Surgical Techniques to Optimize Early Urinary Continence Recovery Post Robot Assisted Radical Prostatectomy for Prostate Cancer

Urinary Continence After Robot-Assisted Laparoscopic Radical Prostatectomy Using the Peritoneal Fixation Technique

INTRODUCTION

The Retzius-sparing technique for prostate cancer has shown favorable continence recovery outcomes. Magnetic resonance imaging after Retzius-sparing showed that the bladder anterior wall is widely connected to the abdominal wall, which contributes to urinary continence. We aimed to evaluate whether the Peritoneal Fixation technique, which involves suturing the anterior bladder wall onto the abdominal wall above the pubic bone, contributes to the recovery of urinary continence.

METHODS

Patients who underwent robot-assisted laparoscopic radical prostatectomy between May and September 2023 were included in the study. We investigated urinary incontinence on the day of catheter removal and 1 month postoperatively. The posterior urethral angle was evaluated at rest and under abdominal pressure.

RESULTS

A total of 54 patients who underwent the Peritoneal Fixation technique (n = 27) and conventional surgery (n = 27) were included. The continence acquisition rate on the day after catheter removal was significantly higher in the Peritoneal Fixation group (40.7%) than in the conventional group (7.4%) (p < 0.05). At 1 month postoperatively, the Peritoneal Fixation group showed favorable results, with a continence rate of 44.4% compared with 29.6% in the conventional group (p = 0.26). The change in the posterior urethral angle at rest and during abdominal pressure significantly differed between the Peritoneal Fixation and conventional groups (-3.0° vs. 2.7°; p < 0.05), indicating that the urethra is being pushed from the rectal side in the Peritoneal Fixation group.

CONCLUSION

The use of the Peritoneal Fixation technique for prostate cancer suggests the potential for achieving favorable urinary continence outcomes.

Factors Contributing to Early Recovery of Urinary Continence Following Radical Prostatectomy: A Narrative Review

Stress urinary incontinence (SUI) is a common condition in patients following radical prostatectomy (RP), which has a significant impact on all aspects of quality of life and is associated with significant social stigma. The factors that improve urinary incontinence in patients following surgery remain controversial. The aim of our narrative review was to identify and synthesise the latest evidence on pre-, intra- and post-operative factors and predictors that contribute to early continence recovery after RP. In this narrative review, primary resources were identified by searching PubMed, EMBASE and Medline, and secondary resources were collected by cross-referencing citations in the relevant articles. We started our review by searching for systematic reviews of factors and predictors that contribute to early recovery of urinary continence after RP. We then reviewed societal guidelines such as the American Urological Association and European Urological Association guidelines on male urinary incontinence. This review focuses on the pre-, intra and postoperative factors that influence postoperative SUI after RP, as well as highlighting modifications in surgical techniques that lead to early continence recovery. Increasing age, higher BMI, shorter membranous urethral length (MUL), and larger PV are independent prognostic factors for SUI within 3 months after RP. Factors such as modified surgical technique preservation of anatomical structure lead to influence postoperative early continence recovery. SUI after RP is influenced by various factors. These factors include not only anatomical landmarks and patient-related factors such as age, BMI, length of MUL and prostate volume, but also prior transurethral resection or laser enucleation of the prostate, the surgeon's expertise, the surgical approach and NS technique.

Modified Retzius-sparing robot-assisted radical prostatectomy for cases with anterior tumor: a propensity score-matched analysis

OBJECTIVE

To compare the outcomes between a modified Retzius-sparing robot-assisted radical prostatectomy (mRS-RARP) technique and conventional robot-assisted radical prostatectomy (Con-RARP) technique for cases with anterior prostate cancer (PCa), especially positive surgical margin (PSM) rates and urinary continence (UC).

PATIENTS AND METHODS

We retrospectively included 193 mRS-RARP and 473 Con-RARP consecutively performed by a single surgeon for anterior PCa. Perioperative complications, pathology, and continence were compared after propensity score matching using 9 variables.

RESULTS

After matching (n = 193 per group), PSM were not significantly different in the two groups (16.1% in mRS-RARP group vs. 15.0% in Con-RARP group, p = 0.779). The UC at catheter removal and at 1-month was significantly higher in the mRS-RARP (24.9% vs. 9.8%, p < 0.001; 29.0% vs. 13.5%, p < 0.001, respectively), but not at 3-, 6-, and 12-month follow-ups (p = 0.261, 0.832, and 0.683, respectively).

CONCLUSION

mRS-RARP seems to be an oncologically safe approach for patients with anterior PCa. Compared with the conventional approach, mRS-RARP approach shows benefits in the short-term postoperative UC recovery.

Association between 3D membranous urethral parameters and urinary continence recovery after RARP

OBJECTIVES

To evaluate whether the urinary continence (UC) recovery after robotic-assisted radical prostatectomy (RARP) relates to the membranous urethral length (MUL) and the membranous urethral complex volume (MUV).

MATERIALS AND METHODS

120 patients who underwent RARP were enrolled according to the different times of UC recovery and examined using prostate magnetic resonance imaging (MRI) before surgery. The membranous urethral (MU) parameters were measured using the three-Dimensional (3D) model reconstructed by holographic technology, such as total MUV (tMUV), exposed MUV (eMUV), full MUL (fMUL) and exposed MUL (eMUL). Statistical software SPSS 26.0 was used to analyze the data and compare the MU parameters and baseline data in different groups.

RESULTS

Patients with larger tMUV (p = 0.038), eMUV (p = 0.003), longer fMUL (p = 0.025), eMUL (p = 0.044) had better UC after removal of the catheter, and eMUV (OR = 1.002, 95%CI = 1.001-1.004, p = 0.004) was a predictor; the patients with younger age (p = 0.021), lower VPSS score (p = 0.004) and larger eMUV (p = 0.012) and longer eMUL (p = 0.049) had better UC recovery one month after RARP while eMUV (OR = 1.002, 95% CI = 1.000-1.003, p = 0.008) and VPSS score (OR = 0.886, 95% CI = 0.806-0.973, p = 0.011) were independent risk factors; The patients with younger age (p = 0.018), larger tMUV (p = 0.029), eMUV (p = 0.016) had better UC recovery three months after RARP. eMUV (OR = 1.002, 95% CI = 1.000-1.004, p = 0.042) and age (OR = 0.904, 95% CI = 0.818-0.998, p = 0.046) were independent risk factors.

CONCLUSION

This clinical study shows that patients with larger MUV and longer MUL can return to UC earlier after surgery. Among that, eMUV is a better predictor.

Retzius-Sparing Robotic-Assisted Prostatectomy: Technical Challenges for Surgeons and Key Prospective Refinements

Robotic-assisted radical prostatectomy (RARP) is the gold standard for localized prostate cancer. Several RARP approaches were developed and described over the years, aimed at improving oncological and functional outcomes. In 2010, Galfano et al described a new RARP technique, known as Retzius-sparing RARP (RS-RARP), a posterior approach through the Douglas space that spares the anterior support structures involved with urinary continence and sexual potency. This approach has been used increasingly in many centers around the world comparing its results with those of the most used standard anterior approach. Several randomized controlled trials, systematic reviews and meta-analyses demonstrated an important advantage relative to standard anterior RARP in terms of early urinary continence recovery, with comparable perioperative and long-term oncological outcomes. Several surgeons are concerned regarding RS-RARP because it appears to increase the risk of positive surgical margins (PSMs). However, this statement is based on low-certainty evidence. Indeed, the available studies compared the results of surgeons who had an initial experience with posterior RARP with those who had a solid experience with anterior RARP. Recent evidence strongly suggests that RS-RARP is feasible and safe not only in low- and intermediate-risk prostate cancer patient but also in challenging scenario such as high-risk setting, salvage prostatectomy and after transurethral resection of the prostate.

Quality of life after non-nerve-sparing, robot-assisted radical prostatectomy

OBJECTIVE

To evaluate quality of life (QOL) after non-nerve-sparing, robot-assisted radical prostatectomy (RARP) and factors associated with worsened QOL.

METHODS

Patients who underwent non-nerve-sparing RARP (n = 115) were enrolled. The Expanded Prostate Cancer Index Composite and 8-item Short Form Health Survey were used to evaluate QOL at baseline and postoperative 1, 3, 6, 12, and 24 months. Preoperative factors were evaluated by multivariate analysis for worsened QOL.

RESULTS

Postoperative 24-month urinary QOL worsened in 68 of 115 (59%) patients. In multivariate analysis, membranous urethral length ≥10.8 mm [odds ratio (OR): .26, 95% confidence interval (CI): .07-.96] and intravesical prostatic protrusion ≥12 mm (OR: .14, 95% CI .06-.35) were significantly associated with maintaining postoperative 24-month urinary QOL. Significantly more patients with intravesical prostatic protrusion ≥12 mm than < 12 mm had improved urinary QOL. At postoperative 24 months, 43 of 115 (38%) patients had worsened sexual QOL. In multivariate analysis, higher Sexual Health Inventory for Men score (OR: 8.39, 95% CI 2.28-30.9), sexual activity (OR: 6.94, 95% CI: 2.27-21.2), and intercourse activity (OR: 6.81, 95% CI: 1.64-28.3) preoperatively were significantly associated with worsened postoperative 24-month sexual QOL. More patients with high preoperative intercourse activity (12/23,53%) had significantly worsened (p = .009) QOL regarding sexual bother than those who had no preoperative intercourse activity (21/92, 23%).

CONCLUSION

After non-nerve-sparing RARP, patients with long membranous urethral length and/or intravesical prostatic protrusion maintain urinary QOL. Patients with high intercourse activity presented with impairment of sexual QOL after non-nerve-sparing RARP.

Improved early and late continence following robot-assisted radical prostatectomy with concurrent bladder neck fascial sling (RoboSling)

Objective

To describe a novel RoboSling technique performed at the time of robot-assisted radical prostatectomy (RARP) and its utility for enhancing urinary function recovery postoperatively.

Materials and Methods

The surgical technique involves harvesting a vascularised, fascial flap from the peritoneum on the posterior aspect of the bladder. Following completion of prostatectomy, the autologous flap is tunnelled underneath the bladder and incorporated into the rectourethralis and vertical longitudinal detrusor fibres at the posterior bladder neck with a modified Rocco suture. After urethra-vesical anastomosis is completed, the corners of the flap are hitched up to Cooper's ligament bilaterally with V-Loc sutures, tensioned and secured creating a bladder neck sling. A prospective, longitudinal cohort study was performed of 193 consecutive patients undergoing RARP between December 2016 and September 2019. The first 163 patients underwent standard RARP, and the last 30 patients had the RoboSling technique performed concurrently. Continence outcomes were the primary outcomes assessed using pad number and Expanded Prostate Cancer Composite (EPIC)-urinary domain questionnaire. Operative time (OT), estimated blood loss (EBL), complications and oncological outcomes were secondary outcomes.

Results

The two groups were comparable for demographics and clinicopathological variables. At 3 months, zero pad usage (p = 0.005) and continence rates, defined as EPIC score ≥ 85 (p = 0.007), were both higher in the RoboSling group. EBL, complication rate and positive surgical margin rate did not differ between the two groups. Superior zero pad usage was observed at 1 year in the RoboSling group (p = 0.029). The RoboSling technique added on average 16 min to OT.

Conclusions

The RoboSling procedure at the time of RARP was associated with earlier return to continence without negatively impacting other postoperative outcomes. This improvement in continence outcomes was maintained long term.

Randomized controlled trial comparing open anterograde anatomic radical retropubic prostatectomy with retrograde technique

Objective

Radical prostatectomy is the recommended treatment for localized prostate cancer; however, it is an invasive procedure that can leave serious morbidity. Robot-assisted radical prostatectomy was introduced with the aim of reducing postoperative morbidity and facilitating rapid recovery compared to the traditional Walsh's open radical retropubic prostatectomy. Therefore, a protocol was developed to perform an open prostatectomy comparable to that performed by robotics, but without involving novel instrumentation.

Methods

A total of 220 patients diagnosed with localized prostate cancer underwent radical prostatectomy. They were divided into two groups: anterograde technique (115 patients) and the retrograde method (105 patients). The study outcomes were observed 3 months after surgery.

Results

No differences were found in terms of surgical time, hospital stay, and suction drainage. However, reduced bleeding was observed in the anterograde technique (p=0.0003), with rapid anastomosis duration (p=0.005). Among the patients, 60.9% undergoing the anterograde technique were continent 3 months after surgery compared to 42.9% treated by the retrograde method (p=0.007). Additionally, fewer complications in terms of the number (p=0.007) and severity (p=0.0006) were observed in the anterograde technique.

Conclusion

The anterograde method displayed increased efficiency in reducing complications, compared to the retrograde technique.

The progress of dorsal vascular complex control strategy in radical prostatectomy

Radical prostatectomy has undergone a development from open to laparoscopic surgery to a surgical robotic approach. With improved surgical equipment and the continuous development of surgical techniques, various surgical strategies for controlling the dorsal vascular complex (DVC) during RP have been investigated, which affect intraoperative blood loss, postoperative tumour control and postoperative urinary and sexual function. The present narrative review summarizes the latest anatomical information about the prostatic apex and DVC and then describes the three types of DVC control. More detailed anatomy of the DVC is required and the optimal DVC control under different situations needs further research.

A retrospective study to evaluate the effect of preoperative hormonal therapy on continence recovery

Objective

To evaluate whether different preoperative hormonal therapy options affect postoperative continence and to identify risk/protective factors for continence recovery.

Methods

This is a retrospective analysis of several clinical trials (NCT04356430, NCT04869371, NCT04992026 and NCT05406999). Data from patients treated with hormonal therapy followed by RARP were collected and analyzed. Continence was defined as 0 pad/day or one safety pad.

Results

The study included 230 patients with adequate information. The median time to continence recovery is 8 weeks. A total of 216 (93.9%) participants recovered to urinary continence within 12 months after surgery. 21 (9.1%) participants achieved immediate continence. 69, 85, 27 and 14 participants restored continence at 1 month, 1-3 month, 3-6 month, 6-12 month, accounting for 30.0%, 40.0%, 11.7% and 6.1% accordingly. No difference in continence recovery was found among different preoperative hormonal treatment options (p=0.821). Cox regression showed that membranous urethral length (MUL) was the only independent factor influencing urinary continence recovery either in the univariate analysis (OR=1.13, 95%CI: 1.04-1.22, p=0.002) or in the multivariate analysis (OR=1.12, 95%CI: 1.04-1.20, p=0.002). Different preoperative treatment options were not associated with urinary recovery. More advanced preoperative T stage (OR=0.46, 95%CI: 0.24-0.85, p=0.014) delayed the recovery of immediate continence. MUL was associated with continence restoring at 1 month (OR=1.20, 95%CI: 1.03-1.39, p=0.017), 3 month (OR=1.27, 95%CI: 1.07-1.51, p=0.006), 6 month (OR=1.34, 95%CI: 1.07-1.67, p=0.011) and 12 month (OR=1.36, 95%CI: 1.01-1.84, p=0.044).

Conclusion

There is no difference in postoperative continence recovery among ADT, ADT+Docetaxel and ADT+Abiraterone preoperative treatment options. More advanced T stage indicated poor immediate continence recovery. Longer membranous urethral length was a promotional factor for both short-time and long-time continence recovery.

The development and assessment of a predicting nomogram for the recovery of immediate urinary continence following laparoscopic radical prostatectomy

Purpose

This study aimed to develop a nomogram to predict the recovery of immediate urinary continence in laparoscopic radical prostatectomy (LRP) patients.

Methods

A prediction model was developed based on a dataset of 154 LRP patients. Immediate urinary continence was defined as free from using pads within 7 days after the removal of the urinary catheter. The least absolute shrinkage and selection operator regression (LASSO) model was applied to screen the features. Multivariate logistic regression analysis was used to establish prediction model integrating the features selected from the LASSO regression analysis. Receiver operating curve (ROC), calibration and decision curve analysis (DCA) were used to assess the model's discrimination, calibration and clinical utility.

Results

The identified features of the prediction model included age, body mass index (BMI) and three pelvic anatomic parameters measured by MRI: membranous urethral length (MUL), intravesical prostatic protrusion length (IPPL) and puborectalis muscle width (PMW). The nomogram showed good discrimination with an are under the curve(AUC) of 0.914 (95% CI, 0.865-0.959, p < 0.001). Moreover, good calibration was showed in the model. Lastly, DCA showed that the nomogram was clinically useful.

Conclusion

The developed novel nomogram that can predict the possibility for post-prostatectomy patients to recover immediate urinary continence could be used as a counseling tool to explain urinary incontinence to patients after LRP.

Sustainable functional urethral reconstruction improves early urinary continence after robot-assisted radical prostatectomy: a randomised controlled trial

OBJECTIVE

To evaluate the impact of sustainable functional urethral reconstruction (SFUR) on early recovery of urinary continence (UC) after robot-assisted radical prostatectomy.

PATIENTS AND METHODS

Overall, 96 patients with primary prostate cancer were randomised into the SFUR or standard group (n = 48 each). The primary outcome was the 1-month UC recovery. Secondary outcomes included short-term (≤3 months) UC recovery, urinary function, micturition-related bother, perioperative complications, and oncological outcomes. Kaplan-Meier curves and Cox proportional hazard models were used to assess the 3-month UC recovery. Generalised estimating equations were used to compare postoperative urinary function and micturition-related bother.

RESULTS

The 1-month UC recovery rates, median 24-h pad weights, and median operative time in the SFUR and standard groups were 73% and 49% (P = 0.017), 0 and 47 g (P = 0.001), and 125 and 103 min (P = 0.025), respectively. The UC recovery rates in the SFUR vs standard groups were 53% vs 23% at 1 week (P = 0.003), 53% vs 32% at 2 weeks (P = 0.038), and 93% vs 77% at 3 months (P = 0.025). The median time to UC recovery in the SFUR and standard groups was 5 and 34 days, respectively (log-rank P = 0.006); multivariable Cox regression supported this result (hazard ratio 1.73, 95% confidence interval 1.08-2.79, P = 0.024). Similar results were observed when UC was defined as 0 pads/day. Urinary function (P = 0.2) and micturition-related bother (P = 0.8) were similar at all follow-up intervals. The perioperative complication rates, positive surgical margin rates, and 1-year biochemical recurrence-free survival were comparable between both groups (all P > 0.05).

CONCLUSION

SFUR resulted in earlier UC recovery without compromising postoperative urinary function. Long-term validation and multicentre studies are required to confirm the results of this novel technique.

Independent Factors Affecting Postoperative Short-Term Urinary Continence Recovery after Robot-Assisted Radical Prostatectomy

Background

Our team had firstly applied the transvesical approach to robot-assisted radical prostatectomy (RARP) in patients afflicted with localized prostate cancer (PCa). The present study aims to present the postoperative recovery of urinary continence (UC) following the anterior, transvesical, and posterior approaches to RARP for localized PCa and evaluate the independent predictors to early UC recovery after RARP.

Methods

Patients harboring localized PCa and receiving anterior, transvesical, and posterior approaches to RARP between January 2017 and June 2020 were enrolled in this analysis. Results on UC recovery were compared between these three approaches with the Kaplan–Meier method. All clinical and pathological variables were further analyzed via univariable and multivariable regression analysis to determine the independent factors contributing to short-term UC recovery after RARP.

Results

A total of 135, 73, and 66 instances were included in the anterior, transvesical, and posterior groups, respectively. Over the postoperative follow-up period, both the transvesical and posterior approaches showed an advantage over the anterior approach in promoting postoperative UC recovery (both p values <0.001). Three months after surgery, 55 (40.7%), 4 (5.5%), and 5 (7.6%) patients failed to UC in the anterior, transvesical, and posterior groups, respectively. Patient age, preoperative PSA, prostate volume, biopsy Gleason score, surgical approach, extended lymph node dissection technique, nerve-sparing technique, and positive lymph node were related to UC status based on univariable analyses (p < 0.05). Multivariable analysis results point patient age, prostate volume, surgical approach, and nerve-sparing technique as independent factors that affect postoperative UC recovery after RARP.

Conclusions

The application of transvesical approach to RARP for localized PCa could obtain promising outcomes in terms of postoperative UC recovery. In addition, surgical strategies encompassing the nerve-sparing technique and the Retzius-sparing procedures, namely, the transvesical or posterior approach, during RARP could independently enable early achievement of postoperative continence.

Impact of preoperative factors on recovery of continence after artificial urinary sphincter implantation in postprostatectomy incontinence

Background

The purpose of this study was to determine the influence of preoperative factors on the recovery of continence after artificial urinary sphincter (AUS) implantation in postprostatectomy incontinence.

Materials and methods

Seventy-two patients who underwent AUS implantation between April 2006 and March 2020 were analyzed. The clinical features and preoperative urodynamic parameters were correlated with the postoperative continence rate using linear and logistic regression analysis. The recovery of continence was defined by the patient requiring no use of a protective urine pad during the 24 hours.

Results

Of the 72 patients, 57 (79.2%) recovered continence (dry group), while 15 (20.8%) were wearing more than 1 pad per day (wet group) on the last follow-up visit. In the clinical characteristics, only the interval between radical prostatectomy and AUS (in months) showed a statistically significant difference (35.4 ± 26.2 in the dry group, 22.7 ± 12.2 in the wet group, p = 0.009). Other preoperative clinical features such as the underlying disease, surgical methods, size of prostate, tumor stage, and radio nor hormonal therapy did not present statistically significant differences.

Of the preoperative urodynamic parameters, only the abdominal leak point pressure (ALPP) showed statistical significance when related to surgical outcomes by 88.6 ± 33.6 in the dry group and 66.1 ± 29.6 in wet the group (P = 0.024). The number of patients for whom ALPP was higher than 80 cm H₂O was 61.4% in the dry group and 20% in the wet group (95% confidence interval: 1.612-25.11). Other preoperative UDS features including detrusor underactivity, maximum urethral closure pressure, and others were not statistically significant.

Conclusions

The interval between RP and AUS, as well as the preoperative ALPP, can be possible predictive factors for the surgical outcomes of AUS implantation. In addition, an ALPP of >80 cm H₂O has a high degree of predictability for success of AUS surgical outcomes in post-RP incontinence.

Cryopreserved placental tissue allograft accelerates time to continence following robot-assisted radical prostatectomy

Intra-operatively placed cryopreserved placental tissue allograft (CPTA) has shown promise in expediting the recovery urinary continence (UC) following robot-assisted radical prostatectomy (RARP). In this retrospective review of a prospectively maintained single-surgeon, single-institution RARP database, we compare three groups of patients: historical controls (C; N = 183 men) that received no allograft versus two different CPTA products (total CPTA N = 162 [A1 N = 81; A2 N = 81]). The CPTA product was intra-operatively placed as an onlay over the area of the neurovascular bundles during RARP. CPTA cases had significantly faster median time to UC (A1 = 1.4 months; A2 = 1.45 months) versus controls (1.64 months), p = 0.01. On multivariable analysis, use of A1 (HR 1.55, 95% CI [1.14-2.09], p = 0.005) and use of A2 (HR 1.53, CI [1.11-2.11], p = 0.01) were significantly associated with quicker return of UC. Older age (HR 0.97, CI [0.96-0.99], p = 0.001) and non-organ-confined clinical stage (HR 0.51, CI [0.26-1.0] p = 0.05), were significantly associated with slower return of UC. In a propensity score-matched analysis of 77 CPTA patients with sufficient follow-up versus controls, there was significantly less biochemical recurrence (BCR; p = 0.01). Our study indicates that CPTA use appears to accelerate time to UC in age- and performance status-matched men undergoing RARP without increased risk of BCR.

Systematic review comparing Anterior vs Retzius-sparing robotic assisted radical prostatectomy: can the approach really make a difference?

INTRODUCTION

Retzius-Sparing Robotic Assisted Radical Prostatectomy (RS-RARP) is a novel surgical approach to radical prostatectomy. Its pioneers have suggested an improved recovery of urinary continence, while maintaining adequate cancer control. Aim of this systematic review is to explore available data on RS-RALP and compare functional, oncologic and perioperative results of RS-RARP compared to anterior RARP.

EVIDENCE ACQUISITION

A search following PRISMA guidelines was performed including the combination of the following words: retzius AND sparing AND radical AND prostatectomy. 93 articles were identified and 13 were included in the systematic review, including 3 randomized controlled trials (RCT), 4 prospective studies and 6 retrospective studies.

EVIDENCE SYNTHESIS

All available randomized trials confirmed an improved immediate continence for RS-RARP, with rates ranging 51-71%, compared to 21-48% for anterior RARP. However, this advantage was progressively lost with no significant difference found after 6 months. Moreover, a prospective study found no discrepancy in terms of quality of life across the two techniques. Erectile function was difficult to compare, as patients had different baseline erectile function across studies and rate of neurovascular preservation was not comparable. Surgical approach remains controversial regarding positive margin rate, although related to the surgeon's experience and clinical stage. Biochemical recurrence-free survival appears similar between the two approaches.

CONCLUSIONS

RS-RARP improves early urinary continence recovery compared to anterior RARP, with this advantage being lost after 3 to 6 months. Erectile function and quality of life were however comparable between the two techniques. The results concerning the rate of positive margins remained controversial. Future studies with longer follow-up are needed to better assess oncologic outcomes.

Incremental modification of robotic prostatectomy technique can lead to aggregated marginal gains to significantly improve functional outcomes without compromising oncological control

INTRODUCTION AND OBJECTIVES

Surgeons should aim for continuous quality improvement. The aim of this study was to evaluate the impact of incremental changes to Robot Assisted Radical Prostatectomy (RARP) technique on intra-operative and early post-operative outcomes.

PATIENTS AND METHODS

All cases of RARP performed by a single surgeon in a tertiary institution over a 2-year period were included in this evaluation. Routine clinical data were collected. Cases were retrospectively allocated to four groups depending on key technical steps (1 = standard anterior approach; 2 = anterior approach with preservation of endopelvic fascia, puboprostatic fascia and urachus; 3 = posterior approach for nerve spare, with preservation of endopelvic fascia, puboprostatic fascia and urachus; 4 = Retzius-sparing posterior approach).

RESULTS

187 patients were allocated to groups: 1 = 22, 2 = 53, 3 = 90, 4 = 22. There were no significant differences in pre-operative characteristics, except age: 1 = 62.5, 2 = 62, 3 = 62.5, 4 = 58.5 (p = 0.02). Intra-operative differences were found in console time: 1 = 195, 2 = 167, 3 = 195 4 = 136.5 min (p < 0.001); and proportion of non-nerve sparing cases: 1 = 36%, 2 = 17%, 3 = 13%, 4 = 0% (p = 0.044). No significant differences were found in lymph node dissections, blood loss or complications. Post-operatively, no differences were found in length of stay, pathological characteristics, margin status, lymph node yield, complications or PSA levels. Significant differences were seen in pad-free continence at 6 weeks: 1 = 23%, 2 = 23%, 3 = 34%, 4 = 73% (p < 0.01); and social continence (using 1 pad) at 6-weeks: 1 = 59%, 2 = 87%, 3 = 81%, 4 = 95% (p = 0.01). Significant differences in pad-free continence persisted at 12 months: 1 = 63%, 2 = 81%, 3 = 78%, 4 = 100% (p = 0.019).

CONCLUSION

Our results suggest that aggregated marginal gains from incremental modification of RARP leads to significantly improved continence outcomes without compromising patient safety or oncological control.

Posterior musculofascial reconstruction in robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

BACKGROUND

Delayed recovery of urinary continence is a major adverse effect of robotic-assisted laparoscopic prostatectomy (RALP) in men undergoing prostate cancer treatment. To address this issue, a number of surgical techniques have been designed to reconstruct the posterior aspect of the rhabdosphincter, which is responsible for urinary continence after removal of the prostate; however, it is unclear how well they work.  OBJECTIVES: To assess the effects of posterior musculofascial reconstruction RALP compared to no posterior reconstruction during RALP for the treatment of clinically localized prostate cancer.

SEARCH METHODS

We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings, up to 12 March 2021. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which participants were randomized to undergo variations of posterior musculofascial reconstruction RALP versus no posterior reconstruction during RALP for clinically localized prostate cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data from the included studies. Primary outcomes were: urinary continence recovery within one week after catheter removal, at three months after surgery, and serious adverse events. Secondary outcomes were: urinary continence recovery at six and twelve months after surgery, potency recovery twelve months after surgery, positive surgical margins (PSM), and biochemical recurrence-free survival (BCRFS). We performed statistical analyses using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach.

MAIN RESULTS

Our search identified 13 records of eight unique RCTs, of which six were published studies and two were abstract proceedings. We included 1085 randomized participants, of whom 963 completed the trials (88.8%). All participants had either cT1c or cT2 or cT3a disease, with a mean prostate-specific antigen level of 8.15 ng/mL. Primary outcomes Posterior reconstruction RALP (PR-RALP) may improve urinary continence one week after catheter removal compared to no posterior reconstruction during RALP (risk ratio (RR) 1.25, 95% confidence interval (CI) 0.90 to 1.73; I² = 42%; studies = 5, participants = 498; low CoE) although the CI also includes the possibility of no effect. Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 84 more men per 1000 (33 fewer to 244 more) reporting urinary continence recovery.  Posterior reconstruction may have little to no effect on urinary continence three months after surgery compared to no posterior reconstruction during RALP (RR 0.98, 95% CI 0.84 to 1.14; I² = 67%; studies = 6, participants = 842; low CoE). Assuming 701 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 14 fewer men per 1000 (112 fewer to 98 more) reporting urinary continence after three months. PR-RALP probably results in little to no difference in serious adverse events compared to no posterior reconstruction during RALP (RR 0.75, 95% CI 0.29 to 1.92; I² = 0%; studies = 6, participants = 835; moderate CoE). Assuming 25 per 1000 men undergoing standard RALP experience a serious adverse event at this time point, this corresponds to six fewer men per 1000 (17 fewer to 23 more) reporting serious adverse events.  Secondary outcomes PR-RALP may result in little to no difference in recovery of continence 12 months after surgery compared to no posterior reconstruction during RALP (RR 1.02, 95% CI 0.98 to 1.07; I² = 25%; studies = 3, participants = 602; low CoE). Assuming 918 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 18 more men per 1000 (18 fewer to 64 more) reporting urinary continence recovery.  We are very uncertain about the effects of PR-RALP on recovery of potency 12 months after surgery compared to no posterior reconstruction during RALP (RR 1.02, 95% CI 0.82 to 1.26; I² = 3%; studies = 2, participants = 308; very low CoE). Assuming 433 per 1000 men undergoing standard RALP are potent at this time point, this corresponds to nine more men per 1000 (78 fewer to 113 more) reporting potency recovery.  PR-RALP may result in little to no difference in positive surgical margins compared to no posterior reconstruction during RALP (RR 1.24, 95% CI 0.65 to 2.33; I² = 50%; studies = 3, participants = 517; low CoE). Assuming 130 per 1000 men undergoing standard RALP have a positive surgical margin, this corresponds to 31 more men per 1000 (46 fewer to 173 more) reporting positive surgical margins.  PR-RALP may result in little to no difference in biochemical recurrence compared to no posterior reconstruction during RALP (RR 1.36, 95% CI 0.74 to 2.52; I² = 0%; studies = 2, participants = 468; low CoE). Assuming 70 per 1000 men undergoing standard RALP have experienced biochemical recurrence at this time point, this corresponds to 25 more men per 1000 (18 fewer to 107 more) reporting biochemical recurrence.  AUTHORS' CONCLUSIONS: This review found evidence that PR-RALP may improve early continence one week after catheter removal but not thereafter. Meanwhile, adverse event rates are probably not impacted and surgical margins rates are likely similar. This review was unable to determine if or how these findings may be impacted by the person's age, nerve-sparing status, or clinical stage. Study limitations, imprecision, and inconsistency lowered the certainty of evidence for the outcomes assessed.

Evaluation of image-based prognostic parameters of post-prostatectomy urinary incontinence: A literature review

Prostate cancer is the second most common male cancer, and radical prostatectomy is a highly effective treatment for intermediate and high-risk disease. However, post-prostatectomy urinary incontinence remains a major functional side-effect in patients undergoing radical prostatectomy. Despite recent improvements in preoperative imaging quality and surgical techniques, it remains challenging to predict or prevent occurrence of this complication. The aim of this research was to review the current published literature on pre- and postoperative imaging evaluation of the prostate and pelvic structures, to identify added value in the prediction of post-prostatectomy urinary incontinence. A computerized bibliographic search of the PubMed library was carried out to identify imaging-based articles evaluating the pelvic floor and surrounding structures pre- and/or postradical prostatectomy to predict post-prostatectomy urinary incontinence. A total of 32 articles were included. Of these, 29 papers assessed the importance of magnetic resonance imaging evaluation, with a total of 16 parameters evaluated. The most common parameters were intravesical protrusion, the membranous urethral length, prostatic volume and periurethral fibrosis. Preoperative membranous urethral length and its preservation after surgery showed the strongest correlation with urinary incontinence. Three studies evaluated ultrasound, with all carried out postoperatively. This technique benefits from a dynamic evaluation, and the results are promising for proximal urethral hypermobility and the degree of bladder neck funneling on the Valsalva maneuver. Several imaging studies evaluated the predictors of post-prostatectomy urinary incontinence, with preoperative membranous urethral length offering the most promise. However, the current literature is limited by the single-center nature of studies, and the heterogeneity in patient populations and methodologies used.

Transvesical Retzius-Sparing Versus Standard Robot-Assisted Radical Prostatectomy: A Retrospective Propensity Score-Adjusted Analysis

Objectives

To estimate the safety and efficiency of transvesical Retzius-sparing robot-assisted radical prostatectomy (T-RARP) compared with standard robot-assisted radical prostatectomy (S-RARP) for localized prostate cancer (PCa).

Materials and Methods

174 patients bearing localized PCa and undergoing T-RARP or S-RARP between October 2017 and January 2020 were retrospectively enrolled in our analysis. All potential baseline confounders were strictly restrained with propensity-score matching (PM) method (1: 1). Within the matched setting, the perioperative and functional outcomes were compared between the T-RARP and S-RARP groups, while the oncological results and functional recovery of the two arms were presented with Kaplan-Meier curves.

Results

Finally, 114 and 60 eligible patients harbouring localized PCa were identified in the S-RARP and T-RARP group, respectively. No significant differences between the two groups were found in all baseline characteristics after PM. Within the matched cohort, no case was converted to open surgery in either group. The T-RARP group was significantly related to a higher mean operative time (p = 0.001) and shorter median hospital stay length (p < 0.001). There were not significant differences in the median estimated blood loss and specimen Gleason score between the two arms. The proportions of transfusion, pT3a disease, postoperative complication, and positive surgical margin in the T-RARP group were also comparable to that in the S-RARP group. The mean prostate-specific antigen and median erectile functional scores did not differ significantly between the two groups at postoperative 3 months and last follow-up. T-RARP vs. S-RARP had significantly improved urinary continence (UC) rates at the removal of catheter (p < 0.001) and postoperative 3 months (p < 0.001), but the significant difference between the two groups in UC recovery disappeared at last follow-up (p = 0.119). No significant difference in biochemical recurrence-free survival was observed following the two surgeries (p = 0.727).

Conclusions

T-RARP by experienced hands was feasible for selected patients with clinically localized PCa, yielding significantly improved early return to UC and similar erectile functional preservation without compromising oncological control when compared with the standard approach.

Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Salvage Versus Primary Robot-assisted Radical Prostatectomy: A Propensity-matched Comparative Effectiveness Study from a High-volume Tertiary Centre

Background

Salvage robot-assisted radical prostatectomy (sRARP) is a potential treatment option for locally recurrent prostate cancer (PCa) after nonsurgical primary treatment. There are minimal data comparing outcomes between propensity-matched sRARP and primary robot-assisted radical prostatectomy (RARP).

Objective

The primary objective is to compare perioperative, oncological, and functional outcomes of sRARP with primary RARP, and the secondary is to compare outcomes between sRARP after whole and focal gland therapy.

Design, setting, and participants

A 1:1 propensity-matched comparison was carried out of 135 sRARP cases with primary RARP cases from a cohort of 3852 consecutive patients from a high-volume tertiary centre.

Outcome measurements and statistical analysis

Perioperative, oncological, and functional outcomes including complication rates, positive surgical margins, biochemical recurrence (BCR), continence, and erectile dysfunction (ED) were retrospectively collected.

Results and limitations

There were no significant differences in patient characteristics between sRARP and primary RARP groups. In the salvage and primary groups, median (interquartile range) follow-up periods were 521 (304–951) and 638 (394–951) d, grade III–V Clavien-Dindo complication rates were 1.5% and 0% (p = 0.310), BCR rates were 31.9% and 14.1% (p < 0.001) at the last follow-up, pad-free continence rates were 78.8% and 84.3% at 2 yr (p = 0.337), and ED rates were 94.8% and 76.3% (p < 0.001), respectively. Comparing the whole and focal gland groups, BCR rates were 36.7% and 29.1% (p = 0.687) at follow-up, pad-free continence rates were 53.1% and 89.3% at 2 yr (p < 0.001), and ED rates were 98% and 93% (p = 0.214), respectively.

Conclusions

Salvage RARP has similar perioperative outcomes to primary RARP with inferior potency rates. Post–focal therapy sRARP has similar recurrence and continence rates to primary RARP. Post–whole gland therapy, complication, and recurrence rates are higher, and there is a higher risk of urinary incontinence.

Patient summary

We report the largest propensity-matched comparison of salvage robot-assisted radical prostatectomy (RARP) after focal and whole gland therapy. Salvage RARP is a feasible procedure for the treatment of locally recurrent prostate cancer in high-volume centres; however, patients should be counselled appropriately as to the different outcomes.

Use of Duloxetine for Postprostatectomy Stress Urinary Incontinence: A Systematic Review

CONTEXT

The recommended treatment of postprostatectomy stress urinary incontinence (PPSUI) after failure of pelvic floor muscle training is primarily surgical intervention with a male sling or artificial urinary sphincter. The use of pharmacological therapy in this setting is unlicensed and controversial.

OBJECTIVE

To systematically review the available evidence regarding the efficacy and safety of duloxetine for the treatment of stress urinary incontinence following prostate surgery (radical or endoscopic).

EVIDENCE ACQUISITION

The EMBASE, MEDLINE/PubMed, and Cochrane Central Register of Controlled Trials were searched from inception up until April 17, 2020. All studies evaluating the role of duloxetine in men with PPSUI were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed data extraction. The quality of evidence and risk of bias were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE); Cochrane; and Risk of Bias in Nonrandomised Studies of Interventions (ROBINS-I) tools.

EVIDENCE SYNTHESIS

The search yielded 234 studies. After excluding duplicates, 140 titles and abstracts were screened, and eight reports (348 patients) were eligible for inclusion in the final review. Duloxetine was assessed in two scenarios: (1) early use to reduce the time to attain continence and (2) treatment of persistent PPSUI. Most men had mild-to-moderate incontinence at baseline. Overall, duloxetine resulted in a mean dry rate of 58% (25-89%), mean improvement in pad number of 61% (12-100%), and mean improvement in 1-h pad weight of 68% (53-90%) at short-term follow-up (mean 1-9 mo; low to moderate certainty of evidence). However, mean adverse event rates were relatively high, and treatment was discontinued in 38% (low certainty of evidence).

CONCLUSIONS

Duloxetine has demonstrated good short-term cure and/or improvement in treating men with persistent PPSUI, as well as in reducing the time to attain continence. However, a proportion of men discontinue treatment due to adverse events. The overall certainty evidence is moderate to low, with heterogeneity between studies and methodological limitations. However, we have highlighted the need for further randomised trials with longer follow-up, utilising consistent outcome reporting measures. Despite these limitations, the findings from this review will aid patient counselling regarding this less invasive treatment option, thereby allowing personalisation of care centred around the values and preferences of individual patients.

PATIENT SUMMARY

Duloxetine has good success rates in the short term, in terms of improving incontinence symptoms in men who have undergone prostate surgery. However, some men experience side effects bad enough to require cessation of treatment. Further studies are needed to determine whether duloxetine maintains its effectiveness in the long term.

Hood Technique for Robotic Radical Prostatectomy-Preserving Periurethral Anatomical Structures in the Space of Retzius and Sparing the Pouch of Douglas, Enabling Early Return of Continence Without Compromising Surgical Margin Rates

BACKGROUND

A common side effect following radical prostatectomy is urinary incontinence. Here, we describe a novel surgical technique to reduce postoperative urinary incontinence and facilitate early return of continence.

OBJECTIVE

To describe the novel "hood technique" for robotic-assisted radical prostatectomy (RARP).

DESIGN, SETTING, AND PARTICIPANTS

This is an institutional review board-approved prospective study of 300 patients (median age 64 yr) with localized prostate cancer treated with the RARP hood technique at a major urban hospital between April 2018 and March 2019. The exclusion criteria were as follows: patients with anterior tumor location based on biopsy or multiparametric magnetic resonance imaging. All but one patient participated in follow-up over 12 mo after the procedure.

SURGICAL PROCEDURE

The RARP "hood technique" was performed to preserve the detrusor apron, puboprostatic ligament complex, arcus tendineus, endopelvic fascia, and pouch of Douglas.

MEASUREMENTS

Clinical data collected included pre- and intraoperative variables, and postoperative functional and oncological outcomes and complications. Descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

Continence rates at 1, 2, 4, 6 12, 24, and 48 wk after catheter removal were 21%, 36%, 83%, 88%, 91%, 94%, and 95%, respectively. Positive surgical margin rate was 6%. Thirty patients (9.7%) experienced complications after RARP: 17 (5.7%), 11 (3.6%), and one (0.4%) had Clavien-Dindo grade I, II, and III complications, respectively. This study was conducted within a single health system and may not be generalizable. The study lacked randomization and a comparative arm.

CONCLUSIONS

Results indicate that the hood technique spares musculofascial structures anterior to the urethral sphincter complex with early return of continence after surgery, without compromising positive surgical margin rates. Exclusion of anterior tumor location contributed to a reduction in positive surgical margins.

PATIENT SUMMARY

By better preservation of anatomical structures around the urethra, we were able to achieve early return of urinary continence without a negative impact on complications and cancer outcomes.

Retzius-sparing versus standard robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

BACKGROUND

Robotic-assisted laparoscopic prostatectomy (RALP) is widely used to surgically treat clinically localized prostate cancer. It is typically performed using an approach (standard RALP) that mimics open retropubic prostatectomy by dissecting the so-called space of Retzius anterior to the bladder. An alternative, Retzius-sparing (or posterior approach) RALP (RS-RALP) has been described, which is reported to have better continence outcomes but may be associated with a higher risk of incomplete resection and positive surgical margins (PSM).

OBJECTIVES

To assess the effects of RS-RALP compared to standard RALP for the treatment of clinically localized prostate cancer.

SEARCH METHODS

We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings, up to June 2020. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included trials where participants were randomized to RS-RALP or standard RALP for clinically localized prostate cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified and abstracted data from the included studies. Primary outcomes were: urinary continence recovery within one week after catheter removal, at three months after surgery, and serious adverse events. Secondary outcomes were: urinary continence recovery six and 12 months after surgery, potency recovery 12 months after surgery, positive surgical margins (PSM), biochemical recurrence-free survival (BCRFS), and urinary and sexual function quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

Our search identified six records of five unique randomized controlled trials, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. Mean age of participants was 64.6 years and mean prostate-specific antigen was 6.9 ng/mL. About 54.2% of participants had cT1c disease, 38.6% had cT2a-b disease, and 7.1 % had cT2c disease. Primary outcomes RS-RALP probably improves continence within one week after catheter removal (risk ratio (RR) 1.74, 95% confidence interval (CI) 1.41 to 2.14; I² = 0%; studies = 4; participants = 410; moderate-certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS-RALP may increase continence at three months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06 to 1.68; I² = 86%; studies = 5; participants = 526; low-certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS-RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47 to 4.17; studies = 2; participants = 230; very low-certainty evidence). Secondary outcomes There is probably little to no difference in continence recovery at 12 months after surgery (RR 1.01, 95% CI 0.97 to 1.04; I² = 0%; studies = 2; participants = 222; moderate-certainty evidence). Assuming 982 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 10 more men per 1000 (29 fewer to 39 more) reporting continence recovery.  We are very uncertain about the effect of RS-RALP on potency recovery 12 months after surgery (RR 0.98, 95% CI 0.54 to 1.80; studies = 1; participants = 55; very low-certainty evidence).  RS-RALP may increase PSMs (RR 1.95, 95% CI 1.19 to 3.20; I² = 0%; studies = 3; participants = 308; low-certainty evidence) indicating a higher risk for prostate cancer recurrence. Assuming 129 per 1000 men undergoing standard RALP have positive margins, this corresponds to 123 more men per 1000 (25 more to 284 more) with PSMs. We are very uncertain about the effect of RS-RALP on BCRFS compared to standard RALP (hazard ratio (HR) 0.45, 95% CI 0.13 to 1.60; I² = 32%; studies = 2; participants = 218; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Findings of this review indicate that RS-RALP may result in better continence outcomes than standard RALP up to six months after surgery. Continence outcomes at 12 months may be similar. Downsides of RS-RALP may be higher positive margin rates. We are very uncertain about the effect on BCRFS and potency outcomes. Longer-term oncologic and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade-offs and the limitations of the evidence with their patients when considering this approach.

Retzius-sparing robot-assisted radical prostatectomy improves early recovery of urinary continence: a randomized, controlled, single-blind trial with a 1-year follow-up

OBJECTIVE

To evaluate the impact of Retzius-sparing robot-assisted radical prostatectomy (posterior approach) on early recovery of urinary continence (UC) compared to the conventional approach (anterior approach) for the treatment of clinically localized prostate cancer (PCa).

METHODS

A total of 110 consecutive patients with clinically localized PCa were prospectively randomized in a 1:1 ratio to an anterior group (n = 55) or a posterior group (n = 55). The primary outcome was immediate UC, defined as freedom from any pad use within 1 week after removal of the urinary catheter. The UC rate following surgery was also calculated with Kaplan-Meier curves, and the log-rank test was used for statistical comparison. Intra-operative outcomes, pathological data and oncological outcomes, including positive surgical margin (PSM) status and biochemical recurrence-free survival (BCRFS), were also compared between the two groups. The comparison of the two approaches was also analysed in subgroups after risk stratification.

RESULTS

Of the patients who underwent the posterior approach, 69.1% achieved immediate UC compared with 30.9% in the anterior group (relative risk 2.24, 95% confidence interval [CI] 1.48-3.51; P = 0.000). The relative Kaplan-Meier curves for UC during the 12-month follow-up revealed statistically better recovery in the posterior group when compared with the anterior group (hazard ratio [HR] 1.51, 95% CI 1.01-2.24; log-rank P = 0.007). No statistically significant differences were observed between the groups regarding complications (P = 0.399), PSM status (P = 0.225) or BCRFS (HR 4.80, 95% CI 0.97-23.78; log-rank P = 0.111). In sub-analyses, no significant difference between the two approaches with regard to UC recovery in patients with high-risk PCa was observed (HR 1.26, 95% CI 0.63-2.51; log-rank P = 0.415).

CONCLUSIONS

The Retzius-sparing approach significantly improved early recovery of UC compared to the conventional approach. Further prospective studies are needed to confirm the benefits of the Retzius-sparing approach for clinically localized PCa, especially for high-risk cases.

Pelvic Floor Muscle Training in Radical Prostatectomy and Recent Understanding of the Male Continence Mechanism: A Review

OBJECTIVE

Pelvic floor muscle training (PFMT) is recommended as part of supportive care for patients with prostate cancer. It can assist in reducing treatment-related symptoms such as urinary incontinence. This literature review aims to discuss recent innovative findings on the pathophysiology of the male continence mechanism and implications for PFMT in radical prostatectomy.

DATA SOURCES

CINAHL, Embase, Web of Science, Emcare and PsycINFO were searched until January 2020.

CONCLUSION

Nurses providing supportive care for patients undergoing radical prostatectomy can engage in-clinic in the instruction and recommendation of pre- and postoperative PFMT and delivering guidance on home-based programs to promote motor learning.

IMPLICATIONS FOR NURSING PRACTICE

Optimal postoperative urinary incontinence outcomes are suggested to be promoted by preoperative PFMT. Training focused on the urethral and anterior pelvic floor muscle complex has been shown to facilitate mid urethral occlusion required for continence. Prescription of PFMT should be individualised, focusing on skill acquisition and motor learning, which is in line with recent knowledge developments in male pelvic floor anatomy.

Predictors of urinary toxicity with MRI-assisted radiosurgery for low-dose-rate prostate brachytherapy

PURPOSE

MRI-assisted radiosurgery (MARS) is a modern technique for prostate brachytherapy that provides superior soft tissue contrast. The purpose of this analysis was to evaluate treatment planning factors associated with urinary toxicity, particularly damage to the membranous urethra (MUL) and external urethral sphincter (EUS), after MARS.

MATERIAL AND METHODS

We retrospectively reviewed 227 patients treated with MARS. Comparisons were made between several factors including preimplantation length of the MUL and EUS dosimetric characteristics after implantation with longitudinal changes in American Urological Association (AUA) urinary symptom score.

RESULTS

Rates of grade 3 urinary incontinence and obstructive urinary symptoms were 4% and 2%. A piecewise mixed univariate model revealed that MUL and V₂₀₀, V₁₅₀, V₁₂₅, and D₅ to the EUS were all associated with increased rates of urinary toxicity over time. On univariate logistic regression, MUL >14.2 mm (odds ratio [OR] 2.03 per cm³, 95% confidence interval [CI] 1.10-3.77, p = 0.025), V₁₂₅ to the EUS (OR 3.21 cm³, 95% CI 1.18-8.71, p = 0.022), and use of the I-125 isotope (OR 3.45, 95% CI 1.55-7.70, p = 0.001) were associated with subacute urinary toxicity (i.e., that occurring at 4-8 months). Optimal dose-constraint limits to the EUS were determined to be V₂₀₀ < 0.04 cm³ (p = 0.002), V₁₅₀ < 0.12 cm³ (p = 0.041), V₁₂₅ < 0.45 cm³ (p = 0.033), D₃₀ < 160 Gy (p = 0.004), and D₅ < 218 Gy (p = 0.016).

CONCLUSIONS

MARS brachytherapy provides detailed anatomic information for treatment planning, implantation, and quality assurance. Overall rates of urinary toxicity are low; however, several dosimetric variables associated with the EUS were found to correlate with urinary toxicity.

Improving early urinary continence recovery after radical prostatectomy by applying a sutureless technique for maximal preservation of the intrapelvic urethra: A 17-year single-surgeon experience

BACKGROUND

There is a growing concern about postsurgical outcomes of radical prostatectomy, especially in the younger population and patients with earlier tumor stages. Here, we present our 17 years' experience of sutureless vesico-urethral alignment after radical prostatectomy with a focus on postoperative functional urinary outcomes.

METHODS

Data of 784 patients who underwent radical prostatectomy during 2001-2017 were evaluated retrospectively. Before surgery, patients' demographic information, pathologic stage, margin of surgery, prostate-specific antigen, and Gleason score were obtained. Then, serum prostate-specific antigen level, urinary continence, potency, and other functional outcomes of surgery were recorded after each postoperative visit.

RESULTS

The mean age (±standard deviation) of patients was 61.3 (±6.30) years. The median (IQ_25-75) duration of follow-up was 30 (12-72) months. Full continence was achieved in 90% and 95.9% of patients at 3 and 6 months post surgery and 96.4% of the patients were continent at the last follow-up visit. Bladder neck stricture occurred in 167 patients (21.3%). During the follow-up period, none of the patients complained of total incontinence and at the last visit, 36.6% of patients reported potency. The frequency of grade 2 continence was significantly higher in patients with high-stage tumors (T3/T4), high Gleason score (⩾8), high preoperative serum prostate-specific antigen (>20 ng/dL), and positive margin of surgery. Potency had a significant relationship with age, stage of the disease, and preoperative prostate-specific antigen.

CONCLUSION

Maximal sparing of intrapelvic urethral length through sutureless vesico-urethral alignment technique results in excellent early urinary continence recovery after radical prostatectomy. A more advanced tumor stage (T1/T2), a higher Gleason score, high preoperative prostate-specific antigen, as well as positive surgical margin are risk factors of postoperative incontinence in patients who undergo radical prostatectomy.

Anatomical robotic prostatectomy: technical factors to achieve superb continence and erectile function

Debate continues as to the superiority of robotic versus open radical prostatectomy for the surgical treatment of localized prostate cancer. Despite this controversy, retrospective data from high volume centres has demonstrated RARP is associated with improved pentafecta outcomes with lower transfusion rates, less incontinence, lower positive surgical margins and improved potency. Advocates of robotic assisted radical prostatectomy (RARP) believe an enhanced visual field, the precision afforded by robotic technology as well as lack of bleeding, sharp dissection and delicate tissue handling lead to improved outcomes. Prostate Cancer is the second most common cancer diagnosed in men, and as the number of post-surgical patients increases, the complications of urinary incontinence and erectile dysfunction not only have a significant negative impact on patients' quality of life, but have become an expanding part of clinical practice. This article outlines what are believed to be the most important strategies based on anatomical knowledge and technical expertise, that allow robotic prostatectomists to achieve superb outcomes in urinary and erectile function.

Association of preoperative urethral parameters on magnetic resonance imaging and immediate recovery of continence following Retzius-sparing robot-assisted radical prostatectomy

Background

Studies regarding predictive factors of urinary continence following Retzius-sparing radical prostatectomy (RP) is limited. This study was designed to evaluate association of urethral parameters on preoperative magnetic resonance imaging (MRI) and immediate recovery of urinary continence following Retzius-sparing robot assisted radical prostatectomy (RS-RARP).

Methods

This retrospective cohort study enrolled 156 patients with clinically localized prostate cancer who underwent MRI before RS-RARP. We measured the following structures on preoperative MRI: minimal residual membranous urethral length (mRUL), peri-urethral sphincter complex (PSC) thickness, urethral wall thickness (UWT), the thicknesses of the levator ani muscle (LAM) and obturator internus muscle (OIM). Immediate urinary continence was defined as patients reported freedom from using safety pad within 7 days after removal of urinary catheter. Patients were divided into two groups according the median of each parameter on MRI. We retrospectively analyzed the patients in term of preoperative clinical factors and postoperative urinary continence.

Results

A total of 100 patients (64.1%) reported immediate urinary continence after RS-RARP. Immediate urinary continence was significantly more in patients with longer mRUL (≥8.70 mm) than in patients with shorter mRUL (<8.70 mm; P=0.000). On multivariable analysis, longer mRUL was significantly related to immediate urinary continence after RS-RAPA (odds ratio 8.265; P=0.000). PSC, UWT, LAM and OIM were not associated with immediate urinary continence.

Conclusions

Our results firstly demonstrated that preoperative mRUL measured on MRI was an independent predictor of immediate urinary continence following RS-RARP. Therefore, preservation of membranous urethra is still the anatomical basis of better urinary outcome after RS-RARP.

Early continence after radical prostatectomy: A systematic review

BACKGROUND AND OBJECTIVE

Urinary incontinence is the adverse effect with more impact on patients' quality of life after undergoing radical prostatectomy. The objective of this study is to review the present evidence that describes the variations on surgical techniques which aim to preserve urinary continence after radical prostatectomy.

EVIDENCE ACQUISITION

We searched the literature on PubMed, Cochrane, and ScienceDirect according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement, using the PICO review protocol. The search terms were urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot-assisted laparoscopic prostatectomy, robotic prostatectomy. We identified 1,603 registers, and 27 articles were reviewed for meeting the inclusion criteria. Six of them are randomized clinical trials and 4 of them, meta-analysis.

EVIDENCE SYNTHESIS

The surgical techniques more frequently used to achieve early urinary continence are bladder neck and neurovascular bundles preservation, as well as the reconstruction of the rhabdosphincter. The latter has been presented in three randomized clinical trials. Even though some approaches have obtained improved functional outcomes, the lack of consensus on the definition of urinary incontinence and its measurement methods have not advocated for the creation of technical recommendations based on scientific evidence.

CONCLUSIONS

The reconstruction of the rhabdosphincter is the only technique that has shown improved functional results through randomized trials. The current evidence is limited and heterogenous, and more studies with consistent criteria are needed in order to establish a standard surgical technique.

Very Early Continence After Radical Prostatectomy and Its Influencing Factors

Introduction and Objectives: Surgical techniques such as preservation of the full functional-length of the urethral sphincter (FFLU) have a positive impact on postoperative continence rates. Thereby, data on very early continence rates after radical prostatectomy (RP) are scarce. The aim of the present study was to analyze very early continence rates in patients undergoing FFLU during RP.

Materials and Methods: Very early-continence was assessed by using the PAD-test within 24 h after removal of the transurethral catheter. The PAD-test is a validated test that measures the amount of involuntary urine loss while performing predefined physical activities within 1 h (e.g., coughing, walking, climbing stairs). Full continence was defined as a urine loss below 1 g. Mild, moderate, and severe incontinence was defined as urine loss of 1–10 g, 11–50 g, and >50 g, respectively.

Results: 90 patients were prospectively analyzed. Removal of the catheter was performed on the 6th postoperative day. Proportions for no, mild, moderate and severe incontinence were 18.9, 45.5, 20.0, and 15.6%, respectively. In logistic regression younger age was associated with significant better continence (HR 2.52, p = 0.04), while bilateral nerve-sparing (HR 2.56, p = 0.057) and organ-confined tumor (HR 2.22, p = 0.078) showed lower urine loss, although the effect was statistically not significant. In MVA, similar results were recorded.

Conclusion: Overall, 64.4% of patients were continent or suffered only from mild incontinence at 24 h after catheter removal. In general, reduced urine loss was recorded in younger patients, patients with organ-confined tumor and in patients with bilateral nerve sparing. Severe incontinence rates were remarkably low with 15.6%.

Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes

OBJECTIVES

To summarize the current evidence on Retzius-sparing (RS)-robot-assisted radical prostatectomy (RARP) and to compare its oncological, peri-operative and functional outcomes with those of standard retropubic RARP (S-RARP).

MATERIALS AND METHODS

After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the 'PICO' (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure [RS-RARP vs S-RARP]) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri-operative and functional outcomes were recorded and analysed.

RESULTS

A shorter operating time was associated with RS-RARP (weighted mean difference [WMD] 14.7 min, 95% confidence interval [CI] -28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI -31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio [OR] 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S-RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS-RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004).

CONCLUSION

Our analysis confirms that RS-RARP is a safe and feasible alternative to S-RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve.

Morphologic changes after bladder neck intussusception in laparoscopic radical prostatectomy contribute to early postoperative continence

PURPOSE

To explore the mechanism and efficacy of the modified bladder neck intussusception in laparoscopic radical prostatectomy (LSRP) on postoperative early continence.

METHODS

We prospectively collected clinical information of prostate cancer patients who underwent LSRP with modified bladder neck intussusception (n = 10) and non-intussusception (n = 10). At postoperative 1 month, the prostate-specific antigen (PSA), pad test, real-time magnetic resonance imaging (rt-MRI), and flow rate were performed. At postoperative 3 months, the PSA, pad test, international prostate symptom score (IPSS), overactive bladder symptom score (OABSS), incontinence questionnaire short form (ICI-Q-SF), and quality of life (Qol) were recorded.

RESULTS

The intussusception and non-intussusception patients had similar baseline characteristics. At postoperative 3 months, intussusception patients had lower OABSS than non-intussusception patients (P = 0.038). The non-intussusception patients suffered from more severe incontinence (P = 0.026). The continence rate of intussusception patients was significantly higher (90% vs. 20%, P = 0.005). And intussusception patients had significantly lower Qol scores (P = 0.038). According to the morphologic analysis by rt-MRI, there were 7/10 non-intussusception patients and 2/10 intussusception patients having funnel-shaped bladder necks at Valsalva movement. The intussusception patients had larger angle between anterior and posterior wall at bladder neck (P = 0.029) and longer length of functional posterior urethra (P = 0.029). During micturition, the intussusception bladder neck was found to move less dynamically on X-axis and Y-axis, but the difference did not reach significance.

CONCLUSIONS

The modified technique of bladder neck intussusception in laparoscopic radical prostatectomy prolongs the length of functional posterior urethra and is effective to improve postoperative early continence.

Predictors for immediate recovery of continence following Retzius-sparing robot-assisted radical prostatectomy: a case-control study

PURPOSE

We evaluated urinary continence in a series of consecutive patients who underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) to identify the preoperative predictors of the return to immediate urinary continence.

METHODS

110 consecutive patients who underwent RS-RARP for clinically localized prostate cancer were retrospectively collected. Patients reported freedom from using safety pad (0 pad/day) within 7 days after removal of urinary catheter were defined as immediate urinary continent.

RESULTS

A total of 85 patients (77.27%) were immediate urinary continent after RS-RARP. Patients with immediate urinary continence were significantly younger (66.92 ± 5.73 vs. 69.68 ± 4.99 years, p = 0.031) than those who were incontinent. Furthermore, the prostate volume was significantly smaller (30.90 vs. 44.60 ml, p = 0.001) and preoperative international prostate symptom score (IPSS) was significantly lower (Mild 76.5% vs. 24.0%, Moderate 20.0% vs. 32.0%, and Severe 3.5% vs. 44.0%, p = 0.000) in patients with immediate urinary continence compared with those who were not. On univariable regression analysis, patient's age (OR 0.907, p = 0.035), prostate volume (OR 0.935, p = 0.000), moderate (OR 0.196, p = 0.007), and severe IPSS (OR 0.025, p = 0.000) (compared with mild IPSS) were independent adverse predictors of immediate urinary continence. On multivariable analysis, prostate volume (OR 0.955, p = 0.032) and severe preoperative IPSS (OR 0.044, p = 0.000) (compared with mild IPSS) were independent adverse predictors of immediate urinary continence after RS-RARP.

CONCLUSIONS

RS-RARP hastens the recovery of urinary continence after surgery. Prostate volume and severe preoperative IPSS were independent adverse predictors of the return to immediate urinary continence.

Total anatomical reconstruction during robot-assisted radical prostatectomy: focus on urinary continence recovery and related complications after 1000 procedures

OBJECTIVES

To present the functional and oncological outcomes after ≥1 year of follow-up, following an experience of >1000 robot-assisted radical prostatectomies (RARPs) with our standardised total anatomical reconstruction (TAR) technique. To evaluate which factors influence postoperative continence recovery in order to obtain a nomogram to predict the risk of postoperative urinary incontinence (UI).

PATIENTS AND METHODS

The enrolment phase began in June 2013 and ended in May 2017. Patients were prospectively included in the study with the following inclusion criteria: (i) localised prostate cancer (clinical stages cT1-3, cN0, cM0); (ii) indication for RP; and (iii) preoperative multiparametric prostate magnetic resonance imaging. All patients underwent RARP with the TAR technique done at the end of the demolitive phase. The continence rates were assessed at 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal. Patients were defined as continent if they answered 'zero pad' or 'one safety pad' per day. A logistic regression model was used to evaluate the potential impact of some pre- and intraoperative factors on postoperative urinary continence recovery. Model discrimination was assessed using an area under (AUC) the receiver operating characteristic (ROC) curve. A nomogram to predict the risk of postoperative UI after RARP with the TAR technique was generated based on the logistic model.

RESULTS

In all, 1008 patients were enrolled in our study. At 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal, 621 (61.61%), 594 (58.93%), 803 (79.66%), 912 (90.48%), 950 (94.25%) and 956 (94.84%) patients were continent, respectively. In the logistic regression model, the variables analysed had a higher impact on continence recovery at 4 and 12 weeks. At 4 weeks, the postoperative odds of urinary continence recovery increased with the absence of diabetes [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.41-5.41] and D'Amico low vs high risk (OR 2.01, 95% CI 1.01-3.99). At 12 weeks, urinary continence increased with the absence of diabetes (OR 3.01, 95% CI 1.23-7.35), D'Amico low vs high risk (OR 4.04, 95% CI 1.56-10.47), and D'Amico intermediate vs high risk (OR 3.33, 95% CI 1.66-6.70). ROC curves were drawn and an AUC value of 61.9% (95% CI 57.49-66.36) at 4 weeks and 63.8% (95% CI 58.03-69.65) at 12 weeks were computed. Based on these parameters, two nomograms (at 4 and 12 weeks postoperatively) were generated.

CONCLUSION

The TAR technique conferred excellent results in the early recovery of urinary continence. Two nomograms were created, to predict preoperatively the postoperative odds of urinary continence recovery at 4 and 12 weeks after RARP by integrating the presence of diabetes and D'Amico risk classification.

Precision prostate cancer surgery: an overview of new technologies and techniques

Over the past few years several new technologies have become available for the management of PCa. The implementation of robotic surgery allowed an unprecedented refinement of surgical techniques, and the RARP procedure is constantly evolving. Nowadays research is mainly focused towards a "tailored" case-specific surgical approach that might allow to achieve PCa control while preserving urinary continence and erectile function. Therefore, in contemporary urology era, several new tools have been introduced to optimize surgical planning, to aid surgical navigation, and to refine surgical execution. In this non-systematic review emerges that a better imaging technique in the preoperative setting can facilitate surgical planning. Moreover, in the intraoperative setting, new tools for image-guided surgical navigation are promising and will allow real time understanding of surgical anatomy. In the next future, a more personalized approach for the minimally invasive surgical treatment of PCa will be available, and the achievement of the best oncological and functional outcomes will be obtained.

Anatomical, surgical and technical factors influencing continence after radical prostatectomy

Radical prostatectomy (RP) is the most frequent treatment with curative intent performed for prostate cancer to date. Different surgical approaches (perineal, transperitoneal, and extraperitoneal) and techniques (laparoscopic and robot assisted) have been described to increase the efficiency and potentially diminish the postoperative complications of this procedure. The aim of this narrative review is to investigate and define the factors that influence postprostatectomy urinary continence. We highlighted the anatomical landmarks and the modifications of surgical techniques aimed at improving the continence rates and thus, patient quality of life. After RP, the long-term continence rates range from 84% to 97%. In order to achieve good continence rates, a careful dissection along with meticulous anatomical reconstruction is required. To this end, a detailed knowledge of the periprostatic anatomy is mandatory.

Functional recovery after radical prostatectomy for prostate cancer

With the enthusiasm regarding robotic application in radical prostatectomy in accordance with the widespread use of serum prostate-specific antigen as a screening test, the number of surgeries performed for complete removal of the gland is increasing continuously. However, owing to the adjacent anatomical location of the prostate to the nerve and urethral sphincter complex, functional recovery, namely improvement from post-prostatectomy incontinence (PPI) and post-prostatectomy erectile dysfunction, still remains a main problem for patients who are reluctant to undergo surgery and tend to choose alternative ways instead. Since the late 1980s, the introduction of radical prostatectomy by open surgical modalities, the depth of the anatomical understanding of the structure surrounding the prostate is getting tremendous, which leads to the development of new surgical modalities and techniques that are consequently aimed at reducing the incidences of PPI and erectile dysfunction. Briefly, recent data from robotic radical prostatectomy, particularly on PPI, are quite acceptable, but by contrast, the reported potency regain rate still remains <20%, which indicates the need for advanced surgical modification to overcome it. In this review, the authors summarized the recent findings on the anatomy and surgical techniques reported up to now.

Review of optimal techniques for robotic-assisted radical prostatectomy

PURPOSE OF REVIEW

Robotic-assisted radical prostatectomy has been rapidly adopted and is now the standard of care in the surgical management of prostate cancer. Since the initial description in 2001, the technique has evolved to optimize oncological functional outcomes. Herein, we review key techniques for the robotic-assisted radical prostatectomy.

RECENT FINDINGS

With the current influx of new technology such as focal therapy, stereotactic body radiation therapy and prostate-sparing treatments, there is greater emphasis on maximizing outcomes of robotic-assisted radical prostatectomy. The evidence-based techniques of optimizing oncological outcomes including the lymph node dissection and improving cancer control through minimizing positive surgical margins are reviewed. Improvements in functional recovery has also been seen with technical modifications such as nerve sparing, preservation of the urethral support structures and the bladder neck and the urethra-vesical reconstruction.

SUMMARY

Robotic prostatectomy has demonstrated adequate long-term oncologic success and satisfactory functional recovery. As technology and techniques in robotic-assisted surgery evolve, surgeons will continue to optimize techniques to maximize functional outcome recovery and cancer control. Further studies are actively being conducted to provide level one evidence in multiple aspects of the robotic-assisted radical prostatectomy.