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| Is Retzius-sparing robot-assisted radical prostatectomy associated with better functional and oncological outcomes? Literature review and meta-analysis |
Najib Isse Diriea,Gaurab Pokhrela,Wei Guana,Mukhtar Adan Muminb,Jun Yanga,Jackson Ferdinand Masauc,Hu Henglonga,Shaogang Wanga,*( )
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a.Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
b.Department of Urology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China;
c.Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China |
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Abstract Objective To evaluate the efficiency, safety and clinical outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) in comparison with the standard RARP.Methods A systematic search from Web of Science, PubMed, EMBase, Cochrane Library and Google Scholar was performed using the terms “Retzius-sparing”, “Bocciardi approach” and “robot-assisted radical prostatectomy”. Video articles and abstract papers for academic conferences were excluded. Meta-analysis of interested outcomes such as positive surgical margins (PSMs) and continence recovery was undertaken. A comprehensive literature review of all studies regarding Retzius-sparing (RS) approach was conducted and summarized.Results From 2010 to 2017, 11 original articles about RS-RARP approach were retrieved. Of that, only four studies comparing the RS-RARP approach to the conventional RARP were comparable for meta-analysis. Faster overall continence recovery within 1 month after the surgery was noted in the RS group (61% vs. 43%; p = 0.004). PSMs of pT2 and pT3 stages were not significantly different between the groups (10.0% vs. 7.4%; p = 0.39 and 13.1% vs. 9.5%, p = 0.56, respectively). Of all the studies, only one reported sexual recovery outcomes after RS treatment in which 40% of the participants achieved sexual intercourse within the first month.Conclusion Though more technically demanding than the conventional RARP, the RS technique is a safe and feasible approach. This meta-analysis and literature review indicates that RS technique, as opposed to the conventional approach, is associated with a faster continence recovery while PSMs were comparable between the two groups. The limitations of observational studies and the small data in our meta-analysis may prevent an ultimate conclusion. Future well-designed RCTs are needed to validate and confirm our findings.
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Received: 08 August 2017
Available online: 09 February 2018
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Corresponding Authors:
Shaogang Wang
E-mail: sgwangtjm@163.com
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| Outcome of interest | No. of studies | No. of participants RS-/C-RARP | OR (95%CI) | p-Value | Study heterogeneity | | Chi-squared test | df | I2 (%) | p | | Continence recovery | Overall recovery | 4 | 250/250 | 3.53 (1.48-8.40) | 0.004 | 7.72 | 3 | 61 | 0.05 | | Completely dry | 4 | 250/250 | 4.07 (2.03-8.14) | 0.0001 | 6.69 | 3 | 55 | 0.08 | | PSMs | pT2 | 3 | 190/190 | 1.38 (0.66-2.87) | 0.38 | 0.82 | 2 | 0 | 0.66 | | pT3 | 3 | 190/190 | 1.39 (0.46-4.13) | 0.56 | 3.98 | 2 | 50 | 0.14 |
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Meta-analysis: Continence recovery and PSMs of RS-RARP vs. C-RARP.
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| First author, year | Study design | Study participant | Mean age (year) | Operative time (min) | Mean PSA level (ng/mL) | Estimated blood loss (mL) | Biopsy Gleason score | Pathological stage | Mean hospital stay (day) | Mean catheter length (day) | | Group 1 | Group 2 | Group 1 | Group 2 | Group 1 | Group 2 | Group 1 | Group 2 | Group 1 | Group 2 | Group 1 Group 2 | Group 1 Group 2 | Group 1 | Group 2 | Group 1 | Group 2 | | Galfano et al., 2010 [17] | Case series | 5 | - | 58 | - | 329 | - | 5.64 | - | 420 | - | ≤6 | 3 | - | T1 | - | - | 6.4 | NA | 10.6 | - | | 7 | 2 | - | T2 | 5 | - | | 8-10 | - | - | T3 | - | - | | Galfano et al., 2013 [23] | Prospective | 200 | - | 65 | - | 110 | - | 6.6 | - | 250 | - | ≤6 | 128 | - | T1 | - | - | 7 & 4.5a | - | 7 | - | | 7 | 64 | - | T2 | 68 | - | | 8-10 | 8 | - | T3 | 32 | - | | Lim 2014 et al. [22], | Retrospective | 50 | 50 | 65.7 | 66.2 | 117 | 141 | 12.8 | 10.5 | 299 | 260 | ≤6 | 26 | 20 | T1 | - | - | 4.8 | 5.5 | NA | NA | | 7 | 15 | 20 | T2 | 41 | 38 | | 8-10 | 9 | 8 | T3 | 9 | 12 | | Jenjitranant et al., 2016 [18] | Case report | 1 | - | 73 | - | 210 | - | 11.53 | - | 250 | - | ≤6 | - | - | T1 | - | - | 6 | - | 13 | - | | 7 | 1 | - | T2 | 1 | - | | 8-10 | - | - | T3 | - | - | | Raheem et al., 2016 [19] | Case report | 1 | - | 61 | - | 240 | - | 6.7 | - | 300 | - | ≤6 | - | - | T1 | - | - | 4 | - | - | - | | 7 | 1 | - | T2 | - | - | | 8-10 | - | - | T3 | - | - | | Santok et al., 2016 [24] | Retrospective | 294 | - | 66.2 | - | 162 | - | 8.6 | - | 308 | - | ≤6 | 145 | - | T1 | - | - | 6.3 | - | - | - | | 7 | 149 | - | T2 | 191 | - | | 8-10 | - | - | T3 | 103 | - | | Dalela et al., 2017 [25] | RCT | 60 | 60 | 61 | 61.5 | NA | NA | 5.7 | 5.4 | NA | NA | ≤6 | 18 | 20 | T1 | 40 | 46 | NA | NA | NA | NA | | 7 | 42 | 40 | T2 | 20 | 13 | | 8-10 | - | - | T3 | - | - | | Eden et al., 2017 [26] | Retrospective | 40 | 40 | 63 | 65 | 200 | 223 | 5.4 | 6.8 | 200 | 200 | ≤6 | - | - | T1 | - | - | 2 | 2 | 8 | 14 | | 7 | 40 | 40 | T2 | 3 | 2 | | 8-10 | - | - | T3 | 7 | 2 | | Sayyid et al., 2017 [27] | Prospective | 100 | 100 | 61 | 62 | 120 | 144 | 8.75 | 7.07 | 100 | 100 | ≤6 | 19 | 25 | | | | 1 | 1 | 10.5 | 10.5 | | 7 | 62 | 51 | ≤T2 | 66 | 77 | | 8-10 | 19 | 24 | ≥T3 | 34 | 23 |
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Summary of all studies about Retzius-sparing robot-assisted radical prostatectomy.
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Dissection planes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). (A) Transverse view of RS-RARP. Outside the red line is the untouched area of the surgery containing the anterior compartment (dorsal venous complex, veil of Aphrodite, puboprostatic ligaments and the accessory pudendal arteries) and neuro-vascular bundles. (B) Sagittal section of the anatomic spaces crossed during the Bocciardi approach for RARP. The red line shows the intrafascial plane and the yellow line shows the extrafascial plane, with the Denonvillier's fascia in the middle (black). U, urethra. (Reproduced with the permission of Elsevier, License number: 4155670913161).
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Retzius-sparing robot-assisted radical prostatectomy technique. (A) 4 cm incision on the peritoneum; (B) Fascial plane selection; (C) Urethro-vesical anastomosis; (D) Specimen (prostate). BN, bladder neck; C, catheter; FP, fascial plane; P, peritoneum; SV, seminal vesicle; U, urethra.
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Continence recovery (RS-RARP vs. C-RARP). (A) Overall continence recovery. (B) Completely dry. RS-RARP, Retzius-sparing robot-assisted radical prostatectomy; C-RARP, conventional robot-assisted radical prostatectomy; M-H, Mantel-Haenszel.
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Positive surgical margins of RS-RARP vs. C-RARP. (A) pT2 (pathological stage). (B) pT3 (pathological stage). RS-RARP, Retzius-sparing robot-assisted radical prostatectomy; C-RARP, conventional robot-assisted radical prostatectomy; M-H, Mantel-Haenszel.
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Complication rates of RS-RARP vs. C-RARP. RS-RARP. Retzius-sparing robot-assisted radical prostatectomy; C-RARP, conventional robot-assisted radical prostatectomy; M-H, Mantel-Haenszel.
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