TRANS DOUGLAS ROBOTIC RADICAL PROSTATECTOMY: OUR EXPERIENCE

Yazan Al Shali1, Luca Topazio1, Domenico Autieri1, Saba Khorrami1, Tiziano Verdacchi1, Michele De Angelis1, Filippo Annino1
  • 1 Ospedale San Donato A.U.S.L. 8 - U.O.C. Urologia (Arezzo)

Objective

Aim of the present study is to report our 3 years experience (December 2011 – July 2014) and results of Trans Douglas Robotic Radical Prostatectomy (1).

Materials and Methods

Fortyfive males underwent robotic radical prostatectomy during a 32 months study period. The surgical approach was that described by Bocciardi et al in 2010 with a trans-douglas approach and preservation of the anterior compartment wich contains all of the structures thought to play a role in maintenance of continence and potency. Mean patient age was 64.84 yr (IQR:52-74 yr). Mean Psa was 7.47 ng/ml (IQR:4.6-13.5 ng/ml). Gleason score at biopsy was 6 (3+3) in 26 patients, 7(3+4) in 12 patients, 8(4+4) in 3 patients, 10(5+5) in 2 patients and Gleason 3 in 1 patient. Mean volume prostate was 50.1 g (IQR:26-108). Mean preoperative EHS was 3.04.

Results

Mean operative time was 172.44 minutes (IQR:105-265 minutes), mean hospital stay was 2.3 days (IQR: 2-3 days). No perioperative complications were found and only 1 (2.2%) patient was rehospitalized due to fever. No transfusion was needed in any patient. 39 (86.6%) nerve sparing techniques were performed (of which 2 monolateral) while the extrafascial approach was performed in 6 cases (13.3%). 11 (24%) patients underwent a bilateral iliac-obturatory lymphadenectomy. Histological examination reported in our population the presence of 25 (55.5%) pT2 and 20 (44.5%) pT3. Pathologic Gleason score confirmed the previous one in 29 (64.4%) cases, showed a higher grade in 10 (22.2%) cases, while a lower grade was found in 6 (13.3%) cases. Positive surgical margins were found in 45% of pT3 population and in 16% of pT2 population. Mean PSA nadir (two months after surgery) was 0.07 ng/ml (IQR: 0,001-1,7) with one biochemical relapse in a patient with lymph node recurrence. Regarding functional outcomes 24 (63.1%) had immediate continence (defined as the no need of pad), 34 (75.5%) at one month and 38 (84.5%) at three months. 7 patients (15.5%) had still incontinence of which 2 patients wear 2 pads daily and 5 wear 1 pad daily. Regarding sexual functional outcomes, data of 29 patients that described a preoperative EHS of 3-4/4 who underwent a nerve sparing approach showed that 15 patients (51%) described an EHS of 3-4/4 with a mean recovery time of 47.8 days.

Discussions

Trans Douglas approach for RALP is because of anatomic considerations and greater respect for the structures involved in the mechanisms of potency and continence. This new approach presents several theoretical advantages over the traditional technique. First, it allows for the possibility of performing not just completely intrafascial prostatectomies, as Bocciardi explained, but also for interfascial and extrafascial ones. Our study has a main limitation linked to the nonrandomized and noncomparative design, but it represents a natural step during the development of a new surgical technique. Furthermore is carachterized by a heterogenous population that shows the presence of pT3 in almost half of patients.

Conclusion

Our impression is that Trans Douglas Robotic Prostatectomy is feasible and reproducible. As regards functional outcomes our data suggest that this technique is oncologically safe and, thanks to the preservation of the anterior compartment wich contains all of the structures thought to play a role in maintenance of continence and potency, results in high early continence and potency rates. The anatomic rationale for better results of Trans-Douglas Robotic Prostatectomy compared with traditional RALP is strong however long-term, prospective, comparative, and possibly randomized studies are needed to produce stong evidence and to make this technique an alternative to standard robotic prostatectomy.

References

(1) Galfano A, Ascione A, Grimaldi S, Petralia G, Strada E, Bocciardi AM. A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery. Eur Urol. 2010 Sep;58(3):457-61. doi: 10.1016/j.eururo.2010.06.008. Epub 2010 Jun 16.

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