The Untold Advantages of Retzius-Sparing Robotic Radical Prostatectomy

Abstract

The Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RALP) surgical technique was initially described by Galfano et al.¹ The key difference with this technique is the posterior approach toward prostatic dissection with preservation of the space of Retzius anteriorly. The urinary bladder is not dropped and supporting endopelvic fascia and puboprostatic ligaments are preserved, with minimal distortion of the tissues and planes supporting the urethra, allowing for improved urethral structural support, and, consequently improved urinary continence. Lim et al.² were the next group to report their experience with the Retzius-sparing RALP, with patients undergoing this novel technique having superior early postoperative continence rates. U.S.-based physicians were slower to adopt this novel technique. Dalela et al.³ at Henry Ford Health System prospectively compared the outcomes of patients undergoing posterior RALP to those undergoing an anterior approach, with patients undergoing the posterior approach having superior short- and mid-term continence rates.

Shortly thereafter, we reported our institutional experience; with our series of 100 patients undergoing the Retzius-sparing technique the largest reported U.S.-based cohort to date. Compared with 100 patients undergoing the conventional technique, patients in the experimental arm had superior short and long-term continence rates. Importantly, we were able to confirm the oncologic safety of this novel technique, with no significant difference in the positive surgical margin rates between the two arms (Table 1).⁴

Table 1.

Comparison of Perioperative, Oncologic, and Functional Outcomes of Published Retzius-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy Series

	Console time (median)	Blood loss (median)	Complications	Positive surgical margin	Biochemical recurrence	Continence	Potency
Galfano et al.¹ (group 1: 1st 100 case, group 2: 2nd 100 cases)	Group 1: 120 minutes Group 2: 97.5 minutes	Group 1: 300 mL Group 2: 200 mL	Grade 1–2: 9%–13% Grade 3: 1% Grade 4–5: 0%	pT2: 15% pT3: 45%	1 year BCRFS: 89%–92%	Immediate continence rate: 91%^a 1 year continence rate: 96%	Median 1 year IIEF-5 score: 18 1 year potency rate: 52%
Lim et al.²	117 minutes (mean)	299 mL (mean)	Grade 1: 2% Grade 2: 2% Grade 3: 2% Grade 4–5: 0%	pT2: 12.2% pT3: 22.2%	N/A	4 week complete continence: 70%	N/A
Dalela et al.³	N/A	N/A	Any postoperative complication: 18%	Overall: 25%	1 year BCRFS: 91%	Immediate continence rate: 71%^a Median time to continence: 2 days	N/A
Sayyid et al.⁴	120 minutes	100 mL	Any postoperative complication: 10.3%	pT2: 17.2% pT3: 48.5%	N/A	Immediate continence: 19.6% Median time to continence: 90 days 1 year continence rate: 97.4%	N/A

Within 7 days of catheter removal.

BCRFS = biochemical recurrence-free survival; CD = Clavien–Dindo grade; IIEF = International Index of Erectile Function; N/A = not available.

Admittedly, the Retzius-sparing technique may have a steep learning curve. This may theoretically be associated initially with compromised oncologic/functional outcomes. However, published studies to date have suggested that this is not a significant concern. Furthermore, our extensive experience with this technique suggests that there are additional advantages for this novel approach that have not been sufficiently highlighted to date. These observations are somewhat subjective in nature and thus need to be further evaluated in future studies:

1. Sparing the Space of Retzius, and consequently keeping the bladder attachments intact, may be advantageous in patients who may require surgery in the future that necessitates dropping the bladder or accessing the space of Retzius, such as implant of an artificial urinary sphincter, an inflatable penile prosthesis, or a kidney transplant. Performing a classic RALP through an anterior approach in patients who had a previous kidney transplant is challenging and might compromise the integrity of the ureterovesical anastomosis of the transplanted kidney.

2. Lower incidence of postoperative inguinal hernias: Reports in the literature have suggested that the Retzius-sparing approach may have lower incidence rates of postoperative inguinal hernias. This is possibly due to maintenance of the integrity of the peritoneum around the inguinal cord with the Retzius-sparing approach. This technique however is not expected to lead to a decreased incidence of port site hernias or intra-abdominal complications.

3. Obviating the need to drop the bladder in patients with previous inguinal hernia repair: Presence of adhesions between the surgical mesh and the bladder may make dropping the bladder particularly difficult with the anterior approach. Avoiding this issue with the posterior approach is an obvious advantage.

References

Galfano

, Di Trapani

, Sozzi

, 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; 64:974–980.

Lim

, Kim

, Shin

, et al. Retzius-sparing robot-assisted laparoscopic radical prostatectomy: Combining the best of retropubic and perineal approaches. BJU Int, 2014; 114:236–244.

Dalela

, Jeong

, Prasad

, 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; 72:677–685.

Sayyid

, Simpson

, Lu

, et al. Retzius-sparing robotic-assisted laparoscopic radical prostatectomy: A safe surgical technique with superior continence outcomes. J Endourol, 2017; 31:1244–1250.