Retzius-sparing Robotic Radical Prostatectomy for Surgeons in the Learning Curve: A Propensity Score-matching Analysis

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.

Surgical and functional outcomes of Retzius-sparing robotic-assisted radical prostatectomy versus conventional robotic-assisted radical prostatectomy in patients with biopsy-confirmed prostate cancer. Are outcomes worth it? Systematic review and meta-analysis

BACKGROUND

Radical prostatectomy is the standard of care for prostate cancer. Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is being widely adopted due to positive functional outcomes compared to conventional robotic-assisted radical prostatectomy (c-RARP). Concerns regarding potency, oncological outcomes, and learning curve are still a matter of debate.

METHODS

Following Preferred Instrument for Systematic Reviews and Meta-Analysis guidelines and PROSPERO registration CRD42023398724, a systematic review was performed in February 2023 on RS-RARP compared to conventional c-RARP. Outcomes of interest were continence recovery, potency, positive surgical margins (PSM), biochemical recurrence (BCR), estimated blood loss (EBL), length of stay (LOS), operation time and complications. Data were analyzed using R version 4.2.2.

RESULTS

A total of 17 studies were included, totaling 2751 patients, out of which 1221 underwent RS-RARP and 1530 underwent c-RARP. Continence was analyzed using two definitions: zero pad and one safety pad. Cumulative analysis showed with both definitions statistical difference in terms of continence recovery at 1 month (0 pad odds ratio [OR] = 4.57; 95% confidence interval [CI] = [1.32-15.77]; Safety pad OR = 13.19; 95% CI = [8.92-19.49]), as well as at 3 months (0 pad OR, 2.93; 95% CI = [1.57-5.46]; Safety pad OR = 5.31; 95% CI = [1.33-21.13]). Continence recovery at 12 months was higher in the one safety pad group after RS-RARP (OR = 4.37; 95% CI = [1.97-9.73]). The meta-analysis revealed that overall PSM rates without pathologic stage classification were not different following RS-RARP (OR = 1.13; 95% CI = [0.96-1.33]. Analysis according to the tumor stage revealed PSM rates in pT2 and pT3 tumors are not different following RS-RARP compared to c-RARP (OR = 1.46; 95% CI = [0.84-2.55]) and (OR = 1.41; 95% CI = [0.93-2.13]), respectively. No difference in potency at 12 months (OR = 0.98; 95% CI = [0.69-1.41], BCR at 12 months (OR = 0.99; 95% CI = [0.46-2.16]), EBL (standardized mean difference [SMD] = -0.01; 95% CI = [-0.31 to 0.29]), LOS (SMD = -0.01; 95% CI = [-0.48 to 0.45]), operation time (SMD = -0.14; 95% CI = [-0.41 to 0.12]) or complications (OR = 0.9; 95% CI = [0.62-1.29]) were observed.

CONCLUSIONS

Our analysis suggests that RS-RARP is safe and feasible. Faster continence recovery rate is seen after RS-RARP. Potency outcomes appear to be similar. PSM rates are not different following RS-RARP regardless of pathologic stage. Further quality studies are needed to confirm these findings.

Transition from standard robotic prostatectomy to Retzius-sparing prostatectomy: feasibility and early outcomes

BACKGROUND AND OBJECTIVE

Retzius-sparing robotic-assisted radical prostatectomy (rsRARP) has gained popularity due to superior early continence outcomes compared to standard robotic prostatectomy (sRARP). We evaluate the results of a single surgeon who transitioned from sRARP to rsRARP and compare oncologic and functional outcomes.

METHODS

We retrospectively reviewed all prostatectomies performed by a single surgeon between June 2018 and October 2020. Perioperative, oncologic, and functional data were collected and analyzed. Patients who underwent sRARP were compared with those who underwent rsRARP.

RESULTS

Both groups contained 37 consecutive patients each. Preoperative patient characteristics and biopsy results were similar between the two groups. Perioperative outcomes were significant for longer operative room time and higher proportion of T3 tumors in the rsRARP group. Thirty-day complication and readmission rates were similar between groups. There was no difference in early oncologic outcomes, including positive surgical margin rate, biochemical recurrence, and need for adjuvant or salvage treatments. The time to urinary continence and immediate continence rate was superior in the rsRARP group.

CONCLUSIONS

The Retzius-sparing approach can be safely adopted by surgeons experienced in sRARP without compromising early oncologic outcomes and with the benefit of improved early continence recovery.

Vesicoprostatic muscle reconstruction: a step further for immediate and early urinary continence

OBJECTIVES

The vesicoprostatic muscle (VPM) is a longitudinal smooth muscle that originates from the trigone of the bladder or the opening of the ureter and is involved in urination as part of the detrusor apron. We explored the effect of VPM reconstruction on immediate and early recovery of urinary continence in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP).

PATIENTS AND METHODS

A total of 523 patients with localized prostate cancer were enrolled from June 2018 to June 2020. All patients were diagnosed in our department based on magnetic resonance imaging and pathological findings on prostate biopsy. After 1:1 propensity score matching, 105 patient pairs were matched. The study was approved by our institutional review board and all surgeries were performed by three experienced high-volume surgeons. Demographic data, total operation time, pathological outcomes, the urinary continence rates of the two groups at different times after RALP, and factors influencing postoperative urinary continence after RALP were recorded. Student's t test was used to compare continuous variables and the Pearson χ² test to compare categorical variables. Logistic regression analysis was used to identify factors affecting immediate and early postoperative urinary control.

RESULTS

VPM reconstruction promoted immediate and early recovery of urinary continence (immediate continence, 66.67 vs. 40.00%, P = 0.000; 3-month continence, 80.95 vs. 64.76%, P = 0.008).

CONCLUSIONS

VPM reconstruction improved immediate and early urinary continence in patients who underwent RALP.

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.

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.

A propensity score-matching study on retzius-sparing robotic-assisted radical prostatectomy: Evidence of continence advantage in the early learning curve

OBJECTIVES

To investigate the outcome of retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) compared with conventional RARP in the early learning curve.

METHODS

Consecutive patients with prostate cancer who underwent RS-RARP were included to compare against conventional RARP of the same period. Propensity-score matching was performed based on age, prostate size, nerve-sparing approach, and final pathological risk categories. All patients were re-admitted to undergo trial without Foley catheter from post-operative day 7-10. Clinical follow-up was performed with monitoring of continence (day 0, 3 months, and the latest continence during the study period) and surveillance of PSA level.

RESULTS

Between July 2017 and August 2019, 24 consecutive patients received RS-RARP in our centre. Propensity score matching was performed with the best matched 24 controls receiving conventional RARP. Overall median follow-up duration was 15.5 months. A majority of the patients belonged to the intermediate-risk group, with most of them harbouring pT2 disease (RS-RARP: 87.5%; conventional RARP: 79.2%). More patients in RS-RARP group achieved day-0 continence (33.3% vs 0%, p = 0.002) and 3-month continence (66.7% vs 12.5%, p = 0.001). During the whole study period, more RS-RARP achieved continence with 0 pad (91.7% vs 66.7%, p = 0.033). The mean months to continence is shorter in RS-RARP group (4.0 months vs 13.6 months, p = 0.002). No statistically significant differences between the two groups with respect to surgical margins, post-operative PSA detection, and the use of adjuvant radiotherapy.

CONCLUSIONS

RS-RARP showed better continence rates when compared to conventional RARP even during the learning curve phase.

The impact of transition from conventional robot-assisted radical prostatectomy to retzius sparing robot-assisted radical prostatectomy: A retrospective multivariate analysis

Introduction:

To assess the outcomes of Retzius sparing robotic-assisted radical prostatectomy (RS-RARP) in comparison with the conventional RARP.

Materials and Methods:

A retrospective analysis of 320 cases of RARP, performed from 2014 April to 2019 April, was performed. The predictor variables included age, body mass index, clinical stage, prostate-specific antigen, Gleason score category in biopsy, D'Amico risk category, presence of the median lobe, prior transurethral resection of the prostate, and the ability to perform the RS-RARP. The outcome variables included console time, blood loss, blood transfusion, nerve sparing, bladder neck sparing, positive surgical margins (PSM), number and the site of PSMs, extracapsular invasion, seminal vesicle involvement, complications, continence, erectile function, biochemical recurrence, and adjuvant treatment. Regression analysis was performed using the linear regression for the continuous variables and binary logistic regression for the categorical variables with two levels.

Results:

Three hundred and twenty patients underwent radical prostatectomy from 2014 April to 2019 April. We started the RS-RARP program in December 2016. Twenty-three patients who did not meet the inclusion criteria were excluded and a total of 297 patients were studied. Multivariate analysis demonstrated that RS-RARP was a strong positive independent predictor for continence recovery at 3 months, 6 months, and 12 months. RS-RARP was an independent predictor of reduced console time and increased probability of bladder neck sparing. RS-RARP was also independently associated with increased PSM in the posterolateral, anterolateral, and the apical regions.

Conclusion:

RS-RARP has better continence rates up to 12 months compared with the conventional approach, but is associated with increased PSM at certain locations.

Retzius-Sparing Robot-Assisted Robotic Prostatectomy: Past, Present, and Future

Radical prostatectomy has undergone many adaptations since its inception, including the Retzius-sparing robotic-assisted radical prostatectomy approach. In this article, we review the origins of radical prostatectomy, the theoretic basis for Retzius-sparing robotic-assisted radical prostatectomy, and outline the key steps of the procedure. To date, there have been 9 studies comparing the outcomes of Retzius-sparing robotic-assisted radical prostatectomy with standard robotic-assisted radical prostatectomy, which have demonstrated improved continence outcomes for Retzius sparing robotic assisted radical prostatectomy within the first year and equivalent oncologic efficacy out to 18 months. Further research is needed to evaluate sexual function outcomes as well as long-term oncologic outcomes.

Impact of Retzius-sparing Versus Standard Robotic-assisted Radical Prostatectomy on Penile Shortening, Peyronie's Disease, and Inguinal Hernia Sequelae

Background

Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) has improved urinary function compared with standard robotic-assisted radical prostatectomy (S-RARP). As RS-RARP spares the dorsal vascular complex, pelvic fascia, and anterior abdominal fascia, it may also lower the incidence of “neglected” postprostatectomy sequelae such as penile shortening, Peyronie’s disease, and inguinal hernias.

Objective

To determine whether there are patient-perceived differences in penile shortening, Peyronie’s disease, and inguinal hernia rates among men undergoing RS-RARP versus S-RARP.

Design, setting, and participants

Researchers uninvolved in clinical care and blinded to surgical approach surveyed 60 RS-RARP versus 57 S-RARP men with validated patient-reported items to assess penile shortening, Peyronie’s disease, and inguinal hernia sequelae following surgery.

Intervention

RS-RARP versus S-RARP.

Outcome measurements and statistical analysis

Univariate differences between the two cohorts were analyzed using Student t test. Logistic regression was used to analyze variables associated with postoperative penile shortening. Cox proportional hazards models were used to assess the risk of developing Peyronie’s disease and inguinal hernia postoperatively.

Results and limitations

RS-RARP was associated with less patient-reported penile shortening (41.7% vs 64.9%, p = 0.012), Peyronie’s disease (0% vs 8.7%, p = 0.020), and inguinal hernia (0.0% vs 13.0%, p = 0.004). In adjusted analyses, RS-RARP (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09–0.63, p = 0.004) was associated with lower odds of penile shortening, while a higher body mass index was associated with increased odds of penile shortening (OR 1.13, 95% CI 1.01–1.26, p = 0.037). RS-RARP was not associated with a decreased risk of Peyronie’s disease on Cox proportion hazard model; however, these models are limited due to a limited number of events in our cohort. Limitations include retrospective design, patient-reported outcomes, and small cohorts.

Conclusions

RS-RARP is associated with less patient-reported penile shortening and may decrease the risk of Peyronie’s disease and postoperative inguinal hernia development. These new findings add to research, showing improved urinary continence and quality of life following RS-RARP; however, a prospective study is needed to validate these findings.

Patient summary

Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment, which has shown improved postoperative urinary control compared with the standard technique, likely due to preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia.