Retziussparing robotassisted laparoscopic ... - Wiley Online Library

Robotics and Laparoscopy

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.

Introduction The trifecta (cancer free, potent and continent) in robot-assisted laparoscopic radical prostatectomy (RALP) was proposed in 2005 and has since become the ‘Holy Grail’ that urologists seek to achieve [1]. Continence rates at 1 month after RALP have been reported to be as low as 7.1% [2]. A recent review reported a weighted mean continence rate of 53.2% at 1 month after RALP [3] and another study reported that 55% of patients indicated substantial bother from incontinence at 1-month follow-up [4]. Although most patients eventually regain continence within 1–2 years [3,4], this time lag in improvement could severely affect their quality of life [4]. In the era of open surgery, two approaches to radical prostatectomy (RP) have prevailed, namely the retropubic and

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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.

Keywords prostatectomy, prostate cancer, continence, nerve-sparing, perineal

the perineal approaches, each having advantages and disadvantages. As we entered the age of minimally invasive surgery, the techniques of the retropubic approach were replicated. Many of these techniques have been developed to improve early continence rates after RALP, including various techniques of anterior suspension and posterior reconstruction [2,5]. Most of these techniques aim to restore the normal anatomy so that functional outcomes can be optimised. Nearly all published techniques to date have involved dropping the bladder and entering the Retzius space at some point during RALP. Galfano et al. [6] reported their initial success in performing a novel Retzius-sparing RALP in three out of five patients in 2010. More recently, this Milan group have also reported excellent oncological and functional outcomes in 200 patients who underwent Retzius-sparing RALP [7]; however, their study was a single-arm study © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12705 Published by John Wiley & Sons Ltd. www.bjui.org

Retzius-sparing approach to robot-assisted prostatectomy

without comparison with outcomes of the more conventional non-Retzius-sparing RALP technique, and their reported outcomes have yet to be validated. In the present study, we compared the early peri-operative, oncological and continence outcomes of 50 patients who underwent Retzius-sparing RALP with a database consisting of >500 patients who underwent conventional RALP.

goodness-of-fit test (P = 0.353), which indicated that this model prediction was not significantly different from observed values, thus making the two groups comparable. Surgical Technique

Methods and Materials

Our surgical technique for conventional RALP has been described previously [9]. Our Retzius-sparing RALP technique was similar to that described by Galfano et al. [7]. Modifications used in our technique are as described below.

Patient Selection

Trocar placement

A total of 50 patients who underwent Retzius-sparing RALP in our institution, performed by a single surgeon (K.H.R.), with at least 6 months of follow-up were included in this study. Although we selected only organ-confined, biopsy Gleason 6 tumours for our first five cases, we subsequently expanded our selection criteria to include all patients in whom RPs were indicated. Patients with metastatic disease or suspected lymph node involvement at diagnosis or who were receiving neoadjuvant hormonal therapy were excluded. Tumours with extracapsular extension or seminal vesicle involvement on preoperative staging were not contraindicated in this study.

Trocar placement in our Retzius-sparing RALP technique is largely similar to our conventional RALP technique [9], except the distances of the right-sided robotic ports are 7 cm instead of 8 cm apart from one another and from the camera port (Fig. 1). The EndoWrist scissor is inserted into the right-most port and the Endowrist atraumatic grasper (both Intuitive Surgical, Sunnyvale, CA, USA) into the more medial right-sided port.

Preoperative Evaluation and Postoperative Management All patients had undergone preoperative MRI of prostate and bone scans. Potency was assessed preoperatively at the time of admission using the Sexual Health Inventory for Men score. All patients were managed according to our standard postoperative protocol for RALP during their hospital stay. Patients were seen on postoperative days 8–10 for removal of urinary catheters by the surgeon himself. They were subsequently reviewed 4 weeks after surgery for serum PSA and assessment of their continence with the validated International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form [8].

Mobilisation of the colon and posterior peritoneal incision A 0° lens is used. The patient is placed in a steep Trendelenburg position, and the sigmoid colon is freed from its adherences to the lateral abdominal wall. The bowels are then mobilised cranially to expose the rectovesical space. A horizontal incision is made over the peritoneum in the rectovesical space slightly above the level of the vas deferens. The vas deferens is mobilised and clipped bilaterally. Athermal dissection of seminal vesicles The plane between the seminal vesicles and the surrounding tissues is developed and any vessels identified are secured with 2-mm clips before ligation. Extreme care to avoid coagulation and traction is taken posterolateral to the seminal vesicles Fig. 1 The ports configuration of a totally posterior approach to robot-assisted laparoscopic prostatectomy.

Comparison between Groups, Propensity Matching and Statistical Analysis Patients who underwent Retzius-sparing RALP were compared with a prospectively maintained database of 531 patients who underwent conventional RALP by the same surgeon (K.H.R.) during the period July 2005 to October 2012. A further subset analysis was performed with 50 propensity-score-matched patients from the conventional RALP database. Propensity-score matching was performed using the preoperative variables of age, body mass index, PSA, clinical T-stage, biopsy Gleason score, total number of biopsied positive cores and prostate volumes on TRUS. The discrimination and calibration abilities of the propensity score model were assessed using a Hosmer–Lemeshow

8 cm 5 mm port 7 cm 8 mm port

7 cm

8 cm

8 mm port

8 cm 12 mm port

8 mm port

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because of the close proximity to the neurovascular bundle (NVB). In low-risk cancers, the tips of the seminal vesicles may be left in place to minimize NVB injuries. Both seminal vesicles and vas deferens are then pulled upwards with the grasper. Posterior dissection

Fig. 2 A, Incision of the bladder neck is performed with gentle traction of the prostate downwards. Counter-traction is provided by the bladder attached to the anterior abdominal wall. B, Circumapical dissection of the urethra. This allows the maximum length of the urethra to be spared and improves continence.

a Bladder

The avascular plane between Denonvilliers’ fascia and the posterior prostatic fascia is developed with the aid of the suction by the assistant. The dissection is carried out as far in depth as possible to reach the prostate–urethral junction, keeping close to the prostate at all times to minimise rectal injuries. The NVB is thus freed from the posterior aspect of the prostate.

Bladder Neck

Lateral dissection and nerve-sparing Lateral dissection of the lateral prostatic pedicles commences by displacing the vas deferens and seminal vesicles gently downwards and contralateral to the side of dissection. Starting posterolaterally, dissection of the prostate is performed circumferentially towards the antero-lateral aspect of the prostate and from the bladder neck distally towards the apex of the prostate. Lateral margins of dissection (intrafascial/ interfascial /extrafascial) are dependent on risk of cancer. Respecting the various possible reported anatomy of the NVB, a combination of sharp and blunt dissection is performed, following the curve of the prostate. Any vessels encountered along the way are clipped and divided. Following the principles of tension and energy-free dissection, lateral traction of the NVB and use of coagulation are minimised. Instead, the NVB is peeled from the prostate capsule with the scissors moving longitudinally in a posteromedial and anteromedial direction as far as possible. The dissection continues distally until the lateral aspect of the urethral and the dorsal venous complex (DVC) is visible. The procedure is then repeated on the opposite side. At this stage, the posterior and lateral aspects of the prostate are freed.

Prostate

b

Urethra

Apex of prostate

Bladder neck dissection With the bladder and prostate still attached to the anterior abdominal wall, the prostatovesical junction (Fig. 2A) can be more easily identified by: (1) a notch between the bladder and the prostate; (2) Careful dissection and removal of the peri-vesicle fat around the bladder neck until the detrusor muscles are seen; (3) traction of the prostate downwards to tent the bladder neck. With sharp dissection, the detrusor muscles at the bladder neck are cut and the bladder entered posteriorly. The anterior bladder mucosa is visualised and dissected to form the anterior lip of the bladder neck. The prostate capsule cannot be identified anteriorly where the anterior fibromuscular stroma, including the detrusor apron, is found. At the apex and the base, the prostate stroma blends with the muscle fibres of the urinary sphincter and detrusor muscles, respectively [10]; thus, to avoid a positive anterior

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surgical margin, the anterior bladder neck is retracted anteriorly, and the plane dissection is directed slightly anteriorly towards the anterior abdominal wall but still sparing the detrusor apron and pubovesical complex. Because of this manoeuvre, in some cases, instead of reaching the avascular plane between the DVC and the urethra, the DVC may be opened. Circum-apical dissection of the urethra is performed and the urethra is then dissected a few mm distal to the prostatic notch after the catheter is withdrawn (Fig. 2B). Vesico-urethral anastomosis The scissors and Maryland bipolar forceps are replaced with needle drivers. The vesico-urethral anastomosis is performed (Fig. 3A,B) with two 25-cm 3/0 Synthetic absorbable


Fig. 3 Vesico-urethral anastomosis. A, Anastomosis begins at the 12 o'clock position, starting with the anterior bladder neck and the anterior lid of the urethra. B, The urinary catheter is inserted into the bladder after completing the anastomosis at the 3 and 9 o'clock positions. Anastomosis of the posterior bladder neck and the posterior urethra lid are subsequently performed.

a

Anterior bladder neck

Anterior lid of urethra

b

Packing and closure of peritoneal incision The retroperitoneal space is now packed with absorbable hemostats and tissue glue and anti-adhesives are applied. We routinely close the peritoneal incision, starting in the middle with two 22-cm 3/0 vicryl sutures, tied at their tails with clips. The closure is secured at both ends with Lapra-Ty (Ethicon, Somerville, NJ, USA). Pelvic lymph node dissection Standard pelvic lymph node dissection (PLND) begins with a separate 1–2-cm longitudinal incision made towards the apex of the triangle formed by the medial umbilical ligament and the vas deferens. The base of the triangle is formed by the anterior abdominal wall. PLND of the external iliac, obturator and infraobturator areas are then performed and repeated on the opposite side. Extended PLND (ePLND) commenced with extension of the peritoneal incision into a U-shaped one, as described by Galfano et al. [7]. The boundaries of ePLND include the intrapelvic area (internal iliac, obturator and external iliac), common iliac and up to ureteric crossing. Incisions made for PLND are not closed and a drain is inserted routinely to reduce the risk of lymphocele formation.

Results Posterior bladder neck

Posterior lid of urethra

monofilament sutures knotted at the tails to form a double arm. Starting with the right-sided suture, anastomosis is performed by suturing the anterior bladder neck to the anterior urethra margin at the 12 o’clock position. With a running suture technique, anastomosis is continued anteriorly on the right side until the 3 o’clock position. The procedure is then repeated on the left side from the 11 o’clock to the 9 o’clock position. At this juncture, the catheter is inserted into the bladder and anastomosis of the posterior bladder neck and urethra is resumed bilaterally until both sutures meet close to the 6 o’clock position. A new 16-F silicone catheter is now inserted and its balloon inflated with 10 mL water. Both ends of the sutures are tied together and a water-tight closure is confirmed with 150 mL saline.

A comparison of the baseline characteristics between the conventional RALP and Retzius-sparing RALP groups is shown in Table 1. Before propensity-score matching, tumours in the conventional RALP group tended towards a more advanced clinical T-stage and more positive cores on biopsy. After propensity-matching, both groups were well-matched and there were no significant differences in the studied variables. The mean Sexual Health Inventory for Men score [11] suggested that most patients had moderate erectile dysfunction before surgery. The clinicopathological results are shown in Table 2. Comparing the unmatched conventional RALP group with the Retzius-sparing RALP group, the conventional RALP cohort was found to have significantly more advanced pathological T-staging. There were no significant differences in the length of hospital stay, estimated blood loss or other pathological outcomes when comparing the Retzius-sparing RALP group with either the matched or unmatched conventional RALP groups. The mean console time was significantly shorter with Retzius-sparing RALP. Although there were no significant differences in the positive surgical margin (PSM) rates, there was more tumour extension anteriorly in the Retzius-sparing RALP group when compared with either the matched or unmatched conventional RALP groups. Subgroup analysis of pT2 and pT3 tumours showed no significant differences in the PSM rates for the two approaches (Table 2). © 2014 The Authors BJU International © 2014 BJU International

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Table 1 Comparison of baseline characteristics between Retzius-sparing laparoscopic radical prostatectomy (RALP) and conventional RALP.

Mean age (SEM), years Mean body mass index (SEM), kg/m2 Preoperative PSA (SEM), ng/mL American Society of Anesthesiologists score, n (%) 1 2 3 4 Volume of prostate on TRUS (SEM), mL Biopsy results Mean (SEM) total number of cores biopsied Mean (SEM) total number of positive cores Mean (SEM) percentage of positive cores, % Mean (SEM) maximum percentage of tumour in cores, % Biopsy Gleason score, n (%) ≤6 7 8 9 10 Clinical tumour stage, n (%) T1 T2 T3a T3b T4 Mean preoperative SHIM score (SEM)

Matched conventional RALP N = 50

Retzius-sparing RALP N = 50

P*

Unmatched conventional RALP N = 531

P†

66.2 (1.0) 23.7 (0.4) 10.5 (0.9)

65.7 (1.1) 23.5 (0.3) 12.8 (1.6)

0.718 0.732 0.204

64.6 (0.3) 24.2 (0.1) 12.0 (0.7)

0.312 0.062 0.702

0 (0.0) 26 (52.0) 24 (48.0) 0 (0.0) 32.4 (1.5)

0 (0.0) 29 (58.0) 21 (42.0) 0 (0.0) 33.0 (2.7)

0.082

0.688 0.819

185 (34.8) 208 (39.2) 138 (26.0) 0 (0.0) 36.2 (0.8)

0.264

12.0 (0.4) 2.8 (0.3) 24.2 (2.5) 46 (4)

12.4 (0.2) 3.1 (0.4) 24.8 (2.9) 45 (4)

0.427 0.552 0.880 0.804

11.2 (0.1) 4.0 (0.1) 37.1 (1.2) 52 (1)

0.005 0.048 0.002 0.109

22 (44.0) 20 (40.0) 4 (8.0) 4 (8.0) 0 (0.0)

26 (52.0) 15 (30.0) 7 (14.0) 1 (2.0) 1 (2.0)

0.320

204 (38.4) 166 (31.3) 105 (19.8) 50 (9.4) 6 (1.1)

0.314

20 (40.0) 22 (44.0) 7 (14.0) 1 (2.0)

18 (36.0) 24 (48.0) 7 (14.0) 1 (2.0)

0.950

0.042

14.0 (1.1)

11.1 (1.0)

0.053

187 (35.2) 171 (32.2) 85 (16.0) 75 (14.1) 13 (2.5) 13.0 (0.4)

0.084

RALP, robot-assisted laparoscopic PLND, pelvic lymph node dissection. SHIM, Sexual Health Inventory for Men. *Comparing matched conventional RALP with Retzius-sparing RALP. † Comparing match conventional RALP with whole cohort.

Table 3 shows a comparison of the clinicopathological results between the first and subsequent 25 patients. The mean console time was significantly improved after 25 cases, despite more cases with PLND and there seemed to be a trend towards better oncological outcomes in terms of PSM rates after 25 cases. The complications of both approaches are shown in Table 2. There were two significant postoperative complications in the Retzius-sparing RALP group. One patient developed retention of urine on catheter removal on postoperative day 8. The catheter was reinserted in this patient and he was able to void satisfactorily without significant residual urine when his catheter was removed 3 days later. The other patient had an incisional hernia of the right-most 8-mm robotic port site requiring surgical reduction and repair on postoperative day 5. The early continence rate at 1 month was excellent. A total of 70% of the patients who underwent Retzius-sparing RALP were completely dry and 92% had 0-pad usage (excluding use of safety-liners for drops), and these results were significant compared with either the matched or unmatched conventional RALP groups (Table 2).

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Discussion While perineal RP allows a more precise dissection of the urethra and spares the Retzius space and DVC, it damages the pelvic floor musculature and may lead to worse continence outcomes. Retropubic RP, by contrast, preserves the endopelvic fascia and pelvic floor musculature, but requires the entry into the Retzius space, leading to more surgical trauma anterior to the bladder. In the present Retzius-sparing RALP technique, we combined the best of both approaches. By performing a ‘reverse perineal RP’, both the Retzius space and the pelvic floor anatomy were preserved, minimising surgical trauma, allowing more delicate reconstruction and preserving anatomic normalcy. RP disrupts the normal anatomy, resulting in loss of normal functions. In recent years, many techniques have been developed to restore anatomical normalcy. Our conventional RALP technique included steps such as bladder neck ultra-dissection [12–14], posterior reconstruction of the rhabdosphincter [15,16], nerve-sparing dissection [17,18] and puboperineoplasty [19] in all patients, all of which have been shown to promote early continence recovery and led to an ∼70% continence rate (0 pads used) at 1 month after surgery (matched and unmatched groups).


Table 2 Comparison of clinicopathological results between Retzius-sparing laparoscopic radical prostatectomy (RALP) and conventional RALP. Matched conventional RALP N = 50 Mean (SE) console time, min Mean (SE) estimated blood loss, mL Mean (SE) length of hospital stay, days Mean (SE) prostate weight, g Pathological Gleason score, n (%) ≤6 7 8 9 10 Pathological tumour stage, n (%) T2 T3a T3b T4 PLND, n (%) No PLND Standard PLND Extended PLND Positive lymph node metastases on pathology/PLND PSMs All pT stages, N Positive, n (%) Negative, n (%) pT2 stages, N Positive, n (%) Negative, n (%) pT3 stages, N Positive, n (%) Negative, n (%) Location of positive margins, % Apex Base Anterior Posterior Intra- and postoperative complications, n (%) Yes No Complications (Clavien–Dindo classification), n Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Continence at 4 weeks, n (%) Completely dry Drops with or without safety liners, no pads ≥1 pads used

Retzius-sparing RALP N = 50

P*

P†

Unmatched conventional RALP N = 531

141 (5) 260 (30) 5.5 (0.5) 36.5 (1.7)

117 (4) 299 (26) 4.8 (0.4) 32.6 (2.3)

0.001 0.329 0.207 0.185

146 (2) 391 (11) 5.2 (0.2) 37.5 (0.7)

0.000 0.587 0.387 0.049

13 (26.0) 30 (60.0) 2 (4.0) 5 (10.0) 0 (0.0)

14 (28.0) 29 (58.0) 4 (8.0) 3 (6.0) 0 (0.0)

0.666

150 (28.2) 231 (43.5) 57 (10.7) 89 (16.8) 4 (0.8)

0.449

38 (76.0) 10 (20.0) 2 (4.0) 0 (0.0)

41 (82.0) 6 (12.0) 3 (6.0) 0 (0.0)

0.243

317 (59.7) 147 (27.7) 55 (10.4) 12 (2.2)

0.000

2 (4.0) 40 (80.0) 8 (16.0) 1/48 (2.1)

11 (22.0) 34 (68.0) 5 (10.0) 2/39 (5.1)

0.025

2 (0.4) 337 (63.5) 192 (36.2) 32/529 (6.0)

0.000

50 7 (14.0) 43 (86.0) 38 2 (5.3) 36 (94.7) 12 5 (41.7) 7 (58.3)

50 7 (14.0) 43 (86.0) 41 5 (12.2) 36 (87.8) 9 2 (22.2) 7 (77.3)

5 3 0 0 7 (14.0) 43 (86.0) 2 3 2 0 0 25 (50.0) 12 (24.0) 13 (26.0)

6 2 4 1 3 (6.0) 47 (94.0)

0.489

1.000

0.434

0.642

0.515 0.577 0.018 0.299 0.318

1 1 1 0 0 35 (70.0) 11 (22.0) 4 (8.0)

531 60 (11.3) 471 (88.7) 317 18 (5.7) 299 (94.3) 202 38 (18.8) 164 (81.2) 36 28 1 2 41 (7.7) 490 (92.3)

0.617

0.496 0.173

0.680

0.244 0.447 0.000 0.286 1.000

14 16 11 0 0 0.039

191 (36.0) 166 (31.3) 174 (32.7)

0.000

RALP, robot-assisted laparoscopic PLND, pelvic lymph node dissection. PSM, positive surgical margin. *Comparing matched conventional RALP with Retzius-sparing RALP. † Comparing match conventional RALP with whole cohort.

Despite this respectable figure, our Retzius-sparing RALP technique produced a statistically superior continence rate to conventional RALP. In fact, the rates of 70% (completely dry) and 92% (0 pads used) at 1 month are the highest we have ever achieved using any modifications. We postulate that the improved early continence rate is mainly attributable to the minimisation of surgical trauma and tissue retraction associated with this technique. The pubovesical complex, detrusor apron, levator ani, arcus tendinous and

anterior fixation of the bladder to the abdominal wall served as an important suspensory mechanism, preventing pelvic floor prolapse and urethral hypermobility and maintaining the angulation of the vesicoprostatic junction [4,20,21]. These important structures are preserved with this technique. Consequently, any increased in intra-abdominal pressure will compress on the bladder neck, preventing stress incontinence. Early continence outcomes were significantly inferior in the conventional RALP groups, especially in the unmatched © 2014 The Authors BJU International © 2014 BJU International

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Table 3 Comparison of clinicopathological results between the first 25 and the second 25 patients to undergo Retzius-sparing robot-assisted laparoscopic radical prostatectomy. First 25 patients Mean (SE) console time, min Mean (SE) estimated blood loss, mL Mean (SE) length of hospital stay, days PLND, n (%) No PLND performed PLND performed PSMs, n (%) Positive Negative Location of PSMs, n Apex Base Anterior Posterior Intra- and postoperative complications, n (%) Yes No Continence at 4 weeks, n (%) Completely dry Drops with or without safety liners, no pads ≥1 pads used 0 pads used (safety liners for drops allowed) ≥1 pads used

Second 25 patients

P

126 (6) 311 (36) 4.5 (0.5)

108 (6) 288 (38) 5.1 (0.6)

0.035 0.665 0.429

8 (32.0) 17 (68.0)

3 (12.0) 22 (88.0)

0.006

5 (20.0) 20 (80.0)

2 (8.0) 23 (92.0)

0.417

4 2 3 1

2 0 1 0

0.495 0.290 0.809 0.495

2 (8.0) 23 (92.0)

1 (4.0) 24 (96.0)

0.552

21 (84.0) 3 (12.0) 1 (4.0) 24 (96.0) 1 (4.0)

14 (56.0) 8 (32.0) 3 (12.0) 22 (88.0) 3 (12.0)

0.097

0.297

PLND, pelvic lymph node dissection; PSM, positive surgical margin.

cohort (36% were completely dry compared with 70% in the Retzius-sparing RALP group). One reason for this difference might be the initial learning curve associated with RALP, as the unmatched cohort consisted of our very first patients who underwent RALP. Of the matched patients who underwent conventional RALP, six (12%) were among our initial 100 patients who underwent this procedure and thus the majority (88%) can be considered as performed after our initial learning curve and refinement of our conventional RALP techniques. Despite the fact that most of the patients in the matched conventional RALP group underwent RP after our initial learning curve, the early continence rate was still superior in the patients who underwent Retzius-sparing RALP, suggesting that Retzius-sparing might indeed help the recovery of early continence. A second possible explanation might be that there were more advanced tumours in the unmatched cohort, necessitating wider dissection and more extensive PLND for oncological clearance, thus leading to more tissue trauma. Consequently, the continence rate improved in the matched conventional RALP group. Although not statistically significant, we found that PLND during Retzius-sparing RALP might actually be detrimental to early continence outcomes. As we aim to develop a technique suitable for most tumours, including high-risk tumours, PLND is an essential step in the procedure. No PLND was performed for 11 of the low-risk tumours, eight of which were the initial 15 cases. By extending the peritoneal incision laterally, we were able to perform ePLND in five of our patients undergoing Retzius-sparing RALP. One patient who had

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postoperative incontinence at 1 month requiring 2 pads a day underwent ePLND and three underwent standard PLND. All 11 patients without PLND were absolutely dry at 1 month. Furthermore, more PLND procedures were performed in our second 25 patients undergoing Retzius-sparing RALP, and we observed a drop in patients who were completely dry at 1 month (Table 3). Galfano et al. [7] reported an extraordinary early continence rate of 91% at 7 days after Retzius-sparing RALP; however, it that series, only 36% of patients had any form of PLND as opposed to our 78% PLND rate, and we report a continence rate of 92% at 1 month after Retzius-sparing RALP. Although we do not have recorded findings of continence outcomes at 7 days after Retziussparing RALP, anecdotally we did not observe such a high continence rate at the time of catheter removal. This further reinforced our hypothesis that PLND might be detrimental to early continence outcomes. Preliminary clinicopathological outcomes of Retzius-sparing RALP seemed similar to those of conventional RALP. There were no significant differences in estimated blood loss and complication rates between the two well-matched groups. Console time was significantly shorter in the Retzius-sparing RALP group, probably because of the reduced need for reconstruction procedures. Literature reported PSM rates after RALP ranging from 9.6 to 26% [22]. Although our PSM rate of 14% in the Retzius-sparing RALP group compares well with the available literature, and was not significantly different from that of our conventional RALP group, the higher incidence of


PSMs anteriorly may raise some concerns. Galfano et al. [7] reported an overall PSM rate of 25.5%, with most of the PSMs located at the apex, compared with our rate of 14%, despite our series having more intermediate- and high-risk tumours. The reason for PSMs at the anterior margins may be anatomical. The prostatic capsule is often deficient anteriorly where the anterior fibromuscular stroma and detrusor apron are found. At the apex, no definite plane exists between the prostatic stroma and the muscle fibres of the urinary sphincter [10]. We began to recognise this trend after the first 15 cases and altered our technique with the plane dissection directed slightly anteriorly away from the prostate, taking more of the peri-prostatic fat, while still sparing the detrusor apron but not infrequently sacrificing at least part of the DVC. Since then, only 1/35 patients had PSMs involving the anterior margins, but we would recommend caution in patients with anterior tumours diagnosed preoperatively. The present study as a few limitations. Firstly, as the majority of our patients had at least moderate erectile dysfunction preoperatively, we were unable to assess the potency outcomes of this technique, although Galfano et al. [7] reported an excellent potency rate. Secondly, our data on oncological outcomes are immature. Except for reporting the PSM rates, the short follow-up meant we were unable to assess other oncological outcomes such as biochemical or clinical recurrences. Next, although we have demonstrated the safety and feasibility of the technique, it is undoubtedly difficult and requires experience, especially in the identification and preservation of the bladder neck and the vesico-urethral anastomosis. Thirdly, as this is a relatively new technique, not many surgeons have tried this approach, hence our results are limited to a single-surgeon, single-centre series. Lastly, our cohort is still small and, although promising results are reported, no definite conclusions can be made at this point. Nevertheless, Retzius-sparing RALP may become a new standard in RALP in future because of its various advantages: (1) less surgical trauma/traction and better preservation of anatomical normalcy; (2) excellent oncological outcomes; (3) superior functional outcomes; (4) reduced operating times; and (5) reproducibility. A larger, randomised prospective cohort will be needed to validate its results and to confirm if PLND indeed leads to increased risk of postoperative incontinence. In conclusion, in the present study, we validated the excellent oncological and continence outcomes reported in Galfano’s Retzius-sparing RALP series [7]. We have demonstrated that this technique is reproducible and we were able to perform it in all cases without exception. In addition, by comparing Retzius-sparing RALP with conventional RALP, we demonstrated that retzius-sparing during RALP might indeed lead to early recovery of continence. We also found, however, that PLND seems to affect very early continence outcomes and we recommend modulating patients’ expectations in this

aspect. We also recommend caution in using this technique in patients with anterior tumours; a wider dissection anterior to the prostate and sacrificing of the DVC might be needed in these patients to reduce the PSM rate.

Conflict of Interest None declared.

Acknowledgements We would like to acknowledge Dr Richard Gaston (Department of Urology, Clinique Saint Augustin, Bordeaux, France) for unreservedly sharing this surgical technique with us.

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Correspondence: Koon Ho Rha, Department of Urology, Urological Science Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. e-mail: [email protected] Abbreviations: RALP, robot-assisted laparoscopic radical prostatectomy; RP, radical prostatectomy; NVB, neurovascular bundle; DVC, dorsal venous complex; PLND, pelvic lymph node dissection; ePLND, extended pelvic lymph node dissection; PSM, positive surgical margin.

Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video.