V07-06: Retzius-sparing robot-assisted radical prostatectomy in high-risk prostate cancer patients

Paolo Dell'Oglio*, Milan, Italy, Stefano Tappero, Genova, Italy, Mattia Longoni, Carlo Buratto, Pietro Scilipoti, Silvia Secco, Alberto Olivero, Michele Barbieri, Erika Palagonia, Giancarlo Napoli, Elena Strada, Giovanni Petralia, Dario Di Trapani, Angelo Vanzulli, Aldo Massimo Bocciardi, Antonio Galfano, Milan, Italy

Introduction: Retzius-sparing (RS) robot assisted radical prostatectomy is a valid surgical treatment option for prostate cancer (PCa) patients. However, there is a lack of evidence on the feasibility of this approach in high-risk (HR) PCa patients. In this video we describe our RS-RARP technique for HRPCa patients.

Methods: We present the case of a 66 year-old patient with PSA of 13.8 ng/ml, cT3 on the left side at DRE, an MRI showing 16 mm PIRADS 5 on the left lobe and an ISUP 4 grade PCa at biopsy (17/21 cores). No distant metastases were found at total body CT and bone scan.

Left extrafascial and interfascial right nerve sparing RS with extended lymph node dissection was performed with a four-arm da Vinci Si Surgical System at a high volume centre. After incision of the parietal peritoneum at the anterior surface of the Douglas pouch, dissection of the vasa deferentia, isolation of the seminal vesicles, the Denonvillier’s fascia is medially incised starting from an extrafascial layer and pushed upwards with the posterior surface of the prostate. The dissection is carried out forward to the prostatic apex. On the left side part of the perirectal fat is also pushed upwards with the specimen. Once isolated the posterior aspect of the prostate, a wide left extrafascial plane is carried out laterally to the levator ani fascia. A right unilateral inter-fascial nerve sparing is performed in a standard fashion. The bladder neck is dissected, the anterior surface of the gland is isolated, the Santorini plexus is partially resected. Finally, the apex is isolated from the urethra and the latter is incised.

Results: Operative time and estimated blood loss were 185 min and 150 ml. No intraoperative complications occurred. Final pathology revealed a ISUP 4 grade, pT3aN0R0. The patient was discharged on POD 2 and the suprapubic catheter was removed on POD 7. Follow-up period was uneventful and at 8 months from surgery PSA was undetectable and the urinary continence (UC) fully recovered. 340 HRPCa patients were treated with this technique at our centre. Final pathology reported 9.4% focal and 19.4% extended positive surgical margins. Median follow-up was 47 months. At 4 years of follow-up, BCR-free and additional treatment-free survival were 64 and 57%. The 2-year UC and erectile function recovery were respectively 85% and 50%.

Conclusions: RS in HR-PCa patients is safe and allows optimal intra- peri- and postoperative, oncologic and functional outcomes. RS should be considered a valid surgical treatment option for HRPCa patients in expert hands.

Source of Funding: None.