Re: The Evolution of Retzius-Sparing Robot-Assisted Laparoscopic Prostatectomy: An Idea,Development,Evolution,Assessment,and Long-Term Study Perspective (From Gotlieb et al.,J Endourol 2022;36(8):1077–1082)

Dear Editor:

In August issue of the Journal of Endourology, Gotlieb et al. ¹ reported an analysis of what extent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) development has followed the idea, development, evolution, assessment, and long-term (IDEAL) study recommendations. The authors concluded that there is no evidence in the literature of studies addressing the stages of development and evaluation.

We are grateful that the authors entered the discussion on such a relevant topic, and every effort to improve scientific evidence on RS-RARP is appreciated; however, we have some concerns to discuss.

First, our group, since 2013, advocated the use of the IDEAL framework for further studies; in that publication, we reported a surgical video showing the technical improvements done from the previous publication and the short-term results concerning the first 200 patients, explaining the initially restricted selection criteria and the following widened indications for the procedure. For these reasons, we stated that through that study, we completed the Development stage, and we needed studies for the Evaluation stage ² ; this is undeniable, according to the explanation of stage 2a (Development) given by McCulloch et al. ³ : “development involves the planned use of a procedure in a small group of patients to support experience with its first use and often to refine or modify the precise technique”; those modifications were further discussed in other articles (Table 1, first lines).

Regarding stage 2b (Evaluation/Exploration) it is true that all the initial experiences reported are monocentric. However, the title word of this phase is “learning,” and the learning curve and safety of early adopters have been wisely investigated in several articles where we reported outcomes of the first cases of surgeons that adopted the technique in our group and worldwide. ^4,5

Although the recovery of urinary continence has already been exhaustively investigated, we agree with the necessity of further studies, especially randomized controlled trials investigating as primary outcomes the positive surgical margins, the role of the learning curve phase, and long-term oncologic outcomes between RS-RARP and conventional anterior approach are highly needed to put an end to IDEAL stage 3 (Assessment).

Unfortunately, Gotlieb's study is particularly untimely, as since March 2021 until today, several studies have been published concerning the learning curve of the RS-RARP and completing the stage 2b, corroborating stage 3 and introducing the first long-term data to stage 4 (Table 1).

In summary, the IDEAL validation of a surgical innovation is not a matter of a single study of a single group. Still, it is the most natural expression of the diffusion of a new approach. Looking backward at the IDEAL stages of RS-RARP, we can affirm that we have solid and exhaustive data on the first three stages; the assessment stage needs further oncologic studies, and the long-term stage is ongoing.