title: Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy.
abstract: OBJECTIVE
  To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity.
  
  
  METHODS
  Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal.
  
  
  RESULTS
  Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P = 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥ pT3a) documented on final specimen pathology (16% vs 10%, P = 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach.
  
  
  CONCLUSIONS
  Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.
authors.affiliation: Lefrak Center of Robotic Surgery, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College-New York Presbyterian Hospital, New York, NY 10065, USA. ashtewarimd@gmail.com
authors.forename: Ashutosh K
authors.initials: AK
authors.lastname: Tewari
authors.forename: Abhishek
authors.initials: A
authors.lastname: Srivastava
authors.forename: Kumaran
authors.initials: K
authors.lastname: Mudaliar
authors.forename: Gerald Y
authors.initials: GY
authors.lastname: Tan
authors.forename: Sonal
authors.initials: S
authors.lastname: Grover
authors.forename: Youssef
authors.initials: Y
authors.lastname: El Douaihy
authors.forename: David
authors.initials: D
authors.lastname: Peters
authors.forename: Robert
authors.initials: R
authors.lastname: Leung
authors.forename: Rajiv
authors.initials: R
authors.lastname: Yadav
authors.forename: Majnu
authors.initials: M
authors.lastname: John
authors.forename: James
authors.initials: J
authors.lastname: Wysock
authors.forename: E Daracott
authors.initials: ED
authors.lastname: Vaughan
authors.forename: Sara
authors.initials: S
authors.lastname: Muir
authors.forename: Mahul B
authors.initials: MB
authors.lastname: Amin
authors.forename: Mark
authors.initials: M
authors.lastname: Rubin
authors.forename: Jiangling
authors.initials: J
authors.lastname: Tu
authors.forename: Mohammed
authors.initials: M
authors.lastname: Akthar
authors.forename: Maria
authors.initials: M
authors.lastname: Shevchuk
mesh_terms: D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D011467:Prostate / Q000473:pathology* / Q000601:surgery; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology* / Q000517:prevention & control / Q000601:surgery; D012371:Robotics; D016896:Treatment Outcome; D014521:Urethra / Q000473:pathology* / Q000601:surgery