomes. TURP-induced peri-prostatic adhesions and distorted planes contribute to the difficulty associated with the posterior dissection, bladder neck dissection and nerve-sparing in RARP.( 8 ) The loss of elasticity of the bladder neck and friable urethral stump post-TURP can make the urethra-vesical anastomosis challenging.( 9 ) Studies on open, laparoscopic and radical radical prostatectomy after TURP report a higher risk of PSM, blood loss and bladder neck stricture.( 10 ),( 11 ),( 12 ),( 13 ) Surgical robotic platforms with magnified three-dimensional vision and wristed instruments have been shown to aid the surgeon in challenging dissections. Few studies have compared the outcomes of RARP in men with a prior history of TURP. In the late 2000s, Martin et al. compared RARP versus Open Retropubic Radical Prostatectomy in men who had previous TURP history.( 14 ) 24 men with prior TURP and/or brachytherapy were compared to 510 men without TURP without matching. The groups did not differ in blood loss, hospital stay, operative time, peri-operative, oncological and continence outcomes.( 14 ) Another study by Gupta et al. compared 26 men with TURP history versus 132 unmatched men without prior TURP.( 15 ) This study found more blood loss and poorer continence rates at six and twelve months follow-up (p = 0.07). This study included a predominantly High D’amico risk group (68.35%), which is characteristic of the distribution found in unscreened populations.( 15 ) An unmatched comparison by Su et al. involving 2693 men reported a significantly more blood loss, console time, hospital stay and poorer continence at 12 months in post-TURP men.( 16 ) Some of the early studies even recorded a higher incidence of rectal injury (18.75% vs. 0%, P < 0.001) and major complications (18.8% vs. 1.1%, P < 0.001).( 17 ) A recent comparative study from the US found no remarkable difference in perioperative, oncological and functional outcomes in post-TURP men on three-year follow-up.( 18 ) Our study demonstrated no significant difference in blood loss, console time, hospital stay, postoperative BCR and continence rates in the TURP group, even at two years of follow-up. Tugcu et al. compared RARP outcomes in 25 men with prior TURP/Open simple prostatectomy versus 36 matched men who did not. They found longer console time (195 vs 160 min, p = 0.016), more blood loss (p = 0.001) and frequent need for bladder neck reconstructions (p = 0.001) in the post-TURP men. A significant proportion of post-TURP men developed more bladder neck/anastomotic strictures in this study. However, the study found no significant difference in the 12-month continence and potency rates between the groups.( 19 ) Zugor et al. conducted a propensity score-based matched-pair analysis of RARP outcomes in eighty men with and without previous TURP. This study found longer console times (189 min versus 149 min, p = 0.069) and more frequent bladder neck reconstructions (58.7% versus 2.5%, p = 0.073) in the TURP group, albeit statistically insignificant. Duration of hospital stay, PSM, continence (87.5% versus 91.25%) and potency rates (70.3%/86.5%) were unremarkable among the groups in the study.( 20 ) Another matched-pair analysis from India revealed higher but statistically insignificant rates of PSM (30.5% versus 25%, p = 0.54) in post-TURP men. However, this study did not find any significant difference between the one-year oncological and continence outcomes. On multivariate analysis, previous TURP was not associated with any higher risk of PSM, BCR, or incontinence. However, this study involved an unscreened population with predominantly D’amico high-risk prostate cancers.( 21 ) Liu et al. recently published their systematic review/meta-analysis on this topic. Eight comparative studies involving 4186 patients were analysed. The TURP group had longer console times (p = 0.002), higher blood loss (p = 0.006), and bladder neck reconstruction rates (p = 0.03). The TURP group had high PSM (p = 0.007) with comparable hospital stay, nerve sparing, complication rates, continence recovery, potency and BCR rates on follow-up.( 22 ) Limitations of the study: Our study is a matched study comparing the long-term outcomes of RARP in men with a history of TURP from a high-volume referral centre in the UK. However, it is not without limitations. This is a single-centre, retrospective study conducted among men presenting with predominantly D’amico low and intermediate-risk prostate cancer (> 50% of sample size). Therefore, the results may not be extrapolated to men with high-risk prostate cancer. Despite propensity score-matching, the sample size was small to perform sub-group analysis. Bladder neck reconstruction, duration of catheterisation, potency rates and urethral stricture/bladder neck stenosis rates were not compared due to incomplete data. Conclusion RARP after TURP, although challenging, is technically safe in experienced hands. However, these procedures are ideally suited for high-volume centres and surgeons. The oncological and continence outcomes of RARP in this subset of men are comparable to men without prior TURP in high-volume centre studies. Multi-institutional studies are required to confirm our single-centre findings. Careful patient selection, referral pathways and appropriate robotic skillsets are important for better outcomes in this technically challenging operation. Declarations Funding: No funding was received to conduct the study. Conflict of interest: All the authors declare that they have no conflict of interest. Availability of data and material used in the study: Available on request Acknowledgements: None Ethical clearance: This study was conducted as an audit in our department. Audit number: SU-CA-23-24-062 All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Mr.Danny Darlington Carbin, Mr.Wissam Abou Chedid, Prof.Richard Hindley and Prof.Christopher Eden. Danny Darlington Carbin co-ordinated with the statistical team for analysis & wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript. References Mayer EK, Kroeze SGC, Chopra S, Bottle A, Patel A. Examining the “gold standard”: a comparative critical analysis of three consecutive decades of monopolar transurethral resection of the prostate (TURP) outcomes. BJU Int. 2012;110(11):1595–601. Karlsson CT, Wiklund F, Grönberg H, Bergh A, Melin B. Risk of Prostate Cancer after Trans Urethral Resection of BPH: A Cohort and Nested Case-Control Study. Cancers. 2011;3(4):4127–38. Rm M, Cl W. Incidental detection of population-based prostate cancer incidence rates through transurethral resection of the prostate. Urol Oncol [Internet]. 2002 Oct [cited 2024 Mar 10];7(5). Available from: https://pubmed.ncbi.nlm.nih.gov/12644219/ Christopher Eden, Eden CG, Andrew J. Richards, Richards AJ, Jason Ooi, Ooi J, et al. Previous bladder outlet surgery does not affect medium-term outcomes after laparoscopic radical prostatectomy. BJUI. 2007;99(2):399–402. Zugor V, Labanaris AP, Porres D, Witt JH. Surgical, oncologic, and short-term functional outcomes in patients undergoing robot-assisted prostatectomy after previous transurethral resection of the prostate. J Endourol. 2012;26(5):515–9. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13. Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical anastomosis:the single knot method. Urology. 2003;61(4):699–702. Colombo R, Naspro R, Salonia A, Montorsi F, Raber M, Suardi N, et al. Radical prostatectomy after previous prostate surgery: clinical and functional outcomes. J Urol. 2006;176(6 Pt 1):2459–63; discussion 2463. Acar Ö, Esen T. Robotic Radical Prostatectomy in Patients with Previous Prostate Surgery and Radiotherapy. Prostate Cancer [Internet]. 2014 [cited 2020 Nov 22];2014. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120925/ Menard J, de la Taille A, Hoznek A, Allory Y, Vordos D, Yiou R, et al. Laparoscopic radical prostatectomy after transurethral resection of the prostate: surgical and functional outcomes. Urology. 2008;72(3):593–7. Fragkoulis C, Pappas A, Theocharis G, Papadopoulos G, Stathouros G, Ntoumas K. Open radical prostatectomy after transurethral resection: perioperative, functional, oncologic outcomes. Can J Urol. 2018;25(2):9262–7. Palisaar JR, Wenske S, Sommerer F, Hinkel A, Noldus J. Open radical retropubic prostatectomy gives favourable surgical and functional outcomes after transurethral resection of the prostate. BJU Int. 2009;104(5):611–5. Hampton L, Nelson RA, Satterthwaite R, Wilson T, Crocitto L. Patients with prior TURP undergoing robot-assisted laparoscopic radical prostatectomy have higher positive surgical margin rates. J Robot Surg. 2008;2(4):213–6. Martin AD, Desai PJ, Nunez RN, Martin GL, Andrews PE, Ferrigni RG, et al. Does a history of previous surgery or radiation to the prostate affect outcomes of robot-assisted radical prostatectomy? BJU Int. 2009;103(12):1696–8. Gupta NP, Singh P, Nayyar R. Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate. BJU Int. 2011;108(9):1501–5. Su YK, Katz BF, Sehgal SS, Yu SJS, Su YC, Lightfoot A, et al. Does previous transurethral prostate surgery affect oncologic and continence outcomes after RARP? J Robot Surg. 2015;9(4):291–7. Hung CF, Yang CK, Ou YC. Robotic assisted laparoscopic radical prostatectomy following transurethral resection of the prostate: perioperative, oncologic and functional outcomes. Prostate Int. 2014;2(2):82–9. Rajesh Raj Bajpai, Rajesh Bajpai, Shirin Razdan, Shirin Razdan, Mabel Sánchez, Marcos A Sanchez, et al. Robotic Assisted Radical Prostatectomy After Prior Transurethral Resection of Prostate: An Analysis of Perioperative, Functional, Pathologic, and Oncological Outcomes. J Endourol. 2022; Tugcu V, Atar A, Sahin S, Kargi T, Gokhan Seker K, IlkerComez Y, et al. Robot-Assisted Radical Prostatectomy After Previous Prostate Surgery. JSLS [Internet]. 2015 [cited 2020 Nov 22];19(4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653581/ Zugor V, Labanaris AP, Porres D, Witt JH. Surgical, oncologic, and short-term functional outcomes in patients undergoing robot-assisted prostatectomy after previous transurethral resection of the prostate. J Endourol. 2012;26(5):515–9. Darlington CD, Ashwin Sunil Tamhankar, P. K. Ahluwalia, et al. Does prior transurethral resection of prostate affect the functional and oncological outcomes of robot-assisted radical prostatectomy? A matched-pair analysis. J Robot Surg. 2021;1–7. Liu Y, Qin J, Li KP, Wen Z, Huang J, Jiang Y, et al. Perioperative, functional, and oncologic outcomes in patients undergoing robot-assisted radical prostatectomy previous transurethral resection of prostate: a systematic review and meta-analysis of comparative trials. J Robot Surg. 2023;17(4):1271–85. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 18 Mar, 2024 Reviews received at journal 17 Mar, 2024 Reviewers agreed at journal 17 Mar, 2024 Reviewers invited by journal 17 Mar, 2024 Editor assigned by journal 17 Mar, 2024 Submission checks completed at journal 15 Mar, 2024 First submitted to journal 15 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4109598","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":281040388,"identity":"6f7e6f51-21a3-4dc9-84a8-5e8a8c293160","order_by":0,"name":"Danny Darlington Carbin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYDCCA1DagJmB8cEHIIONnQQtzIYzQFqYidYCVCzNA2IR0sJ3/Oyxxzw1dvnm7LwHpG1+bZPnA7rww8cc3Fokz+SlG/McS7bc2cyXYJzbd9uwDehCyZnbcGsxOJBjJs3bwGxgcJjHIDm35zYjUAsbMy8+LeffgLTUg7Uctuy5bU9Yyw2wLYdBWgybGX7cTiSoRfLGGzPJOceOG1g28xgz9jbcTm5jZmzG6xe+8zlmEm9qqg3M+c+Y//jx57bt/Pbmgx8+4tECAkw8MBZjG5hswK8epOQHnPmHoOJRMApGwSgYgQAA7YlMiSNvBwYAAAAASUVORK5CYII=","orcid":"","institution":"Royal Surrey County Hospital","correspondingAuthor":true,"prefix":"","firstName":"Danny","middleName":"Darlington","lastName":"Carbin","suffix":""},{"id":281040389,"identity":"c09d51d7-6c83-424d-b64f-a1e70fda9525","order_by":1,"name":"Wissam Abou Chedid","email":"","orcid":"","institution":"Royal Surrey County Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wissam","middleName":"Abou","lastName":"Chedid","suffix":""},{"id":281040390,"identity":"7579b4a5-8edc-431b-89e0-a68f80ec2cb2","order_by":2,"name":"Richard Hindley","email":"","orcid":"","institution":"Hampshire Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Hindley","suffix":""},{"id":281040391,"identity":"923f31c3-73f8-44d7-9462-ea74b3b3573b","order_by":3,"name":"Christopher Eden","email":"","orcid":"","institution":"Royal Surrey County Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Eden","suffix":""}],"badges":[],"createdAt":"2024-03-15 17:33:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4109598/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4109598/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-024-01935-5","type":"published","date":"2024-04-03T15:01:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54303957,"identity":"fa4ecbae-aac2-4d2f-8106-38e2ff5b3871","added_by":"auto","created_at":"2024-04-08 15:13:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":245562,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4109598/v1/1a9a3711-913b-4ac2-bf20-c625936f3cde.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcomes of Robot-Assisted Radical Prostatectomy in Men after Trans-Urethral Resection of the Prostate: A Matched-Pair Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTrans-urethral resection of the prostate (TURP) is one of the most common operations performed for Benign Prostatic Hypertrophy (BPH) in the UK.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) TURP removes the adenomatous tissues of the prostate leaving the peripheral zone. Given the increasing incidence of prostate cancer, it is not uncommon to encounter prostate cancer in the TURP histology or prostate cancer developing in the post-TURP peripheral zone.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Definitive treatment for the primary tumour depends on disease and patient factors. Surgical treatment of prostate cancer has seen a significant improvement with the advent of Robot-Assisted Radical Prostatectomy (RARP). However, RARP can be challenging in post-TURP men due to the capsular inflammation and adhesions distorting the peri-prostatic tissue planes. Despite widespread PSA screening, 10% of prostate cancer is detected in TURP specimens, thereby necessitating definitive cancer treatment after TURP.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eRARP in men with a prior history of TURP poses technical challenges to the surgeon. The difficult planes around the prostate after TURP can make nerve-sparing, bladder neck dissection and the subsequent anastomosis difficult. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) However, the three-dimensional vision and precise control of the robot are advantageous in these complex scenarios. RARP after TURP is generally assumed to be associated with poor functional and oncological outcomes.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Very few studies in the literature compare the oncological and functional outcomes of RARP in post-TURP men. Most of these are case series or unmatched comparative studies. Therefore, we conducted a matched-pair study to analyse the oncological and continence outcomes of RARP in post-TURP men matched to men with no prior history of TURP.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe analysed our prospectively maintained robotic prostatectomy database, which documented preoperative, intraoperative and postoperative data of 1280 men who underwent RARP from January 2012 to January 2022. We excluded the RARPs done in the learning curve phase and included only the RARPs done between January 2016 and January 2022. Men who received neoadjuvant hormone therapy or underwent other BPH surgeries such as Simple prostatectomy, HOLEP, Urolift and Rezum were excluded from the study. Thirty men who had RARP after TURP were identified in this period. A 3:1 Propensity score matching was done using the R software for non-TURP versus TURP men for age at surgery, D\u0026rsquo;Amico risk category and body mass index (BMI). On propensity score matching, 90 men were selected from the non-TURP group against the 30 men with prior history of TURP. The operative, postoperative, continence and oncological outcomes were compared between the two groups.\u003c/p\u003e \u003cp\u003eData collection:\u003c/p\u003e \u003cp\u003eWe compared the variables such as age, Gleason grade, prostate volume, console time, blood loss, complications, length of stay, postoperative histology, and status of surgical margins. We followed them up at 3, 12 and 24 months with PSA levels.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) We defined continence as the usage of zero pads and biochemical recurrence (BCR) was defined as a PSA level of \u0026gt;\u0026thinsp;0.2 ng/dl and/or the requirement of radiotherapy or hormone therapy on follow-up. Potency rates were not analysed due to incomplete data. All participants consented to the RARP and the principles of Helsinki Declaration, 1964 were adhered to in the study.\u003c/p\u003e \u003cp\u003eSurgical methods:\u003c/p\u003e \u003cp\u003eAll the surgeries were performed by an expert robotic urological surgeon (CE) using the daVinci Xi robot (Intuitive Surgical, Sunnyvale, CA). We did not perform pre-operative cystoscopy or JJ stent insertion routinely. Based on the preoperative risk stratification, the pelvic lymphadenectomy was performed as and when required. The standard six-port robotic radical prostatectomy was performed by the Martini clinic transperitoneal approach. Seminal vesicles were dissected and the bladder was dropped. Post-TURP, the bladder neck was identified by visual cues like the absence of bladder fat, change in the bladder contour and by appreciation of the compressibility using the robotic instruments. Bladder neck dissection was completed, and nerve sparing was done based on the preoperative MRI scan findings and the D\u0026rsquo;amico risk stratification. Modified Rocco\u0026rsquo;s stitch was taken, and the vesicourethral anastomosis was completed using double-armed sutures by the Van-Velthoven technique over a catheter.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) We do not place abdominal drains, and the catheter was removed after 1\u0026ndash;2 weeks of the surgery based on the surgeon\u0026rsquo;s decision.\u003c/p\u003e \u003cp\u003eStatistical methods:\u003c/p\u003e \u003cp\u003eThe data was compiled using MS Excel Office 2021, and the \u0026lsquo;R\u0026rsquo; software was used for matching. Descriptive data were presented as percentages for categorical variables and median-interquartile range for continuous data. The Fisher Exact test was used to compare proportions (Categorical variables). Continuous variables were analysed using the Wilcoxon sign rank test. A p value of \u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe selected 30 men with a prior history of TURP and matched them 1:3 to 90 men with no previous history of TURP for the analysis. The preperative-data such as BMI, Age, and D\u0026rsquo;amico risk stratification were matched and hence similar between both the groups. None of them were incontinent or had underlying neurological disorders (like parkinsonism, stroke, etc) pre-operatively. Surprisingly, the prostate volume was not statistically different between the two groups (Table-1). The non-TURP group had a statistically higher chance of undergoing complete nerve preservation than the TURP group (p\u0026thinsp;=\u0026thinsp;0.03, Table-2). The operative time, blood loss, length of stay and postoperative complications were unremarkable. Final histological staging and positive surgical margins (PSM) were similar (Table-2). On follow-up, both the early (3-month) and late (24-month) continence rates and biochemical recurrence (BCR) rates were not statistically different between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable-1 Pre-operative data of the two groups in the study\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eCharacteristic N No TURP, N\u0026thinsp;=\u0026thinsp;90\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePrior TURP, N\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge at therapy (years)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67.0 (61.0, 71.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66.5 (61.3, 71.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge groups\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (11%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60\u0026ndash;64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (37%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e65\u0026ndash;69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (22%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70\u0026ndash;74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.5 (25.0, 30.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.0 (25.0, 30.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePSA (ng/ml)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.07\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eClinical stage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecT1-2a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58 (64%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (67%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecT2b\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecT2c-4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 (34%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGleason Grade\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.50\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63 (70%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (60%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (30%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProstate volume\u003csup\u003e1\u003c/sup\u003e (cc)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41 (31,54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (24,49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eD'Amico\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLow\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntermediate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42 (47%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (47%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigh\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39 (43%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (43%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e1 Median (IQR); n (%)\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003cp\u003e2 Wilcoxon rank sum test; Fisher\u0026rsquo;s exact test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr /\u003eTable-2:Peri-operative and follow-up data of the two groups\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tabb\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eCharacteristic N No TURP, N\u0026thinsp;=\u0026thinsp;90\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePrior TURP, N\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConsole time\u003csup\u003e1\u003c/sup\u003e (min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e140 (120,180)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e168 (129,190)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.058\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNerve sparing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComplete\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 (41.12%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (3.33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.03\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePartial\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48 (53.33%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24 (80.00%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (5.55%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (16.67%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlood loss\u003csup\u003e1\u003c/sup\u003e (ml)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e200 (100,200)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e150 (100,275)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.50\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eClavien Dindo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.40\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86 (96%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28 (93%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (6.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHospital stay\u003csup\u003e1\u003c/sup\u003e (days)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePathological staging\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026le;pT2a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (5.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (6.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epT2b\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epT2c\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (56.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ge;pT3a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (42.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (36.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePositive surgical margins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (18%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (17%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eContinence 3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e88 (98%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eContinence 12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eContinence 24 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePSA 3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBCR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePSA 12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBCR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.50\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePSA 24 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e120\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBCR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.90\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003e1 Median (IQR); n (%)\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003e2 Wilcoxon rank sum test; Fisher\u0026rsquo;s exact test\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003cp\u003eBCR\u0026thinsp;=\u0026thinsp;Biochemical recurrence\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe compared the peri-operative, continence and oncological outcomes of RARP between matched men with and without previous history of TURP. The non-TURP group had more complete nerve sparing than the TURP group. The two groups did not statistically differ in the peri-operative, two-year continence and oncological outcomes. TURP-induced peri-prostatic adhesions and distorted planes contribute to the difficulty associated with the posterior dissection, bladder neck dissection and nerve-sparing in RARP.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) The loss of elasticity of the bladder neck and friable urethral stump post-TURP can make the urethra-vesical anastomosis challenging.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Studies on open, laparoscopic and radical radical prostatectomy after TURP report a higher risk of PSM, blood loss and bladder neck stricture.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e),(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e),(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e),(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Surgical robotic platforms with magnified three-dimensional vision and wristed instruments have been shown to aid the surgeon in challenging dissections. Few studies have compared the outcomes of RARP in men with a prior history of TURP.\u003c/p\u003e \u003cp\u003eIn the late 2000s, Martin et al. compared RARP versus Open Retropubic Radical Prostatectomy in men who had previous TURP history.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) 24 men with prior TURP and/or brachytherapy were compared to 510 men without TURP without matching. The groups did not differ in blood loss, hospital stay, operative time, peri-operative, oncological and continence outcomes.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Another study by Gupta et al. compared 26 men with TURP history versus 132 unmatched men without prior TURP.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) This study found more blood loss and poorer continence rates at six and twelve months follow-up (p\u0026thinsp;=\u0026thinsp;0.07). This study included a predominantly High D\u0026rsquo;amico risk group (68.35%), which is characteristic of the distribution found in unscreened populations.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAn unmatched comparison by Su et al. involving 2693 men reported a significantly more blood loss, console time, hospital stay and poorer continence at 12 months in post-TURP men.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Some of the early studies even recorded a higher incidence of rectal injury (18.75% vs. 0%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and major complications (18.8% vs. 1.1%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) A recent comparative study from the US found no remarkable difference in perioperative, oncological and functional outcomes in post-TURP men on three-year follow-up.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Our study demonstrated no significant difference in blood loss, console time, hospital stay, postoperative BCR and continence rates in the TURP group, even at two years of follow-up.\u003c/p\u003e \u003cp\u003eTugcu et al. compared RARP outcomes in 25 men with prior TURP/Open simple prostatectomy versus 36 matched men who did not. They found longer console time (195 vs 160 min, p\u0026thinsp;=\u0026thinsp;0.016), more blood loss (p\u0026thinsp;=\u0026thinsp;0.001) and frequent need for bladder neck reconstructions (p\u0026thinsp;=\u0026thinsp;0.001) in the post-TURP men. A significant proportion of post-TURP men developed more bladder neck/anastomotic strictures in this study. However, the study found no significant difference in the 12-month continence and potency rates between the groups.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eZugor et al. conducted a propensity score-based matched-pair analysis of RARP outcomes in eighty men with and without previous TURP. This study found longer console times (189 min versus 149 min, p\u0026thinsp;=\u0026thinsp;0.069) and more frequent bladder neck reconstructions (58.7% versus 2.5%, p\u0026thinsp;=\u0026thinsp;0.073) in the TURP group, albeit statistically insignificant. Duration of hospital stay, PSM, continence (87.5% versus 91.25%) and potency rates (70.3%/86.5%) were unremarkable among the groups in the study.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Another matched-pair analysis from India revealed higher but statistically insignificant rates of PSM (30.5% versus 25%, p\u0026thinsp;=\u0026thinsp;0.54) in post-TURP men. However, this study did not find any significant difference between the one-year oncological and continence outcomes. On multivariate analysis, previous TURP was not associated with any higher risk of PSM, BCR, or incontinence. However, this study involved an unscreened population with predominantly D\u0026rsquo;amico high-risk prostate cancers.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLiu et al. recently published their systematic review/meta-analysis on this topic. Eight comparative studies involving 4186 patients were analysed. The TURP group had longer console times (p\u0026thinsp;=\u0026thinsp;0.002), higher blood loss (p\u0026thinsp;=\u0026thinsp;0.006), and bladder neck reconstruction rates (p\u0026thinsp;=\u0026thinsp;0.03). The TURP group had high PSM (p\u0026thinsp;=\u0026thinsp;0.007) with comparable hospital stay, nerve sparing, complication rates, continence recovery, potency and BCR rates on follow-up.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study:\u003c/h2\u003e \u003cp\u003eOur study is a matched study comparing the long-term outcomes of RARP in men with a history of TURP from a high-volume referral centre in the UK. However, it is not without limitations. This is a single-centre, retrospective study conducted among men presenting with predominantly D\u0026rsquo;amico low and intermediate-risk prostate cancer (\u0026gt;\u0026thinsp;50% of sample size). Therefore, the results may not be extrapolated to men with high-risk prostate cancer. Despite propensity score-matching, the sample size was small to perform sub-group analysis. Bladder neck reconstruction, duration of catheterisation, potency rates and urethral stricture/bladder neck stenosis rates were not compared due to incomplete data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRARP after TURP, although challenging, is technically safe in experienced hands. However, these procedures are ideally suited for high-volume centres and surgeons. The oncological and continence outcomes of RARP in this subset of men are comparable to men without prior TURP in high-volume centre studies. Multi-institutional studies are required to confirm our single-centre findings. Careful patient selection, referral pathways and appropriate robotic skillsets are important for better outcomes in this technically challenging operation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: No funding was received to conduct the study.\u003c/p\u003e\n\u003cp\u003eConflict of interest: All the authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003eAvailability of data and material used in the study: Available on request\u003c/p\u003e\n\u003cp\u003eAcknowledgements: None\u003c/p\u003e\n\u003cp\u003eEthical clearance: This study was conducted as an audit in our department. Audit number: SU-CA-23-24-062\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Mr.Danny Darlington Carbin, Mr.Wissam Abou Chedid, Prof.Richard Hindley and Prof.Christopher Eden. Danny Darlington Carbin co-ordinated with the statistical team for analysis \u0026amp; wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMayer EK, Kroeze SGC, Chopra S, Bottle A, Patel A. Examining the \u0026ldquo;gold standard\u0026rdquo;: a comparative critical analysis of three consecutive decades of monopolar transurethral resection of the prostate (TURP) outcomes. BJU Int. 2012;110(11):1595\u0026ndash;601.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarlsson CT, Wiklund F, Gr\u0026ouml;nberg H, Bergh A, Melin B. Risk of Prostate Cancer after Trans Urethral Resection of BPH: A Cohort and Nested Case-Control Study. Cancers. 2011;3(4):4127\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRm M, Cl W. Incidental detection of population-based prostate cancer incidence rates through transurethral resection of the prostate. Urol Oncol [Internet]. 2002 Oct [cited 2024 Mar 10];7(5). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/12644219/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/12644219/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristopher Eden, Eden CG, Andrew J. Richards, Richards AJ, Jason Ooi, Ooi J, et al. Previous bladder outlet surgery does not affect medium-term outcomes after laparoscopic radical prostatectomy. BJUI. 2007;99(2):399\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZugor V, Labanaris AP, Porres D, Witt JH. Surgical, oncologic, and short-term functional outcomes in patients undergoing robot-assisted prostatectomy after previous transurethral resection of the prostate. J Endourol. 2012;26(5):515\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical anastomosis:the single knot method. Urology. 2003;61(4):699\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColombo R, Naspro R, Salonia A, Montorsi F, Raber M, Suardi N, et al. Radical prostatectomy after previous prostate surgery: clinical and functional outcomes. J Urol. 2006;176(6 Pt 1):2459\u0026ndash;63; discussion 2463.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcar \u0026Ouml;, Esen T. Robotic Radical Prostatectomy in Patients with Previous Prostate Surgery and Radiotherapy. Prostate Cancer [Internet]. 2014 [cited 2020 Nov 22];2014. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120925/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120925/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMenard J, de la Taille A, Hoznek A, Allory Y, Vordos D, Yiou R, et al. Laparoscopic radical prostatectomy after transurethral resection of the prostate: surgical and functional outcomes. Urology. 2008;72(3):593\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFragkoulis C, Pappas A, Theocharis G, Papadopoulos G, Stathouros G, Ntoumas K. Open radical prostatectomy after transurethral resection: perioperative, functional, oncologic outcomes. Can J Urol. 2018;25(2):9262\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalisaar JR, Wenske S, Sommerer F, Hinkel A, Noldus J. Open radical retropubic prostatectomy gives favourable surgical and functional outcomes after transurethral resection of the prostate. BJU Int. 2009;104(5):611\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHampton L, Nelson RA, Satterthwaite R, Wilson T, Crocitto L. Patients with prior TURP undergoing robot-assisted laparoscopic radical prostatectomy have higher positive surgical margin rates. J Robot Surg. 2008;2(4):213\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin AD, Desai PJ, Nunez RN, Martin GL, Andrews PE, Ferrigni RG, et al. Does a history of previous surgery or radiation to the prostate affect outcomes of robot-assisted radical prostatectomy? BJU Int. 2009;103(12):1696\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta NP, Singh P, Nayyar R. Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate. BJU Int. 2011;108(9):1501\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSu YK, Katz BF, Sehgal SS, Yu SJS, Su YC, Lightfoot A, et al. Does previous transurethral prostate surgery affect oncologic and continence outcomes after RARP? J Robot Surg. 2015;9(4):291\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHung CF, Yang CK, Ou YC. Robotic assisted laparoscopic radical prostatectomy following transurethral resection of the prostate: perioperative, oncologic and functional outcomes. Prostate Int. 2014;2(2):82\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajesh Raj Bajpai, Rajesh Bajpai, Shirin Razdan, Shirin Razdan, Mabel S\u0026aacute;nchez, Marcos A Sanchez, et al. Robotic Assisted Radical Prostatectomy After Prior Transurethral Resection of Prostate: An Analysis of Perioperative, Functional, Pathologic, and Oncological Outcomes. J Endourol. 2022;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTugcu V, Atar A, Sahin S, Kargi T, Gokhan Seker K, IlkerComez Y, et al. Robot-Assisted Radical Prostatectomy After Previous Prostate Surgery. JSLS [Internet]. 2015 [cited 2020 Nov 22];19(4). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653581/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653581/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZugor V, Labanaris AP, Porres D, Witt JH. Surgical, oncologic, and short-term functional outcomes in patients undergoing robot-assisted prostatectomy after previous transurethral resection of the prostate. J Endourol. 2012;26(5):515\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarlington CD, Ashwin Sunil Tamhankar, P. K. Ahluwalia, et al. Does prior transurethral resection of prostate affect the functional and oncological outcomes of robot-assisted radical prostatectomy? A matched-pair analysis. J Robot Surg. 2021;1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Qin J, Li KP, Wen Z, Huang J, Jiang Y, et al. Perioperative, functional, and oncologic outcomes in patients undergoing robot-assisted radical prostatectomy previous transurethral resection of prostate: a systematic review and meta-analysis of comparative trials. J Robot Surg. 2023;17(4):1271\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"continence, robot-assisted radical prostatectomy, transurethral resection of the prostate, trifecta","lastPublishedDoi":"10.21203/rs.3.rs-4109598/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4109598/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003ePrior history of transurethral resection of the prostate (TURP) can complicate Robot-assisted radical prostatectomy (RARP). Very few studies analyse the outcomes of RARP in men with a prior history of TURP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analysed the oncological and functional outcomes of RARP in post-TURP men from our prospectively maintained database. We included the RARP data from January 2016 to January 2022. Thirty men who had RARP with a prior history of TURP were identified (Group 2). They were matched using R software and propensity score matching to 90 men with no previous TURP (Group-1). The groups were matched for age, body mass index (BMI) and D\u0026rsquo;Amico risk category in a 1:3 ratio. The two-year oncological and functional outcomes were compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, the study found no significant difference between the groups in the preoperative parameters, such as BMI, age, clinical stage, prostate volume, and D\u0026rsquo;amico risk grouping. There was no difference in the estimated blood loss. The TURP group had a lower chance of having a nerve spare (p\u0026thinsp;=\u0026thinsp;0.03). The median console time was longer in the TURP group (140 minutes (120,180) versus 168 (129,190) p\u0026thinsp;=\u0026thinsp;0.058). The postoperative complications (Clavien-Dindo 3a 2% versus 6.7%) and hospital stay (median of 2 days), positive surgical margins, continence, and biochemical recurrence rates at 3, 12, and 24 months were not statistically different between the groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn high-volume centres, the oncological and continence outcomes of RARP post-TURP are not inferior to that of men without prior TURP.\u003c/p\u003e","manuscriptTitle":"Outcomes of Robot-Assisted Radical Prostatectomy in Men after Trans-Urethral Resection of the Prostate: A Matched-Pair Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-19 08:23:48","doi":"10.21203/rs.3.rs-4109598/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-18T17:52:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-18T00:54:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3b7ff3fc-9fd7-4a15-a12c-2f425825712a","date":"2024-03-17T22:24:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-17T21:17:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-17T21:14:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-16T02:06:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-03-15T17:32:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e69a4ba2-d608-4937-b720-1ea31bad29bb","owner":[],"postedDate":"March 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-08T15:07:17+00:00","versionOfRecord":{"articleIdentity":"rs-4109598","link":"https://doi.org/10.1007/s11701-024-01935-5","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2024-04-03 15:01:49","publishedOnDateReadable":"April 3rd, 2024"},"versionCreatedAt":"2024-03-19 08:23:48","video":"","vorDoi":"10.1007/s11701-024-01935-5","vorDoiUrl":"https://doi.org/10.1007/s11701-024-01935-5","workflowStages":[]},"version":"v1","identity":"rs-4109598","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4109598","identity":"rs-4109598","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}