A Pragmatic Randomized Controlled Trial Examining the Impact of the Retzius-sparing Approach on Early Urinary Continence Recovery After Robot-assisted Radical Prostatectomy

doi:10.1016/j.eururo.2017.04.029

European Urology

Volume 72, Issue 5, November 2017, Pages 677-685

https://doi.org/10.1016/j.eururo.2017.04.029 Get rights and content

Abstract

Background

Retzius-sparing (posterior) robot-assisted radical prostatectomy (RARP) may expedite postoperative urinary continence recovery.

Objective

To compare the short-term (≤3 mo) urinary continence (UC), urinary function (UF), and UF-related bother outcomes of posterior RARP compared with standard anterior approach RARP.

Design, setting, and participants

A total of 120 patients aged 40–75 yr with low–intermediate-risk prostate cancer (per the National Comprehensive Cancer Network guidelines) underwent primary RARP at a tertiary care institution.

Intervention

Eligible men were randomized to receive either posterior (n = 60) or anterior (n = 60) RARP.

Outcome measurements and statistical analyses

Primary outcome was UC (defined as 0 pads/one security liner per day) 1 week after catheter removal. Secondary outcomes were short-term (≤3 mo) UC recovery, and UF and UF-related bother scores (measured by the International Prostate Symptom Score [IPSS] and IPSS quality-of-life scores, respectively) assessed at 1 and 2 wk, and 1 and 3 mo following catheter removal. Continence outcomes were objectively verified using 24-hr pad weights. UC recovery was analyzed using Kaplan–Meier method and Cox proportional hazards regression; UF and UF-related bother outcomes were compared using linear generalized estimating equations (GEEs). Perioperative complications, positive surgical margin, and biochemical recurrence-free survival (BCRFS) represent secondary outcomes reported in the study.

Results and limitations

Compared with 48% in the anterior arm, 71% men undergoing posterior RARP were continent 1 wk after catheter removal (p = 0.01); corresponding median 24-h pad weights were 25 and 5 g (p = 0.001). Median time to continence in posterior versus anterior RARP was 2 and 8 d postcatheter removal, respectively (log-rank p = 0.02); results were confirmed on multivariable regression analyses. GEE analyses showed that UF-related bother (but not UF) scores were significantly lower in the posterior versus anterior RARP group at 1 wk, 2 wk, and 1 mo on GEE analyses. Incidence of postoperative complications (12% anterior vs 18% posterior) and probability of BCRFS (0.91 vs 0.91) were comparable in the two arms.

Conclusions

In this single-center randomized study, the Retzius-sparing approach of RARP resulted in earlier recovery of UC and lower UF-related bother compared with standard RARP. These results require long-term validation and reproduction by other centers, as well as studies on men with high-risk localized disease.

Patient summary

In our hands, men with low–intermediate-risk prostate cancer undergoing Retzius-sparing robot-assisted radical prostatectomy (RARP) had earlier recovery of urinary continence and lower urinary function-related bother than those undergoing standard RARP.

Introduction

Prostate cancer continues to be the most common solid organ malignancy in men in developed world [1]. The incidence is expected to rise as the population ages and longevity increases. Radical prostatectomy (RP) is arguably the most common treatment offered in those eligible for it. The goal of an RP is to achieve complete cancer control while preserving urinary and sexual faculties.

Studies of open RP have suggested urinary continence following surgery to be one of the most important indicators of quality of life and treatment satisfaction [2], [3]. Analyses of Medicare data have shown that at 1 yr after open surgery, approximately 30% of men continue to experience urinary incontinence (including those operated by high-volume surgeons) [4] or are bothered by it [5]. The highest rates of urinary incontinence and associated bother are noted in the first 2–6 mo after surgery [3], [6], [7]. More recently, increasing utilization and surgeon experience with the robotic platform have improved urinary continence rates to 70–95% at 12 mo [8]. However, lack of urinary continence in the select few and the time to continence continue to be issues of significant bother even among men undergoing robot-assisted radical prostatectomy (RARP) [5].

In this context, Galfano and colleagues [9], [10] have recently described their technique of a Retzius-sparing approach of RARP (posterior RARP), noting urinary continence (measured as 0 pads/one safety liner per day) rate of ∼90% at 1 wk after catheter removal. In a pilot study of 81 patients, we noted a 78% continence rate at 1 wk after catheter removal in patients who underwent the Retzius-sparing approach, compared with 50% in those who underwent the traditional RARP. Encouraged by these findings, we sought to compare the efficacy of conventional (anterior) approach for RARP [11], [12] with that of the posterior approach for RARP on short-term, patient-reported urinary continence, in the setting of a randomized controlled trial (RCT). We hypothesized that patients undergoing posterior RARP will have faster recovery of urinary continence, along with favorable urinary bother outcomes. While this paper focuses on urinary continence, overall urinary function, and urinary bother, the accompanying paper details other secondary outcomes, including sexual function, perioperative morbidity, and short-term oncological outcomes.

Section snippets

Patients and methods

We conducted a two-group, parallel-design, pragmatic trial of 120 consecutive patients aged 40–75 yr with low–intermediate-risk prostate cancer (according to the National Comprehensive Cancer Network [NCCN]) undergoing primary RARP by a single surgical team (M.M./W.J.) at a tertiary care institution (Vattikuti Urology Institute) (see Fig. 1 and Supplementary material for details). Men with a high risk of NCCN, cN1 or M1 prostate cancer, or pre-existing urinary incontinence were excluded. The

Baseline demographics

A total of 120 consecutive, eligible, and consenting patients were randomized to receive either an anterior (n = 60) or a posterior approach (n = 60; of these, three patients were converted to the anterior approach). Notably, 75% and 77% of patients in the anterior and posterior arms, respectively, harbored NCCN intermediate-risk disease (Table 1). Thirty-nine (65%) patients in the anterior and 37/60 (62%) in the posterior RARP arm underwent bilateral veil nerve sparing (p = 0.9).

Primary outcome: urinary continence at 1 wk after catheter removal

In the

Discussion

Within the last decade, a number of technical modifications have been suggested to improve urinary continence in patients undergoing RARP [8], [22], [23]. Schuessler et al [24] were the first to describe the Retzius-sparing approach in a series of nine patients undergoing laparoscopic RP. Additionally, large-scale studies by Prabhu et al [6], Donovan et al [7], and Sanda et al [3] have already shown that the highest rates of urinary incontinence are seen 2–6 mo after surgery, which improve

Conclusions

Our study demonstrates earlier recovery of continence in patients with clinically low–intermediate-risk prostate cancer, undergoing Retzius-sparing prostatectomy without a compromise of perioperative outcomes. These results require long-term validation and reproduction by other centers, as well as studies on men with high-risk localized disease.

References (30)

M.A. Liss et al.
Continence definition after radical prostatectomy using urinary quality of life: evaluation of patient reported validated questionnaires
J Urol
(2010)
V. Prabhu et al.
Long-term continence outcomes in men undergoing radical prostatectomy for clinically localized prostate cancer
Eur Urol
(2014)
V. Ficarra et al.
Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy
Eur Urol
(2012)
A. Galfano et al.
A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery
Eur Urol
(2010)
A. Galfano 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
Eur Urol
(2013)
M. Menon et al.
Vattikuti Institute prostatectomy: technical modifications in 2009
Eur Urol
(2009)
M. Menon et al.
Vattikuti Institute prostatectomy: technique
J Urol
(2003)
M. Menon et al.
Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial
J Urol
(2008)
J.F. Tsui et al.
Pad count is a poor measure of the severity of urinary incontinence
J Urol
(2013)
S.M. Donat
Standards for surgical complication reporting in urologic oncology: time for a change
Urology
(2007)

P.K. Agarwal et al.

Safety profile of robot-assisted radical prostatectomy: a standardized report of complications in 3317 patients

Eur Urol

(2011)

M. Menon et al.

Potency following robotic radical prostatectomy: a questionnaire based analysis of outcomes after conventional nerve sparing and prostatic fascia sparing techniques

J Urol

(2005)

R.M. Califf et al.

Prognostic value of a coronary artery jeopardy score

J Am Coll Cardiol

(1985)

F. Porpiglia et al.

Total anatomical reconstruction during robot-assisted radical prostatectomy: implications on early recovery of urinary continence

Eur Urol

(2016)

V. Student et al.

Advanced reconstruction of vesicourethral support (ARVUS) during robot-assisted radical prostatectomy: one-year functional outcomes in a two-group randomised controlled trial

Eur Urol

(2017)

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A novel anterior approach that involves Retzius space development between the umbilical ligaments is associated with a lower incidence of postoperative inguinal hernia in robotic radical prostatectomy
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To facilitate robotic radical prostatectomy (RP), we developed a novel anterior approach that utilizes a peritoneal incision between the umbilical ligaments to develop the Retzius space without contacting the internal inguinal rings, followed by closure of this space prior to prostatectomy and vesicourethral anastomosis. This approach could decrease the incidence of postoperative inguinal hernia (IH), similar to a Retzius-sparing RP (RS-RP). We compared the incidence of IH following this novel approach with that following conventional anterior RP and RS-RP.
We retrospectively reviewed 532 patients who underwent robotic RP from September 2017 to August 2022. We compared the incidence of IH following novel anterior RP (n = 153) to that following conventional anterior RP (n = 284) and RS-RP (n = 95). We also assessed the independent factors associated with postoperative IH using Cox hazard models.
The 12- and 24-month cumulative incidences of postoperative IH following novel anterior RP were 1.3% and 1.3%, significantly lower than those associated with conventional anterior RP (8.0% and 12.6%, p = 0.009) but not significantly different from those following RS-RP (1.1% and 2.1%, p = 0.782). In multivariate analysis, use of the novel anterior RP approach, RS-RP, and body mass index were independent factors negatively associated with the occurrence of postoperative IH.
This novel anterior approach involves developing the Retzius space between the umbilical ligaments and closure of this space following prostatectomy and vesicourethral anastomosis. It can decrease the incidence of IH compared to the conventional anterior approach. Prospective comparative studies are necessary to confirm the benefits of this approach.
Is Urethral Catheterization Necessary in Retzius-sparing Robot-assisted Radical Prostatectomy?
2023, Urology
To analyze whether urethral catheter (UC)-free anastomosis during Retzius-sparing radical prostatectomy (RP) results in worsening immediate perioperative and postoperative complications.
We retrospectively reviewed records of patients undergoing robotic-assisted RP with or without indwelling UC placement by a single surgeon between January 2020 and March 2022. Clinical and pathological characteristics were evaluated. An independent t-test was used to compare continuous variables, and Pearson’s chi-square test or Fisher exact test was used to compare categorical variables.
One hundred fifteen patients underwent robotic prostatectomy from January 2020 to June 2022. Sixty-two patients had both a UC for 12 hours postoperatively and a suprapubic catheter for 6 days, while in 53 patients a UC was omitted. There was no significant difference noted between the groups regarding age, body mass index, American Society of Anesthesiology score, prostate-specific antigen, stage, node status, or positive margins. There were no significant differences in the rates of anastomotic leak, ileus, or urethral stricture. Patients had a significantly higher pad-free rate in the suprapubic catheter-only group (P = .04) at 3 months. There was no difference in average number of pads used or the number using more than 1 pad/day.
Omission of urethral catheterization during Retzius-sparing RP is safe and doesn’t result in an increased risk in perioperative or postoperative complications, but rather appears to be associated with a significantly improved 3-month pad-free rate.
Lower Detrusor Apron–sparing Robot-assisted Radical Cystectomy and Intracorporeal Neobladder Reconstruction: Technique and Preliminary Outcomes
2023, European Urology Focus
Prior studies on robot-assisted laparoscopic prostatectomy (RALP) have shown that preservation of the anterior periprostatic structures is associated with good functional outcomes in terms of urinary continence and erectile function. With this in mind, we developed a technique for preservation of the lower part of the detrusor apron (LDA) and anterior periprostatic structures at the time of robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction.
To describe our LDA-sparing RARC technique and to assess its safety and outcomes.
We retrospectively evaluated 11 patients who underwent LDA-sparing RARC and ICNB reconstruction at our centre from January 2017 to May 2021.
In brief, after developing the plane posterior to the bladder and prostate, the dissection proceeds laterally on both sides of the prostate in an effort to identify the prostatic pedicle. At this point, the bladder pedicles are sectioned in an antegrade fashion. Once the prostate is reached, the dissection is continued laterally by developing the plane that was previously identified. The neurovascular bundles and the lateral and anterior periprostatic structures are conserved in toto. Neobladder reconstruction is performed intracorporeally.
Postoperative complications, urinary continence (UC), and erectile function (EF).
The median console time was 290 min. The 30-d complication rate was 36%, with two Clavien-Dindo grade II and two grade III complications that were not attributable to the novel surgical technique. At 12 mo, all patients reported daytime UC or use of a safety pad; at night, seven patients were continent or used a safety pad. Regarding 12-mo EF, four patients were potent without a need for medications, while six were potent with the use of oral phosphodiesterase type 5 inhibitors and one with the use of intracavernosal injections. Limitations include the small number of cases.
LDA-sparing RARC is an applicable and reproducible procedure. Our results suggest that this approach is associated with good functional outcomes in terms of UC and EF.
We describe a novel approach for robot-assisted removal of the bladder that allows greater preservation of nerve bundles and other structures. Our study shows that the technique is safe and associated with good outcomes for urinary function and erectile function for patients eligible for this surgical procedure.
Retzius-sparing robotic prostatectomy is associated with higher positive surgical margin rate in anterior tumors, but not in posterior tumors, compared to conventional anterior robotic prostatectomy
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Citation Excerpt :
Oncological safety of rsRARP on the other hand, compared to cRARP is controversial. Although some studies have showed that biochemical recurrence (BCR)-free survival in rsRARP was not inferior compared to cRARP, other studies reported that rsRARP offers a higher positive surgical margin (PSM) than cRARP, especially for anterior tumors.12–16 It was therefore aimed to analyze whether oncological outcomes differed between cRARP and rsRARP, and how tumor location affects the comparison of the oncological outcomes between the two procedures.
The analysis of the oncological outcomes and postoperative continence recovery between conventional robotic-assisted radical prostatectomy (cRARP) and Retzius-sparing RARP (rsRARP), and the effect of the tumor location on them.
A total of 317 patients who underwent cRARP (n = 228) or rsRARP (n = 89) from August 2017 to July 2020 were assessed. Patients were categorized into groups based on the tumor location by pathology. Positive surgical margin (PSM) rates and biochemical recurrence (BCR)-free survivals and continence recovery were compared between the two procedures.
Patient age, prostate-specific antigen (PSA) levels, clinical stages, and Gleason score were not significantly different between the two groups. There was no significant difference in PSM rates (25.8% vs. 33.7%, p = 0.13) or BCR-free survivals (p = 0.28) between cRARP and rsRARP in patients. When tumor was located in the anterior lesion in the prostatectomy pathology, rsRARP was associated with significantly higher PSM rates than cRARP (53.3% in rsRARP vs. 27.0% in cRARP, p = 0.0086), while BCR-free survival did not vary significantly (hazard ratio: 2.15, p = 0.11). When tumors were identified in the posterior in prostatectomy pathology, PSM rates (28.8% in rsRARP vs. 24.7% in cRARP, p = 0.59) or BCR-free survivals (hazard ratio: 0.78, p = 0.51) did not differ significantly between the two groups. rsRARP yielded superior continence recovery in all time points compared to cRARP, which was not affected by the pathological tumor location.
In posterior tumors, rsRARP results in similar oncological outcomes as cRARP with superior continence recovery, while in anterior tumors, rsRARP may associate with higher PSM rate, combined with improved continence recovery.
Modified Retzius-sparing robot-assisted radical prostatectomy for cases with anterior tumor: a propensity score-matched analysis
2024, World Journal of Urology
Retzius-sparing vs. posterior urethral suspension: similar early-phase post-robotic radical prostatectomy continence outcomes
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^†: These authors contributed equally.

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