Retzius-besparende robotassisteret radikal prostatektomi
Summary
Robotassisteret Retzius-besparende radikal prostatektomi er en teknik, der gør det muligt at bevare urinkontinens eller letter genopretning af urinkontinens hos de fleste patienter. Patienterne skal informeres om risikoen for en positiv kirurgisk margin.
Abstract
Teknikken med Retzius-besparende robotassisteret radikal prostatektomi (RS-RARP) og indledende erfaring med det på et enkelt center leveres. Teknikken beskrives trin for trin og illustreres yderligere af en video for at forbedre reproducerbarheden. Tidlige onkologiske og funktionelle resultater blev evalueret. I alt blev 77 patienter inkluderet med en median opfølgning på 11 måneder (interval: 3-21 måneder). Enoghalvtreds procent af patienterne havde lokal højrisiko eller lokalt fremskreden prostatakræft. Der var ingen intraoperative komplikationer, og alle komplikationer af høj kvalitet (2,6%) var relateret til bækkenlymfeknudedissektion udført samtidig med RS-RARP. Median driftstid var 160 min (rækkevidde: 122-265 min) og median hospitalsophold var 3 (interval: 3-8) dage. En positiv kirurgisk margin blev rapporteret i 42,9%. Et års biokemisk gentagelsesfri overlevelse var 90,1%. Efter 6 måneder var alle patienter socialt kontinent, og efter 1 år var 94,3% fuldt kontinent. Af seksuelt aktive patienter, der gennemgik mindst ensidig nervebesparelse, var 43,3% i stand til at have samleje. Denne serie understreger den kirurgiske sikkerhed ved at udføre RS-RARP ved hjælp af en standardiseret teknik og bekræfter den gavnlige effekt på den tidlige tilbagevenden af kontinens. Patienten skal informeres om risikoen for en positiv kirurgisk margin.
Introduction
For at helbrede lokaliserede og udvalgte tilfælde af lokalt avanceret prostatacancer er radikal prostatektomi en af de anbefalede behandlingsmuligheder1. Minimale invasive teknikker (konventionel laparoskopi og robotassisteret laparoskopi) har fordelen til at sænke blodtab, postoperativ smerte og indlæggelsesvarighed sammenlignet med åben radikal prostatektomi 2,3. Blandt de minimale invasive teknikker kombinerer robotassisteret kirurgi fordelene ved minimal invasiv kirurgi med øget fingerfærdighed og bevægelsesfrihed for de kirurgiske instrumenter og med 3-dimensionelt perioperativt syn. I velfinansierede lande er robotassisteret radikal prostatektomi (RARP) blevet den dominerende tilstand til at udføre radikal prostatektomi4.
Urininkontinens, midlertidig eller definitiv, er en almindelig bivirkning af radikal prostatektomi, uanset hvilken måde den er blevet udført5. Med åben (abdominal), laparoskopisk og “standard” anterior RARP (SA-RARP) udføres radikal prostatektomi ved en forreste tilgang, hvor det retropubiske (Retzius ‘) rum åbnes6. Takket være den øgede fingerfærdighed forbundet med RARP er en alternativ anatomisk tilgang mulig, hvor prostata resekteres gennem den rektovesiske pose eller Douglas ‘pose som først beskrevet af Galfano et al.7. Denne bageste tilgang efterlader Retzius’ rum intakt (“Retzius-besparende RARP”; RS-RARP). Den største fordel ved RS-RARP synes at være en højere og hurtigere genopretning af urinkontinens8. Denne undersøgelse har til formål at beskrive detaljeret (som foreslået af Pasadena-konsensuspanelet9) trinene i RS-RARP understøttet af audiovisuelt materiale og at rapportere om de tidlige funktionelle og onkologiske resultater af de første tilfælde i et enkelt center.
Protocol
Representative Results
Discussion
Under RS-RARP udføres hele proceduren ved at nærme blæren gennem den bageste ende. Derfor er den største forskel med SA-RARP bevarelsen af Retzius ‘rum. Bevarelsen af Retzius’ rum har flere anatomiske fordele7: For det første er blæren ikke løsrevet fra bugvæggen, og navlestrengen er ikke transected. Derfor forbliver blæren i sin anatomiske position. For det andet er det forreste detrusorforklæde og puboprostatiske ledbånd ikke transected. Selvom de kaldes puboprostatiske ledbånd, str?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
Der blev ikke opnået finansiering til denne forskning.
Materials
| 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 |
References
- Mottet, N., et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. European Urology. 79 (2), 243-262 (2021).
- Ilic, D., et al. Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localised prostate cancer. The Cochrane Database of Systematic Reviews. 9 (9), (2017).
- Ab del Raheem, A., et al. Retzius-sparing robot-assisted radical prostatectomy versus open retropubic radical prostatectomy: a prospective comparative study with 19-month follow-up. Minerva Urologica e Nefrologica: The Italian Journal of Urology and Nephrology. 72 (5), 586-594 (2020).
- Gandaglia, G., et al. Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 32 (14), 1419-1426 (2014).
- Ficarra, V., et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. European Urology. 62 (3), 405-417 (2012).
- Martini, A., et al. Contemporary techniques of prostate dissection for robot-assisted prostatectomy. European Urology. 78 (4), 583-591 (2020).
- Galfano, A., et al. A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery. European Urology. 58 (3), 457-461 (2010).
- Checcucci, E., et al. Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes. BJU International. 125 (1), 8-16 (2020).
- Montorsi, F., et al. Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. European Urology. 62 (3), 368-381 (2012).
- Stabile, A., et al. Multiparametric MRI for prostate cancer diagnosis: current status and future directions. Nature Reviews. Urology. 17 (1), 41-61 (2020).
- Dindo, D., Demartines, N., Clavien, P. A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery. 240 (2), 205-213 (2004).
- Xylinas, E., et al. Evaluation of combined oncological and functional outcomes after radical prostatectomy: trifecta rate of achieving continence, potency and cancer control–a literature review. Urology. 76 (5), 1194-1198 (2010).
- Walz, J., et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. European Urology. 57 (2), 179-192 (2010).
- Walz, J., et al. A critical analysis of the current knowledge of surgical anatomy of the prostate related to optimisation of cancer control and preservation of continence and erection in candidates for radical prostatectomy: An update. European Urology. 70 (2), 301-311 (2016).
- Albisinni, S., et al. Systematic review comparing Anterior vs Retzius-sparing robotic assisted radical prostatectomy: can the approach really make a difference. Minerva Urology and Nephrology. , (2021).
- Menon, M., et al. Functional recovery, oncologic outcomes and postoperative complications after robot-assisted radical prostatectomy: An evidence-based analysis comparing the Retzius sparing and standard approaches. The Journal of Urology. 199 (5), 1210-1217 (2018).
- Olivero, A., et al. Retzius-sparing robotic radical prostatectomy for surgeons in the learning curve: A propensity score-matching analysis. European Urology Focus. 7 (4), 772-778 (2021).
- Galfano, A., et al. Retzius-sparing robot-assisted radical prostatectomy: early learning curve experience in three continents. BJU International. 127 (4), 412-417 (2021).
- Galfano, A., et al. Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with >/= 1 year of follow-up. European Urology. 64 (6), 974-980 (2013).
- Hoffman, K. E., et al. Patient-reported outcomes through 5 years for active surveillance, surgery, brachytherapy, or external beam radiation with or without androgen deprivation therapy for localized prostate cancer. JAMA. 323 (2), 149-163 (2020).
- Dalela, D., et al. A pragmatic randomized controlled trial examining the impact of the Retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy. European Urology. 72 (5), 677-685 (2017).
- Yossepowitch, O., et al. Positive surgical margins after radical prostatectomy: a systematic review and contemporary update. European Urology. 65 (2), 303-313 (2014).
- Vale, C. L., et al. Adjuvant or early salvage radiotherapy for the treatment of localised and locally advanced prostate cancer: a prospectively planned systematic review and meta-analysis of aggregate data. Lancet. 396 (10260), 1422-1431 (2020).
- Lumen, N., et al. Safe introduction of robot-assisted radical prostatectomy after a training program in a high-volume robotic centre. Urologia Internationalis. 91 (2), 145-152 (2013).
- Galfano, A., Secco, S., Bocciardi, A. M. Mottrie A. Retzius-sparing robot-assisted laparoscopic radical prostatectomy: An international survey on surgical details and worldwide diffusion. European Urology Focus. 6 (5), 1021-1023 (2020).
- Checcucci, E., et al. Precision prostate cancer surgery: an overview of new technologies and techniques. Minerva Urologica e Nefrologica: The Italian Journal of Urology and Nephrology. 71 (5), 487-501 (2019).
- Grasso, A. A., et al. Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis. BJU International. 118 (1), 20-34 (2016).
- Manfredi, M., et al. Total anatomical reconstruction during robot-assisted radical prostatectomy: focus on urinary continence recovery and related complications after 1000 procedures. BJU international. 124 (3), 477-486 (2019).
