title: Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with ≥ 1 year of follow-up.
abstract: BACKGROUND
  Robot-assisted laparoscopic radical prostatectomy (RARP) has become the main surgical option for localized prostate cancer. We recently developed a new approach for RARP, passing through the pouch of Douglas and avoiding all the Retzius structures involved in continence and potency preservation.
  
  
  OBJECTIVE
  To report the functional and oncologic results of our first 200 patients operated on using this new approach.
  
  
  METHODS
  This was a prospective, noncontrolled case series including the first 200 consecutive patients undergoing this kind of surgery (January the 1st, 2010 to December the 31st, 2011).
  
  
  METHODS
  Retzius-sparing RARP.
  
  
  METHODS
  All perioperative, oncologic, and functional data were prospectively recorded. Potency was defined as an International Index of Erectile Function-5 questionnaire score >17; continence was defined as use of no pad or of one safety liner. Oncologic results were reported as positive surgical margins (PSM) and 1-yr biochemical disease-free survival (1y-bDFS). Recurrence was defined as a repeated prostate-specific antigen >0.2 ng/ml. Complications were graded according to the Clavien-Dindo system. The first 100 patients (group 1) were compared with the second 100 (group 2) to evaluate the learning curve effects.
  
  
  CONCLUSIONS
  The median patient age was 65 yr. Comparing the two groups, transfusions were needed in 8% versus 4% of cases in groups 1 and 2, respectively (p=0.02). There was one Clavien-Dindo grade 3b in group 1 versus one grade 3a complication in group 2. In patients with pT2 disease, PSMs were recorded in 22.4% of those in group 1 versus 10.1% in group 2 (p=0.045). 1y-bDFS was 89% in group 1 versus 92% in group 2. For groups 1 and 2, respectively, immediate continence was reached in 92% versus 90% of patients, and the 1-yr continence rate was 96% versus 96%. Considering the 77 potent patients aged <65 yr who underwent bilateral intrafascial nerve-sparing surgery, 40.4% of those in group 1 versus 40% of those in group 2 reached their first intercourse within 1 mo; at 1 yr of follow-up, these figures had increased to 81% versus 71%, respectively (p=0.162). The main limitation of this study is its noncontrolled nature.
  
  
  CONCLUSIONS
  We demonstrated Retzius-sparing RARP to be oncologically safe and to result in high early continence and potency rates. Long-term, prospective, comparative, and possibly randomized studies are needed.
authors.affiliation: Department of Urology, Niguarda Ca' Granda Hospital, Milan, Italy. Electronic address: antoniogalfano@gmail.com.
authors.forename: Antonio
authors.initials: A
authors.lastname: Galfano
authors.forename: Dario
authors.initials: D
authors.lastname: Di Trapani
authors.forename: Francesco
authors.initials: F
authors.lastname: Sozzi
authors.forename: Elena
authors.initials: E
authors.lastname: Strada
authors.forename: Giovanni
authors.initials: G
authors.lastname: Petralia
authors.forename: Manuela
authors.initials: M
authors.lastname: Bramerio
authors.forename: Assunta
authors.initials: A
authors.lastname: Ascione
authors.forename: Marcello
authors.initials: M
authors.lastname: Gambacorta
authors.forename: Aldo Massimo
authors.initials: AM
authors.lastname: Bocciardi
mesh_terms: D000368:Aged; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011468:Prostatectomy / Q000379:methods*; D012371:Robotics; D013997:Time Factors; D016896:Treatment Outcome
keywords: Douglas pouch; Learning curve; Prostate cancer; RARP; Robot-assisted laparoscopic radical prostatectomy