ORIGINAL ARTICLES

RETROPUBIC PROSTATECTOMY A NEW EXTRAVESICAL TECHNIQUE: REPORT ON 20 CASES

To investigate the outcome of retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) compared with conventional RARP in the early learning curve.

Consecutive patients with prostate cancer who underwent RS-RARP were included to compare against conventional RARP of the same period. Propensity-score matching was performed based on age, prostate size, nerve-sparing approach, and final pathological risk categories. All patients were re-admitted to undergo trial without Foley catheter from post-operative day 7–10. Clinical follow-up was performed with monitoring of continence (day 0, 3 months, and the latest continence during the study period) and surveillance of PSA level.

Between July 2017 and August 2019, 24 consecutive patients received RS-RARP in our centre. Propensity score matching was performed with the best matched 24 controls receiving conventional RARP. Overall median follow-up duration was 15.5 months. A majority of the patients belonged to the intermediate-risk group, with most of them harbouring pT2 disease (RS-RARP: 87.5%; conventional RARP: 79.2%). More patients in RS-RARP group achieved day-0 continence (33.3% vs 0%, p = 0.002) and 3-month continence (66.7% vs 12.5%, p = 0.001). During the whole study period, more RS-RARP achieved continence with 0 pad (91.7% vs 66.7%, p = 0.033). The mean months to continence is shorter in RS-RARP group (4.0 months vs 13.6 months, p = 0.002). No statistically significant differences between the two groups with respect to surgical margins, post-operative PSA detection, and the use of adjuvant radiotherapy.

RS-RARP showed better continence rates when compared to conventional RARP even during the learning curve phase.

Despite recent technical innovations in the treatment of benign prostatic hyperplasia (BPH), retrograde ejaculation is still one of the most frequent adverse effects, with a major impact on patients’ quality of life.

To evaluate the efficacy of our technique of urethral-sparing robotic-assisted simple prostatectomy (usRASP) in obtaining effective deobstruction and maintaining anterograde ejaculation, and secondarily, to compare these outcomes with those of a control group of patients who underwent standard robotic adenomectomy according to the Millin technique.

We prospectively enrolled patients between August 2017 and July 2019 with large BPH (prostate volume >80 ml) affected by significant BPH-related lower urinary tract symptoms (LUTS) who underwent usRASP. Then, a retrospective control group treated with standard Millin robotic-assisted simple prostatectomy (RASP) was selected.

The innovative aspect of our technique is the pivotal role of enucleation of the adenoma from all the anatomical structures, especially from the urethra. On the basis of the final results, the patients were divided into three groups (full, partial, or failed urethral sparing). Control group patients underwent standard Millin.

All perioperative and follow-up data were collected, and descriptive, univariate, and multivariate analyses were performed.

Ninety-two patients were enrolled. Full urethral-sparing adenomectomy was performed in 56 cases (60.86%). Urethral-sparing adenomectomy with minimal urethral infraction occurred in 21 cases (22.82%). In 15 patients (16.48%), the procedure was converted to standard RASP. Clavien grade ≥3 complications occurred in two patients (2%). Among the 70 patients with preoperative ejaculation, 57 (81%) maintained anterograde ejaculation at the 12th postoperative month. The maximum flow rate increased (17 m/s from baseline, p =  0.034), and International Prostate Symptom Score decreased rapidly (from 20 to 5 points; p <  0.001). With respect to the technique of the control group patients, usRASP allows the same perioperative and urinary functional outcomes, but with an improvement in terms of sexual function, especially for the ejaculation (p <  0.001 at every time point). A small sample size and short follow-up time are the major limitations of this study.

Urethral-sparing RASP has been found to be a safe and effective procedure that allows resolution of LUTS in large BPH and maintaining of ejaculatory function in a high percentage of patients.

Based on our findings, this technique should be considered as an option when counseling patients with large benign prostatic hyperplasia who are motivated to preserve antegrade ejaculation.

Revisión histórica de los orígenes y de la evolución técnica de la prostatectomía retropúbica en el cáncer de próstata.

Revisión fundamentalmente de los artículos originales sobre el diseño de las técnicas de prostatectomía retropúbica.

Es posible que la primera prostatectomía se realizara a principios del s. xix. Millin (1945) abrió el camino de la prostatectomía retropúbica al diseñar el acceso retropúbico a la próstata. Memmelaar (1949) estructuró la prostatectomía retrógrada. Campbell diseñó la prostatectomía anterógrada (1959). Walsh (1983), basándose en trabajos anatómicos, diseñó la técnica de prostatectomía retrógrada con preservación de la función sexual.

Las aportaciones técnicas acumuladas durante aproximadamente 80 años concluyeron con la descripción de la técnica de Walsh, que se considera en la actualidad la técnica estándar de prostatectomía retropúbica.

Historical review of the origins and technical evolution of retropubic prostatectomy in prostate cancer.

Review of original articles on the design of retropubic prostatectomy techniques.

The first prostatectomy could have been performed in the early 19th century. Millin (1945) opened the way for retropubic prostatectomy with the retropubic access design. Memmelaar (1949) structured retrograde prostatectomy. Campbell designed antegrade prostatectomy (1959). Based on anatomical studies, Walsh (1983) designed retrograde prostatectomy with preservation of sexual function.

Technical inputs accumulated over approximately 80 years concluded with the description of the Walsh technique, which is currently considered the standard technique for retropubic prostatectomy.