Complete urethral preservation in robot‐assisted radical prostatectomy: step‐by‐step description of surgical technique

摘要

Robot-assisted radical prostatectomy (RARP) is one of the treatment options for localised clinically significant prostate cancer [1]. However, postoperative urinary incontinence (UI) affects 4–31% of patients 12 months after surgery and is associated with a reduced quality of life [2]. Several surgical strategies have been described to reduce the incidence of UI, including anterior and posterior reconstruction [3], dorsal venous complex and preperitoneal space sparing (PSS) [4], but no consensus exists on the best method to achieve early return of continence. Bladder neck preservation (BNP) aims to safeguard the internal sphincter (lisso-sphincter), believed to support passive continence, which was recently supported by a systematic review [5]. This effect could be amplified by increasing the length of the spared intraprostatic urethra to achieve coaptation when intra-abdominal pressure increases [6] (Fig. 1). In fact, a urethral sparing method was described by Tongco et al. [7] in open RPs but was never widely adopted. The advantages of robotic surgery allow for improved anatomical dissection, to go beyond the standard BNP and dissect the intraprostatic urethra away from the prostatic tissue in a reproducible way. In this paper, we describe the steps and anatomical landmarks to perform the complete urethral preservation (CUP) technique. Our objective was to evaluate the rate of immediate continence recovery (ICR), and present oncological outcomes in a cohort of patients with a minimum 1-year follow-up (Video 1). We retrospectively collected data for patients with prostate cancer who underwent RARP with CUP at University College London Hospitals, from June 2021 to August 2022. Surgeries were performed by a single high-volume urological surgeon (G.S.), and by trainees under supervision, using the da Vinci X/Xi® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA). A successful CUP was defined as the incision of the urethra at the proximal end of the verumontanum with direct end-to-end anastomosis to the membranous urethra. Continence outcomes were collected during clinical follow-up. ICR was defined as the absence of leakage and the use of zero pads immediately after urethral catheter removal. Biochemical recurrence (BCR) was defined as a PSA level of 0.2 ng/mL at any point after RARP. All data were collected by a dedicated database manager as part of the prospective audit within the quality assurance programme, additional data specific for this project were collected retrospectively by T.A.H., R.A., G.S., L.T. and O.A. Descriptive statistical analysis was performed using R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). Trocar placement is standard for anterior RARP [8]. After developing the Retzius space, removal of pre-prostatic fat to expose the puboprostatic ligaments, the bladder is retracted cranially and posteriorly using a ProGrasp® instrument (Intuitive Surgical Inc.). An incision is made in the bladder muscular fibres with monopolar scissors proximal to the edge of the puboprostatic ligaments (Fig. 2A). By changing the tension of bladder retraction posteriorly, dissection proceeds along the avascular plane of the lateral vesico-prostatic junction, where the plane resembles the ‘spine of an open book’ (Fig. 2B). Once the vertical fibres of the urethra are identified, perform blunt dissection along the lateral edges using the active opening of the fenestrated bipolar (FB) forceps (Fig. 2C). Correct alignment is indicated by finding the white avascular plane. The FB forceps can be used to lift the prostate away from the urethra, exposing its anterior surface at the most distal point achievable (Fig. 2D). The urethra appears thin and changes trajectory near the level of the verumontanum. The anterior urethra is incised horizontally at the most distal point. If needed, the catheter can be used for anterior retraction with the ProGrasp to expose the verumontanum. Otherwise, exert cranial retracti