The effect of the presence of a median lobe on the outcomes of robot-assisted laparoscopic radical prostatectomy

Aim: To report the effect of the presence of a median lobe on perioperative outcomes, positive surgical margin (PSM) rates and short-term urinary continence outcomes after robotassisted laparoscopic radical prostatectomy (RARP). Patients and Methods: We analyzed data from 1,693 consecutive patients who underwent RARP by a single surgeon for treatment of clinically localized prostate cancer. Patients were categorized into two groups based on the presence or absence of a median lobe identified during RARP. Outcomes analyzed included operative time, estimated blood loss (EBL), nervesparing procedure, overall complication rates, length of hospital stay, days with catheter, presence of anastomotic leakage on cystogram, number of bladder neck reconstruction procedures, tumor volume, pathological stage, PSM rates, pathological Gleason score and continence rates. Continence was defined as the use of ‘no pads’ based on the patient responses to the Expanded Prostate Cancer Index Composite questions at 1, 4, 6, 12 and 24 weeks after catheter removal. Results: Median lobe was intraoperatively identified in 323 (19%) patients. Patients with a median lobe were slightly older (median 63 vs. 60 years, p<0.001), had higher PSA levels (median 5.7 vs. 4.7 ng/ml, p<0.001) and higher AUA-SS before RARP (10 vs. 6, p<0.001). The number of bladder neck reconstruction procedures (93.5% vs. 65.7%, p<0.001) and the median prostate weight (64 vs. 46 g, p<0.001) were also higher. Both groups had equivalent EBL, length of hospital stay, days with catheter, pathological stage, pathological Gleason score, nerve-sparing procedures, complication rates, anastomotic leakage rates, mean tumor volume, PSM rates and PSM rate at the bladder neck. The median OR time was slightly greater in patients with median lobe (80 vs. 75 minutes, p<0.001). There was no difference in the operative time between the two groups when stratifying this result by prostate weight. Continence rates were also equivalent between patients with and without a median lobe at 1 week (27.8% vs. 27%, p=0.870), 4 weeks (42.3% vs. 48%, p=0.136), 6 weeks (64.1% vs. 69.5%, p=0.126), 12 weeks (82.5% vs. 86.8%, p=0.107) and 24 weeks (91.5% vs. 94.1%, p=0.183). Finally, the median time to recovery of continence was similar between the groups based on the Kaplan–Meier curves (median: 5 weeks, 95% CI=4.41-5.59 vs. median: 5 weeks, 95% CI=4.66-5.34; log rank test, p=0.113). Conclusion: The presence of a median lobe does not affect perioperative outcomes, PSM rates and early continence outcomes in patients undergoing RARP performed by an experienced surgeon. There was a slight increase in the operative time in patients with a median lobe which was, however, related to the larger prostate size in this group.