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

Abstract

ObjectivesTo estimate the safety and efficiency of transvesical Retzius-sparing robot-assisted radical prostatectomy (T-RARP) compared with standard robot-assisted radical prostatectomy (S-RARP) for localized prostate cancer (PCa).Materials and Methods174 patients bearing localized PCa and undergoing T-RARP or S-RARP between October 2017 and January 2020 were retrospectively enrolled in our analysis. All potential baseline confounders were strictly restrained with propensity-score matching (PM) method (1: 1). Within the matched setting, the perioperative and functional outcomes were compared between the T-RARP and S-RARP groups, while the oncological results and functional recovery of the two arms were presented with Kaplan-Meier curves.ResultsFinally, 114 and 60 eligible patients harbouring localized PCa were identified in the S-RARP and T-RARP group, respectively. No significant differences between the two groups were found in all baseline characteristics after PM. Within the matched cohort, no case was converted to open surgery in either group. The T-RARP group was significantly related to a higher mean operative time (p = 0.001) and shorter median hospital stay length (p < 0.001). There were not significant differences in the median estimated blood loss and specimen Gleason score between the two arms. The proportions of transfusion, pT3a disease, postoperative complication, and positive surgical margin in the T-RARP group were also comparable to that in the S-RARP group. The mean prostate-specific antigen and median erectile functional scores did not differ significantly between the two groups at postoperative 3 months and last follow-up. T-RARP vs. S-RARP had significantly improved urinary continence (UC) rates at the removal of catheter (p < 0.001) and postoperative 3 months (p < 0.001), but the significant difference between the two groups in UC recovery disappeared at last follow-up (p = 0.119). No significant difference in biochemical recurrence-free survival was observed following the two surgeries (p = 0.727).ConclusionsT-RARP by experienced hands was feasible for selected patients with clinically localized PCa, yielding significantly improved early return to UC and similar erectile functional preservation without compromising oncological control when compared with the standard approach.

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

“…Based on our results, both the transvesical and posterior approaches are superior over the anterior approach concerning postoperative early return to UC, which could be attributed to the common advantage of these two Retzius-sparing surgeries. Both the transvesical and posterior techniques allowed the prostate gland to be removed without disrupting the integrity of Retzius space, thus providing a strong rationale for achieving enhanced UC recovery after RARP [ 9 , 11 ]. 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 ].…”

“…The anterior approach was done following the modified technique proposed by Menon et al [ 12 ], while the posterior approach was carried out as described by Galfano et al [ 8 ]. As presented in our published studies [ 9 – 11 ], the detailed surgical steps of the transvesical approach to RARP are shown in Figure 1 . Anatomically extended pelvic lymph node dissection (ePLND) was conventionally executed on condition that the preoperative estimated risk in lymph node metastasis exceeded 5%, while the performance of ePLND was routinely abandoned in patients with a lower risk of nodal involvement.…”

“…However, urologists were slow to adopt the posterior approach because of the steep learning curve and specific comments regarding the uncertainties of increased positive surgical margin (PSM) [ 9 ]. Recently, our team first conducted the transvesical approach to RARP, another procedure that avoids entry to the Retzius space, in patients afflicted with localized prostate cancer (PCa) [ 9 – 11 ], thus promoting early UC recovery. Based on the outcomes of transvesical RARP for localized PCa [ 9 – 11 ], the transvesical approach could serve as a valid alternative to RARP in selected patients, providing promising postoperative UC with compromising oncologic control for localized PCa.…”

Functional Preservation and Oncologic Control following Robot-Assisted versus Laparoscopic Radical Prostatectomy for Intermediate- and High-Risk Localized Prostate Cancer: A Propensity Score Matched Analysis

“…Postoperative follow-up was regularly arranged every 3 months within the first year after surgery and every 6 months from the second year after surgery for each patient. Each case routinely underwent postoperative PSA tests every 3 months to monitor the biochemical recurrence (BCR), which was considered as the occurrence that two consecutive rising serum PSA values measured on two separate occasions were 0.2 ng/mL or greater after prostatectomy [ 2 , 25 ]. BCR-free survival was regarded as the interval length from the date of surgery to that of BCR.…”

“…BCR-free survival was regarded as the interval length from the date of surgery to that of BCR. Urinary continence (UC) was considered as no use of pads or use of a single safety pad within 24 hours [ 2 , 25 ]. A safety pad was defined as “no involuntary loss of urine, but a pad was still used.” In the meantime, urinary incontinence was defined as the use of > one pad within 24 hours.…”