Retzius-sparing robotic radical prostatectomy

Abstract

Traditional approach to the prostate during radical prostatectomy (RP) when performed by open, laparoscopic, or robotic means has been from its anterior aspect first and has involved suture ligation and division of the dorsal vein complex (DVC), division of the puboprostatic ligaments, and incision of the endopelvic fascia on either side of the prostate. These steps are necessary to liberate the prostate from its surrounding attachments, even though concern has always existed about the likely association between disruption of these structures and postprostatectomy incontinence (PPI). Although perineal prostatectomy leaves these structures intact, it has failed to become widely accepted because of the small incidence of postoperative fecal incontinence and the difficulty in performing a pelvic lymphadenectomy (PLND) when this is indicated. Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) was first described by Galfano et al.1 It represents the continuation in an anterior direction of the posterior approach to the vasa and seminal vesicles through a posterior peritonectomy, first described as a part of initial step of laparoscopic RP by Guillonneau and Vallencien in 2000.2 The challenges of this approach include a small workspace, no lateral aiming point when dissecting the lateral pedicles of the prostate, an inability to look into the bladder after bladder neck division to verify the position of the ureteric orifices, and an inverted relationship between the bladder and prostate during dissection and reconstruction. A PubMed search of the English language using the term “Retzius-sparing radical prostatectomy” was conducted before writing this review of the technique. The important role played by the structures anterior to the apex of the prostate in stabilizing the external urinary sphincter has been revealed by the significantly better early urinary continence noted in published series of RS-RARP, which includes small randomized controlled trials done by Menon and coworkers and Asimakopoulos and colleagues (Table 1).345678 The results show that initial continence is approximately three times better than that after anterior approach (AA) RP. Based on the fact that of the various consequences of RP that negatively impact a patient's quality of life,9 postprostatectomy SUI (PPSUI) has the greatest single influence.10 This is of considerable importance to patients and is likely to reduce the appeal of nonsurgical options for treating operable prostate cancer.Table 1: Published series of Retzius-sparing robot-assisted radical prostatectomy3 4 5 6 7 8At least theoretically, preservation of the arteries within the DVC, as well as the accessory pudendal arteries found in 30% of men, might also lead to better postoperative potency, and the author has started to see a trend that supports this, although longer follow-up supported by patient-reported outcome questionnaires is needed to clarify this observation. The author also feels that being forced to begin the neurovascular bundle (NVB) preservation (or indeed, excision, if that is the aim) posterior to the prostate by freeing it in the intrafascial or interfascial plane before dividing the lateral pedicles, as one is during RS-RARP, results in a lower risk of inadvertent NVB injury, especially to the proximal NVB, and better postoperative potency. A further advantage of RS-RARP includes a shorter operating time through the omission of several steps done during AA-RARP: mobilization of the bladder, defatting the prostate, incision of the endopelvic fascia, ligation and division of the DVC, and anatomical reconstruction such as insertion of a Rocco suture. In addition, recent analysis of the author's first 320 cases (Table 2) showed similar operating time for prostates <70 g and >70 g (179 min and 177 min; P ≤ 0.001), a similar transfusion rate (3 units and 1 unit; P = 0.94), a similar postoperation hospital stay (1.9 nights and 1.8 nights; P = 1.00), similar Clavien 1, 2