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

Abstract

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.

Keywords: Retzius-sparing; high-risk prostate cancer; positive surgical margins; radical prostatectomy; urinary continence.

Figure 1

Steps of standard RARP. (a) Bladder neck incision; (b) prostate posterior plane; (c) right prostate pedicle; (d) left prostate pedicle; (e) prostate isolation up to the apex; (f), urethra incision.

Figure 2

Steps of Retzius-sparing RARP. (a) Peritoneum incision; (b) seminal vesicles isolation; (c) sovrapubic stitches; (d) prostate posterior face isolation; (e) bladder neck incision; (f) urethra incision.