Retzius-sparing Robot-assisted Simple Prostatectomy: Perioperative and Short-term Functional Outcomes Assessed via Validated Questionnaires

Abstract

Background and objective: Several surgical procedures have been reported for treatment of male patients with lower urinary tract symptoms (LUTS) secondary to large benign outlet obstruction (BOO). The diffusion of robotic surgery offers the possibility to perform open simple prostatectomy (SP) with a minimally-invasive approach. Our aim was to report outcomes of the Retzius-sparing robot-assisted SP (RS-RASP) technique.

Methods: This was a single centre, prospective study. Patients with LUTS secondary to BOO and a prostate volume of >100 ml underwent RS-RASP performed with a da Vinci surgical system in four-arm configuration for a transperitoneal approach. Data for intraoperative and perioperative complications were collected. Functional outcomes were assessed via validated patient questionnaires. Univariable and multivariable regression analyses were used to identify predictors of complications and achievement of a trifecta composite outcome.

Key findings and limitations: The median patient age was 69 yr and the median prostate volume was 150 ml. The median operative time was 175 min, with estimated blood loss of 350 ml. The median in-hospital stay and median catheterisation time were 3 d and 9 d, respectively. Within 90 d, the incidence of complications was 3% for grade 1, 19% for grade 2, and 2% for grade 3 complications. At 7-mo follow-up, statistically significant improvements in International Prostate Symptom Scores (total score and quality of life), International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) scores, and the maximum flow rate were observed (all p < 0.0001). According to ICIQ-UI SF scores, 20%, 6%, and 3% of the patients had slight, moderate, or severe urinary incontinence (UI), respectively. Urgency UI was experienced by 14% of the patients and stress UI by 10%. Most of the patients with UI reported leakage of a small amount of urine and they did not wear pads.

Conclusions: RS-RASP was associated with good perioperative outcomes and a low prevalence of high-grade complications. Significant LUTS relief was achieved, but some patients experienced slight urgency or stress UI at short-term follow-up.

Patient summary: We explored a surgical technique called Retzius-sparing robot-assisted simple prostatectomy to treat men with bothersome urinary symptoms caused by a large prostate. The technique led to good results, with minimal bleeding and few complications during surgery. This surgery could be a beneficial choice for patients with stubborn urinary symptoms and a large prostate gland.

Keywords: Benign outlet obstruction; Complications; Continence; Lower urinary tract symptoms; Robot-assisted simple prostatectomy; Robotic surgery; Simple prostatectomy.

Fig. 1

Trocar placement for Retzius-sparing robot-assisted simple prostatectomy.

Fig. 2

Surgical steps in Retzius-sparing robot-assisted simple prostatectomy. (A) Vertical incision of the posterior bladder wall and placement of two Vicryl 2-0 stay stitches to keep the bladder open during the entire procedure. (B) Location of the ureteric orifices. (C) Incision at the edge of the adenoma between the 4-o’clock and 6-o’clock positions to find the correct plane between the adenoma and the peripheral zone of the gland and initial posterior dissection. (D) Anterolateral dissection of the adenoma. (E) Anterior commissurotomy to ease final dissection of the adenoma. (F) Appearance of the prostatic bed after insertion of V-Loc 3-0 haemostatic sutures. (G) Appearance of the bladder neck after advancing the bladder neck mucosa to the prostatic apex. (H) Posterior bladder wall after double-layer Filbloc suturing.

Fig. 3

Functional results for the 87 patients treated with Retzius-sparing robot-assisted simple prostatectomy. ICIQ-UI SF = International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form; IIEF = International Index of Erectile Function; IPSS = International Prostate Symptom Score; IQR = interquartile range.