Does Early Continence Recovery Merit More Complex Surgery?

Since its development in the early 2000s, robot-assisted radical prostatectomy (RARP) has become the most common surgical treatment for prostate cancer. About 85% of the 90,000 radical prostatectomies performed in the United States each year are done robotically.

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Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) is a modified form of RARP first introduced in Italy in 2010. While it has been shown in multiple comparative studies to provide early continence recovery with comparable oncological outcomes, the more technically challenging surgery has been slow to gain ground in the United States.

Board-certified urologist Alberto Pieretti, MD, with Cleveland Clinic Weston Hospital, was the first to use the approach at Cleveland Clinic in Florida when he joined the five-hospital regional health system in 2022. Today he is among a handful of surgeons in the state that offer RS-RARP.

“I learned the Retzius-sparing technique during my advanced training at two high-volume centers and saw first-hand the patient benefits,” says Dr. Pieretti. “I believe this approach provides a speedy recovery of the urinary function, improving patient quality of life and patient satisfaction. I use it in about 75% of cases.”

Anatomic preservation

A number of robotic surgical approaches have been developed over the past two decades to access and remove the prostate, which lies deep within the pelvis just underneath the bladder. Some of the techniques were designed to either avoid damaging neurovascular bundles important for erections that run alongside the gland or the neighboring continence apparatus important for maintaining urinary function.

During a traditional RARP, the bladder is separated from the anterior abdominal wall so that the prostate can be accessed between the bladder and pelvic bone. With a Retzius-sparing approach, the prostate is accessed from behind the bladder, using a posterior approach that preserves the pelvic fascia, anterior abdominal fascia, dorsal vascular complex, and the accessory pudendal arteries.

“Both approaches provide better immediate postoperative outcomes than open surgery, such as less blood loss, scarring, and pain, and a quicker recovery,” says Dr. Pieretti. “But the Retzius-sparing technique also can result in better functional outcomes with quality-of-life benefits.”

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QoL benefits

According to the US Preventive Services Task Force, approximately 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence while two-thirds of men will experience long-term erectile dysfunction. Much of the research on functional outcomes comparing RARP and RS-RARP focuses on these two major side effects.

For example, in a recent study reported in Nature’s Prostate Cancer and Prostatic Diseases, researchers saw significantly higher urinary continence recovery with the Retzius-sparing approach over standard RARP, with the largest difference 1 week following catheter removal (91.2% vs 54.3%). By 3 months the recovery gap shrank to 96.1% vs. 83.8%, still a significant difference (p = 0.01). But at 6 months, the study and control group rates were comparable (97% vs 90.5%, p = 0.09).

“I see similar rapid continence recovery in my practice with some patients experiencing an immediate return following surgery,” says Dr. Pieretti. “In my experience, older patients can take longer to regain continence, but they still improve faster with the Retzius-sparing approach.”

While RS-RARP has consistently demonstrated early continence recovery in multiple studies, there has been less consistency in potency outcomes, as addressed by the authors in the Nature study. “Trends in sexual dysfunction suggest improvement, but we need more research,” notes Dr. Pieretti.

Less common side effects associated with radical prostatectomy, including penile shortening, Peyronie’s disease, and inguinal hernias, have not received as much scrutiny. But a 2020 study did demonstrate a lower incidence of these conditions among patients undergoing RS-RARP versus RARP.

In the study, no men undergoing RS-RARP experienced Peyronie’s disease or inguinal hernias versus 8.7%  and 13% of patients undergoing a traditional approach, respectively. There was also less patient-reported penile shortening (41.7% vs 64.9%) with RS-RARP.

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Ideal candidate

Prostate cancer is the second most common cancer in males, with an estimated 288,300 new cases projected in 2023, according to the American Cancer Society. Over the past decade the incidence has been steadily rising, with some 70% of prostate cancer cases diagnosed at the local stage.

“A majority of patients diagnosed with localized prostate cancer are candidates for a Retzius-sparing prostatectomy because most tumors occur in the peripheral, posterior portion of the prostate,” says Dr. Pieretti. “Research has shown patients with anterior tumors do better with a standard anterior robotic approach in terms of oncologic outcomes.”

He points to a 2023 study that found a significantly higher positive surgical margin (PSM) rate and higher biochemical progression (BCP) probability with RS-RARP than conventional RARP in cases involving anterior lesions but not with posterior tumors.

“Tumor location and disease stage are among the factors that go into deciding the most appropriate surgical approach,” adds Dr. Pieretti. “If a tumor is invading the bladder neck, for example, I’ll use an anterior approach instead of the Retzius-sparing method.”

Dr. Pieretti emphasizes that in the appropriate patient these surgical technical innovations can improve a patient’s quality of life without compromising oncologic outcomes. “At the end of the day, I want to do what’s best for my patient and that means maximizing oncologic and functional outcomes,” he says.