Retzius‐sparing robot‐assisted radical prostatectomy improves early recovery of urinary continence: a randomized, controlled, single‐blind trial with a 1‐year follow‐up

Abstract

To evaluate the impact of Retzius-sparing robot-assisted radical prostatectomy (posterior approach) on early recovery of urinary continence (UC) compared to the conventional approach (anterior approach) for the treatment of clinically localized prostate cancer (PCa). Methods A total of 110 consecutive patients with clinically localized PCa were prospectively randomized in a 1:1 ratio to an anterior group (n = 55) or a posterior group (n = 55). The primary outcome was immediate UC, defined as freedom from any pad use within 1 week after removal of the urinary catheter. The UC rate following surgery was also calculated with Kaplan-Meier curves, and the log-rank test was used for statistical comparison. Intra-operative outcomes, pathological data and oncological outcomes, including positive surgical margin (PSM) status and biochemical recurrence-free survival (BCRFS), were also compared between the two groups. The comparison of the two approaches was also analysed in subgroups after risk stratification. Results Of the patients who underwent the posterior approach, 69.1% achieved immediate UC compared with 30.9% in the anterior group (relative risk 2.24, 95% confidence interval [CI] 1.48-3.51; P = 0.000). The relative Kaplan-Meier curves for UC during the 12-month follow-up revealed statistically better recovery in the posterior group when compared with the anterior group (hazard ratio [HR] 1.51, 95% CI 1.01-2.24; log-rank P = 0.007). No statistically significant differences were observed between the groups regarding complications (P = 0.399), PSM status (P = 0.225) or BCRFS (HR 4.80, 95% CI 0.97-23.78; log-rank P = 0.111). In sub-analyses, no significant difference between the two approaches with regard to UC recovery in patients with high-risk PCa was observed (HR 1.26, 95% CI 0.63-2.51; log-rank P = 0.415). Conclusions The Retzius-sparing approach significantly improved early recovery of UC compared to the conventional approach. Further prospective studies are needed to confirm the benefits of the Retzius-sparing approach for clinically localized PCa, especially for high-risk cases.

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

“…The routine placement of pelvic drainage and the longer routine duration of indwelling urinary catheter in the S-RARP group could also translate into a higher risk of postoperative infection (29). In our analysis, the more frequent (3.3%) appearance of > Grade II complication (symptomatic lymphocele) after surgery could greatly blame on the more performances of ePLND in the S-RARP group, while the published probability of > Grade II postoperative complication after S-RARP ranged from 0% to 6.6% (5,30,31). The similarity in the tendency towards major postoperative complications demonstrated the safety of the two surgical procedures in managing localized PCa.…”

“…Given the reported rates of UC varying from 78% to 97.5% within postoperative 1 month after the posterior RARP (5,33), our data exhibited the efficiency of T-RARP in strengthening early UC recovery. Interestingly, the significant difference in UC rates between the two groups was annihilated along with the gradual recovery to UC in the S-RARP group at the last follow-up, which could attribute to the gradually generated fibrosis surrounding the urethra as a supportive layer and reposition of the peritoneum and related structures which were damaged during S-RARP (30,34). The proportion (30%) of UC on the removal of catheter in the T-RARP group of our series was consistent with that (28.7%) following RARP with posterior reconstruction in a prospective analysis (35) involving 803 patients with PCa, while the early UC rate obtained after RARP with posterior reconstruction ranged from 19.0% to 74.2% in published literatures (36,37).…”

“…All key technical points of the transvesical approach were completed in the intentionally incised bladder without disrupting the integrity of Retzius space and recto-vesical pouch, thus providing a strong rationale for obtaining promising UC recovery. All UC-related structures in the Retzius space were spared to provide a strong supportive mechanism and stabilize the urethra (30,32), such as the endopelvic fascia, puboprostatic ligaments and detrusor apron. After applying PM method, all biological/preoperative elements which may affect UC recovery were comparable between the T-RARP and S-RARP groups.…”

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

“…However, technical improvements and a more thorough understanding of the anatomy of the prostate and its surrounding structures did not help more in further limitations in the incidence of urinary incontinence (8,9), a particularly feared complication of RP (9,10). This situation was considerably improved following the introduction of an innovative surgical method, well known as the "Retzius-sparing" approach or the posterior approach, by Bocciardi et al (11) The posterior method merely approaches the prostate gland through Douglas' pouch, thus circumventing the related anatomical structures in Retzius' space, which are strongly related to urinary continence (UC) (11).…”

“…This situation was considerably improved following the introduction of an innovative surgical method, well known as the "Retzius-sparing" approach or the posterior approach, by Bocciardi et al (11) The posterior method merely approaches the prostate gland through Douglas' pouch, thus circumventing the related anatomical structures in Retzius' space, which are strongly related to urinary continence (UC) (11). The advantage of the posterior approach over the conventional approach in the early recovery of UC has been repeatedly confirmed with high-level evidence from several well-designed prospective randomized trials (9,10,12).…”