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.
The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.
To cure localized and selected cases of locally advanced prostate cancer, radical prostatectomy is one of the recommended treatment options1. Minimal invasive techniques (conventional laparoscopy and robot-assisted laparoscopy) have the advantage to lower blood loss, postoperative pain, and duration of hospitalization as compared to open radical prostatectomy2,3. Among the minimal invasive techniques, robot-assisted surgery combines the advantages of minimal invasive surgery with increased dexterity and freedom of movement of the surgical instruments and with 3-dimensional perioperative vision. In well-resourced countries, robot-assisted radical prostatectomy (RARP) has become the predominant mode to perform radical prostatectomy4.
Urinary incontinence, temporary or definitive, is a common side effect of radical prostatectomy, irrespective of the mode by which it has been performed5. With open (abdominal), laparoscopic, and "standard" anterior RARP (SA-RARP), radical prostatectomy is performed by an anterior approach in which the retropubic (Retzius') space is opened6. Thanks to the increased dexterity associated with RARP, an alternative anatomic approach is possible in which the prostate is resected through the rectovesical pouch or Douglas' pouch as first described by Galfano et al.7. This posterior approach leaves the Retzius' space intact ("Retzius-sparing RARP"; RS-RARP). The main advantage of RS-RARP appears to be a higher and faster recovery of urinary continence8. This study aims to describe in detail (as suggested by the Pasadena consensus panel9) the steps of RS-RARP supported by audiovisual material and to report on the early functional and oncological outcomes of the first cases in a single center.
This study has been submitted to the local ethics committee of Ghent University Hospital and institutional approval has been granted (EC UZG 2019/1506). The study has been registered in the Belgian study registry under reference B670201941650. All patients provided written informed consent.
1. Patient preparation and positioning
2. Docking the robotic system
Figure 1: The patient cart with 4 robotic arms. Please click here to view a larger version of this figure.
3. Dissection of the seminal vesicles
4. Posterolateral dissection of the prostate
5. Dissection of the bladder neck
6. Anterior and prostatic apex dissection
7. Vesico-urethral anastomosis
8. Extraction of the prostate and closure of the incisions
9. Postoperative care
All patients with local or locally advanced prostate cancer with a life expectancy >10 years and with no anesthesiologic contra-indications were offered RS-RARP as one of the treatment options for their disease. Patients undergoing cytoreductive radical prostatectomy for metastatic prostate cancer in the context of a clinical trial or salvage radical prostatectomy were not offered RS-RARP, and patients with anterior tumors were preferably offered SA-RARP. Patients with a follow-up of fewer than 3 months were excluded. Before the operation, all patients had a measurement of serum prostate-specific antigen (PSA) and underwent MRI. The biopsy grade group was assessed preoperatively by histological examination of a transrectal or transperineal prostate biopsy. The clinical T stage was assessed by digital rectal examination and local tumor extension on MRI. Tumor location and prostate volume were evaluated by MRI. Risk group stratification was done according to international guidelines1. Postoperative complications were graded according to the Dindo-Clavien classification11. Histological examination of the radical prostatectomy specimen was used to assess the pathological T-stage and the tumor margins. Tumor cells in contact with the inked margin were considered a positive surgical margin. During the first postoperative year, patients were followed at 2 and 6 weeks and 3, 6, 9, and 12 months. Thereafter, patients were followed twice a year. Besides history taking and clinical examination, every postoperative visit (except the one at 2 weeks) included a measurement of PSA. Biochemical recurrence after RS-RARP was defined as any postoperative PSA > 0.2 ng/mL or three consecutive PSA rises below 0.2 ng/mL. Outcome parameters evaluated during every postoperative visit were biochemical recurrence, urinary continence status, and potency. These parameters were selected as radical prostatectomy aims to achieve the "Trifecta". This trifecta consists of being cured (no biochemical recurrence), being continent for urine, and maintaining potency12. Social continence was defined as a maximum one safety pad whereas full continence was defined as no loss of urine in any circumstances.
Between February 2020 and August 2021, 77 patients were treated with RS-RARP by a single surgeon with a large experience in SA-RARP (approximately 1,000 cases). The median patient age was 65 years (range: 45-79 years) with a median serum Prostate Specific Antigen (PSA) of 7.7 ng/mL (range: 2.2-21.1 ng/mL). Other preoperative tumor characteristics are summarized in Table 1.
Table 1: Patient and tumor characteristics. Please click here to download this Table.
Pelvic lymph node dissection (PLND) was performed in 30 (39%) patients but none of these patients were affected by lymph node invasion. Four (5.2%), 38 (49.4%), and 35 (45.5%) patients underwent no nerve-sparing, unilateral nerve-sparing, and bilateral nerve-sparing, respectively. The median operation time was 160 min (range: 122-265 min). None of the patients needed conversion to an anterior robotic or open approach and nobody suffered an intra-operative complication. The median hospital stay was 3 days (range: 3-8 days). There were 9 (11.9%) patients with a grade 1 complication, all due to the need for a prolonged urinary catheter stay. In two (2.6%) patients, this prolonged catheter stay was due to leakage at the vesico-urethral anastomosis observed during the "leak-test". One (1.3%) patient was treated with antibiotics for a surinfected lymphocele (grade 2 complication). Two (2.6%) other patients suffered a high-grade complication (grade IIIa) consisting of an infected lymphocele that needed percutaneous drainage. These last three patients underwent PLND. Thirty-seven (48.1%) patients had either extracapsular extension (pT3a) or seminal vesicle invasion (pT3b) on final pathological examination. The other 40 patients were classified with pT2 disease. Positive surgical margin (PSM) was reported in 33 (42.9%) patients. Substratified by pathological T-stage, 11 (27.5%) and 22 (59.5%) patients with T2 and T3-stage, respectively, were reported with a PSM. After a median follow-up of 11 months (range: 3-21 months), seven (9.1%) patients suffered a biochemical recurrence and were referred for early salvage radiotherapy. All these seven patients had the final pathological pT3 stage. Estimated 1-year biochemical recurrence-free survival (BRFS) is 90.1% (standard error: 3.6%). Perioperative outcomes are summarized in Table 2.
Table 2: Perioperative and oncological outcomes. Please click here to download this Table.
After 3 months, 71 (92.2%) were socially continent. After 6 months, all evaluable patients were socially continent. Full continence was achieved in 43 (55.8%) after 3 months. Full continence gradually increased and after 12 months, 94.3% of evaluable patients were fully continent. Further details on urinary continence are provided in Table 3.
Table 3: Postoperative continence status at different time points. Please click here to download this Table.
Thirty patients with at least 1-year follow-up and that were sexually active before RS-RARP underwent unilateral or bilateral nerve-sparing. Of them, 13 (43.3%) were able to achieve an erection sufficient for sexual intercourse with or without medical assistance. More detailed information on potency is provided in Table 4.
Table 4: Potency status of sexually active patients with at least 1-year follow-up. Please click here to download this Table.
During RS-RARP, the whole procedure is performed by approaching the bladder through the posterior end. Consequently, the main difference with SA-RARP is the preservation of the Retzius' space. Preservation of Retzius' space has several anatomical advantages7: First, the bladder is not detached from the abdominal wall and the umbilical ligaments are not transected. Therefore, the bladder remains in its anatomical position. Second, the anterior detrusor apron and puboprostatic ligaments are not transected. Although called puboprostatic ligaments, these ligaments extend to the anterior surface of the bladder and should be better called pubovesical ligaments13. These ligaments are an important support of the continence mechanism13. The anterior detrusor apron contains muscle fibers originating from the detrusor muscle and might also have a function in maintaining urinary continence13. Third, the dorsal venous complex (DVC) is not transected without the need for hemostatic suturing7. Given the proximity of the DVC to the urethral sphincter, parts of the urethral sphincter might be included in these hemostatic sutures rendering them afunctional14. These anatomical advantages are beneficial for the early recovery of urinary continence. A systematic review and meta-analysis showed a significantly lower risk of urinary incontinence after 1, 3, 6, and 12 months8. This benefit is the most pronounced in the early postoperative period as another systematic review showed that there is no significant difference after 6 months based on the results of solely the randomized controlled trials15. In absolute terms, Menon et al. reported 3- and 12-month social continence rates of 93.3% and 98.3%, respectively, and 3- and 12-month full continence rates of 76% and 96%, respectively16. Olivero et al. reported a 12-month social continence rate of 90.1%-94.2%17. A multicentric study showed a 12-month full continence rate of 90.3%18. The continence data reported in the series here corroborate these encouraging findings regarding early return to urinary continence.
Erectile dysfunction is another adverse effect after radical prostatectomy but data after RS-RARP are sparse. High-volume centers reported that 71%-86.5% of patients after RS-RARP were able to achieve penetrative intercourse, which is higher compared to the 43% of patients reported in this series16,17,18,19. This might in part be due to differences in patient population, the extent of nerve-sparing, and the definition of erectile dysfunction. Menon et al. excluded patients who were no longer interested in sexual intercourse after RS-RARP16 whereas in this series all patients that were sexually active before RS-RARP were taken into account. Other series restricted evaluation of erectile function to patients <65 years who underwent bilateral intrafascial nerve-sparing17,18,19. A large contemporary series reported that only 31% of patients were able to achieve penetrative intercourse 5 years after radical prostatectomy20. Although the initial description of RS-RARP included a complete intrafascial nerve-sparing7, the plane of nerve-sparing (extrafascial versus interfascial versus intrafascial14) can be selected intra-operatively after correct identification of the endopelvic fascia and Denonvilliers' fascia.
At the end of the procedure, the peritoneum is closed again over the dissection area. Closure of the peritoneum reestablishes the retroperitoneal space with a higher likelihood that postoperative bleeding (especially in the case of nerve-sparing where coagulation is avoided) will be contained in this space. In the present study, the high-grade complications rate was low (2.6%) and not related to bleeding or the need for transfusion. In fact, all the severe complications herein were related to PLND and not to RS-RARP itself. Dalela et al. reported an 8.3% high-grade complication rate with RS-RARP and these complications were also exclusively linked to PLND21. Other surgeons reported an equally low high-grade complication rate underlining the safety of RS-RARP8,16,17,18,19.
To preserve Retzius' space and the neurovascular bundles, a close dissection to the surface of the prostate is necessary with an increased risk of PSM as a drawback. A higher PSM-rate with RS-RARP as compared to SA-RARP has indeed been reported8. With RS-RARP, the risk of PSM varied between 14% and 40%8,17,18,19. The PSM rate of 43% in this series is at the high end of this reported range. This might be explained by the fact that more than half of the patients had local high risk or locally advanced disease (with an inherently higher risk of PSM22) whereas this was excluded or sparse in other series16,17,18,19,21. On the other hand, the 1-year BRFS of 90.1% reported here is completely in line with the 89%-95.6% 1-year BRFS reported in other series17,18,19,21. Dalela et al. reported no differences in 1-year BRFS between RS-RARP and SA-RARP21. Even with PSM, a definitive cure without adjuvant radiotherapy after RARP is possible (up to 60%) and close monitoring of these patients is advised with early salvage radiotherapy in case the PSA would rise again23. This series report on the authors' initial cases performed and is subject to a learning curve. The surgical team was proficient in performing SA-RARP but did not follow any specific training before starting with RS-RARP with the exception of watching a video of the technique. Galfano et al. observed that it will need at least 50 cases to lower the PSM rate18. A dedicated teaching program may overcome this problem of the learning curve17,24.
In the authors' experience, the RS-RARP is technically more demanding compared to SA-RARP. The anatomical landmarks are sparse and therefore thorough knowledge of the anatomy of the prostate and periprostatic tissues is necessary23. The authors find early identification of the endopelvic fascia useful to guide later dissection of the bladder neck. Before anastomosis, it is difficult to identify the opened bladder neck. Stay sutures at the bladder neck facilitate this identification and are highly recommended in the authors' experience, among others7. The anastomosis is made in a smaller working space as compared to SA-RARP. The four-arm Xi robotic system used in this series reduces the risk of collision of instruments in confined spaces and facilitates the execution of RS-RARP. Despite these technical demands, the series herein confirm the safety of RS-RARP. Notably, the technique described in this series is only one way to perform RS-RARP and many (minor) modifications are possible25,26.
Many surgeons performing SA-RARP perform posterior reconstruction (PR) before anastomosis, and this is not done with RS-RARP. An advantage of PR is that it reduces tension at the anastomosis with less risk of postoperative urinary leakage27. However, as the bladder remains in its original position during RS-RARP, no difficulties were encountered to perform a tension-free anastomosis. The 2.6% urinary leakage rate found here falls within the range of 0%-11.5% reported with PR during SA-RARP19,24,27. PR may facilitate return to early continence27. However, preservation of the puboprostatic ligaments and anterior detrusor apron is likely to be more important for urinary continence7,8 and may compensate for the lack of PR during RS-RARP.
As mentioned above, data about long-term outcomes in patients with local high risk or locally advanced disease are sparse16,17,18,19,21. The oncological safety of the technique in this patient group needs to be established yet and future studies on this topic are needed to clarify this. Furthermore, the functional outcomes of SA-RARP can be improved by performing total anatomical reconstruction (TAR)28. A randomized controlled trial comparing RS-RARP versus SA-RARP with TAR is needed to assess whether one technique is superior to the other for oncological and functional outcomes.
The authors have nothing to disclose.
No funding was obtained for this research.
adhesive tape | BSNmedical | 15200028 | Tensoplast |
assistant trocar 5mm | Aesculap | EKO17R | reusable trocar |
assistant trocar 12mm | Conmed | iAS12-120LPi | AirSeal trocar |
barbed wire | Covidien | VLOCM0024 | for vesico-urethral anastomosis |
Cadiere forceps | Intuitive | 470049 | robotic instrument, grasper |
camera 30° | Intuitive | 470027 | endoscope |
cefazolin | Sandoz | BE217296 | Belgian farmaceutical registration |
CO2-insufflator | Conmed | AS-iFS2 | AirSeal insufflator |
Da Vinci Xi system | Intuitive | 600062 | robotic system |
endobag | Covidien | 173050G | Endo Catch 10mm |
endoscopic hem-o-lok applier | Teleflex | 544995T | to apply the locking clips |
fenestrated bipolar forceps | Intuitive | 470205 | robotic instrument, bipolar forceps |
Hasson cone 8mm trocar | Intuitive | 470398 | only at the camera trocar |
heparin, low molecular weight (enoxaparin) | Sanofi | BE144347 | Belgian farmaceutical registration |
hydrogel coated latex transurethral catheter | Bard | D226416 | Biocath |
insufflation cable | Conmed | ASM-EVAC1 | AirSeal Tri-lumen filtered tube set |
laparoscopic grasper | Aesculap | PO235R | Atraumatic wave grasper, double action |
large needle driver | Intuitive | 470006 | roboic instrument, needle driver |
locking clip | Grena | 5-13mm | Click'aVplus |
metallic clips 5mm | Aesculap | PL453SU | for vessel ligation |
monopolar curved scissor | Intuitive | 470179 | robotic instrument, hot shears |
mosquito clamp | Innovia Medical | MQC2025-D | to secure bladder suspension stitch |
natriumlaurylsulfoacetate-sorbitol-natriumcitratedihydrate clysma | Johnson & Johnson Consumer BV | RVG 05069 | Belgian farmaceutical registration |
polyglactin 3.0 suture | Ethicon | V442H | stay suture bladder neck, subcutaneous sutures |
polyglactin 1 suture | Ethicon | D9708 | stay suture fascia and fascia closurie |
povidone-iodine alcoholic solution | Mylan | BE230736 | Belgian farmaceutical registration |
robotic trocar 8mm | Intuitive | 470002 | standard length |
Skin stapler | Covidien | 8886803712 | skin closure |
sterile drapes robotic arms | Intuitive | 470015 | draping system robotic arms |
suction-irrigation device | Geyi | GYSL-5X330 | laparoscopic use by assitant |
suspension sutures | Ethicon | 628H | Ethilon 2-0 nylon suture |
thrombo-embolus deterrent stockings | Covidien | 7203 | T.E.D. stockings |
warming blanket device | 3M | 54200 | Bear Hugger |