Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy.

Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes.

To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy.

A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques.

Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described.

Different surgical approaches and techniques for robotic prostatectomy have been analyzed.

Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials.

Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies.

We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology.

European urology. 2020 Aug 01 [Epub ahead of print]

Alberto Martini, Ugo Giovanni Falagario, Arnauld Villers, Paolo Dell'Oglio, Elio Mazzone, Riccardo Autorino, Marcio Covas Moschovas, Maurizio Buscarini, Carlo Andrea Bravi, Alberto Briganti, Guilherme Sawczyn, Jihad Kaouk, Mani Menon, Silvia Secco, Aldo Massimo Bocciardi, Gongxian Wang, Xiaochen Zhou, Francesco Porpiglia, Alexandre Mottrie, Vipul Patel, Ashutosh K Tewari, Francesco Montorsi, Richard Gaston, N Peter Wiklund, Ashok K Hemal

Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy. Electronic address: ., Department of Urology and Organ Transplantation, University of Foggia, Foggia, Italy., Department of Urology, CHU Lille, Université de Lille, Lille, France., Department of Urology, Niguarda Hospital, Milan, Italy., Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium., Department of Urology, Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA., AdventHealth Global Robotics Institute, Celebration, FL, USA., Università Campus Biomedico, Rome, Italy., Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy., Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, OH, USA., Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA., Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China., Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy., Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA., Department of Urology, Clinique Saint Augustin, Bordeaux, France., Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA.