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
Menée sur 200 patients atteints d'un cancer de la prostate traité entre 2010 et 2011 (âge médian des patients : 65 ans ; durée de suivi supérieure à 1 an), cette étude prospective évalue l'efficacité, du point de vue de la survie, de la qualité des marges de résection, de la récupération de la continence et de la fonction érectile, et les effets indésirables d'une prostatectomie radicale laparoscopique assistée par robot avec préservation de l'espace de Retzius
Background : Robot-assisted laparoscopic radical prostatectomy (RARP) has become the main surgical option for localized prostate cancer. We recently developed a new approach for RARP, passing through the pouch of Douglas and avoiding all the Retzius structures involved in continence and potency preservation.
Objective : To report the functional and oncologic results of our first 200 patients operated on using this new approach.
Design, setting, and participants : This was a prospective, noncontrolled case series including the first 200 consecutive patients undergoing this kind of surgery (January 2010 to December 2011).
Surgical procedure : Retzius-sparing RARP.
Outcome measurements and statistical analysis : All perioperative, oncologic, and functional data were prospectively recorded. Potency was defined as an International Index of Erectile Function-5 questionnaire score >17; continence was defined as use of no pad or of one safety liner. Oncologic results were reported as positive surgical margins (PSM) and 1-yr biochemical disease-free survival (1y-bDFS). Recurrence was defined as a repeated prostate-specific antigen >0.2 ng/ml. Complications were graded according to the Clavien-Dindo system. The first 100 patients (group 1) were compared with the second 100 (group 2) to evaluate the learning curve effects.
Results and limitations : The median patient age was 65 yr. Comparing the two groups, transfusions were needed in 8% versus 4% of cases in groups 1 and 2, respectively (p=0.02). There was one Clavien-Dindo grade 3b in group 1 versus one grade 3a complication in group 2. In patients with pT2 disease, PSMs were recorded in 22.4% of those in group 1 versus 10.1% in group 2 (p=0.045). 1y-bDFS was 89% in group 1 versus 92% in group 2. For groups 1 and 2, respectively, immediate continence was reached in 92% versus 90% of patients, and the 1-yr continence rate was 96% versus 96%. Considering the 77 potent patients aged <65 yr who underwent bilateral intrafascial nerve-sparing surgery, 40.4% of those in group 1 versus 40% of those in group 2 reached their first intercourse within 1 mo; at 1 yr of follow-up, these figures had increased to 81% versus 71%, respectively (p=0.162). The main limitation of this study is its noncontrolled nature.
Conclusions : We demonstrated Retzius-sparing RARP to be oncologically safe and to result in high early continence and potency rates. Long-term, prospective, comparative, and possibly randomized studies are needed.
Take Home Message : After an adequate learning curve, robot-assisted laparoscopic radical prostatectomy performed through a small incision in the Douglas space, without opening the Retzius space, allows optimal immediate continence control and early potency recovery without compromising the oncologic safety.
http://linkinghub.elsevier.com/retrieve/pii/S0302283813006611 2013