Introduction: Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been associated with better functional outcomes when compared with conventional RARP.1–3 Nonetheless, it is technically a challenging operation because of the limited space within the surgical area. This video presentation aims to summarize the key steps of the RS-RARP and demonstrate a simple technique for suspension of the edge of parietal peritoneum after incision at the Douglas pouch for better exposure of the surgical area. In this context, we also present operative, oncologic, and functional outcomes in a consequent series of our patients who underwent RS-RARP with suspension of the peritoneum.
Materials and Methods: We retrospectively reviewed medical records of 92 patients who underwent RS-RARP in department of urology, Acibadem M.A. Aydinlar University, Altunizade Hospital, between July 2017 and June 2020. RS-RARP was performed using the DaVinci® Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). The key steps of the surgery is demonstrated.4 A simple technique to suspend the cut peritoneal edge by 0 vicryl suture with Weck® Hem-o-lok® clip at the tail end is also described.
Results: The mean age of the patients was 64.0 ± 7.0 years, mean prostate volume was 51 ± 23 cc, and the median prostate-specific antigen level was 6.12 (4.43–11.00) ng/mL. The mean body mass index of the patients was 26.47 ± 3.34 kg/m2. The mean total operative time, which describes the interval between anesthesia induction and termination of the anesthesia, was 313 ± 94 minutes. The estimated blood loss was 100 (50–100) mL. Extended pelvic lymph node (LN) dissection was performed in 62 (67.4%) patients. The median total number of dissected LN and LN with metastatic deposits were 13 (9–18) and 0 (0–0), respectively. No intraoperative or late postoperative complications were observed in any patients, whereas early postoperative complication was observed in 8 (8.7%) patients. Clavien–Dindo (CD)-2, CD-3A, and CD-3B complications were observed in 1 (1.1%), 4 (4.3%), and 3 (3.3%) patients, respectively. The median length of hospital stay and catheterization duration was 2 (2–3) and 8 (7–10) days, respectively. The distribution of the patients in terms of International Society of Urologic Pathology-grade groups (−1, −2, −3, −4, and −5) was 5 (5.4%), 39 (42.4%), 32 (34.8%), 5 (5.4%), and 10 (10.9%), respectively. Clinically significant prostate cancer was observed in 88 (95.7%) patients according to Epstein's criteria. Surgical margin positivity was observed in 15 (16.3%) patients. Of these patients, pT2, pT3a, and pT3b disease were observed in 6 (40.0%), 5 (33.3%), and 4 (26.7%) patients, respectively. pT2 disease was present in 55 (59.8%) of the patients, whereas 26 (28.3%) and 11 (12.0%) of them had pT3a and pT3b disease, respectively. The median tumor volume was 3.00 (1.60–6.25) cm3. Complete urinary control (no leakage) rates in week-1, month-1, month-3, month-6, and month-12 were 67.1%, 80%, 87.1%, 95.7%, and 97.1%, respectively. In the same period, safety pad usage ratios were 20%, 8.6%, 8.6%, 4.3%, 2.9%, respectively. Of these patients, erectile dysfunction rates in month-1, month-3, month-6, and month-12 were 66.7%, 56.9%, 35.3%, and 25.5%, respectively.
Conclusion: Suspension of the peritoneum by 0 vicryl suture with an end-tail Weck® Hem-o-lok® clip can be considered for better and wider exposure of the surgical area during RS-RARP without compromising oncologic and functional outcomes.