Retzius-sparing Robot-assisted Radical Prostatectomy Leads to Durable Improvement in Urinary Function and Quality of Life Versus Standard Robot-assisted Radical Prostatectomy Without Compromise on Oncologic Efficacy: Single-surgeon Series and Step-by-step Guide

Egan, Jillian; Marhamati, Shawn; Carvalho, Filipe L.F.; Davis, Meghan F.; O’Neill, John; Lee, Harry; Lynch, John H.; Hankins, Ryan; Hu, Jim C.; Kowalczyk, Keith

doi:10.1016/j.eururo.2020.05.010

Cited by 71 publications

(91 citation statements)

References 29 publications

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“…Findings of this review are limited to PSMs and to BCRFS approximately 12 months after surgery, which both represent surrogate outcomes for disease‐specific survival. Based on these findings, claims of comparable oncological outcomes appear premature [15]. Extended follow‐up from existing and future studies may provide more information.…”

Section: Discussionmentioning

confidence: 99%

“…Retzius‐sparing RALP differs from the standard anterior approach by preserving the structural integrity of the anterior attachments of the bladder to the pubis, which may translate into earlier and better continence outcomes. It also maintains bladder suspension via the urachus and median umbilical ligaments, preventing bladder descent deeper into the pelvis [15]. Whereas the specific contribution of each of these anatomical structures is unclear, the assumption is that preservation of a more ‘normal’ anatomy aids the return of urinary continence.…”

Section: Introductionmentioning

confidence: 99%

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Retzius‐sparing versus standard robot‐assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

et al. 2021

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Objectives To assess the effects of Retzius‐sparing (RS) robotic‐assisted laparoscopic prostatectomy (RALP) compared to standard RALP for the treatment of clinically localized prostate cancer. Methods We performed a systematic search of multiple databases and the grey literature with no restrictions on the language of publication or publication status, up until June 2020. We included randomized controlled trials (RCTs) comparing RS‐RALP with standard RALP. We performed a meta‐analysis using a random‐effect model. The quality of evidence was assessed on an outcome basis according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Results Our search identified six records of five unique RCTs, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. The mean age of participants was 64.6 years and the mean prostate‐specific antigen level was 6.9 ng/mL. Approximately 54.2% of participants had cT1c disease, 38.6% had cT2a‐b disease, and 7.1% had cT2c disease. RS‐RALP probably improves continence within 1 week after catheter removal (risk ratio [RR] 1.74, 95% confidence interval [CI] 1.41–2.14; I2 = 0%; studies = 4; participants = 410; moderate‐certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS‐RALP may increase continence at 3 months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06–1.68; I2 = 86%; studies = 5; participants = 526; low‐certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS‐RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47–4.17; studies = 2; participants = 230; very low‐certainty evidence). Conclusions The findings of this review indicate that RS‐RALP may result in better continence outcomes than standard RALP up to 6 months after surgery. Continence outcomes at 12 months may be similar. The disadvantages of RS‐RALP may be higher positive surgical margin rates. We are very uncertain about the effect on biochemical recurrence‐free survival and potency outcomes. Longer‐term oncological and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade‐offs and the limitations of the evidence with their patients when considering this approach.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Retzius‐sparing versus standard robot‐assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

et al. 2021

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“…[19][20][21] Although preservation of the dorsal vascular complex and endopelvic fascia was supposed to lead to a better outcome for sexual function, the recovery rate of erectile function after RS-RARP was similar to that after conventional nerve-sparing RARP in several studies (Table 1). [21][22][23][24] Transvesical RARP Desai et al first described transvesical RARP in a cadaveric study. 25 Thereafter, Zhou et al reported the outcome of 35 consecutive patients who underwent transvesical RARP in a clinical setting.…”

Section: Rs-rarpmentioning

confidence: 99%

“…Although preservation of the dorsal vascular complex and endopelvic fascia was supposed to lead to a better outcome for sexual function, the recovery rate of erectile function after RS‐RARP was similar to that after conventional nerve‐sparing RARP in several studies (Table 1). 21–24 …”

Section: Surgical Procedures For Nerve Sparingmentioning

confidence: 99%

Comprehensive approach for preserving cavernous nerves and erectile function after radical prostatectomy in the era of robotic surgery

et al. 2021

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A nerve-sparing procedure during robot-assisted radical prostatectomy has been considered one of the most important techniques for preserving postoperative genitourinary function. The reason is that adequate nerve-sparing procedures could preserve both erectile function and lower urinary tract function after surgery. When a nerve-sparing procedure is carried out, the cavernous nerves themselves cannot be visualized, despite the magnified viewing field during robot-assisted radical prostatectomy. Thus, nerve-sparing procedures have been considered challenging operations, even now. However, because not all surgeons have carried out a sufficient number of nerve-sparing procedures, the development of new nerve-sparing procedures or new methods for mapping the cavernous nerves is required. Recently, various new operative techniques, for example, Retzius-sparing robot-assisted radical prostatectomy, transvesical robot-assisted radical prostatectomy and retrograde release of neurovascular bundle technique during robot-assisted radical prostatectomy, have been developed. In addition, new surgical devices, for example, biological/bioengineering solutions for cavernous nerve protection and devices for identifying the cavernous nerves during radical prostatectomy, have developed to preserve the cavernous nerves. In contrast, limitations or problems in preserving cavernous nerves and postoperative erectile function have become apparent. In particular, the recovery rate of erectile function, the positive surgical margin rate at the site of nerve-sparing and the indications for nerve sparing have become obvious with the accumulation of much evidence. Furthermore, predictive factors for postoperative erectile function after nerve-sparing procedures have also been clarified. In this article, the importance of a comprehensive approach for early recovery of erectile function in the robot-assisted radical prostatectomy era is discussed.

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“…The posterior RARP described by Bocciardi et al (4), known as the "Retzius-sparing" method, approaches to prostate gland through Douglas' pouch and avoids any disturbance to the related anatomical structures in Retzius' space, thus resulting in a faster UC recovery (5). However, the dissemination of posterior RARP has been hindered due to its steep learning curve and the scarcity of valid evidences to confirm the reproducibility of short-term outcomes, the exhibition of improved long-term outcomes and the identification of oncologic efficacy (6)(7)(8). The transvesical approach to RARP (T-RARP) was merely applied on two cadavers with the da Vinci-S robotic system before, exhibiting the technical feasibility in human body (9).…”

Section: Introductionmentioning

confidence: 99%

Transvesical Retzius-Sparing Versus Standard Robot-Assisted Radical Prostatectomy: A Retrospective Propensity Score-Adjusted Analysis

et al. 2021

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ObjectivesTo estimate the safety and efficiency of transvesical Retzius-sparing robot-assisted radical prostatectomy (T-RARP) compared with standard robot-assisted radical prostatectomy (S-RARP) for localized prostate cancer (PCa).Materials and Methods174 patients bearing localized PCa and undergoing T-RARP or S-RARP between October 2017 and January 2020 were retrospectively enrolled in our analysis. All potential baseline confounders were strictly restrained with propensity-score matching (PM) method (1: 1). Within the matched setting, the perioperative and functional outcomes were compared between the T-RARP and S-RARP groups, while the oncological results and functional recovery of the two arms were presented with Kaplan-Meier curves.ResultsFinally, 114 and 60 eligible patients harbouring localized PCa were identified in the S-RARP and T-RARP group, respectively. No significant differences between the two groups were found in all baseline characteristics after PM. Within the matched cohort, no case was converted to open surgery in either group. The T-RARP group was significantly related to a higher mean operative time (p = 0.001) and shorter median hospital stay length (p < 0.001). There were not significant differences in the median estimated blood loss and specimen Gleason score between the two arms. The proportions of transfusion, pT3a disease, postoperative complication, and positive surgical margin in the T-RARP group were also comparable to that in the S-RARP group. The mean prostate-specific antigen and median erectile functional scores did not differ significantly between the two groups at postoperative 3 months and last follow-up. T-RARP vs. S-RARP had significantly improved urinary continence (UC) rates at the removal of catheter (p < 0.001) and postoperative 3 months (p < 0.001), but the significant difference between the two groups in UC recovery disappeared at last follow-up (p = 0.119). No significant difference in biochemical recurrence-free survival was observed following the two surgeries (p = 0.727).ConclusionsT-RARP by experienced hands was feasible for selected patients with clinically localized PCa, yielding significantly improved early return to UC and similar erectile functional preservation without compromising oncological control when compared with the standard approach.

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Retzius-sparing Robot-assisted Radical Prostatectomy Leads to Durable Improvement in Urinary Function and Quality of Life Versus Standard Robot-assisted Radical Prostatectomy Without Compromise on Oncologic Efficacy: Single-surgeon Series and Step-by-step Guide

Cited by 71 publications

References 29 publications

Retzius‐sparing versus standard robot‐assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

Retzius‐sparing versus standard robot‐assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

Comprehensive approach for preserving cavernous nerves and erectile function after radical prostatectomy in the era of robotic surgery

Transvesical Retzius-Sparing Versus Standard Robot-Assisted Radical Prostatectomy: A Retrospective Propensity Score-Adjusted Analysis

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