The body of evidence to consider the Retzius-sparing approach favors early urinary continence recovery after robot-assisted radical prostatectomy is increasing

Radical prostatectomy is arguably the most frequently offered treatment patients with low or intermediate risk cancer of the prostate. Its main objective is complete cancer removal without sequelae, but results are sometimes darkened by the functional impairment posed by the emergence of urinary incontinence, erectile dysfunction or other voiding and vowel problems that negatively impact patient satisfaction. With the attempt to overcome these drawbacks, radical prostatectomy has undergoing a remarkable transformation in the last decades, determined by the tendency to favor minimally invasive approaches and high-volume therapeutic units because surgeon experience with the technique offers the best results.

Refinements achieved during laparoscopic prostatectomy (1) have been improved by robotics but the debate whether robot-assisted radical prostatectomy (RARP) achieves better continence results that open radical prostatectomy is not totally closed (2) and continence recovery continues to be a significant problem for our patients. Galfano and collaborators were pioneers in defining a posterior “Retzius-sparing” approach in robotic surgery (3). This revolutionary approach consisted on passing through the pouch of Douglas following a completely intrafascial plane and avoiding damage of all the Retzius structures involved in continence and potency preservation: neurovascular bundles, Aphrodite’s veil, endopelvic fascia, Santorini’s plexus and puboprostatic ligaments. There is a strong growing body of evidence to consider the Retzius-sparing RARP ideally combines the best of retropubic and perineal approaches. The first feasibility study for “Retzius-sparing” RARP simply based on a short series of patients but Galfano et al. later established a prospective non-randomized study with consecutive patients intervened during 2 years. Results achieved in their first 100 patients were compared to those of the second hundred to evaluate the learning curve effect of the technique. Continence rate achieved within the first year of surgery was 96%. Also 40% and 71–81% of baseline potent patients aged <65 years were able to reach intercourse within first month and first year, respectively using this approach (4).

Many other surgical individual maneuvers have been promoted and tested to improve continence results in the era of robot-assisted radical prostatectomy (5). One of the best accepted is the preservation of membranous urethral length that is especially retained in the nerve-sparing technique that leads also to improved continence recovery in a meta-analysis (6). Another tip is the reconstruction of Denonvilliers’ using the Rocco technique to perform posterior musculofascial reconstruction that has been confirmed in a systematic review to favor early acquisition of continence (7). Also bladder neck suspension with an absorbable suture that fixes the vesico-urethral anastomosis to the pubic periosteum, and bladder neck plication by a running stitch during RARP is more controversial. Even the type of suture used for vesico-urethral anastomosis could also play a role itself as non-barbed sutures may have a favourable effect on continence while barbed-sutures could induce more tissue damage (8). A careful dissection of the prostatic apex and delicate anatomical reconstruction has been recently reported to increase excellent results for early continence recovery associated to RARP, from 70% at week 1 to 98% at month 6 (9). Of course these results cannot be generalized to low-volume centers.

Now, there is a strong growing body of evidence to consider the superiority of Retzius-sparing RARP to promote early continence recovery without impact on surgical margins or biochemical failure. Surgical trauma is minimized and the combination of pubovesical complex, detrusor apron, levator ani, arcus tendinous and anterior fixation of the bladder prevents urethral hypermobility and facilitates early continence recovery. Lim et al. compared a series of patients prospectively undergoing Retzius-sparing RARP with a database of patients treated with conventional RARP (10). Shorter operative time and faster recovery of continence were demonstrated, but the limitations of the study design were undeniable. Very recently Dalela et al. have conducted the first single-center randomized controlled clinical trial to evaluate the impact of the Retzius-sparing posterior RARP on early urinary continence recovery in comparison to anterior conventional RARP, with 60 patients on each arm with low or intermediate-risk prostate cancer (11). Primary outcomes was continence recovery (none or 1 security pad/day) 1 week after catheter removal, and secondary outcomes were time to continence recovery and patient reported outcomes (PROs) such as IPSS and QoL score. One week continence was 71% for the posterior approach and 48% for the anterior one (P=0.01). Posterior approach led to an earlier recovery (median 2 vs. 8 days) and lower bother score as well (11). Desirably these solid results should be confirmed by larger multicenter studies and also in high-risk localised disease (12). Also more solid results regarding not only continence but also oncologic efficacy (positive margin rate, probability of biochemical failure) and security (complications) in the long-term will be welcome.

In summary, the body of evidence to consider the Retzius-sparing approach could favor early urinary continence recovery after RARP and better PRO measurements is definitely increasing after the publication of Dalela et al. (11) and that should lead to development of further studies comparing results of this variant of RARP and open radical prostatectomy. Maybe then robotic assistance could determine a more noticeable clinical advantage over its open counterpart. However, oncologic data must not be forgotten and thereof we can anticipate a long way before the clinical dilemma of which is the best RARP approach is solved.

Acknowledgements

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by the Section Editor Xiao Li (Department of Urologic Surgery, the Affiliated Cancer Hospital of Jiangsu Province of Nanjing Medical University, Nanjing, China).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/amj.2017.08.16). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nuñez-Mora C, García-Mediero JM, Cabrera-Castillo PM, et al. Results of simplified urethropexy in the recovery of continence after radical laparoscopic prostatectomy. J Endourol 2011;25:1759-62. [Crossref] [PubMed]
2. Yaxley JW, Coughlin GD, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 2016;388:1057-66. [Crossref] [PubMed]
3. Galfano A, Ascione A, Grimaldi S, et al. A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery. Eur Urol 2010;58:457-61. [Crossref] [PubMed]
4. Galfano A, Di Trapani D, Sozzi F, 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;64:974-80. [Crossref] [PubMed]
5. Haga N, Takinami R, Tanji R, et al. Comprehensive approach for post-prostatectomy incontinence in the era of robot-assisted radical prostatectomy. Fukushima J Med Sci 2017;63:46-56. [Crossref] [PubMed]
6. Reeves F, Preece P, Kapoor J, et al. Preservation of the neurovascular bundles is associated with improved time to continence after radical prostatectomy but not long-term continence rates: results of a systematic review and meta-analysis. Eur Urol 2015;68:692-704. [Crossref] [PubMed]
7. Rocco B, Cozzi G, Spinelli MG, et al. Posterior musculofascial reconstruction after radical prostatectomy: a systematic review of the literature. Eur Urol 2012;62:779-90. [Crossref] [PubMed]
8. Haga N, Kurita N, Yanagida T, et al. Effects of barbed suture during robot-assisted radical prostatectomy on postoperative tissue damage and longitudinal changes in lower urinary tract outcome. Surg Endosc 2017; [Epub ahead of print]. [Crossref] [PubMed]
9. Porpiglia F, Bertolo R, Manfredi M, et al. Total Anatomical Reconstruction During Robot-assisted Radical Prostatectomy: Implications on Early Recovery of Urinary Continence. Eur Urol 2016;69:485-95. [Crossref] [PubMed]
10. Lim SK, Kim KH, Shin TY, et al. Retzius-sparing robot-assisted laparoscopic radical prostatectomy: combining the best of retropubic and perineal approaches. BJU Int 2014;114:236-44. [Crossref] [PubMed]
11. Dalela D, Jeong W, Prasad MA, et al. A Pragmatic Randomized Controlled Trial Examining the Impact of the Retzius-sparing Approach on Early Urinary Continence Recovery After Robot-assisted Radical Prostatectomy. Eur Urol 2017; [Epub ahead of print]. [Crossref] [PubMed]
12. Abdollah F, Dalela D, Sood A, et al. Functional outcomes of clinically high-risk prostate cancer patients treated with robot-assisted radical prostatectomy: a multi-institutional analysis. Prostate Cancer Prostatic Dis 2017; [Epub ahead of print]. [Crossref] [PubMed]