Anatomical retro‐apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy

Abstract

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To describe a novel synchronous approach to apical dissection during robotic‐assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro‐apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P= 0.04). This marked improvement in the retro‐apical group occurred despite a significantly higher incidence of aggressive cancer (≥pT3a) documented on final specimen pathology (16% vs 10%, P= 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.

A cohort study investigating patient expectations and satisfaction outcomes in men undergoing robotic assisted radical prostatectomy

“…Furthermore, 89% of those not having intercourse were also satisfied. From our own published data, 87% of previously potent patients having bilateral nerve-sparing regain potency by the end of the first postoperative year [16]. However, the high early sexual satisfaction rates do not match the mediocre erectile function rates achieved at this time point.…”

Prevalence and risk factors of contralateral extraprostatic extension in men undergoing radical prostatectomy for unilateral disease at biopsy: A global multi-institutional experience

“…This may be explained by the challenge of differentiating the prostate from the dorsal venous complex and the sphincter of the urethra. 22 The overall incidence of cPSM was low (6%). PSM may occur following a surgical incision through the prostate or through preexisting EPE.…”

The Role of Staging MRI in Predicting Apical Margin Positivity for Robot-Assisted Laparoscopic Radical Prostatectomy

“…Apical dissection is the most important step in radical prostatectomy, because it affects not only cancer control, but also postoperative continence and sexual function. Even taking into account the advantage of the da Vinci surgical system, which provides a magnificent 3D view and intuitive instrument manipulation, the probability of PSMs in the prostatic apex remains high for various reasons [12]. From an anatomical point of view, unlike other parts of the prostate gland, the apex lacks a true and well-defined capsule [17].…”

“…Therefore, the occurrence of PSMs is one of the most important outcomes to be evaluated in any surgical treatment proposed for prostate cancer. The most common location for PSMs after RARP is the apex [12]. The aim of this study was to investigate the association between surgical margin positivity and preoperative MRI findings in patients who had undergone RARP, with a particular focus on the apex of the prostate, and to evaluate the role of preoperative MRI in decision-making in relation to nerve-sparing procedures.…”