Will Retzius-sparing Prostatectomy Be the Future of Prostate Cancer Surgery?

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.

Efficacy of the transvesical approach for robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision for the treatment of localized prostate cancer

Objective

This study explores the feasibility and safety of the transvesical approach of robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision.

Methods

From June 2017 to May 2021, 41 patients aged from 51 to 69 years underwent the transvesical approach of robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision (L-RALP). The prostate volume was 22.0-57.8 ml (mean: 36.3 ± 11.1 ml), with a preoperative PSA value of 3.7-12.3 ng/ml (mean: 7.3 ± 1.2 ng/mL). All preoperative Gleason scores were less than or equal to 7 points, and the preoperative TNM stage ranged from T2a to T2b. All patients were diagnosed with prostate cancer by preoperative prostate biopsy or postoperative pathological specimens after prostatectomy. The operation, blood loss, hospitalization, erectile function and postoperative urinary continence were recorded. Patients were defined as continent if they answered "zero pad" per day, and they were invited to fill out The International Consultation on Incontinence Questionnaire (ICI-Q-SF) after the catheter removal at 4 and 24 weeks.

Results

All the operations were completed by robotic-assisted radical prostatectomy without transition to open surgery. The surgery time was 105-131 min (mean: 111.3 ± 14.9 min), with an estimated blood loss of 50-220 ml (mean: 95.5 ± 27.3 ml). The postoperative hospital stay was 3-8 days (mean: 5.2 ± 1.7 days), and the postoperative catheter was removed after 5-7 days (mean: 6.3 ± 1.1 days). After 24 weeks of follow-up, 35 cases (85.4%, 35/41) obtained immediate urinary continence after the catheter removal in 24h. All patients had regained continence 24 weeks postoperatively (100%, 41/41).

Conclusion

The transvesical approach of robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision is a safe and effective surgical technique, beneficial for early continence recovery and erectile function, and it is also suitable for prostate cancer patients after prostate enucleation.

Salvage Retzius sparing robotic assisted radical prostatectomy: the first brazilian experience

Introduction:

Salvage Radical Prostatectomy after radiation therapy is challenging and associated with high rates of serious complications (1, 2). The novel Retzius-Sparing RARP (RS-RARP) approach has shown excellent continence outcomes (3, 4).

Purpose:

To describe step-by-step our Salvage Retzius-Sparing RARP (sRS-RARP) operative technique and report feasibility, safety and the preliminary oncological and continence outcomes in the post-radiation scenario.

Materials and Methods:

Twelve males presenting local prostate cancer recurrence after radiotherapy that underwent sRS-RARP were included. All patients performed preoperative multiparametric MRI and PSMA-PET. Surgical technique: 7cm peritoneum opening at Douglas pouch, Recto-prostatic space development, Seminal vesicles and vas deferens isolation and section, Extra-fascial dissection through peri-prostatic fat, Neurovascular bundle control, Bladder neck total preservation and opening, Anterior dissection at Santorini plexus plane, Apex dissection with urethra preservation and section, Prostate release, Vesicouretral modified Van Velthoveen anastomosis, Rocco Stitch, Oncological and continence outcomes reported with minimum 1-year follow-up.

Results:

Ten patients had previously received external beam radiation (EBR) whereas two received previous brachytherapy plus EBR. At 1, 3 and 12 months after surgery, 25%, 75% and 91.6% of the men used one safety pad or less, respectively. No major complications or blood transfusions were reported. Final pathology reported pT2b 41.6%, pT2c 33.3% and pT3a 25%, positive surgical margins 25%, positive lymph nodes were not found, biochemical recurrence 16.6%.

Conclusion:

Salvage Retzius-Sparing Robotic Assisted Radical Prostatectomy approach appears to be technically feasible and oncologically safe with potential to provide better continence outcomes.

Retzius-sparing robot-assisted radical prostatectomy: Perioperative and immediate continence outcomes of an initial series

OBJECTIVE

The objective of this work is to present initial perioperative, immediate continence and oncological results in a series of 25 prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy.

MATERIAL AND METHODS

We retrospectively analyzed a series of 25 patients treated with Retzius-sparing robot-assisted radical prostatectomy for cT1-T2b prostate cancer between 2018-2019. The 5 stages of surgery are described. We make a descriptive statistic of our initial series and its outcomes in terms of immediate continence, defined as the use of 0 pad/diapers or 1 safety pad/diaper every 24 hours, one week after catheter removal.

RESULTS

Median follow-up, 6 months (3-18). Median PSA, 6.1 ng/ml (4-14.3). All surgeries were performed through a posterior intrafascial approach, and bilateral nerve-sparing was carried out in 84% of the cases. Affected surgical margins were present in 28%, being the apex the most frequent site of affectation. Surgical complications: 1 (4%) patient required transfusion of blood products in the immediate postoperative period. Mean hospital stay was 48 hours. Functional outcomes: 80% of the patients present immediate continence. 80% of continent patients do not require the use of any safety pads/diapers. Oncological outcomes: 84% are free of biochemical-progression in a median follow-up of 6 months.

CONCLUSIONS

Initial functional results in terms of immediate continence are very satisfactory in patients who have undergone Retzius-sparing robot-assisted radical prostatectomy without negative impact on prognosis.

Preservation of continence in radical prostatectomy patients: a laparoscopic surgeon's perspective

Introduction

Preserving continence in patients who underwent radical prostatectomy is of utmost importance. Therefore, modification of surgical technique that would contribute to the regaining of continence with a shortest possible delay after the procedure and adequate evaluation of chances of continence recovery should be considered.

Material and methods

A PubMed database search was performed to review the current literature concerning the physiology and anatomy of sphincter mechanisms, perioperative risk factors, the effects of surgical techniques on post-prostatectomy continence and post-operative management.

Results

Modifications of surgical approach with an aim to minimize damage to the sphincter complex, maintenance of maximal urethral length to enable safe anastomosis, and the reconstruction of the urethral support system appears necessary. The patient should also be informed about the chances of regaining continence after surgery.

Conclusions

There is a need to develop a predictive model to stratify patients according to risk of incontinence and implement adequate action to minimize those risks including preoperative pelvic floor muscle training and/or surgical technique modification.

Functional Recovery, Oncologic Outcomes and Postoperative Complications after Robot-Assisted Radical Prostatectomy: An Evidence-Based Analysis Comparing the Retzius Sparing and Standard Approaches

PURPOSE

We report a 1-year update of functional urinary and sexual recovery, oncologic outcomes and postoperative complications in patients who completed a randomized controlled trial comparing posterior (Retzius sparing) with anterior robot-assisted radical prostatectomy.

MATERIALS AND METHODS

A total of 120 patients with clinically low-intermediate risk prostate cancer were randomized to undergo robot-assisted radical prostatectomy via the posterior and anterior approach in 60 each. Surgery was performed by a single surgical team at an academic institution. An independent third party ascertained urinary and sexual function outcomes preoperatively, and 3, 6 and 12 months after surgery. Oncologic outcomes consisted of positive surgical margins and biochemical recurrence-free survival. Biochemical recurrence was defined as 2 postoperative prostate specific antigen values of 0.2 ng/ml or greater.

RESULTS

Median age of the cohort was 61 years and median followup was 12 months. At 12 months in the anterior vs posterior prostatectomy groups there were no statistically significant differences in the urinary continence rate (0 to 1 security pad per day in 93.3% vs 98.3%, p = 0.09), 24-hour pad weight (median 12 vs 7.5 gm, p = 0.3), erection sufficient for intercourse (69.2% vs 86.5%) or postoperative Sexual Health Inventory for Men score 17 or greater (44.6% vs 44.1%). In the posterior vs anterior prostatectomy groups a nonfocal positive surgical margin was found in 11.7% vs 8.3%, biochemical recurrence-free survival probability was 0.84 vs 0.93 and postoperative complications developed in 18.3% vs 11.7%.

CONCLUSIONS

Among patients with clinically low-intermediate risk prostate cancer randomized to anterior (Menon) or posterior (Bocciardi) approach robot-assisted radical prostatectomy the differences in urinary continence seen at 3 months were muted at the 12-month followup. Sexual function recovery, postoperative complication and biochemical recurrence rates were comparable 1 year postoperatively.