Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy

Martini, Alberto; Falagario, Ugo Giovanni; Villers, Arnauld; Dell’Oglio, Paolo; Mazzone, Elio; Autorino, Riccardo; Moschovas, Marcio Covas; Buscarini, Maurizio; Bravi, Carlo Andrea; Briganti, Alberto; Sawczyn, Guilherme; Kaouk, Jihad; Menon, Mani; Secco, Silvia; Bocciardi, Aldo Massimo; Wang, Gongxian; Zhou, Xiaochen; Porpiglia, Francesco; Mottrie, Alexandre; Patel, Vipul; Tewari, Ashutosh; Montorsi, Francesco; Gaston, R.; Wiklund, Nils; Hemal, Ashok K.

doi:10.1016/j.eururo.2020.07.017

Cited by 91 publications

(43 citation statements)

References 36 publications

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“…Similar to the posterior approach, the initial dissection starts posteriorly, thus greatly shortening the learning curve in a highly experienced hand. The process of urethrovesical anastomosis in this transvesical fashion is almost identical to that in the anterior approach, which we were proficient in (25). The insignificantly higher frequency (3.8%) of > Grade II postoperative complications in the P-RARP group may be related to the higher rate of cT2c prostate cancer.…”

Section: Discussionmentioning

confidence: 66%

“…Given the magnifications and the millimetric robotic instruments used during RARP, the detailed understanding of the periprostatic anatomy has been greatly improved (24), thus translating into a more precise dissection and a higher level of tissue preservation during prostatectomy (25). On the strength of more detailed knowledge of the periprostatic anatomy obtained with robots, Desai et al (13) tentatively applied the transvesical approach to RARP on two fresh cadavers, demonstrating the technical feasibility of the procedure in the human body.…”

Section: Discussionmentioning

confidence: 99%

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Transvesical Versus Posterior Approach to Retzius-Sparing Robot-Assisted Radical Prostatectomy: A Retrospective Comparison With a 12-Month Follow-Up

et al. 2021

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ObjectivesTo assess the perioperative, functional, and oncological outcomes of transvesical robot-assisted radical prostatectomy (T-RARP) and posterior robot-assisted radical prostatectomy (P-RARP) for localized prostate cancer.Materials and MethodsWe analyzed the data of 96 patients who underwent T-RARP or P-RARP for localized prostate cancer between January 2017 and June 2019 in a retrospective fashion.ResultsNo significant differences in the baseline characteristics existed between the T-RARP and P-RARP arms. Both interventions were successfully performed without open conversion in either group. T-RARP was associated with a slightly more operative time (135.3 vs. 127.3 min) and estimated blood loss (105.2 vs. 94.2 mL) than P-RARP, but the differences were not significant (both p > 0.05). The likelihood of transfusion, ≤Grade II, and >Grade II postoperative complications, pT3a disease and positive surgical margins in the T-RARP group was comparable with that in the P-RARP group. No significant differences were noted between these two arms in terms of UC at the removal of catheter and nocturia (p = 0.750 and p = 0.684, respectively), and all included patients recovered UC at 3 months postoperatively. The median International Index of Erectile Function-5 score in both groups remains comparable before and after RARP. The patients in the T-RARP and P-RARP groups had a similar biochemical recurrence-free survival (p = 0.387).ConclusionsBoth T-RARP and P-RARP by experienced hands are feasible for well-selected patients with prostate cancer, obtaining similar outcomes in terms of perioperative results, UC and erectile function, and oncological control within short-term follow-up.

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Section: Discussionmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

Transvesical Versus Posterior Approach to Retzius-Sparing Robot-Assisted Radical Prostatectomy: A Retrospective Comparison With a 12-Month Follow-Up

et al. 2021

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“…All UC-related structures in the Retzius space, such as the endopelvic fascia, puboprostatic ligaments, and detrusor apron, were preserved to provide a strong supportive mechanism and stabilize the urethra [ 2 , 22 , 23 ]. Unlike the posterior approach, the transvesical method, which was firstly applied by our team, was carried out similarly to the transperitoneal anterior technique after bladder neck excision with Douglas' pouch being preserved [ 10 , 24 ]. In the present study, the continence rates at postoperative 3 months in both the transvesical (94.5%) and posterior (92.4%) groups were comparable with various studies testing the posterior approach, with rates of 59.7%–94.9% [ 25 – 27 ], while the continence rate (59.3%) obtained after the anterior approach was similar to that (29.5%–73.7%) acquired using the anterior method in reported data [ 28 ].…”

Section: Discussionmentioning

confidence: 99%

Independent Factors Affecting Postoperative Short-Term Urinary Continence Recovery after Robot-Assisted Radical Prostatectomy

Deng

Chen

Jiang

et al. 2021

Journal of Oncology

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Background. Our team had firstly applied the transvesical approach to robot-assisted radical prostatectomy (RARP) in patients afflicted with localized prostate cancer (PCa). The present study aims to present the postoperative recovery of urinary continence (UC) following the anterior, transvesical, and posterior approaches to RARP for localized PCa and evaluate the independent predictors to early UC recovery after RARP. Methods. Patients harboring localized PCa and receiving anterior, transvesical, and posterior approaches to RARP between January 2017 and June 2020 were enrolled in this analysis. Results on UC recovery were compared between these three approaches with the Kaplan–Meier method. All clinical and pathological variables were further analyzed via univariable and multivariable regression analysis to determine the independent factors contributing to short-term UC recovery after RARP. Results. A total of 135, 73, and 66 instances were included in the anterior, transvesical, and posterior groups, respectively. Over the postoperative follow-up period, both the transvesical and posterior approaches showed an advantage over the anterior approach in promoting postoperative UC recovery (both p values <0.001). Three months after surgery, 55 (40.7%), 4 (5.5%), and 5 (7.6%) patients failed to UC in the anterior, transvesical, and posterior groups, respectively. Patient age, preoperative PSA, prostate volume, biopsy Gleason score, surgical approach, extended lymph node dissection technique, nerve-sparing technique, and positive lymph node were related to UC status based on univariable analyses ( p < 0.05 ). Multivariable analysis results point patient age, prostate volume, surgical approach, and nerve-sparing technique as independent factors that affect postoperative UC recovery after RARP. Conclusions. The application of transvesical approach to RARP for localized PCa could obtain promising outcomes in terms of postoperative UC recovery. In addition, surgical strategies encompassing the nerve-sparing technique and the Retzius-sparing procedures, namely, the transvesical or posterior approach, during RARP could independently enable early achievement of postoperative continence.

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“…Third, this technique should be used with caution in high-risk PCa patients according to the concrete situation. It is relatively safe in tumor control of low- and intermediate-risk PCa patients in the context of high-quality research data currently available ( 29 , 30 ).…”

Section: Discussionmentioning

confidence: 99%

A Combined Technology to Protect the Anatomic Integrity of Distal Urethral Sphincter Complex in Radical Prostatectomy Improves Early Urinary Continence Recovery Without Sacrifice of Oncological Outcomes

et al. 2021

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PurposeOur primary aim was to present a combined technique to protect the anatomic integrity of distal urethral sphincter complex (DUSC) during minimally invasive radical prostatectomy (RP) and discuss its impact on urinary continence (UC) recovery. The second aim was to define the learning curve of the combined technique.MethodsWe conducted a non-randomized retrospective study. There were 314 consecutive patients who received RP by the same urologist surgeon with more than 2,000 prior cases in Shanghai Ruijin Hospital between March 2017 and April 2020. Included in this study were 263 patients with clinical T1–T2 stage. We modified a combined RP (Comb-RP) technique including endopelvic fascia no-incising technique, dorsal venous complex (DVC) no-ligation technique, intrafascial dissection technique, and anterior reconstruction technique so as to preserve the anatomic integrity of DUSC. The patients were assigned to two groups: a Comb-RP group and a conventional RP (Conv-RP) group. Continence rates were assessed every 3 months after removal of the catheter. UC was defined as 0 pad per day. Peri-operative variables of the patient including operation time, estimated blood lost (EBL), positive surgical margin (PSM), and postoperative complications were also collected. Scatter-graphs of learning curves were drawn using locally weighted scatterplot smoothing (LOWESS).ResultsRP was accomplished smoothly in all 263 cases. The pad-free UC rates in Conv-RP group and Comb-RP group were 17.3 vs. 27.8% (P = 0.048) at the removal of the catheter, 35.8 vs. 50.0% (P = 0.027) at 1 month, 60.5 vs. 76.1% (P = 0.012) at 3 months, 87.7 vs. 96.5% (P = 0.022) at 6 months, and 94.7 vs. 97.7% (P = 0.343) at 12 months. Kaplan–Meier analysis showed significantly higher and faster continence recovery in the Comb-RP group (mean 4.9 vs. 2.6 months, Log Rank P = 0.001). There was no significant difference in PSM rate between the Comb-RP and Conv-RP group (31.1 vs. 31.2%, P =0.986). The learning curves of peri-operative variables, oncological and functional outcomes achieved the lowest point or plateau at the 20th–60th cases.ConclusionsThe anatomic integrity and intact pelvic floor interplay of DUSC is important for its function. Our combined technique was a safe and feasible technique for improving early UC in RP with no significantly increased PSM rate and no significant difference in long-term UC.

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Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy

Cited by 91 publications

References 36 publications

Transvesical Versus Posterior Approach to Retzius-Sparing Robot-Assisted Radical Prostatectomy: A Retrospective Comparison With a 12-Month Follow-Up

Transvesical Versus Posterior Approach to Retzius-Sparing Robot-Assisted Radical Prostatectomy: A Retrospective Comparison With a 12-Month Follow-Up

Independent Factors Affecting Postoperative Short-Term Urinary Continence Recovery after Robot-Assisted Radical Prostatectomy

A Combined Technology to Protect the Anatomic Integrity of Distal Urethral Sphincter Complex in Radical Prostatectomy Improves Early Urinary Continence Recovery Without Sacrifice of Oncological Outcomes

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