Is It Safe to Switch from a Standard Anterior to Retzius-Sparing Approach in Robot-Assisted Radical Prostatectomy?

Article Is It Safe to Switch from a Standard Anterior to Retzius-Sparing Approach in Robot-Assisted Radical Prostatectomy? Edward Lambert 1,2, *, Charlotte Allaeys 1 , Camille Berquin 1 , Pieter De Visschere 3 , Sofie Verbeke 4 , Ben Vanneste 5,6 , Valerie Fonteyne 5 , Charles Van Praet 1,† and Nicolaas Lumen 1,† 1 2 3 4 5 6 * † Citation: Lambert, E.; Allaeys, C.; Berquin, C.; De Visschere, P.; Verbeke, S.; Vanneste, B.; Fonteyne, V.; Van Praet, C.; Lumen, N. Is It Safe to Switch from a Standard Anterior to Retzius-Sparing Approach in Robot-Assisted Radical Prostatectomy? Curr. Oncol. 2023, 30, 3447–3460. https://doi.org/10.3390/ curroncol30030261 Received: 10 February 2023 Revised: 7 March 2023 ERN eUROGEN Accredited Centre, Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium; (C.V.P.) Junior ERUS/YAU Working Group on Robot-Assisted Surgery of the European Association of Urology, 6803 AA Arnhem, The Netherlands Department of Radiology and Nuclear Medicine, Ghent University Hospital, 9000 Ghent, Belgium Department of Pathology, Ghent University Hospital, 9000 Ghent, Belgium Department of Radiation Oncology, Ghent University Hospital, 9000 Ghent, Belgium Department of Radiation Oncology (MAASTRO), GROW—School for Oncology and Developmental Biology, Maastricht UMC, 6229 HX Maastricht, The Netherlands Correspondence: These authors contributed equally to this work. Abstract: Background: Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been shown to lead to better outcomes regarding early continence compared to standard anterior RARP (SA-RARP). The goal of this study was to assess the feasibility and safety of implementing RS-RARP in a tertiary center with experience in SA-RARP. Methods: From February 2020, all newly diagnosed non-metastatic prostate cancer patients for whom RARP was indicated were evaluated for RS-RARP. Data from the first 100 RS-RARP patients were prospectively collected and compared with data from the last 100 SA-RARP patients. Patients were evaluated for Clavien Dindo grade ≥3a complications, urinary continence after 2 and 6 weeks, 3, 6 and 12 months, erectile function, positive surgical margins (PSMs) and biochemical recurrence (BCR). Results: There was no significant difference in postoperative complications at Clavien-Dindo grade ≥3a (SA-RARP: 6, RS-RARP: 4; p = 0.292). At all time points, significantly higher proportions of RS-RARP patients were continent (p < 0.001). No significant differences in postoperative potency were observed (52% vs. 59%, respectively, p = 0.608). PSMs were more frequent in the RS-RARP group (43% vs. 29%, p = 0.034), especially in locally advanced tumors (pT3: 64.6% vs. 43.8%, p = 0.041—pT2: 23.5% vs. 15.4%, p = 0.329). The one-year BCR-free survival was 82.6% vs. 81.6% in the SA-RARP and RS-RARP groups, respectively (p = 0.567). The median follow-up was 22 [18–27] vs. 24.5 [17–35] months in the RS-RARP and SA-RARP groups, respectively (p = 0.008). Conclusions: The transition from SA-RARP to RS-RARP can be safely performed by surgeons proficient in SA-RARP. Continence results after RS-RARP were significantly better at any time point. A higher proportion of PSMs was observed, although it did not result in a worse BCR-free survival. Published: 17 March 2023 Keywords: radical prostatectomy; Retzius-sparing; urinary continence; erectile dysfunction; biochemical recurrence; robotic surgery Copyright: © 2023 by the authors. 1. Introduction Licensee MDPI, Basel, Switzerland. Prostate cancer is the second most prevalent cancer worldwide, with one in nine men being diagnosed with the disease during their life. With an estimated 1.4 million diagnoses and 375,000 deaths in 2020, prostate cancer is the second most commonly diagnosed and fifth most lethal cancer in men [1]. Radical prostatectomy is, besides external beam radiation therapy and brachytherapy, a recommended treatment option for localized and selected cases of locally ad- Accepted: 10 March 2023 This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Curr. Oncol. 2023, 30, 3447–3460. https://doi.org/10.3390/curroncol30030261 https://www.mdpi.com/journal/curroncol Curr. Oncol. 2023, 30 3448 vanced prostate cancer. Different surgical approaches have been reported, but all surgical techniques—including open retropubic prostatectomy, laparoscopic prostatectomy or robot-assisted radical prostatectomy—have a risk of temporary or persistent urinary incontinence [2]. Urinary incontinence after radical prostatectomy may strongly affect the quality of life of prostate cancer patients [2]. In the last decade, robot-assisted radical prostatectomy has gained popularity due to its minimally invasive character and improved dexterity, with a decrease in blood loss, postoperative pain, and duration of hospitalization [3]. In the standard anterior robotassisted radical prostatectomy (SA-RARP), the Retzius space is opened in a similar fashion to the open retropubic and laparoscopic approach [4]. In 2010 Galfano, et al. [5] published an alternative surgical approach for robot-assisted radical prostatectomy through the Douglas pouch in which the Retzius space remains intact (Retzius-sparing robot-assisted radical prostatectomy, RS-RARP). This innovative surgical technique avoids damage to the supportive fascial structures of the bladder. In comparison to SA-RARP, the Santorini plexus, the endopelvic fascia, puboprostatic ligaments, and the detrusor apron remain intact in RS-RARP [6]. Different prospective trials have reported better outcomes in terms of early continence in RS-RARP than SA-RARP, with immediate continence results ranging from 51–76% for RS-RARP compared to 21–60% in SA-RARP [7–10]. However, higher proportions of positive surgical margins have been reported with uncertain biochemical recurrence-free survival results [10]. Therefore, the goal of this study was to assess the feasibility and safety of the implementation of RS-RARP in a medium volume (ca. 100 cases/year) tertiary center with experience in SA-RARP, with a special focus on functional and oncological outcomes. 2. Materials and Methods RS-RARP was implemented on 7 February 2020 in our institution. All patients with newly diagnosed prostate cancer for whom radical prostatectomy was indicated were evaluated for RS-RARP. The decision to perform RS-RARP was of the surgeon’s choice, and patients with anterior tumors close to the bladder neck continued to be treated with ‘classic’ SA-RARP. Our RS-RARP procedure has previously been described in detail [11]. In brief, the RS-RARP procedure starts with the incision of the peritoneum above the vasa deferentes up until the Douglas pouch, where the peritoneal fold is incised. The vasa deferentes are dissected and cut at the tip of the seminal vesicles. Denonvilliers’ fascia is peeled off of the semin (...truncated)