Retzius-Sparing Robot-Assisted Radical Prostatectomy

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.

Transcript

The Retzius-sparing robot-assisted approach improves functional outcomes in patients with prostate cancer undergoing radical prostatectomy. The Retzius-sparing robot-assisted approach improves early return of urinary continence after radical prostatectomy. To begin, place the patient in a supine position, securing the arms and legs.

Then, to enable trocar insertion, make a 2 to 2.5-centimeter skin incision longitudinally, about one centimeter above the umbilicus. Insert an eight-millimeter robotic camera trocar with Hasson cone on the peritoneal cavity, and attach the clamps of the cones to the stay sutures at the fascia. Bring the patient to a 30 to 35 degrees Trendelenburg position to free the minor pelvis from the small bowel.

Then, horizontally to the camera trocar, place two eight-millimeter trocars for the robotic instruments on the left of the camera trocar, and one on the right, keeping a six to eight centimeter distance between trocars. Move the patient cart to the right hand side of the patient, until the third arm is connected to the camera trocar. Connect the three other eight-millimeter trocars with at least 10-centimeter distance between the arms to avoid collision during operative movements.

To access the seminal vesicles, incise the peritoneum above the vas deferens on both sides, and continue medially until these incisions reach each other. At the lateral edge of the incision, dissect the vas deferens in a circumferential fashion and transect it. Then, dissect the vas deferens medially, until the tip of the seminal vesicle is reached.

If there's no evidence of seminal vesicle invasion, peel off the Denonvilliers'fascia, medially from the vast deferens. After dissection, secure the vessels at the tip and lateral surface of the seminal vesicle by bipolar hemostasis, and transect them. For lateral dissection of the prostate, retract the seminal vesicle medially using Cadiere forceps for the right side, and an assistant laparoscopic grasper for the left side.

To facilitate access to the prostate and bladder neck, place a straight needle with a non-resorbable suture through the upper part of the peritoneal incision, two to three centimeters above the pubic bone, just medially from the medial umbilical ligament. Perforate the upper part of the peritoneal incision and the underlying fatty tissue with the straight needle. For handling of erectile nerves with the bilateral nerve sparing approach, create a plane by blunt dissection between the prostatic fascia and the Denonvilliers'fascia, up to the apex of the prostate and laterally until the prostatic vessels are encountered.

For the non-nerve sparing approach, as in this case, incise the Denonvilliers'fascia one to two milliliters below the prostate base. Then, dissect the anterior surface of the rectum and more laterally, in the perirectal fatty tissue. For the unilateral nerve sparing approach, first, perform the bilateral nerve sparing method at the side of nerve sparing, and the non-nerve sparing method at the side of non-nerve sparing.

Then, incise the Denonvilliers'fascia at the midline, above the rectal wall. Next, bring the prostatic pedicle under tension and make a window with the monopolar scissors. Secure the part of the pedicle using a large polymer locking clip, applied through the 12-millimeter assistant trocars.

Then, transect at the prostatic side of the clip. Peel off the neurovascular bundle from the prostatic fascia by blunt dissection, and by keeping the bundle under slight tension using a progressive medial and upward retraction with the Cadiere forceps. For the dissection of the bladder neck, grasp the seminal vesicles by Cadiere forceps and retract them downward to create tension between the bladder neck and prostate base.

Then, make a one-centimeter incision of the mucosa at the posterior aspect of the bladder neck to inspect the urethral catheter. Place an absorbable polyglactin 3/0 suture at the posterior aspect of the bladder neck. Then, grasp the stay suture with the fenestrated bipolar forceps, and move upward until the anterior part of the bladder neck becomes visible.

Incise the mucosa further, to release the bladder neck from the base of the prostate. Then, place a second stay suture at the anterior aspect of the bladder neck, before completely releasing the bladder neck. For anterior dissection, follow the anterior surface of the prostate using a combination of blunt dissection and monopolar incision, sparing the Santorini's plexus, the puboprostatic ligaments, and the Retzius space.

For the prostatic apex dissection, make a one to two-millimeter incision of the circular fibers of the urethra, caudally toward the apex of the prostate. Then, push the circular fibers toward the apex of the prostate to expose the inner longitudinal layer of the urethra. Transect the inner layer as close to the prostate as possible to preserve the sphincter.

Insert an endo bag through the 12-millimeter assistant trocar to put in the prostate and seminal vesicles. To identify the bladder neck and mucosa of the bladder. pull the anterior stay suture.

Then, place the first suture of the first absorbable barbed wire outside in, just the lateral to the right of the 12 o'clock position on the bladder neck. Identify the urethra by moving the tip of the urethral catheter into the membranous urethra, before placing the suture on the urethra inside out and slightly lateral to the right of the 12 o'clock position. Then, place the first suture of the second absorbable barbed wire outside in, lateral to the left of the 12 o'clock position on the bladder neck, and inside out on the urethra at the same position.

Repeat the suturing with the second barbed wire outside in on the bladder neck, and inside out on the urethra twice, until the nine o'clock position is reached. Perform suturing on the right side with the first barbed wire outside in on the bladder neck, and inside out on the urethra until the six o'clock position is reached. Then, continue the anastomosis on the left side, going from the nine o'clock to the six o'clock position.

Once done, grasp the tip of the catheter to place in the bladder and insufflate the balloon. Then, tighten the last sutures on the left and right sides, until the bladder and urethral mucosa are approximated. Check the water tightness of the anastomosis by instilling 120 milliliters of water in the bladder.

Using remains of the barbed wires, close the peritoneal incision from medial to lateral on both sides. To extract the prostate, incise the supraumbilical skin and fascia incision. Then, close all skin incisions with skin staplers.

In this study, 77 patients were treated with Retzius-sparing robot-assisted radial prostatectomy. The median patient age was 65, with a serum prostate-specific antigen of 7.7 nanograms per milliliter. The preoperative tumor characteristics of patients are summarized in the table.

The median operation time was 160 minutes, and the median hospital stay was three days. Nine patients developed grade one complications due to prolonged urinary catheter stay. Two patients suffered a high grade complication consisting of an infected lymphocele, requiring percutaneous drainage.

One patient was treated with antibiotics for an infected lymphocele. 37 patients had either extra capsule or extension, or seminal vesicle invasion on final pathological examination. The other 40 patients were classified with PT2 disease.

Furthermore, a positive surgical margin was reported in 33 patients. After a follow up of 11 months, seven patients suffered a biochemical recurrence. In postoperative continent status, after three months, 71 patients were socially continent.

After six months, all evaluable patients were socially continent. Full continence was achieved in 43 patients after three months. Full continence gradually increased, and after 12 months, 94.3%of a evaluable patients were fully continent.

The detailed information on the potency status of sexually active patients with at least one year follow up is shown here. During anterior dissection, sparing of the Santorini's plexus, the puboprostatic ligaments, and the Retzius space, are crucial to improve the functional outcome of this approach. The procedure can also be performed by the classic robot anterior approach, or even the open approach.

The question remains, whether these approaches yield the same oncological and functional outcomes.

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Journal (Medicine)

Journal (Medicine)

Retzius-Sparing Robot-Assisted Radical Prostatectomy

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