Beyond the Learning Curve of the Retzius-sparing Approach for Robot-assisted Laparoscopic Radical Prostatectomy: Oncologic and Functional Results of the First 200 Patients with ≥1 Year of Follow-up

Galfano, Antonio; Trapani, Dario; Sozzi, Francesco; Strada, E.; Petralia, Giovanni; Bramerio, Manuela; Ascione, A.; Gambacorta, Marcello; Bocciardi, Aldo Massimo

doi:10.1016/j.eururo.2013.06.046

Cited by 223 publications

(201 citation statements)

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“…Recently, several techniques to improve the functional outcome of RARP have been reported, for example, regional pelvic cooling during prostatectomy, 25 dissection of neurovascular bundles without tension and any use of electrocautery, 26 and a novel approach passing through the pouch of Douglas and avoiding the Retzius structures. 27 The results of these methods, particularly urinary continence, are usually determined according to pad use, pad tests of urinary leakage, and satisfaction questionnaires regarding continence status.…”

Section: Commentmentioning

confidence: 99%

Urodynamic Evaluation Before and Immediately After Robot-assisted Radical Prostatectomy

Kadono

Ueno

Yaegashi

et al. 2014

Urology

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Section: Commentmentioning

confidence: 99%

Urodynamic Evaluation Before and Immediately After Robot-assisted Radical Prostatectomy

Kadono

Ueno

Yaegashi

et al. 2014

Urology

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“…2 In a recent study, Galfano and colleagues found that a surgical technique sparing the Reitzus structures yielded higher early continence rates. 3 It has also been implied that younger age, positive surgical margins and absence of preoperative urinary incontinence are clear predictors of better functional outcomes. 4 Finally, Sammon and colleagues concluded that the type of nerve-sparing performed and placement of a percutaneous suprapubic tube for bladder drainage postoperatively were independently predictive of never requiring a pad after RARP.…”

Section: Introductionmentioning

confidence: 99%

Predictors of early continence following robot-assisted radical prostatectomy

Lavigueur-Blouin

Noriega

Valdivieso

et al. 2015

CUAJ

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Introduction: Functional outcomes after robot-assisted radical prostatectomy (RARP) greatly influence patient quality of life. Data regarding predictors of early continence, especially 1 month following RARP, are limited. Previous reports mainly address immediate or 3-month postoperative continence rates. We examine preoperative predictors of pad-free continence recovery at the first follow-up visit 1 month after RARP. Methods: Between January 2007 and January 2013, preoperative and follow-up data were prospectively collected for 327 RARP patients operated on by 2 fellowship-trained surgeons (AEH and KCZ). Patient and operative characteristics included age, body mass index (BMI), staging, preoperative prostate-specific antigen (PSA), prostate weight, International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM) score and type of nervesparing performed. Continence was defined by 0-pad usage at 1 month follow-up. Univariate and multivariate logistic regression models were used to assess for predictors of early continence. Results: Overall, 44% of patients were pad-free 1 month post-RARP. In multivariate regression analysis, age (odds ratio [OR] 0.946, confidence interval [CI] 95%: 0.91, 0.98) and IPSS (OR: 0.953, CI 95%: 0.92, 0.99) were independent predictors of urinary continence 1 month following RARP. Other variables (BMI, staging, preoperative PSA, SHIM score, prostate weight and type of nerve-sparing) were not statistically significant predictors of early continence. Limitations of this study include missing data for comorbidities, patient use of pelvic floor exercises and patient maximal activity. Moreover, patient-reported continence using a 0-pad usage definition represents a semiquantitative and subjective measurement. Conclusion: In a broad population of patients who underwent RARP at our institution, 44% of patients were pad-free at 1 month. Age and IPSS were independent predictors of early continence after surgery. Men of advanced age and those with significant lower urinary tract symptoms prior to RARP should be counselled on the increased risk of urinary incontinence in the early stages.

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“…Conceptually, RS-RARP is a new paradigm in approach and those learning this technique will need to commit to it and may get worse before they get better. Indeed, Bocciardi had dramatic improvement in T2-PSM rates from his first 100 patients (22%) to the next 100 (10%), indicating a prolonged learning period [3]. Finally, whether the results can be replicated in high-risk disease also remains unanswered.…”

mentioning

confidence: 99%

“…This rapid early return to continence was supported across multiple assessments: pad weight, time to continence, and the proportion of patients with no leakage at 1 month From the published results available, including this Level 1 evidence, there seems little doubt that 1 week after a RS-RARP men are more likely to be continent compared to standard RARP (Table 1) . [3][4][5]. However, this begs the question, is this an important outcome in a cancer operation?…”

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confidence: 99%

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Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP) vs standard RARP: it's time for critical appraisal

et al. 2018

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Since robot-assisted radical prostatectomy (RARP) started to be regularly performed in 2001, the procedure has typically followed the original retropubic approach, with incremental technical improvements in an attempt to improve outcomes. These include the running Van-Velthoven anastomosis, posterior reconstruction or 'Rocco stitch' [1], and cold ligation of the Santorini plexus/dorsal vein to maximise urethral length. In 2010, Bocciardi's team in Milan proposed a novel posterior or 'Retzius-sparing' RARP (RS-RARP), mirroring the classic open perineal approach [2]. This allows avoidance of supporting structures, such as the puboprostatic ligaments, endopelvic fascia, and Santorini plexus, preserving the normal anatomy as much as possible and limiting damage that may contribute to improved postoperative continence and erectile function. There has been much heralding of the excellent functional outcomes in both the medical and the lay press, but as yet no focus or real mention of any potential downsides of this new technique.The RS-RARP approach demands staying very close to the prostate throughout its mobilisation by hugging the capsule, bladder neck sparing, and performing nerve sparing with dissection in an intra-or interfascial plane. The key attraction of this technique is proposed to be an earlier return to continence, with encouraging early results from Bocciardi's team. In their first 200 patients, performed by a single experienced surgeon, they found 90% of patients to be continent at 1 week after surgery, irrespective of learning curve [3]. These results were further supported by Rha's Korean group, who published a 50 patient-matched comparison study and found that 70% of patients in their RS-RARP group were completely dry at 1 month (70% vs 50% in the standard RARP group, P = 0.039) [4]. Neither of these studies used randomisation or blinding, and outcomes were reported subjectively. A subsequent randomised controlled trial (RCT) by Menon's group, at the Vattikuti Institute, allocated 60 patients to each arm to undergo either standard RARP or RS-RARP [5]. In a group of patients with low-and intermediate-risk localised prostate cancer (International Society of Urological Pathology [ISUP] grades 1-3), they found that 71% of patients were continent (0/1 pad/day) at 1 week after surgery vs 48% in the standard RARP group (P = 0.01). This rapid early return to continence was supported across multiple assessments: pad weight, time to continence, and the proportion of patients with no leakage at 1 month From the published results available, including this Level 1 evidence, there seems little doubt that 1 week after a RS-RARP men are more likely to be continent compared to standard RARP (Table 1) . [3][4][5]. However, this begs the question, is this an important outcome in a cancer operation? The median time to achieve continence was reduced by 6 days (RS-RARP 2 vs 8 days standard RARP), and from a patient-reported outcome measures perspective (IPSS qualityof-life score), a statistically significant difference w...

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Beyond the Learning Curve of the Retzius-sparing Approach for Robot-assisted Laparoscopic Radical Prostatectomy: Oncologic and Functional Results of the First 200 Patients with ≥1 Year of Follow-up

Cited by 223 publications

References 21 publications

Urodynamic Evaluation Before and Immediately After Robot-assisted Radical Prostatectomy

Urodynamic Evaluation Before and Immediately After Robot-assisted Radical Prostatectomy

Predictors of early continence following robot-assisted radical prostatectomy

Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP) vs standard RARP: it's time for critical appraisal

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