Trifecta results in Retzius-sparing robotic radical prostatectomy: results of a high-volume center

Abstract

Aim: We aimed to evaluate trifecta outcomes after Retzius-sparing robot-assisted radical prostatectomy (rs-RARP).

Methods: We evaluated 1488 patients who had undergone rs-RARP at our institution from 2011 to 2019. All patients filled out questionaries for functional outcomes before surgery, and only patients with baseline continence and IIEF-5 scores of > 16 were included. Biochemical recurrence (BCR) was defined as two consecutive prostatic specific antigen levels of > 0.2 ng/mL after rs-RARP. Postoperative continence was defined as the use of no pads. Potency was defined as the ability to achieve erections for sexual intercourse, with or without phosphodiesterase-5 (PDE-5) inhibitors. A multivariable logistic regression model was performed to identify predictors of trifecta outcome.

Results: In total, 1240 patients were included in the analysis. During the 24-month follow-up time, 149 patients (11.9%) harbored BCR. Urinary continence was observed in 981 patients (79.5%), while 171 (13.8%) still used a safety pad daily after 24 months. Sexual potency was reported in 643 patients (51.9%), of whom 379 (30.6%) had spontaneous erections and 264 (21.3%) used a PDE-5 inhibitor. Overall, the trifecta outcome was reached by 42.1% of the study’s population. The trifecta outcome was easily reached by younger patients and patients who underwent a full nerve-sparing (NS) prostatectomy. In the multivariable model, age [odds ratio (OR) = 0.89; 95% confidence interval (CI): 0.84-0.90; P < 0.01] and type of NS surgery [partial NS (OR = 3.34; 95%CI: 1.01-11; P = 0.04) full NS (OR = 4.57; 95%CI: 1.86-12; P < 0.01)] resulted as independent predictors.

Conclusion: rs-RARP is associated with optimal trifecta outcome rate. Age and NS technique are independent predictors of trifecta outcomes.

Keywords

Prostate cancer / robot-assisted radical prostatectomy / Retzius sparing / functional outcomes / trifecta outcome

References

[1] Sood A,Menon M.Retzius-sparing robot-assisted radical prostatectomy.BJU Int2019;123:7-8

[2] Patel VR,Schatloff O.Critical review of ‘pentafecta’ outcomes after robot-assisted laparoscopic prostatectomy in high-volume centres.BJU Int2011;108:1007-17

[3] Bianchi L,Fossati N.Oncologic outcomes in prostate cancer patients treated with robot-assisted radical prostatectomy: results from a single institution series with more than 10 years follow up.Minerva Urol Nefrol2019;71:38-46

[4] Inoue S,Hayashi T,Matsubara A.Longitudinal analysis of trifecta outcome in Japanese patients with prostate cancer following robot-assisted laparoscopic radical prostatectomy.World J Urol2020;

[5] Bianco FJ Jr,Eastham JA.Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (“trifecta”).Urology2005;66:83-94

[6] Patel VR,Chauhan S.Continence, potency and oncological outcomes after robotic-assisted radical prostatectomy: early trifecta results of a high-volume surgeon.BJU Int2010;106:696-702

[7] Novara G,D'Elia C,Cavalleri S.Trifecta outcomes after robot-assisted laparoscopic radical prostatectomy.BJU Int2011;107:100-4

[8] Borregales LD,Tal O.‘Trifecta’ after radical prostatectomy: is there a standard definition?.BJU Int2013;112:60-7

[9] Galfano A,Grimaldi S,Strada E.A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery.Eur Urol2010;58:457-61

[10] Mottet N,Briers E.EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer—2020 update. Part 1: screening, diagnosis, and local treatment with curative intent.Eur Urol2021;79:243-62

[11] Dalela D,Prasad MA.A pragmatic randomized controlled trial examining the impact of the Retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy.Eur Urol2017;72:677-85

[12] Menon M,Jamil M.Functional recovery, oncologic outcomes and postoperative complications after robot-assisted radical prostatectomy: an evidence-based analysis comparing the Retzius sparing and standard approaches.J Urol2018;199:1210-7

[13] Checcucci E,Fiori C.Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes.BJU Int2020;125:8-16

[14] Olivero A,Piccinelli M.Retzius-sparing robotic radical prostatectomy for surgeons in the learning curve: a propensity score-matching analysis.Eur Urol Focus2021;7:772-8

[15] Galfano A,Bocciardi AM.Retzius-sparing robot-assisted laparoscopic radical prostatectomy: an international survey on surgical details and worldwide diffusion.Eur Urol Focus2020;6:1021-3

[16] Galfano A,Panarello D.Pain and discomfort after Retzius-sparing robot-assisted radical prostatectomy: a comparative study between suprapubic cystostomy and urethral catheter as urinary drainage.Minerva Urol Nefrol2019;71:381-5

[17] Kowalczyk KJ,O'Neill J.Impact of Retzius-sparing versus standard robotic-assisted radical prostatectomy on penile shortening, Peyronie's disease, and inguinal hernia sequelae.Eur Urol Open Sci2020;22:17-22 PMCID:PMC8317841

[18] Davis M,Marhamati S,Kowalczyk KJ.Retzius-sparing robot-assisted robotic prostatectomy: past, present, and future.Urol Clin North Am2021;48:11-23

[19] Rosen RC,Smith MD,Peña BM.Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction.Int J Impot Res1999;11:319-26

[20] Montorsi F,Rosen RC.Pasadena Consensus PanelBest practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel.Eur Urol2012;62:368-81

[21] Autorino R,Dasgupta P.Precision surgery and genitourinary cancers.Eur J Surg Oncol2017;43:893-908

[22] Porpiglia F,Manfredi M.Total anatomical reconstruction during robot-assisted radical prostatectomy: implications on early recovery of urinary continence.Eur Urol2016;69:485-95

[23] Puliatti S,Eissa A.Effect of puboprostatic ligament reconstruction on continence recovery after robot-assisted laparoscopic prostatectomy: our initial experience.Minerva Urol Nefrol2019;71:230-9

[24] Campobasso D,Amparore D.Total anatomical reconstruction during robot-assisted radical prostatectomy in patients with previous prostate surgery.Minerva Urol Nefrol2019;71:605-11

[25] Xylinas E,Durand X.Evaluation of combined oncological and functional outcomes after radical prostatectomy: trifecta rate of achieving continence, potency and cancer control--a literature review.Urology2010;76:1194-8

[26] Eastham JA,Kattan MW.Predicting an optimal outcome after radical prostatectomy: the trifecta nomogram.J Urol2008;179:2207-10; discussion 2210-1 PMCID:PMC4270351

[27] Shikanov SA,Zagaja GP.Trifecta outcomes after robotic-assisted laparoscopic prostatectomy.Urology2009;74:619-23

[28] Checcucci E,DE Cillis S.San Luigi Study GroupThe importance of anatomical reconstruction for continence recovery after robot assisted radical prostatectomy: a systematic review and pooled analysis from referral centers.Minerva Urol Nephrol2021;73:165-77