Alberto Martini1, Ugo Giovanni Falagario2, Arnauld Villers3, Paolo Dell'Oglio4, Elio Mazzone5, Riccardo Autorino6, Marcio Covas Moschovas7, Maurizio Buscarini8, Carlo Andrea Bravi9, Alberto Briganti9, Guilherme Sawczyn10, Jihad Kaouk10, Mani Menon11, Silvia Secco4, Aldo Massimo Bocciardi4, Gongxian Wang12, Xiaochen Zhou12, Francesco Porpiglia13, Alexandre Mottrie5, Vipul Patel7, Ashutosh K Tewari14, Francesco Montorsi9, Richard Gaston15, N Peter Wiklund14, Ashok K Hemal16. 1. Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy. Electronic address: martini.alberto@hsr.it. 2. Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy. 3. Department of Urology, CHU Lille, Université de Lille, Lille, France. 4. Department of Urology, Niguarda Hospital, Milan, Italy. 5. Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium. 6. Department of Urology, Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA. 7. AdventHealth Global Robotics Institute, Celebration, FL, USA. 8. Università Campus Biomedico, Rome, Italy. 9. Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy. 10. Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, OH, USA. 11. Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA. 12. Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China. 13. Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy. 14. Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA. 15. Department of Urology, Clinique Saint Augustin, Bordeaux, France. 16. Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Abstract
BACKGROUND: Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes. OBJECTIVE: To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques. SURGICAL PROCEDURE: Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described. MEASUREMENTS: Different surgical approaches and techniques for robotic prostatectomy have been analyzed. RESULTS AND LIMITATIONS: Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials. CONCLUSIONS: Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies. PATIENT SUMMARY: We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology.
BACKGROUND: Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes. OBJECTIVE: To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques. SURGICAL PROCEDURE: Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described. MEASUREMENTS: Different surgical approaches and techniques for robotic prostatectomy have been analyzed. RESULTS AND LIMITATIONS: Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials. CONCLUSIONS: Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies. PATIENT SUMMARY: We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology.
Authors: Umberto Carbonara; Paolo Minafra; Giuseppe Papapicco; Gaetano De Rienzo; Vincenzo Pagliarulo; Giuseppe Lucarelli; Antonio Vitarelli; Pasquale Ditonno Journal: Eur Urol Open Sci Date: 2022-05-23
Authors: Benedikt Hoeh; Mike Wenzel; Lukas Hohenhorst; Jens Köllermann; Markus Graefen; Alexander Haese; Derya Tilki; Jochen Walz; Marina Kosiba; Andreas Becker; Severine Banek; Luis A Kluth; Philipp Mandel; Pierre I Karakiewicz; Felix K H Chun; Felix Preisser Journal: Front Surg Date: 2022-02-22