Retzius‐sparing robot‐assisted radical prostatectomy: early learning curve experience in three continents

Abstract

Objective To assess the effect of surgical experience on peri‐operative, functional and oncological outcomes during the first 50 Retzius‐sparing robot‐assisted radical prostatectomy (RsRARP) cases performed by surgeons naïve to this novel approach. Materials and Methods We retrospectively evaluated the initial cases operated by 14 surgeons in 12 different international centres. Pre‐, peri‐ and postoperative features of the first 50 patients operated by each surgeon in all the participating centres were collected. The effect of surgical experience on peri‐operative, functional and oncological outcomes was firstly evaluated after stratification by level of surgical experience (initial [≤25 cases] and expert [>25 cases]) and after using locally weighted scatterplot smoothing to graphically explore the relationship between surgical experience and the outcomes of interest. Results We evaluated 626 patients. The median follow‐up was 13 months in the initial group and 9 months in the expert group (P = 0.002). Preoperative features overlapped between the two groups. Shorter console time (140 vs 120 min; P = 0.001) and a trend towards lower complications rates (13 vs 5.5%; P = 0.038) were observed in the expert group. The relationship between surgical experience and console time, immediate urinary continence recovery and Clavien–Dindo grade ≥2 complications was linear, without reaching a plateau, after 50 cases. Conversely, a non‐linear relationship was observed between surgical experience and positive surgical margins (PSMs). Conclusions In this first report of a multicentre experience of RsRARP during the learning curve, we found that console time, immediate urinary continence recovery and postoperative complications are optimal from the beginning and further quickly improve during the learning process, while PSM rates did not clearly improve over the first 50 cases.

Challenging cases in high-risk prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy

“…Conversely, neither BML nor previous BPH surgery may affect the reliability of RS-RARP in terms of PSMs. Noteworthy, we failed to observe a relationship between SE and PSMs, suggesting that the learning process might be longer than expected [30] also in expert hands, as demonstrated in other settings [20]. Nevertheless, the rate of PSMs observed in the current report, is in line with those reported for high-risk PCa patients treated with anterior approach [31,32].…”

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

“…To date, some studies have reported the learning curves of LRP and RALRP. An early study reported the safety and efficacy of Retzius-sparing RALRP, and there was a linear relationship between surgery experience and imitated UC in the first 50 cases, without reaching a plateau ( 23 ). Some authors asserted that with >100 cases, the plateau on early continence is achievable ( 24 ).…”

“…Some authors asserted that with >100 cases, the plateau on early continence is achievable ( 24 ). Regarding PSMs, the evidence available is controversial: some researchers did not find improvement of the PSM rate during the learning curve ( 23 , 25 ), while others, in a single surgeon series, found an overall reduction of positive margins with the amount of experience ( 26 ). In an early series about traditional RARP, Patel and colleagues ( 27 ) showed that operative times and EBL are reduced with the experience of the surgeon.…”

Is It Safe to Switch from a Standard Anterior to Retzius-Sparing Approach in Robot-Assisted Radical Prostatectomy?

“…This innovative surgical technique avoids damage to the supportive fascial structures of the bladder. In comparison to SA-RARP, the Santorini plexus, the endopelvic fascia, puboprostatic ligaments, and the detrusor apron remain intact in RS-RARP [ 6 ]. Different prospective trials have reported better outcomes in terms of early continence in RS-RARP than SA-RARP, with immediate continence results ranging from 51–76% for RS-RARP compared to 21–60% in SA-RARP [ 7 , 8 , 9 , 10 ].…”