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Article of the Week: Retzius-sparing RALP: combining the best of retropubic and perineal approaches

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video demonstrating the Retzius-sparing approach to robot-assisted prostatectomy.

If you only have time to read one article this week, it should be this one.

Retzius-sparing robot-assisted laparoscopic radical prostatectomy: combining the best of retropubic and perineal approaches

Sey Kiat Lim*, Kwang Hyun Kim*, Tae-Young Shin*, Woong Kyu Han*, Byung Ha Chung*, Sung Joon Hong*, Young Deuk Choi* and Koon Ho Rha*

*Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea and Department of Urology, Changi General Hospital, Singapore

OBJECTIVE

To compare the early peri-operative, oncological and continence outcomes of Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RALP) with those of conventional RALP.

MATERIALS AND METHODS

Data from 50 patients who underwent Retzius-sparing RALP and who had at least 6 months of follow-up were prospectively collected and compared with a database of patients who underwent conventional RALP. Propensity-score matching was performed using seven preoperative variables, and postoperative variables were compared between the groups.

RESULTS

A total of 581 patients who had undergone RALP were evaluated in the present study. Although preoperative characteristics were different before propensity-score matching, these differences were resolved after matching. There were no significant differences in mean length of hospital stay, estimated blood loss, intra- and postoperative complication rates, pathological stage of disease, Gleason scores, tumour volumes and positive surgical margins between the conventional RALP and Retzius-sparing RALP groups. Console time was shorter for Retzius-sparing RALP. Recovery of early continence (defined as 0 pads used) at 4 weeks after RALP was significantly better in the Retzius-sparing RALP group than in the conventional RALP group.

CONCLUSIONS

The present results suggest that Retzius-sparing RALP, although technically more demanding, was as feasible and effective as conventional RALP, and also led to a shorter operating time and faster recovery of early continence. Retzius-sparing RALP was also reproducible and achievable in all cases.

Editorial: Pushing the robot-assisted prostatectomy envelope – to the safety limits? Better outcomes

The present article by Lim et al. [1] describing the new technique for robot-assisted radical prostatectomy is provocative. It really does highlight the dramatic improvement in outcomes of prostate cancer surgery for men over the last 25 years. What used to be a 3-week hospital stay with a 50% incontinence rate and a 100% impotence rate [2, 3] now becomes a day case with a high likelihood of excellent urinary control early after surgery and a fair potential for potency preservation. Twenty-five years ago men who underwent radical prostatectomy were truly brave patients.

Lim et al. report a single series by the senior author of 50 cases performed using the so-called Retzius preservation technique. Their cohort of 50 patients treated this way was compared with a retrospective cohort of the surgeon’s patients. The patients had lower-risk disease and patients who had seminal vesicle invasion or extracapsular extension noted preoperatively, presumably on MRI, were excluded from the series. The authors report a shorter operating time and an earlier return to urinary continence in the first 6 months after surgery.

I guess where surgeons are now taking us is to an attempt to remove the prostate from the hammock of neurovascular, muscular and fascial tissue surrounding it, without disturbing the anatomy [4]. If this can be achieved then radical prostatectomy with minimal morbidity is a very compelling choice for the primary treatment of prostate cancer.

The authors’ hypothesis is that preservation of the levator fascia, puboprostatic ligaments and detrusor apron will fix the bladder somewhat like a sling would, with support at the bladder neck during increased intra-abdominal pressure.

It should be noted, however, that the present paper represents a single series of patients selected after a long learning curve by a very experienced surgeon. These excellent outcomes may simply reflect the fact that the surgeon is now extremely technically capable. It is contentious to assume that a propensity score matching of a retrospective cohort would represent a true comparator to contemporary outcomes. These excellent outcomes probably reflect technical improvements achievable with more risky and innovative surgery – after many cases. The authors should be congratulated on pushing the envelope to achieve even better outcomes for patients undergoing this operation, but the exclusion of patients with high-risk disease is probably the major negative aspect of their report. It has become increasingly obvious that patients with high-risk disease are those who benefit most from radical prostatectomy surgery. Surgery for patients with very-low-risk disease (Gleason 6) is probably unnecessary. Nevertheless, with continued insights such as those provided by these surgeons, we may be able to increase the range of patients to whom Retzius-sparing surgery in higher risk cohorts can be offered.

Anthony J. Costello
Department of Urology, Royal Melbourne Hospital, Parkville, Victoria, Australia

References

  1. Lim SK, Kim KH, Shin T-Y et al. Retzius-sparing Robot-assisted Laparoscopic Radical Prostatectomy – combining the best of retropubic and perineal approaches. BJU Int 2014; 114: 236–244
  2. Wein AJ, Kavousi LR, Novick AC, Partin AW, Peters CA. Campbell-Walsh Urology, 10th edn. Saint Louis, MO: Saunders, 2011: 5688
  3. Catalona WJ, Carvalhal GF, Mager DE, Smith DS. Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol 1999; 162: 433–438
  4. Costello AJ, Brooks M, Cole OJ. Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU Int 2004; 94: 1071–1076

Video: Retzius-sparing approach to RALP

Retzius-sparing robot-assisted laparoscopic radical prostatectomy: combining the best of retropubic and perineal approaches

Sey Kiat Lim*, Kwang Hyun Kim*, Tae-Young Shin*, Woong Kyu Han*, Byung Ha Chung*, Sung Joon Hong*, Young Deuk Choi* and Koon Ho Rha*

*Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, South Korea and Department of Urology, Changi General Hospital, Singapore

OBJECTIVE

To compare the early peri-operative, oncological and continence outcomes of Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RALP) with those of conventional RALP.

MATERIALS AND METHODS

Data from 50 patients who underwent Retzius-sparing RALP and who had at least 6 months of follow-up were prospectively collected and compared with a database of patients who underwent conventional RALP. Propensity-score matching was performed using seven preoperative variables, and postoperative variables were compared between the groups.

RESULTS

A total of 581 patients who had undergone RALP were evaluated in the present study. Although preoperative characteristics were different before propensity-score matching, these differences were resolved after matching. There were no significant differences in mean length of hospital stay, estimated blood loss, intra- and postoperative complication rates, pathological stage of disease, Gleason scores, tumour volumes and positive surgical margins between the conventional RALP and Retzius-sparing RALP groups. Console time was shorter for Retzius-sparing RALP. Recovery of early continence (defined as 0 pads used) at 4 weeks after RALP was significantly better in the Retzius-sparing RALP group than in the conventional RALP group.

CONCLUSIONS

The present results suggest that Retzius-sparing RALP, although technically more demanding, was as feasible and effective as conventional RALP, and also led to a shorter operating time and faster recovery of early continence. Retzius-sparing RALP was also reproducible and achievable in all cases.

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