Retzius-Sparing Robot-Assisted Radical Prostatectomy

Summary

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

Abstract

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Introduction

To cure localized and selected cases of locally advanced prostate cancer, radical prostatectomy is one of the recommended treatment options¹. Minimal invasive techniques (conventional laparoscopy and robot-assisted laparoscopy) have the advantage to lower blood loss, postoperative pain, and duration of hospitalization as compared to open radical prostatectomy^2,3. Among the minimal invasive techniques, robot-assisted surgery combines the advantages of minimal invasive surgery with increased dexterity and freedom of movement of the surgical instruments and with 3-dimensional perioperative....

Protocol

This study has been submitted to the local ethics committee of Ghent University Hospital and institutional approval has been granted (EC UZG 2019/1506). The study has been registered in the Belgian study registry under reference B670201941650. All patients provided written informed consent.

1. Patient preparation and positioning

1. Preparation
   1. Follow contemporary internationally accepted guidelines to diagnose prostate cancer and to set the indication for radical prostatectomy¹. Use multiparametric MRI for local staging as this provides important information about prostate volume....

Results

All patients with local or locally advanced prostate cancer with a life expectancy >10 years and with no anesthesiologic contra-indications were offered RS-RARP as one of the treatment options for their disease. Patients undergoing cytoreductive radical prostatectomy for metastatic prostate cancer in the context of a clinical trial or salvage radical prostatectomy were not offered RS-RARP, and patients with anterior tumors were preferably offered SA-RARP. Patients with a follow-up of fewer than 3 months were excluded.......

Discussion

During RS-RARP, the whole procedure is performed by approaching the bladder through the posterior end. Consequently, the main difference with SA-RARP is the preservation of the Retzius' space. Preservation of Retzius' space has several anatomical advantages⁷: First, the bladder is not detached from the abdominal wall and the umbilical ligaments are not transected. Therefore, the bladder remains in its anatomical position. Second, the anterior detrusor apron and puboprostatic ligaments are .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
adhesive tape	BSNmedical	15200028	Tensoplast
assistant trocar 5mm	Aesculap	EKO17R	reusable trocar
assistant trocar 12mm	Conmed	iAS12-120LPi	AirSeal trocar
barbed wire	Covidien	VLOCM0024	for vesico-urethral anastomosis
Cadiere forceps	Intuitive	470049	robotic instrument, grasper
camera 30°	Intuitive	470027	endoscope
cefazolin	Sandoz	BE217296	Belgian farmaceutical registration
CO2-insufflator	Conmed	AS-iFS2	AirSeal insufflator
Da Vinci Xi system	Intuitive	600062	robotic system
endobag	Covidien	173050G	Endo Catch 10mm
endoscopic hem-o-lok applier	Teleflex	544995T	to apply the locking clips
fenestrated bipolar forceps	Intuitive	470205	robotic instrument, bipolar forceps
Hasson cone 8mm trocar	Intuitive	470398	only at the camera trocar
heparin, low molecular weight (enoxaparin)	Sanofi	BE144347	Belgian farmaceutical registration
hydrogel coated latex transurethral catheter	Bard	D226416	Biocath
insufflation cable	Conmed	ASM-EVAC1	AirSeal Tri-lumen filtered tube set
laparoscopic grasper	Aesculap	PO235R	Atraumatic wave grasper, double action
large needle driver	Intuitive	470006	roboic instrument, needle driver
locking clip	Grena	5-13mm	Click'aVplus
metallic clips 5mm	Aesculap	PL453SU	for vessel ligation
monopolar curved scissor	Intuitive	470179	robotic instrument, hot shears
mosquito clamp	Innovia Medical	MQC2025-D	to secure bladder suspension stitch
natriumlaurylsulfoacetate-sorbitol-natriumcitratedihydrate clysma	Johnson & Johnson Consumer BV	RVG 05069	Belgian farmaceutical registration
polyglactin 3.0 suture	Ethicon	V442H	stay suture bladder neck, subcutaneous sutures
polyglactin 1 suture	Ethicon	D9708	stay suture fascia and fascia closurie
povidone-iodine alcoholic solution	Mylan	BE230736	Belgian farmaceutical registration
robotic trocar 8mm	Intuitive	470002	standard length
Skin stapler	Covidien	8886803712	skin closure
sterile drapes robotic arms	Intuitive	470015	draping system robotic arms
suction-irrigation device	Geyi	GYSL-5X330	laparoscopic use by assitant
suspension sutures	Ethicon	628H	Ethilon 2-0 nylon suture
thrombo-embolus deterrent stockings	Covidien	7203	T.E.D. stockings
warming blanket device	3M	54200	Bear Hugger