Impact of Pelvic Anatomical Changes Caused by Radical Prostatectomy

Retzius sparing robot-assisted radical prostatectomy: optimizing functional results

PURPOSE

The aim of this study is to critically evaluate the existing body of evidence regarding the efficacy of Retzius-sparing radical prostatectomy (RS-RARP) in achieving improved functional outcomes. Moreover, we explored possible strategies to further optimize functional outcomes.

METHODS

Following PRISMA guidelines, a systematic review (PROSPERO ID CRD42024539915) was performed on 9th September 2023 on PubMed, Scopus, and Web of Science. Only original articles in the English language reporting functional outcomes after RS-RARP were included.

RESULTS

Overall, the search string yielded 99 results on PubMed, 122 on Scopus, and 120 on Web Of Science. After duplicate exclusion, initial screening and eligibility evaluation, a total of 47 studies were included in the qualitative analysis, corresponding to a cohort of 13.196 patients. All studies reported continence recovery. RS-RARP appeared to achieve better and faster continence recovery compared to S-RARP. However, it should be noted that continence definition was heterogeneous and not based on validated condition-specific questionnaires. Seven (15%) studies provided for any sort of rehabilitation for urinary incontinence after RS-RARP. 22 studies analyzed potency recovery rates, showing no difference between RS-RARP and S-RARP. The evaluation of this outcome poses a great challenge due to the lack of standardized assessment tools and reporting methods. Only two studies reported on the consistent use of post-operative PDE5i as penile rehabilitation.

CONCLUSIONS

The current review highlights the satisfactory functional results of Retzius-sparing robot assisted radical prostatectomy, which holds true irrespective of disease stage and prostate volume, with promising results even in patients previously treated for BPH or in the salvage setting. How can we optimize those results? The answer does not probably lie in further refinement of the surgical technique, but in giving greater attention to patient counselling and rehabilitation strategies in order to minimize regret and maximize satisfaction.

Membranous urethral length is the single independent predictor of urinary continence recovery at 12 months following Retzius-sparing robot-assisted radical prostatectomy

The influence of anatomical parameters on urinary continence (UC) after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) remains uncharted. Our objective was to evaluate their association with UC at 3, 6 and 12 months post-operatively. Data from patients who underwent RS-RARP were prospectively collected. Continence was defined as no pad use. Anatomic variables were measured on preoperative magnetic resonance imaging (MRI). Regression analyses were performed to identify predictors of UC at each time point. We included 158 patients with a median age of 60 years, most of whom had a localized tumor (≤ cT2). On multivariate analyses, at 3 months post-surgery, urinary incontinence (UI) rises with age, odds ratio (OR) 1.07 [95% confidence interval (CI) 1.004-1.142] and with prostate volume (PV), OR 1.029 (95% CI 1.006-1.052); it reduces with longer membranous urethral length (MUL), OR 0.875 (95% CI 0.780-0.983) and with higher membranous urethral volume (MUV), OR 0.299 (95% CI 0.121-0.737). At 6 months, UI rises with PV, OR 1.033 (95% CI 1.011-1.056) and decreases with MUV, OR 0.1504 (95% CI 0.050-0.444). Significantly, at 12 months post-surgery, the only predictor of UI is MUL, OR 0.830 (95% CI 0.706-0.975), establishing a threshold associated with a risk of UI of 5% (MUL > 15 mm) in opposition to a risk of 25% (MUL < 10 mm). This single institutional study requires external validation. To our knowledge, this is the first prospective cohort study supporting MUL as the single independent predictor of UC at 12 months post-surgery. By establishing MUL thresholds, we enable precise patient counseling.

Anxiety, depression, urinary continence, and sexuality in patients undergoing radical prostatectomy: preliminary findings

OBJECTIVES

Evaluate the relationship between psychological distress, namely anxiety and depression, with urinary continence and recovery of erectile function in patients undergoing radical prostatectomy (RP).

METHODS

We retrospectively analyzed data from 33 consecutive patients who underwent RP in a single tertiary-referral academy between 01/2018 to 01/2019. We used the International Index of Erectile Function (IIEF-15), the Sexual Complaints Screener for Men (SCS-M), and the Hospital Anxiety and Depression Scale (HADS), validated questionnaires for the assessment of sexual function, anxiety, and depression experiences, respectively. These questionnaires were administered at the pre-surgical visit, after surgery, and at intermediate follow-ups (three, six, and twelve months).

RESULTS

The analysis of the questionnaires completed during follow-up shows that erectile function is the most affected, with 90% erectile dysfunction (ED) at three months after surgery. In terms of emotional states, anxiety prevails in the first months following surgery and is statistically significantly associated with incontinence (p = 0.02). Depressive symptoms, on the other hand, appear later and prevail over anxiety at six months after surgery, although not statistically significant.

CONCLUSIONS

In the early post-surgical phase anxiety and ED are the most frequently detected components, while depressive experiences and decreased desire, typical of later stages, have not yet fully emerged.

Radical Prostatectomy and Anatomical Controversies: The Urethral Sphincter and the Elusive Continence Mechanisms

Prostate cancer incidence is rising [...].

Modified anterior approach preserving Retzius space versus standard anterior approach robot-assisted radical prostatectomy: A matched-pair analysis

Objective

To compare our initial perioperative and postoperative outcomes of the modified anterior approach (MA) with Retzius space preservation robot-assisted radical prostatectomy (RARP) with the standard anterior approach (SA) RARP.

Materials and methods

A retrospective analysis was performed on 116 patients with RARP completed by the same surgeon between September 2019 and March 2022. They were divided into SA-RARP group (77 cases) and MA-RARP group (39 cases). Propensity score matching was performed using eight preoperative variables, including age, BMI, preoperative PSA, biopsy Gleason score, prostate volume, D'Amico risk classification, SHIM, and clinical T stage. Functional outcome was assessed by urine pad count and SHIM after surgery, and oncological outcome was assessed by statistics of postoperative pathological findings as well as follow-up postoperative PSA. The median follow-up was 13 months and 17 months for MA-RARP and SA-RARP groups respectively.

Results

Propensity score matching was performed 1:1, and baseline data were comparable between the two groups after matching. Comparison of postoperative data: MA-RARP group had less mean EBL than SA-RARP group (200 vs 150 ml, p = 0.033). PSM did not differ between groups (p = 1). In terms of urinary control recovery, the MA-RARP group showed significant advantages in urinary control recovery at 24 h, 2 weeks, 1 month and 3 months after catheter removal, respectively (48.6% vs 5.7%, p < 0.001; 80% vs 22.9%, p < 0.001; 94.3% vs 51.4%, p < 0.001; 100% vs 74.3%, p = 0.002). This advantage gradually disappeared 6 months or more after surgery. The median time to recovery of sexual function was shorter in the MA-RARP group (165 vs 255 d, p = 0.001).

Conclusion

MA-RARP is safe and reliable, and can achieve better early urinary control function and sexual function recovery while achieving the primary tumor control goal.