Retzius sparing robotic assisted radical prostatectomy vs. conventional robotic assisted radical prostatectomy: a systematic review and meta-analysis

Modified Retzius-sparing robot-assisted radical prostatectomy for cases with anterior tumor: a propensity score-matched analysis

OBJECTIVE

To compare the outcomes between a modified Retzius-sparing robot-assisted radical prostatectomy (mRS-RARP) technique and conventional robot-assisted radical prostatectomy (Con-RARP) technique for cases with anterior prostate cancer (PCa), especially positive surgical margin (PSM) rates and urinary continence (UC).

PATIENTS AND METHODS

We retrospectively included 193 mRS-RARP and 473 Con-RARP consecutively performed by a single surgeon for anterior PCa. Perioperative complications, pathology, and continence were compared after propensity score matching using 9 variables.

RESULTS

After matching (n = 193 per group), PSM were not significantly different in the two groups (16.1% in mRS-RARP group vs. 15.0% in Con-RARP group, p = 0.779). The UC at catheter removal and at 1-month was significantly higher in the mRS-RARP (24.9% vs. 9.8%, p < 0.001; 29.0% vs. 13.5%, p < 0.001, respectively), but not at 3-, 6-, and 12-month follow-ups (p = 0.261, 0.832, and 0.683, respectively).

CONCLUSION

mRS-RARP seems to be an oncologically safe approach for patients with anterior PCa. Compared with the conventional approach, mRS-RARP approach shows benefits in the short-term postoperative UC recovery.

Long-term outcomes of pelvic-fascia sparing robotic-assisted radical prostatectomy versus standard technique: Superior urinary function and quality of life without compromising oncologic efficacy in a single-surgeon series

BACKGROUND

Prostatic fascia-sparing robotic-assisted radical prostatectomy (PFS-RARP) has improved short-term postoperative continence compared to standard prostatectomy (S-RARP) but long-term differences remain unclear.

MATERIALS AND METHODS

One hundred two S-RARP followed by 239 PFS-RARPs were performed by a single surgeon. Univariate analyses were performed with t-test, χ2, Wilcoxon rank sum, Fisher exact, and analysis of variance (ANOVA). Regression models analyzed associates of EPIC-CP scores and oncologic outcomes. Cox proportional hazards modeling assessed postoperative continence. Primary outcomes included patient-reported urinary incontinence (UI) via EPIC-CP and continence rates. Secondary outcomes included EPIC-CP scores, positive surgical margins (PSM), and biochemical recurrence (BCR). Perioperative outcomes and time to continence were measured.

RESULTS

Median follow-up for PFS-RARP vs. S-RARP was 26 vs. 65 months. PFS-RARP demonstrated improved EPIC-CP UI and total scores at 24 months. On multivariate analysis, PFS-RARP was associated with improved EPIC-CP UI and total scores through 18 months, but not with PSM or BCR. PFS-RARP had a 39% and 66% reduced risk of incontinence using 0 and 0 to 1 pad-use definitions (HR 0.61, 95% CI 0.39 - 0.95; HR:0.34, 95% CI 0.16 - 0.76). Continence returned faster with PFS-RARP (0 PPD: 91.0 days vs. 261 days, P < 0.001; 0-1 PPD: 32.7 days vs. 171 days, P < 0.001). There were no differences in PSM (35% vs. 25%, P = 0.064). There were more anterior PSM in PFS-RARP vs. S-RARP (47% vs. 26% P = 0.035), but no differences in BCR (16% vs. 22% P = 0.241).

CONCLUSIONS

PFS-RARP improves continence and patient-reported QOL up to 24 months postoperatively without compromising oncologic outcomes.

Retzius-sparing vs. posterior urethral suspension: similar early-phase post-robotic radical prostatectomy continence outcomes

Stress urinary incontinence (SUI) is a risk of robotic-assisted radical prostatectomy (RP) which can be a frustrating problem for both surgeons and patients. We aim to compare short-term continence outcomes between patients undergoing Retzius Sparing RP (RS-RP) and those undergoing standard RP with the inclusion of a PUS suture technique and suprapubic tube (PUS-RP). A retrospective review of 105 consecutive patients who underwent RP was performed, comparing patients who underwent RS-RP and PUS-RP. Our main outcome was pad usage as a surrogate for SUI. Patients were evaluated 4 weeks following RP and again at approximately 3 months. Continence was defined as no pad usage or up to one safety pad per day. Risk factors associated with not being continent were identified using univariate and multivariate analyses. In our cohort, 52 patients underwent RS-RP and 53 patients underwent PUS-RP. The two groups had similar patient demographics. Although not statistically significant, there was a higher rate of a positive surgical margin in the RS-RP compared to PUS-RP (25% vs 15%, p = 0.204). At one month follow-up for PUS-RP and RS-RP, there was no significant difference in the frequency of continent men (69.2% vs. 76.9%, p = 0.302). At 3-month follow-up for the two groups of patients, again, there was no significant difference in the frequency of continence for PUS-RP and RS-RP (86.2% vs 88%, p = 0.824). Patients who underwent RS-RP had similar rates of continence to those patients undergoing PUS-RP in the short-term post-operative period.

Retzius-Sparing Robotic-Assisted Prostatectomy: Technical Challenges for Surgeons and Key Prospective Refinements

Robotic-assisted radical prostatectomy (RARP) is the gold standard for localized prostate cancer. Several RARP approaches were developed and described over the years, aimed at improving oncological and functional outcomes. In 2010, Galfano et al described a new RARP technique, known as Retzius-sparing RARP (RS-RARP), a posterior approach through the Douglas space that spares the anterior support structures involved with urinary continence and sexual potency. This approach has been used increasingly in many centers around the world comparing its results with those of the most used standard anterior approach. Several randomized controlled trials, systematic reviews and meta-analyses demonstrated an important advantage relative to standard anterior RARP in terms of early urinary continence recovery, with comparable perioperative and long-term oncological outcomes. Several surgeons are concerned regarding RS-RARP because it appears to increase the risk of positive surgical margins (PSMs). However, this statement is based on low-certainty evidence. Indeed, the available studies compared the results of surgeons who had an initial experience with posterior RARP with those who had a solid experience with anterior RARP. Recent evidence strongly suggests that RS-RARP is feasible and safe not only in low- and intermediate-risk prostate cancer patient but also in challenging scenario such as high-risk setting, salvage prostatectomy and after transurethral resection of the prostate.

Urinary Continence Recovery after Retzius-Sparing Robot Assisted Radical Prostatectomy and Adjuvant Radiation Therapy

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) allows the preservation of the structures advocated to play a crucial role in the continence mechanism. This study aims to evaluate the association between adjuvant radiation therapy (aRT) and urinary continence (UC) recovery after RS-RARP. For the purpose of the current study, all patients submitted to RS-RARP for prostate cancer (PCa) at a single high-volume European institution between January 2010 and December 2021 were identified. Only patients that harbored pT2 stage with positive surgical margins or pT3/pN1 stage with or without positive surgical margins were included in the analyses. Two groups of patients were identified as follows: patients who had undergone aRT and patients submitted to observation (no-aRT patients). As per definition, aRT was delivered within 1-6 months after surgery. After 1:1 propensity score matching, 124 aRT patients were compared with 124 no-aRT patients who continued standard follow-up protocol after surgery. UC recovery was 81 vs. 84% in aRT vs. no-aRT patients (p = 0.7). In multivariable Cox regression analyses, aRT did not reach the independent predictor status for UC recovery at 12 months. In the subgroup analysis including only aRT patients, only the nerve-sparing technique was independently associated with UC recovery at 12 months. Conversely, the type of aRT (IMRT/VMAT vs. 3D-CRT) did not reach the independent predictor status for UC recovery at 12 months. The current study is the first to address the association between aRT and UC recovery in patients treated with RS-RARP for PCa. Based on our data, aRT is not associated with worse UC recovery. In the cohort of patients treated with aRT, the nerve-sparing technique independently predicted UC recovery.

Retzius-sparing robot-assisted radical prostatectomy after previous trans-urethral resection of the prostate: Assessment of functional and oncological outcomes

BACKGROUND

no data exist concerning functional and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP), in patients previously treated with trans-urethral resection of the prostate (p-TURP), for benign prostate obstruction. Our study addressed the impact of p-TURP on immediate and 12-months urinary continence recovery (UCR), as well as peri-operative outcomes and surgical margins, after RS-RARP.

METHODS

all patients treated with RS-RARP for prostate cancer at a single high-volume European institution, between 2010 and 2021, were identified and stratified according to p-TURP status. Logistic, Poisson and Cox regression models were performed.

RESULTS

Of 1386 RS-RARP patients, 99 (7%) had history of p-TURP. Between p-TURP and no-TURP patients no differences were detected regarding both intra- and post-operative complications (p values = 0.9). The rates of immediate UCR were 40 vs 67% in p-TURP vs no-TURP patients (p < 0.001). At 12 months from RS-RARP, the rates of UCR were 68 vs 94% in p-TURP vs no-TURP patients (p < 0.001). At multivariable logistic and Cox regression models, p-TURP was independently associated, respectively, with lower immediate (odds ratio [OR]: 0.32, p < 0.001) and 12-months UCR (hazard ratio: 0.54, p < 0.001). At multivariable Poisson analyses, p-TURP predicted longer operative time (rate ratio: 1.08, p < 0.001) but not longer length of stay or time to catheter removal (p values > 0.05). Positive surgical margins rates were 23 vs 17% in p-TURP vs no-TURP patients (p = 0.1), which translated in a non-statistically significant multivariable OR of 1.14 (p = 0.6).

CONCLUSIONS

p-TURP does not increase surgical morbidity but portends longer operative time and worse urinary continence after RS-RARP.

Is It Safe to Switch from a Standard Anterior to Retzius-Sparing Approach in Robot-Assisted Radical Prostatectomy?

Background: Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been shown to lead to better outcomes regarding early continence compared to standard anterior RARP (SA-RARP). The goal of this study was to assess the feasibility and safety of implementing RS-RARP in a tertiary center with experience in SA-RARP. Methods: From February 2020, all newly diagnosed non-metastatic prostate cancer patients for whom RARP was indicated were evaluated for RS-RARP. Data from the first 100 RS-RARP patients were prospectively collected and compared with data from the last 100 SA-RARP patients. Patients were evaluated for Clavien Dindo grade ≥3a complications, urinary continence after 2 and 6 weeks, 3, 6 and 12 months, erectile function, positive surgical margins (PSMs) and biochemical recurrence (BCR). Results: There was no significant difference in postoperative complications at Clavien-Dindo grade ≥3a (SA-RARP: 6, RS-RARP: 4; p = 0.292). At all time points, significantly higher proportions of RS-RARP patients were continent (p < 0.001). No significant differences in postoperative potency were observed (52% vs. 59%, respectively, p = 0.608). PSMs were more frequent in the RS-RARP group (43% vs. 29%, p = 0.034), especially in locally advanced tumors (pT3: 64.6% vs. 43.8%, p = 0.041—pT2: 23.5% vs. 15.4%, p = 0.329). The one-year BCR-free survival was 82.6% vs. 81.6% in the SA-RARP and RS-RARP groups, respectively (p = 0.567). The median follow-up was 22 [18–27] vs. 24.5 [17–35] months in the RS-RARP and SA-RARP groups, respectively (p = 0.008). Conclusions: The transition from SA-RARP to RS-RARP can be safely performed by surgeons proficient in SA-RARP. Continence results after RS-RARP were significantly better at any time point. A higher proportion of PSMs was observed, although it did not result in a worse BCR-free survival.

Comparative analysis of early post-operative outcomes between retzius-sparing and anterior approach robotic radical prostatectomy for a single surgeon

Introduction:

The aim of this study was to compare intraoperative and early post-operative outcomes between retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) versus standard approach for RARP (S-RARP).

Patients and methods:

All RARPs by a single surgeon were included and divided into two groups: (1) standard approach including combined anterior–posterior approach (S-RARP); (2) retzius-sparing posterior approach (RS-RARP). Allocation was based on prostate size and location of index lesion on MRI. Initial post-operative follow-up was at 6 weeks.

Results:

Overall, 169 RARPs were performed between March 2018 and October 2021: S-RARP = 99 versus RS-RARP = 70. There was no significant difference in pre-operative body mass index (BMI), prostate-specific antigen (PSA), International Society of Urological Pathology (ISUP) grade group and clinical T stage. Intraoperative differences were found in blood loss (300 versus 200 mL, p = 0.008), console time (180 versus 135 minutes, p < 0.001) favouring RS-RARP, with no differences in nerve-spare or lymph node dissection. Post-operatively, no difference was found in ISUP grade, pathological T stage, positive surgical margins, number of lymph nodes sampled, readmissions or complications. Gland size in the RS group was smaller (38 versus 29 g, p = 0.001). Early (6 weeks) post-op follow-up showed a significant difference between groups for both pad-free continence (35% versus 53%, p = 0.011) and social continence (79% versus 89%, p = 0.024), but no difference for erectile function recovery (27% versus 50% of baseline) and post-op PSA levels < 0.1 ng/mL (85% versus 93%).

Conclusion:

Even early in the learning curve, continence recovery, operative time and blood loss were significantly better for RS-RARP than S-RARP. Margin status and PSA levels are comparable to published literature for both groups. Standardised training in RS-RARP might help to improve the uptake of this novel technique.

Level of evidence:

2.

Retzius-sparing robot-assisted radical prostatectomy in a medium size oncological center holds adequate oncological and functional outcomes

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has emerged as a surgical option for patients with prostatic cancer in high-volume centers. The objective is to assess oncological and functional outcomes when implementing RS-RARP in a medium-volume center without previous experience of robotic surgery. This is a prospective observational single-center study. Patients operated between July 2017 and April 2020 were divided into two consecutive groups, A and B, each with 104 patients. The surgeons had prior experience in laparoscopic surgery and underwent robotic training. Positive surgical margin (PSM) status, urinary continence, and erectile function projected by Kaplan-Meier curves, together with patient reported quality of life outcomes at 12 months post-surgery were documented. Median patient age was 63 years (IQR = 59-67), overall PSM rate were 33%, 28% for pT2 disease. Pre-operative values showed no significant difference between both groups. The rate of urinary continence dropped from 81 to 78% (SE = 5.7) (Group A) and from 90 to 72% (SE = 6.3) (Group B) using the International Consultation on Incontinence Questionnaire-Short Form. Baseline sexual function was regained in 41% (Group A) and 47% (Group B) of patients. The median Expanded Prostate Index Composite-26 total score decreased from 86 to 82. These outcomes relate favorably to prior reports. There was a clinically significant decrease in median operative time in the successive groups with post-operative complications occurring in less than 2% of surgical procedures overall. A 12-month follow-up suggests that RS-RARP may be safely introduced in a medium-volume center without previous experience of robotic surgery.

Optimizing Nerve Sparing in Robotic-Assisted Radical Prostatectomy: A Comparative Investigation of Traditional and Modified Endopelvic Fascia Preservation Techniques

Background

Prostate cancer (PCa) is the second most common cancer and the sixth leading cause of cancer-related mortality in men. In 2000, Abbou performed the first robot-assisted radical prostatectomy, and radical prostatectomy has developed rapidly. Robot-assisted radical prostatectomy (RARP) is a valuable therapeutic option for the management of localized Pca.

Objective

To present the functional outcome of robot-assisted laparoscopic radical prostatectomy using traditional and modified endopelvic fascia preservation methods in a single center in Vietnam.

Methods

We prospectively analyzed a series of 65 patients diagnosed with prostate cancer from 2020 to 2023. All of those were operated by DaVinci Si system robot-assisted laparoscopic prostatectomy. Twenties patients were applied with a modified nerve-sparing technique, intrafascial dissection, and lateral prostatic fascia preservation, leaving the lateral tissue, including the neurovascular bundle, untouched and covered. We used the traditional approach, intrafascial nerve-sparing with open endopelvic fascia and lateral prostatic fascia in 45 cases. Patients were followed up to 12 months to assess the continence and erectile function by using IIEF-5 and EPIC questionnaires.

Results

The study sample included 65 cases; the mean patient age was 64.21 ± 6.68, erection rate after surgery at six months in bilateral NS was 36.58% (15/41) in the traditional group, and 68.42% (13/19) in the modified group (p=0.028). The patient did not recover erectile ability in the group of elderly patients (>65 years old) and unilateral nerve-sparing group. The continence rate six months after surgery was 86.66 % in the conventional group and 85% in the modified group, with no significant difference between the two groups. In the potency group, the IIEF-5 score was 13 ± 4.9, and the EPIC-26 score was 62.20 ± 10.04. Erectile ability in the modified group was better than the traditional group at six months after surgery.

Conclusion

Our results showed better potency recovery in the modified group. These results should be tested in future research with randomized studies.

Simple and reliable predictive factor for early recovery of urinary continence after non-nerve-sparing robot-assisted laparoscopic radical prostatectomy

Post-prostatectomy urinary incontinence is one of the greatest concerns for both patients and urologists. The aim of this study is to elucidate simple and reliable factors contributing to early recovery of urinary continence (UC) and to develop a prediction model for early continence recovery after robot-assisted laparoscopic non-nerve-sparing radical prostatectomy (non-NS RARP). A retrospective analysis of 212 consecutive patients who underwent non-NS RARP by a single surgeon was carried out. Early recovery of urinary continence was defined as using no pads or one security pad per day within 1 month. Preoperative membranous urethral length (MUL) was measured on MRI, and the urinary continence at the standing position (UCSP) after removal of the catheter was examined during cystourethrography 6 days after surgery. Multivariable analysis was performed to detect predictive and postoperative factors associated with early recovery of urinary continence. The early continence recovery rate was 56.1%. Multivariable analysis revealed that MUL ≥ 13 mm, UCSP, and age ≤ 67 were the independent factors for early continence recovery. Early recovery rates were 97.1% for good risk, 76.3% for intermediate risk, and 28.4% for poor risk when divided into three risk groups by the sum score of three independent factors. Preoperative MUL, UCSP, and age are independent predictors of early recovery of UC in non-NS RARP, and our simple prediction model with the combination of the three factors could be a useful tool in clinical practice.

Salvage Retzius-Sparing Radical Prostatectomy: A Review of Complications, Functional Outcomes, and Oncologic Outcomes

(Background) Radiation failure for localized prostate cancer is seen in 20-60% of patients who do not undergo extirpative surgery. Though potentially curative, salvage prostatectomy (SS) has not been frequently performed historically due to high rates of complications and postoperative incontinence. With the advent of robotic-assisted radical prostatectomy, these rates appear to be improved. Retzius-sparing approaches have additionally been shown to improve continence outcomes in the index setting, and may further improve continence outcomes in salvage cases while maintaining oncologic integrity. (Methods) We performed a literature review and qualitative analysis of published papers on salvage Retzius-sparing robotic-assisted radical prostatectomy (SRS). Three studies met criteria and were included in analysis. (Results) There were more patients with Gleason Grade Group 1 disease after initial treatment in the SRS group vs. SS (22% vs. 8%). Patients most frequently underwent external beam radiation therapy in both groups (52% vs. 49%). 30-day complication rates were 10% and 26% for SRS and SS, respectively. Continence outcomes were significantly improved in SRS with 59% of continence (based on study criteria) compared to 38% in SS. Time to continence was similarly improved for SRS. Positive surgical margins and biochemical recurrence were not significantly different between SRS and SS in any study. (Conclusions) SRS is a safe and feasible option for salvage treatment of localized prostate cancer and may improve postoperative continence outcomes. Positive surgical margin and biochemical recurrence rates are similar to those reported in SS.

Retzius Sparing Radical Prostatectomy Versus Robot-assisted Radical Prostatectomy: Which Technique Is More Beneficial for Prostate Cancer Patients (MASTER Study)? A Systematic Review and Meta-analysis

CONTEXT

Retzius sparing robot-assisted radical prostatectomy (RS-RARP) is increasingly being used, but results of pertinent studies on perioperative, functional, and oncological outcomes comparing the Retzius sparing approach with standard robot-assisted radical prostatectomy (RARP) remain inconsistent.

OBJECTIVE

To evaluate the effectiveness of RS-RARP compared with standard RARP, in terms of perioperative, functional, and oncological outcomes.

EVIDENCE ACQUISITION

We performed a systematic search using multiple databases (PubMed, MEDLINE, EMBASE, and Cochrane Central) until March 2021. Only randomized controlled trials (RCTs) and prospective studies were eligible for study inclusion. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were respected. Studies were critically appraised for the risk of bias. Primary outcomes were continence/potency recovery, as well as positive surgical margin (PSM) rates. Secondary outcomes included total intra- and perioperative complication rates.

EVIDENCE SYNTHESIS

Four RCTs and six prospective observational studies were included in this systematic review. The meta-analysis revealed that PSM rates in ≤pT2 tumors were statistically significantly higher, following RS-RARP as compared with RARP (risk ratio [RR]=1.39; 95% confidence interval [CI]=[1.01-1.91]). PSM rates in ≥pT3 tumors tended to be higher following RS-RARP (RR=1.36; 95% CI=[0.74-2.50]), although statistical significance was not reached. Immediate continence recovery was higher and significantly advantageous for RS-RARP (RR=1.81; 95% CI=[1.26-2.60]). Continence recovery also tended to be higher at 3 and 6 mo in the RS-RARP group (RR=1.57; 95% CI=[0.69-3.58] and RR=1.22; 95% CI=[0.89-1.66], respectively). The urinary continence recovery at 12 mo was similar in both groups (RR=1.14; 95% CI=[0.98-1.32]). A meta-analysis of included studies showed no significant difference concerning the return of erectile function and major complication rates between RS-RARP and RARP (RR=1.05; 95% CI=[0.76-1.45] and (RR=0.79; 95% CI=[0.07-8.74], respectively).

CONCLUSIONS

Available data suggest a statistically significant advantage in favor of RS-RARP in terms of immediate urinary continence recovery. PSM rates in localized ≤pT2 tumors are statistically significantly higher following RS-RARP. Potency and serious complication rates appear to be similar.

PATIENT SUMMARY

Our meta-analysis of the current evidence shows a significant advantage for Retzius sparing robot-assisted radical prostatectomy (RS-RARP) over robot-assisted radical prostatectomy in terms of immediate urinary continence recovery, but positive cancer margins are higher following RS-RARP. There was no significant difference in the preservation of erectile function and overall postoperative complication rates between both the techniques.

Challenging cases in high-risk prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy

OBJECTIVE

To evaluate the relationship between enlarged prostate, bulky median lobe (BML) or prior benign prostatic hyperplasia (BPH) surgery and perioperative functional, and oncological outcomes in high-risk (HR) prostate cancer (PCa) patients treated with Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

METHODS

320 HR-PCa patients treated with RS-RARP between 2011 and 2020 at a single high-volume center. The relationship between prostate volume, BML, prior BPH surgery and perioperative outcomes, Clavien-Dindo (CD) grade ≥ 2 90-day postoperative complications, positive surgical margins (PSMs), and urinary continence (UC) recovery was evaluated respectively in multivariable linear, logistic and Cox regression models. Complications were collected according to the standardized methodology proposed by EAU guidelines. UC recovery was defined as the use of zero or one safety pad.

RESULTS

Overall, 5.9% and 5.6% had respectively a BML or prior BPH surgery. Median PV was 45 g (range: 14-300). The rate of focal and non-focal PSMs was 8.4% and 17.8%. 53% and 10.9% patients had immediate UC recovery and CD ≥ 2. The 1- and 2-yr UC recovery was 84 and 85%. PV (p = 0.03) and prior BPH surgery (p = 0.02) was associated with longer operative time. BML was independent predictor of time to bladder catheter removal (p = 0.001). PV was independent predictor of PSMs (OR: 1.02; p = 0.009). Prior BPH surgery was associated with lower UC recovery (HR: 0.5; p = 0.03).

CONCLUSION

HR-PCa patients with enlarged prostate have higher risk of PSMs, while patients with prior BPH surgery have suboptimal UC recovery. These findings should help physicians for accurate preoperative counseling and to improve surgical planning in case of HR-PCa patients with challenging features.

Comparison of Retzius-sparing versus standard robot-assisted radical prostatectomy for prostate cancer

INTRODUCTION AND OBJECTIVES

We aim to compare the first year oncological and functional outcomes of Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) and standard robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

Eighty-eight patients who underwent robotic radical prostatectomy between 2018-2019 were included. We compared the minimum one-year follow-up results of patients who underwent Rs-RARP or RARP in terms of oncological and functional outcomes. Potency was assessed with the Sexual Health Inventory for Men (SHIM) score and was defined as an erection sufficient for penetration. Continence was defined as the absence of urinary incontinence with no safety pad. Patients were evaluated in the first month of follow-up and subsequently, every three months.

RESULTS

Forty-six patients in Rs-RARP and 42 patients in the RARP group were enrolled. Catheter removal time was shorter in the Rs-RARP group (12 vs. 14 days, p = 0.001). At the 1st month visit, 41 patients (%89) were continent (no pads) in the Rs-RARP group while 25 patients (%59) were continent in the RARP group (p = 0.001). Patients who underwent Rs-RARP achieved faster recovery of urinary continence (Log-rank, p = 0.001). After one year of follow-up, 43 patients (93%) in Rs-RARP group and 38 patients (90%) in RARP group were continent (p = 0.6). Potency rates were 38.7% in Rs-RARP and 34.4% in RARP group (p = 0.28). There were no cases of biochemical recurrence in any group.

CONCLUSIONS

Rs-RARP is a feasible technique, providing early return of continence. However, overall continence rates were similar at the end of the one-year follow-up.

Outcomes of Retzius-sparing versus conventional robot-assisted radical prostatectomy: A KSER update series systematic review and meta-analysis

Background

Robotic‐assisted radical prostatectomy(RARP) is widely used to surgically treat of localized prostate cancer. Among RARP, retzius-sparing techniques(RS-RARP) are implemented through douglas pouch, not the existing conventional approach(C-RARP). We conducted an updated systematic review and meta-analysis including recent published papers.

Materials & methods

Systematic review was performed following the PRISMA guideline. PubMed, EMBASE, and Cochrane Library were searched up to August 2021. We conducted meta-analysis as follows; Participants, patients with biopsy-proven PCa; Interventions, Patients underwent C-RARP or RS-RALP; Outcomes, comparison of continence recovery rate, positive surgical margins(PSM), complication, operation time and estimated blood loss(EBL) included for analysis.

Results

Thirteen studies with a total of 2917 patients were included for meta-analysis. Among them, three were randomized controlled trials (RCT) studies and the rest were non-RCT studies. Incontinence was analyzed with zero pad and safety pad, respectively. There showed a statistically significant advantage for RS-RARP in terms of continence recovery at 1 month(0 pad; OR 0.28, (0.16–0.47), safety-pad; OR 0.12 (0.07–0.22), p<0.001), as well as at 3 months(0 pad; OR 0.31 (0.18–0.53), safety-pad; OR 0.23 (0.14–0.40) p<0.001), 6 months(0 pad; OR 0.29 (0.17–0.51), safety-pad; OR 0.13 (0.06–0.27), p<0.001). And after 12 months, RS-RARP showed better results only in the safety-pad(0 pad; OR 0.64 (0.35–1.18), p = 0.15, safety-pad; OR 0.12 (0.04–0.36), p<0.001). In PSM, there was no statistical difference between two group at overall stage, but RS-RARP was observed to be higher than C-RARP in pT3 subgroup analysis(OR 0.74 (0.55–0.99), p = 0.047) (Fig 1). Whereas, there was no significant difference between the two groups in complication, operation time, and EBL.

Conclusions

Our analysis showed that RS-RARP is superior about early continence recovery than C-RARP. However, RS-RARP showed relatively high PSM in locally advanced PCa of pT3 or above. Therefore, although RS-RARP has few advantages about functional outcomes, we think that caution should be exercised when approaching patients with high-risk local diseases.

Retzius-sparing Robot-assisted Radical Prostatectomy in High-risk Prostate Cancer Patients: Results from a Large Single-institution Series

Background

Retzius-sparing (RS) robot-assisted radical prostatectomy represents a valid surgical treatment option for prostate cancer (PCa) patients. However, the available evidence on the role of RS in high-risk (HR) PCa setting is sparse.

Objective

To describe our RS technique for HR-PCa patients and to evaluate intra-, peri-, and postoperative oncological and functional outcomes.

Design, setting, and participants

A total of 340 D’Amico HR-PCa patients underwent RS at a single high-volume centre between 2011 and 2020.

Surgical procedure

Surgical procedures were performed by five experienced robotic surgeons.

Measurements

Complications were collected according to the standardised methodology proposed by the European Association of Urology guidelines. Postoperative outcomes were evaluated in patients with complete follow-up data (n = 320). Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values of ≥0.2 ng/ml. Urinary continence (UC) recovery was defined as the use of zero or one safety pad. Kaplan-Meier and multivariable logistic and Cox regression models were performed.

Results and limitations

Fourteen patients (4%) experienced intraoperative complications and 52 90-d complications occurred in 44 patients (14%), of whom 24 had Clavien-Dindo 3a/b. Final pathology reported 49% International Society of Urological Pathology (ISUP) grade 4–5, 55% ≥pT3a, and 28.8% positive surgical margins (PSMs; 9.4% focal and 19.4% extended PSMs). The median follow-up was 47 mo. Overall, 35.3% and 1.3% harboured BCR and died from PCa. At 4 yr of follow-up, BCR-free survival and additional treatment-free survival were 63.6% and 56.6%, respectively. ISUP 4–5 at biopsy (odds ratio [OR]: 2.6), prostate volume (OR: 1.03), partial or full nerve sparing (OR: 1.9), and full bladder neck preservation (OR: 2.2) were independent predictors of PSMs. Pathological ISUP 4–5 (hazard ratio [HR]: 1.5) and PSMs (HR: 2.3) were independent predictors of BCR. Pathological ISUP 4–5 (HR: 1.5), PSMs (HR: 2.4), pT ≥3b (HR: 1.8), and pN ≥1 (HR: 1.8) were independent predictors of additional treatment. Immediate UC recovery was recorded in 53% patients. The 1- and 2-yr UC recovery and erectile function recovery were, respectively, 84% and 85%, and 43% and 50%.

Conclusions

RS in HR-PCa patients allows optimal intra-, peri-, and postoperative outcomes. The RS approach should be considered a valid surgical treatment option for HR-PCa patients in expert hands.

Patient summary

Relying on the largest cohort of high-risk prostate cancer patients treated with Retzius sparing (RS), we observed that the RS approach is safe and allows optimal cancer control, without significantly compromising functional outcomes.

Comparison of Retzius-sparing and conventional robot-assisted laparoscopic radical prostatectomy regarding continence and sexual function: an updated meta-analysis

ABSTACT

BACKGROUND: Studies comparing C-RARP and RS-RARP have reported different results and the choice between the two operation methods remains controversia.

METHODS

We present the meta-analysis on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The meta-analysis was carried out using Review Manager 5.3 (Cochrane Collaboration, Oxford, United Kingdom) and Stata SE 14.0. The mean difference (MD) with 95% confidence intervals (CI) were used to describe the results of continuous data; odds ratio (OR) with 95% CI were used to describe dichotomous data. Statistical significance was set at P < 0.05.

RESULTS

The meta-analysis revealed that RS-RARP had a statistically significant advantage in terms of continence recovery immediately after operation (OR: 0.40, 95% CI: 0.20-0.77; P = 0.007) (Fig. 2a), after 1 month (OR: 0.17, 95% CI: 0.10-0.29; P < 0.00001) (Fig. 2b), after 3 months (OR: 0.18, 95% CI: 0.09-0.36; P < 0.00001) (Fig. 2c), after 6 months (OR: 0.26, 95% CI: 0.15-0.46; P < 0.00001) (Fig. 2d) and after 12 months (OR: 0.50, 95% CI: 0.28-0.89; P = 0.02) (Fig. 2e).

CONCLUSIONS

This meta-analysis found that RS-RARP had better postoperative continence recovery than C-RARP, while sexual function recovery rates were not significantly different. There were also no significant differences in operation time, intraoperative blood loss, length of stay, positive margin rate and complications.

Single-port, Retzius-sparing robotic-assisted radical prostatectomy: feasibility and early outcomes

BACKGROUND Determine safety and feasibility of single-port, Retzius-sparing robot-assisted radical prostatectomy (SP-rsRARP) using the da Vinci® SP (Intuitive Surgical, Sunnyvale, CA, USA) robotic platform in men with adenocarcinoma of the prostate. PATEINTS AND METHODS Twenty-eight consecutive men with prostate cancer underwent SP-rsRARP by one of two surgeons (J.B., S.C.). Data for peri-operative, pathologic, and functional outcomes were collected prospectively and retrospectively analyzed. RESULTS Mean (SD) follow-up was 6 (3) months. Mean age was 65.3 years old with an average body mass index of 25.2 kg/m2. Mean preoperative PSA was 10.2 ng/mL. Average prostate weight was 42 grams. Three patients (11%) had prior radiation to the prostate. There were no intraoperative complications or conversions of technique. Lymphadenectomy was performed in twenty-four (86%) patients and nerve-sparing in fourteen (46%). Mean operative time (skin to skin) was 234 minutes with an average estimated blood loss of 148 mL. Length of hospital stay averaged 23 hours. Seventeen (61%) of the patients did not require opioids for post-operative pain. Two Clavien Grade IIIa complications occurred (lymphocele aspiration, dilation of bladder neck contracture). Pathological grade group was group 1 (0%), grade 2 (57%), group 3 (29%) and group 4-5 (14%). Pathologic stage was T2 (15/28, 54%) and T3a,b (13/28, 46%). Five patients (18%) had a positive surgical margin, four (80%) of whom had T3 disease. One patient (4%) had a detectable PSA in follow-up and opted for adjuvant radiation. Twenty-three patients (82%) were continent at foley removal. Post-operative mean SHIM scores in those who underwent nerve-sparing was 18 at 3-months follow-up. CONCLUSIONS SP-rsRARP appears safe and feasible. Early continence rates are promising. Full characterization of outcomes require longer follow-up and larger cohort validation.

Does transition from standard to Retzius-sparing technique in robot-assisted radical prostatectomy affect the functional and oncological outcomes?

OBJECTIVE

To appraise the outcomes on the Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) learning curve of a surgeon with previous experience of anterior (standard) RARP.

MATERIALS AND METHODS

The first 50 cases during the Rs-RARP learning curve (group 1) and 50 cases after the second 100 cases with the standard approach (group 2) were comprised in the study. Patients who used zero or one safety pads were considered continent. Erectile function recuperation was characterized as the competence to achieve penetrative intercourse without receiving any medication. All patients were reevaluated at two weeks, first, third, sixth, and 12th months after surgery using IIEF-5, PSA level, and continence status.

RESULTS

Immediate continence rates following catheter removal were 32/50 (64%) in Rs-RARP group and 26/50 (52%) in S-RARP group (p = 0.224). The continence recovery rate was 48/50 (96%) in Rs-RARP group and 46/50 (92%) in the S-RARP group at 12 months follow-up (p = 0.400). Total nerve-sparing surgery was enforced in 36/50 (72%) patients for group 1 and 35/50 (70%) patients for group 2. Potency recovery was 27/43 (62.8%) in Rs-RARP and 30/44 (68.2%) for S-RARP at 12 months follow up (p = 0.597). Surgical margin positivity was detected in 6/50 (12%) cases in the Rs-RARP group and in 4/50 (8%) cases in the S-RARP (p = 0.444).

CONCLUSIONS

Functional and oncological results are not negatively affected in the first 50 cases for a surgeon who is experienced in S-RARP before transition to the Rs-RARP method.

Independent Factors Affecting Postoperative Short-Term Urinary Continence Recovery after Robot-Assisted Radical Prostatectomy

Background

Our team had firstly applied the transvesical approach to robot-assisted radical prostatectomy (RARP) in patients afflicted with localized prostate cancer (PCa). The present study aims to present the postoperative recovery of urinary continence (UC) following the anterior, transvesical, and posterior approaches to RARP for localized PCa and evaluate the independent predictors to early UC recovery after RARP.

Methods

Patients harboring localized PCa and receiving anterior, transvesical, and posterior approaches to RARP between January 2017 and June 2020 were enrolled in this analysis. Results on UC recovery were compared between these three approaches with the Kaplan–Meier method. All clinical and pathological variables were further analyzed via univariable and multivariable regression analysis to determine the independent factors contributing to short-term UC recovery after RARP.

Results

A total of 135, 73, and 66 instances were included in the anterior, transvesical, and posterior groups, respectively. Over the postoperative follow-up period, both the transvesical and posterior approaches showed an advantage over the anterior approach in promoting postoperative UC recovery (both p values <0.001). Three months after surgery, 55 (40.7%), 4 (5.5%), and 5 (7.6%) patients failed to UC in the anterior, transvesical, and posterior groups, respectively. Patient age, preoperative PSA, prostate volume, biopsy Gleason score, surgical approach, extended lymph node dissection technique, nerve-sparing technique, and positive lymph node were related to UC status based on univariable analyses (p < 0.05). Multivariable analysis results point patient age, prostate volume, surgical approach, and nerve-sparing technique as independent factors that affect postoperative UC recovery after RARP.

Conclusions

The application of transvesical approach to RARP for localized PCa could obtain promising outcomes in terms of postoperative UC recovery. In addition, surgical strategies encompassing the nerve-sparing technique and the Retzius-sparing procedures, namely, the transvesical or posterior approach, during RARP could independently enable early achievement of postoperative continence.

Comparison of Retzius-Sparing Robot-Assisted Radical Prostatectomy vs. Conventional Robot-Assisted Radical Prostatectomy: An Up-to-Date Meta-Analysis

Background: The Retzius space-sparing robot-assisted radical prostatectomy (RS-RARP) has shown better results in urinary continence, but its efficacy and safety compared to conventional robot-assisted radical prostatectomy (c-RARP) remain controversial.

Material and Methods: A research was conducted in Medline via PubMed, Cochrane Library, EMBASE, and Web of Science up to January 4, 2021, to identify studies comparing RS-RARP to c-RARP. We used RevMan 5.3 and STATA 14.0 for meta-analysis.

Results: A total of 14 studies involving 3,129 participants were included. Meta-analysis showed no significant difference in positive surgical margins (PSMs), but the RS-RARP group had significantly higher PSM rates in the anterior site [odds ratio (OR) = 2.25, 95% CI: 1.22–4.16, P = 0.01]. Postoperative continence in RS-RARP group at 1 month (OR = 5.72, 95% CI: 3.56–9.19, P < 0.01), 3 months (OR = 6.44, 95% CI: 4.50–9.22, P < 0.01), 6 months (OR = 8.68, 95% CI: 4.01–18.82, P < 0.01), and 12 months (OR = 2.37, 95% CI: 1.20–4.70, P = 0.01) was significantly better than that in the c-RARP group. In addition, the RS-RARP group had a shorter console time (mean difference = −16.28, 95% CI: −27.04 to −5.53, P = 0.003) and a lower incidence of hernia (OR = 0.35, 95% CI: 0.19–0.67, P = 0.001). However, there were no significant differences in estimated blood loss, pelvic lymph node dissection rate, postoperative complications, 1-year-biochemical recurrence rate, and postoperative sexual function.

Conclusions: Compared with c-RARP, RS-RARP showed better recovery of continence, shorter console time, and lower incidence of hernia. Although there was no significant difference in overall PSM, we suggest that the surgeon should be more careful if the lesion is in the anterior prostate.

A Combined Technology to Protect the Anatomic Integrity of Distal Urethral Sphincter Complex in Radical Prostatectomy Improves Early Urinary Continence Recovery Without Sacrifice of Oncological Outcomes

Purpose

Our primary aim was to present a combined technique to protect the anatomic integrity of distal urethral sphincter complex (DUSC) during minimally invasive radical prostatectomy (RP) and discuss its impact on urinary continence (UC) recovery. The second aim was to define the learning curve of the combined technique.

Methods

We conducted a non-randomized retrospective study. There were 314 consecutive patients who received RP by the same urologist surgeon with more than 2,000 prior cases in Shanghai Ruijin Hospital between March 2017 and April 2020. Included in this study were 263 patients with clinical T1–T2 stage. We modified a combined RP (Comb-RP) technique including endopelvic fascia no-incising technique, dorsal venous complex (DVC) no-ligation technique, intrafascial dissection technique, and anterior reconstruction technique so as to preserve the anatomic integrity of DUSC. The patients were assigned to two groups: a Comb-RP group and a conventional RP (Conv-RP) group. Continence rates were assessed every 3 months after removal of the catheter. UC was defined as 0 pad per day. Peri-operative variables of the patient including operation time, estimated blood lost (EBL), positive surgical margin (PSM), and postoperative complications were also collected. Scatter-graphs of learning curves were drawn using locally weighted scatterplot smoothing (LOWESS).

Results

RP was accomplished smoothly in all 263 cases. The pad-free UC rates in Conv-RP group and Comb-RP group were 17.3 vs. 27.8% (P = 0.048) at the removal of the catheter, 35.8 vs. 50.0% (P = 0.027) at 1 month, 60.5 vs. 76.1% (P = 0.012) at 3 months, 87.7 vs. 96.5% (P = 0.022) at 6 months, and 94.7 vs. 97.7% (P = 0.343) at 12 months. Kaplan–Meier analysis showed significantly higher and faster continence recovery in the Comb-RP group (mean 4.9 vs. 2.6 months, Log Rank P = 0.001). There was no significant difference in PSM rate between the Comb-RP and Conv-RP group (31.1 vs. 31.2%, P =0.986). The learning curves of peri-operative variables, oncological and functional outcomes achieved the lowest point or plateau at the 20th–60th cases.

Conclusions

The anatomic integrity and intact pelvic floor interplay of DUSC is important for its function. Our combined technique was a safe and feasible technique for improving early UC in RP with no significantly increased PSM rate and no significant difference in long-term UC.

Transvesical Retzius-Sparing Versus Standard Robot-Assisted Radical Prostatectomy: A Retrospective Propensity Score-Adjusted Analysis

Objectives

To estimate the safety and efficiency of transvesical Retzius-sparing robot-assisted radical prostatectomy (T-RARP) compared with standard robot-assisted radical prostatectomy (S-RARP) for localized prostate cancer (PCa).

Materials and Methods

174 patients bearing localized PCa and undergoing T-RARP or S-RARP between October 2017 and January 2020 were retrospectively enrolled in our analysis. All potential baseline confounders were strictly restrained with propensity-score matching (PM) method (1: 1). Within the matched setting, the perioperative and functional outcomes were compared between the T-RARP and S-RARP groups, while the oncological results and functional recovery of the two arms were presented with Kaplan-Meier curves.

Results

Finally, 114 and 60 eligible patients harbouring localized PCa were identified in the S-RARP and T-RARP group, respectively. No significant differences between the two groups were found in all baseline characteristics after PM. Within the matched cohort, no case was converted to open surgery in either group. The T-RARP group was significantly related to a higher mean operative time (p = 0.001) and shorter median hospital stay length (p < 0.001). There were not significant differences in the median estimated blood loss and specimen Gleason score between the two arms. The proportions of transfusion, pT3a disease, postoperative complication, and positive surgical margin in the T-RARP group were also comparable to that in the S-RARP group. The mean prostate-specific antigen and median erectile functional scores did not differ significantly between the two groups at postoperative 3 months and last follow-up. T-RARP vs. S-RARP had significantly improved urinary continence (UC) rates at the removal of catheter (p < 0.001) and postoperative 3 months (p < 0.001), but the significant difference between the two groups in UC recovery disappeared at last follow-up (p = 0.119). No significant difference in biochemical recurrence-free survival was observed following the two surgeries (p = 0.727).

Conclusions

T-RARP by experienced hands was feasible for selected patients with clinically localized PCa, yielding significantly improved early return to UC and similar erectile functional preservation without compromising oncological control when compared with the standard approach.

Retzius-sparing versus standard robot-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

OBJECTIVES

To assess the effects of Retzius-sparing (RS) robotic-assisted laparoscopic prostatectomy (RALP) compared to standard RALP for the treatment of clinically localized prostate cancer.

METHODS

We performed a systematic search of multiple databases and the grey literature with no restrictions on the language of publication or publication status, up until June 2020. We included randomized controlled trials (RCTs) comparing RS-RALP with standard RALP. We performed a meta-analysis using a random-effect model. The quality of evidence was assessed on an outcome basis according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Our search identified six records of five unique RCTs, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. The mean age of participants was 64.6 years and the mean prostate-specific antigen level was 6.9 ng/mL. Approximately 54.2% of participants had cT1c disease, 38.6% had cT2a-b disease, and 7.1% had cT2c disease. RS-RALP probably improves continence within 1 week after catheter removal (risk ratio [RR] 1.74, 95% confidence interval [CI] 1.41-2.14; I² = 0%; studies = 4; participants = 410; moderate-certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS-RALP may increase continence at 3 months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06-1.68; I² = 86%; studies = 5; participants = 526; low-certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS-RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47-4.17; studies = 2; participants = 230; very low-certainty evidence).

CONCLUSIONS

The findings of this review indicate that RS-RALP may result in better continence outcomes than standard RALP up to 6 months after surgery. Continence outcomes at 12 months may be similar. The disadvantages of RS-RALP may be higher positive surgical margin rates. We are very uncertain about the effect on biochemical recurrence-free survival and potency outcomes. Longer-term oncological and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade-offs and the limitations of the evidence with their patients when considering this approach.

Early urinary continence recovery following retzius-sparing robotic-assistant radical prostatectomy with suprapubic catheter: a short-term follow-up outcome

OBJECTIVE

To evaluate the recovery of early urinary continence in patients with prostate cancer using a suprapubic catheter during Retzius-sparing robotic-assistant laparoscopic prostatectomy.

PATIENTS AND METHODS

From January 2018 to January 2019, 223 patients diagnosed with prostate cancer who underwent Retzius-sparing robotic-assistant laparoscopic prostatectomy in Diakonie Klinikum Stuttgart were involved in our study. From January 2018 to June 2018, patients (112 cases) only had an indwelling urinary catheter during Retzius-sparing robotic-assistant laparoscopic prostatectomy, while from July 2018 to January 2019, patients (111 cases) were offered an extra suprapubic catheter during operation. The recovery of early urinary continence of patients was mainly investigated one month later.

RESULTS

The overall early urinary continence rate was 81.61%. Patients with suprapubic catheter had better urinary control results, compared to patients with only indwelling urinary catheter (87.39% vs 75.89%, p = 0.027). In addition, International Prostate Symptom Score and irritative subscore in patients with good urinary control were significantly lower than that in patients with urinary incontinence. Suprapubic catheter insertion (OR 0.395; 95% CI 0.190-0.821) and advanced pathological tumor stage (T3a-T4) (OR 2.061; 95% CI 1.008-4.217) were two independent influencing factors for early urinary continence recovery in patients who underwent Retzius-sparing robotic-assistant laparoscopic prostatectomy through multivariate logistic regression analysis.

CONCLUSION

Suprapubic catheter insertion may be helpful for early urinary continence recovery in patients with Retzius-sparing Robotic-assistant laparoscopic prostatectomy. Advanced pathological tumor stage (T3a-T4) before Retzius-sparing robotic-assistant laparoscopic prostatectomy might be associated with poor urinary control.

Simple suturing of the bladder neck muscle layer at the vesicourethral anastomosis site to the dorsal vein complex during anterior reconstruction led to a better postoperative urinary continence after robot-assisted laparoscopic prostatectomy

OBJECTIVES

To elucidate whether a modified technique for anterior reconstruction could improve urinary continence after robot-assisted laparoscopic radical prostatectomy (RALP).

METHODS

Among 325 consecutive patients who underwent RALP at our hospital, 297 patients were included in this retrospective study, who had complete records including the status of postoperative urinary continence. Among these 297 patients, 194 underwent anterior reconstruction by suturing the lateral bladder wall to the arcus tendineus of the pectineal fascia without fixation of the vesicourethral anastomosis site to the dorsal vein complex (DVC) (lateral-suture group). In the remaining 103 patients, simple suturing of the bladder neck muscle layer at the vesicourethral anastomosis site with DVC to immobilize the vesicourethral anastomosis site (immobilized group) was performed. Those who did not required a pad was defined as continent.

RESULTS

Operative and console times were significantly shorter in the immobilized group (242 vs. 268 min; p = 0.03, and 174 vs. 203 min; p = 0.009, respectively). Although there was no significant difference between the groups regarding the recovery of urinary continence within 3 months after RALP (21 vs. 22% at 1 month; p = 0.77, and 54 vs. 60% at 3 months; p = 0.33, respectively), more patients achieved urinary continence in the immobilized group than lateral-suture group after 6 months (71 vs. 83% at 6 months; p = 0.03 and 82 vs. 96% at 12 months; p = 0.001, respectively).

CONCLUSIONS

Simple suture of the bladder neck muscle layer at the vesicourethral anastomosis site to DVC led to a better urinary continence status 6 months or later after RALP.

How to Prevent and Manage Post-Prostatectomy Incontinence: A Review

PURPOSE

To provide an overview of the currently available evidence relating to the prevention and management strategies of urinary incontinence (UI) after radical prostatectomy (RP).

MATERIALS AND METHODS

A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning post-RP UI. The search strategy included these words: urinary continence; urinary continence recovery; urinary incontinence; radical prostatectomy; and prostate cancer.

RESULTS

Post-RP UI still represents a challenging issue for both urologic patients and clinicians. A complete preoperative assessment of the risk factors associated with post-RP UI aids both in counseling those patients with a higher estimated likelihood of postoperative UI and in identifying those who would probably benefit from preventive strategies in the preoperative and in the intraoperative settings. Over the last decades different surgical strategies based on either the "preservation" or the "reconstruction" of the anatomical elements responsible for urinary continence (UC) led to an overall improvement of postoperative functional outcomes. Finally, several therapeutic strategies should be evaluated for the postoperative UI management. Artificial urinary sphincter implantation represents the gold standard for treatment, notwithstanding its wide adoption is limited due to high costs and significant risk of surgical revision. In this context, male sling positioning seems the most promising strategy, in particular in mild and moderate post-RP UI.

CONCLUSIONS

To enhance the likelihood of obtaining an optimal UC recovery after RP, it is here strongly suggested to intervene throughout the overall clinical management process thus including the pre-, intra- and postoperative settings.

[Pre-, intra- and postoperative predictors of functional outcome following radical prostatectomy]

Maintaining continence and erectile function is crucial for quality of life after radical prostatectomy. This review provides an overview of available evidence concerning preoperative risk stratification as well as intra- and postoperative factors determining functional outcomes after radical prostatectomy.Current data indicate that patient factors including age, baseline erectile function, prostate size, body-mass index and comorbidity status are valid predictors of functional outcome after prostatectomy. While surgical methods do not seem to have any influence, intraoperative procedures like nerve-sparing techniques, the extent of pelvic floor reconstruction as well as surgeons' experience have a significant impact on postoperative potency and continence. Rehabilitation consisting of pelvic floor training and use of PDE-5 inhibitors also contributes significantly to the recovery of erectile function and urinary continence.In summary, numerous adjustments of treatment can help to improve functional results and thus the quality of life after prostatectomy. A careful preoperative selection of suitable patients by urologists and integration of knowledge of periprostatic nerve and fascial structures into the surgical procedure are decisive factors.

Retzius-sparing robot-assisted radical prostatectomy: early learning curve experience in three continents

OBJECTIVE

To assess the effect of surgical experience on peri-operative, functional and oncological outcomes during the first 50 Retzius-sparing robot-assisted radical prostatectomy (RsRARP) cases performed by surgeons naïve to this novel approach.

MATERIALS AND METHODS

We retrospectively evaluated the initial cases operated by 14 surgeons in 12 different international centres. Pre-, peri- and postoperative features of the first 50 patients operated by each surgeon in all the participating centres were collected. The effect of surgical experience on peri-operative, functional and oncological outcomes was firstly evaluated after stratification by level of surgical experience (initial [≤25 cases] and expert [>25 cases]) and after using locally weighted scatterplot smoothing to graphically explore the relationship between surgical experience and the outcomes of interest.

RESULTS

We evaluated 626 patients. The median follow-up was 13 months in the initial group and 9 months in the expert group (P = 0.002). Preoperative features overlapped between the two groups. Shorter console time (140 vs 120 min; P = 0.001) and a trend towards lower complications rates (13 vs 5.5%; P = 0.038) were observed in the expert group. The relationship between surgical experience and console time, immediate urinary continence recovery and Clavien-Dindo grade ≥2 complications was linear, without reaching a plateau, after 50 cases. Conversely, a non-linear relationship was observed between surgical experience and positive surgical margins (PSMs).

CONCLUSIONS

In this first report of a multicentre experience of RsRARP during the learning curve, we found that console time, immediate urinary continence recovery and postoperative complications are optimal from the beginning and further quickly improve during the learning process, while PSM rates did not clearly improve over the first 50 cases.

Retzius-sparing versus standard robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

BACKGROUND

Robotic-assisted laparoscopic prostatectomy (RALP) is widely used to surgically treat clinically localized prostate cancer. It is typically performed using an approach (standard RALP) that mimics open retropubic prostatectomy by dissecting the so-called space of Retzius anterior to the bladder. An alternative, Retzius-sparing (or posterior approach) RALP (RS-RALP) has been described, which is reported to have better continence outcomes but may be associated with a higher risk of incomplete resection and positive surgical margins (PSM).

OBJECTIVES

To assess the effects of RS-RALP compared to standard RALP for the treatment of clinically localized prostate cancer.

SEARCH METHODS

We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings, up to June 2020. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included trials where participants were randomized to RS-RALP or standard RALP for clinically localized prostate cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified and abstracted data from the included studies. Primary outcomes were: urinary continence recovery within one week after catheter removal, at three months after surgery, and serious adverse events. Secondary outcomes were: urinary continence recovery six and 12 months after surgery, potency recovery 12 months after surgery, positive surgical margins (PSM), biochemical recurrence-free survival (BCRFS), and urinary and sexual function quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

Our search identified six records of five unique randomized controlled trials, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. Mean age of participants was 64.6 years and mean prostate-specific antigen was 6.9 ng/mL. About 54.2% of participants had cT1c disease, 38.6% had cT2a-b disease, and 7.1 % had cT2c disease. Primary outcomes RS-RALP probably improves continence within one week after catheter removal (risk ratio (RR) 1.74, 95% confidence interval (CI) 1.41 to 2.14; I² = 0%; studies = 4; participants = 410; moderate-certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS-RALP may increase continence at three months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06 to 1.68; I² = 86%; studies = 5; participants = 526; low-certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS-RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47 to 4.17; studies = 2; participants = 230; very low-certainty evidence). Secondary outcomes There is probably little to no difference in continence recovery at 12 months after surgery (RR 1.01, 95% CI 0.97 to 1.04; I² = 0%; studies = 2; participants = 222; moderate-certainty evidence). Assuming 982 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 10 more men per 1000 (29 fewer to 39 more) reporting continence recovery.  We are very uncertain about the effect of RS-RALP on potency recovery 12 months after surgery (RR 0.98, 95% CI 0.54 to 1.80; studies = 1; participants = 55; very low-certainty evidence).  RS-RALP may increase PSMs (RR 1.95, 95% CI 1.19 to 3.20; I² = 0%; studies = 3; participants = 308; low-certainty evidence) indicating a higher risk for prostate cancer recurrence. Assuming 129 per 1000 men undergoing standard RALP have positive margins, this corresponds to 123 more men per 1000 (25 more to 284 more) with PSMs. We are very uncertain about the effect of RS-RALP on BCRFS compared to standard RALP (hazard ratio (HR) 0.45, 95% CI 0.13 to 1.60; I² = 32%; studies = 2; participants = 218; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Findings of this review indicate that RS-RALP may result in better continence outcomes than standard RALP up to six months after surgery. Continence outcomes at 12 months may be similar. Downsides of RS-RALP may be higher positive margin rates. We are very uncertain about the effect on BCRFS and potency outcomes. Longer-term oncologic and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade-offs and the limitations of the evidence with their patients when considering this approach.

Retzius-sparing robot-assisted radical prostatectomy improves early recovery of urinary continence: a randomized, controlled, single-blind trial with a 1-year follow-up

OBJECTIVE

To evaluate the impact of Retzius-sparing robot-assisted radical prostatectomy (posterior approach) on early recovery of urinary continence (UC) compared to the conventional approach (anterior approach) for the treatment of clinically localized prostate cancer (PCa).

METHODS

A total of 110 consecutive patients with clinically localized PCa were prospectively randomized in a 1:1 ratio to an anterior group (n = 55) or a posterior group (n = 55). The primary outcome was immediate UC, defined as freedom from any pad use within 1 week after removal of the urinary catheter. The UC rate following surgery was also calculated with Kaplan-Meier curves, and the log-rank test was used for statistical comparison. Intra-operative outcomes, pathological data and oncological outcomes, including positive surgical margin (PSM) status and biochemical recurrence-free survival (BCRFS), were also compared between the two groups. The comparison of the two approaches was also analysed in subgroups after risk stratification.

RESULTS

Of the patients who underwent the posterior approach, 69.1% achieved immediate UC compared with 30.9% in the anterior group (relative risk 2.24, 95% confidence interval [CI] 1.48-3.51; P = 0.000). The relative Kaplan-Meier curves for UC during the 12-month follow-up revealed statistically better recovery in the posterior group when compared with the anterior group (hazard ratio [HR] 1.51, 95% CI 1.01-2.24; log-rank P = 0.007). No statistically significant differences were observed between the groups regarding complications (P = 0.399), PSM status (P = 0.225) or BCRFS (HR 4.80, 95% CI 0.97-23.78; log-rank P = 0.111). In sub-analyses, no significant difference between the two approaches with regard to UC recovery in patients with high-risk PCa was observed (HR 1.26, 95% CI 0.63-2.51; log-rank P = 0.415).

CONCLUSIONS

The Retzius-sparing approach significantly improved early recovery of UC compared to the conventional approach. Further prospective studies are needed to confirm the benefits of the Retzius-sparing approach for clinically localized PCa, especially for high-risk cases.

Tumour location determined by preoperative MRI is an independent predictor for positive surgical margin status after Retzius-sparing robot-assisted radical prostatectomy

OBJECTIVE

To investigate the influence of tumour location zone on positive surgical margin (PSM) status after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

MATERIALS AND METHODS

A total of 203 consecutive patients with prostate cancer (PCa) who underwent RS-RARP at our centre were divided into three cohorts according to the tumour zonal origin described on preoperative magnetic resonance imaging (MRI). Clinical and pathological characteristics were compared among the three groups. The associations of clinicopathological variables with PSM status after RS-RARP were also evaluated.

RESULTS

The rates of PSM in patients with transition zone (TZ) and mixed origin tumours were significantly higher than in patients with peripheral zone tumours (P < 0.01). Of the PSMs in patients with TZ and mixed origin cancers, 42.0% and 40.9%, respectively, were located at the anterior part of the gland. On multivariate analysis, presence of a TZ tumour was significantly associated with a higher PSM rate after RS-RARP (P < 0.01). Sub-analysis showed that high-risk patients with TZ tumours had a higher risk of PSM after RS-RARP (P < 0.01).

CONCLUSION

Presence of a TZ tumour is an independent risk factor for PSMs after RS-RARP. Preoperative identification of TZ tumours might aid surgical planning for the Retzius-sparing technique, especially in high-risk patients.

Techniques of robotic radical prostatectomy for the management of prostate cancer: which one, when and why

The advent of robotic assistance in surgery has completely revolutionized the surgical management of prostate cancer. It enables precise dissection and reconstruction in order to maximize oncological and functional outcomes. In many parts of the world, robot-assisted laparoscopic radical prostatectomy has evolved to become the surgical standard of care for localized disease, including in appropriately selected patients with high risk prostate cancer. Its role has also been expanded to encompass cytoreductive prostatectomy and salvage radical prostatectomy. As surgical expertise grows with robotic assistance, several novel and non-radical approaches have been developed to further mitigate treatment side effects. Patient characteristics, disease factors and surgeon expertise are important metrics for consideration when selecting the most appropriate technique for any given patient.

Retzius-sparing robot-assisted laparoscopic radical prostatectomy: functional and early oncologic results in aggressive and locally advanced prostate cancer

Background

Retzius-sparing robot-assisted laparoscopic radical prostatectomy (rsRARP) allows entire prostatectomy procedure via the pouch of Douglas. In low- and intermediate-risk prostate cancer (PCa) there is level 1 evidence that the Retzius-sparing approach impacts early continence recovery. Since specific data on aggressive and locally advanced cancer is lacking and avoiding rsRARP is presently suggested, we investigated urinary and sexual recovery, perioperative complications and early oncologic outcomes after rsRARP in this particular cohort.

Methods

Prospectively collected data of 50 consecutive men (median age 66 years) with high-risk PCa who underwent rsRARP in a single institution was analysed retrospectively. The follow-up for all patients was 12 months after surgery.

Results

3 vs. 12 months after surgery, 82% vs. 98% of men used no pad or one safety pad and 50% vs. 72% used no pad. 89% of patients did not observe a decline of continence if postoperative radiotherapy was carried out.

Considering the 17 preoperatively potent patients who underwent bi- or unilateral nerve-sparing surgery, 41% reported their first sexual intercourse within 1 year after rsRARP.

84% of patients had ≥pT3a disease and 42% positive surgical margins. A lymphadenectomy was done in 94% of patients with a median lymph node removal of 15 and lymph node metastasis in 13%.

34% underwent adjuvant radiotherapy and 22% adjuvant androgen deprivation therapy (ADT). 1-year recurrence-free survival was 96%, including 25% of patients on adjuvant or salvage ADT.

Conclusions

RsRARP in high-risk PCa is feasible and results in excellent continence rates, even after postoperative radiotherapy. The potency rates are promising but need further clarification in larger cohorts. Reliable oncologic outcomes require longterm follow-up and are awaited.