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

Cystopexy following anterior-approach robot-assisted radical prostatectomy enhances early continence recovery

To evaluate the effect of cystopexy on continence recovery after anterior-approach transperitoneal robot-assisted radical prostatectomy (RaRP). We retrospectively analyzed continence recovery of patients with prostate cancer receiving RaRP in a transperitoneal anterior-approach manner with or without cystopexy. Continence recovery is defined as complete intact continence without safety pad utility. Demographic data, preoperative cancer staging, intraoperative surgical techniques such as neurovascular bundle (NVB) preservation, bladder neck sparing (BNS), cystopexy and postoperative cancer stage, surgical margin status were analyzed via multivariable and univariable regression analysis to evaluate contributing factors associated with continence recovery. We included one hundred and sixty-one consecutive RaRP performed by a single surgeon from 2011 to 2019 without cystopexy and another forty-one consecutive RaRP performed by another single surgeon with cystopexy from 2019 to 2023. Compared to patients without cystopexy, patients receiving cystopexy after anterior-approach RaRP have significant early continence recovery rate at 1-week (p < 0.0001) and 4-weeks (p = 0.0391). In addition, multivariable regression analysis revealed that BNS contributed to better continence recovery at 4 weeks (p = 0.0094). Patients receiving RaRP without NVB preservation had worse continence recovery at 12 weeks (p = 0.0015) and 24 weeks (p = 0.0098). Cystopexy after anterior -approach RaRP may enhance early recovery of continence at 1 week and 4 weeks. The simple technique may be adapted for a better functional outcome of continence.

Recent Advances in Radical Prostatectomy: A Narrative Review of Surgical Innovations and Outcomes

Prostate cancer is one of the most commonly diagnosed malignancies worldwide and is a major cause of cancer-associated morbidity in men. Radical prostatectomy (RP) is a cornerstone of intervention for organ-confined diseases and offers a potentially curative outcome. In recent decades, RP has undergone transformative changes, moving from open surgery, with significant morbidity, to minimally invasive and robot-assisted techniques. These advances have improved surgical precision, reduced blood loss, and accelerated functional recovery. Key enhancements, such as the "Veil of Aphrodite", hood-sparing, and Retzius-sparing approaches, aim to preserve neurovascular structures vital for continence and sexual function, addressing the persistent challenge of balancing oncological control with quality-of-life outcomes. Single-port (SP) robotic platforms represent the latest frontier, offering various access routes, including extraperitoneal, transvesical, transperitoneal, and transperineal routes, to further reduce incisional morbidity. Early experiences with SP robot-assisted radical prostatectomy(RARP) suggest favorable continence rates and short hospital stays, although concerns remain regarding the technical complexity and potential margin status of the advanced disease. Comparisons across these techniques revealed broadly similar long-term oncological outcomes, underscoring the importance of patient selection, tumor staging, and surgeon expertise. Ongoing innovations in robotic systems, augmented imaging modalities, and personalized surgical planning are likely to refine prostate cancer care and enhance both survival and post-treatment quality of life.

Navigating Now and Next: Recent Advances and Future Horizons in Robotic Radical Prostatectomy

Robotic-assisted radical prostatectomy (RARP) has become the leading approach for radical prostatectomy driven by innovations aimed at improving functional and oncological outcomes. The initial advancement in this field was transperitoneal multiport robotics, which has since undergone numerous technical modifications. These enhancements include the development of extraperitoneal, transperineal, and transvesical approaches to radical prostatectomy, greatly facilitated by the advent of the Single Port (SP) robot. This review offers a comprehensive analysis of these evolving techniques and their impact on RARP. Additionally, we explore the transformative role of artificial intelligence (AI) in digitizing robotic prostatectomy. AI advancements, particularly in automated surgical video analysis using computer vision technology, are unprecedented in their scope. These developments hold the potential to revolutionize surgeon feedback and assessment and transform surgical documentation, and they could lay the groundwork for real-time AI decision support during surgical procedures in the future. Furthermore, we discuss future robotic platforms and their potential to further enhance the field of RARP. Overall, the field of minimally invasive radical prostatectomy for prostate cancer has been an incubator of innovation over the last two decades. This review focuses on some recent developments in robotic prostatectomy, provides an overview of the next frontier in AI innovation during prostate cancer surgery, and highlights novel robotic platforms that may play an increasing role in prostate cancer surgery in the future.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).

Retzius-sparing vs. standard robot-assisted radical prostatectomy for clinically localised prostate cancer: a comparative study

BACKGROUND

Retzius-sparing robot-assisted radical prostatectomy (RARP) is not yet universally accepted due to still limited functional data and some concerns on oncological safety compared to the standard one. We assessed perioperative, pathological and early functional outcomes in patients with clinically localised prostate cancer treated with Retzius-sparing versus standard RARP.

METHODS

A single-surgeon cohort of 207 consecutive patients undergoing RARP was analysed. A later study group of 102 patients receiving the Retzius-sparing approach was compared with an earlier control group of 105 patients receiving the standard one. Urinary continence recovery 1 week after catheter removal was the primary study outcome. Urinary continence recovery 1, 2, 3 and 6 months after catheter removal, potency recovery 6 months postoperatively, rate of perioperative complications and positive surgical margins were secondary study outcomes.

RESULTS

Patients in the study group reported significantly higher urinary continence recovery rates 1 week (91.2% vs. 54.3%, p < 0.001), 1 month (92.2% vs. 66.7%, p < 0.001), 2 months (95.1% vs. 74.3%, p < 0.001), 3 months (96.1% vs. 83.8%, p = 0.01), but not 6 months (97% vs 90.5%, p = 0.09) after catheter removal compared to controls. Potency recovery rates 6 months after catheter removal were significantly higher in the study than the control group (68.2% vs 51.6%, p = 0.03). On multivariable analyses, the Retzius-sparing approach was an independent predictor of 1-week urinary continence recovery, but not of 6-month potency recovery. There were significant differences neither in perioperative complication rate (9.8% in the study vs. 14.3% in the control group, p = 0.28) nor in positive surgical margin rate (9.8% in the study vs. 8.6% in the control group, p = 0.75).

CONCLUSIONS

In a comparative study, we observed a significant improvement in immediate urinary continence, but not in early potency recovery, using the Retzius-sparing compared to the standard approach for RARP, with no increase in perioperative complication and positive surgical margin rate.

Vesicoprostatic muscle reconstruction: a step further for immediate and early urinary continence

OBJECTIVES

The vesicoprostatic muscle (VPM) is a longitudinal smooth muscle that originates from the trigone of the bladder or the opening of the ureter and is involved in urination as part of the detrusor apron. We explored the effect of VPM reconstruction on immediate and early recovery of urinary continence in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP).

PATIENTS AND METHODS

A total of 523 patients with localized prostate cancer were enrolled from June 2018 to June 2020. All patients were diagnosed in our department based on magnetic resonance imaging and pathological findings on prostate biopsy. After 1:1 propensity score matching, 105 patient pairs were matched. The study was approved by our institutional review board and all surgeries were performed by three experienced high-volume surgeons. Demographic data, total operation time, pathological outcomes, the urinary continence rates of the two groups at different times after RALP, and factors influencing postoperative urinary continence after RALP were recorded. Student's t test was used to compare continuous variables and the Pearson χ² test to compare categorical variables. Logistic regression analysis was used to identify factors affecting immediate and early postoperative urinary control.

RESULTS

VPM reconstruction promoted immediate and early recovery of urinary continence (immediate continence, 66.67 vs. 40.00%, P = 0.000; 3-month continence, 80.95 vs. 64.76%, P = 0.008).

CONCLUSIONS

VPM reconstruction improved immediate and early urinary continence in patients who underwent RALP.

Transvesical versus extraperitoneal single-port robotic radical prostatectomy: a matched-pair analysis

OBJECTIVE

To compare our initial perioperative and postoperative outcomes of the single-port (SP) transvesical radical prostatectomy (TVRP) approach with the single-port extraperitoneal radical prostatectomy (ERP) approach.

MATERIALS AND METHODS

Initial consecutive seventy-eight patients underwent SP TVRP between December 2020 and October 2021. Patients with extensive previous abdominal surgeries, or low- to intermediate-risk prostate cancer were selected. Data of consecutive 169 patients treated with SP ERP between February 2019 and November 2020, were used for comparison. Optimal matched-paired analysis of PSA value, biopsy Gleason score, and prostate volume was performed. Preoperative, perioperative, and early functional outcomes were included in the analysis. The median follow-up was 7 months and 9 months for TVRP and ERP groups respectively.

RESULTS

The median total operative time was longer in the TVRP compared to the ERP group (p = .002). There were no differences in intraoperative complications or surgical margin status. TVRP group had less rate of grade 3a Clavien-Dindo complications (p = .026). The Foley catheter duration was 3 (3, 4) days in the TVRP group compared to 7 (7, 8) days in the ERP group (p < .001). There was a consistently improved continence rate in the TVRP group at 6 weeks (72% TVRP, 48% ERP, p = .004), 3 months (97% TVRP, 81% ERP, p = .008), and 6 months postoperatively (100% TVRP, 93% ERP, p = .047). There was no difference in biochemical recurrence at 6 months of follow-up.

CONCLUSION

In our initial series, TVRP allows for a faster continence recovery, without other functional or oncological compromises.

Functional Preservation and Oncologic Control following Robot-Assisted versus Laparoscopic Radical Prostatectomy for Intermediate- and High-Risk Localized Prostate Cancer: A Propensity Score Matched Analysis

AIM

To evaluate the urinary continence (UC), erectile function, and cancer control obtained following robot-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP) for intermediate- and high-risk localized prostate cancer (PCa).

MATERIALS AND METHODS

232 patients bearing intermediate- and high-risk localized PCa were enrolled in this study. Perioperative, functional, and oncological outcomes were analyzed after applying the propensity score matched method.

RESULTS

Within the matched cohort, the RARP group was corrected with a significantly shorter mean operative time than the LRP group (p < 0.001). Patients in the RARP arm were also at a lower risk of ≤ Grade II complications than those in the LRP group (p = 0.036). Meanwhile, the proportions of transfusion and ≥ Grade II complications in the RARP group were similar to those in the LRP group (p = 0.192 and p = 1.000, respectively). No significant differences regarding the rates of pT3 disease and positive surgical margin existed between the two groups. RARP versus LRP tended to a significantly higher percentage of UC recovery within the follow-up period. Significant differences were also found between the RARP and LRP arms in terms of erectile function at postoperative 6 months and the last follow-up (p = 0.013 and p = 0.009, respectively). Statistical comparability in biochemical recurrence-free survival was observed between the two groups (p = 0.228).

CONCLUSIONS

For the surgical management of intermediate- and high-risk localized PCa, RARP tended to a lower risk of ≤ Grade II complications and superior functional preservation without cancer control being compromised than LRP.

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.