title: Robot-assisted partial prostatectomy for anterior prostate cancer: a step-by-step guide.
abstract: To describe a step-by-step guide to robot-assisted anterior partial prostatectomy (RA-APP) for isolated magnetic resonance imaging (MRI)-detected anterior prostate cancer (APC).
  
  
  
  After Institutional Review Board approval, over an 8-year period (2008-2015), 17 consenting patients were enrolled in a prospective, single-arm, single-centre, Idea, Development, Evaluation, Assessment and Long-term evaluation of innovative surgery (IDEAL) phase 2a study. The inclusion criteria comprised pre-urethral, low-intermediate risk APC diagnosed by MRI and targeted biopsies. Patient position and port placement were identical to the transperitoneal RA radical prostatectomy procedure. Three steps of dissection were identified in the following order: (i) retrograde apical, after dorsal venous plexus division, transition zone (TZ) enucleation, and distal peripheral zone (PZ) sectioning; (ii) antegrade, at the bladder neck (BN) after anterior BN sectioning, TZ enucleation up to the verumontanum; and (iii) lateral dissections, including anterolateral PZ sectioning without incision of the endopelvic fascia. We report the incidence of perioperative complications. The RA completion of prostatectomy in four cases with cancer recurrence was performed at 0.3, 2.5, 2 and 2 years, respectively.
  
  
  
  The RA-APP comprised en bloc excision of the anterior part of the prostate comprising of the anterior fibromuscular stroma, BN, prostate adenoma (TZ and median lobe) along with the proximal prostate urethra, PZ apical anterior horns, anterior aspect of the distal (sub-montanal) urethra, and anterior BN. The posterolateral parts of the PZ and distal (sub-montanal) urethra and peri-prostatic tissues were preserved intact. The bladder opening was sutured to the anterior sphincteric urethra wall and PZ lateral edges. The technique was feasible in all cases with no conversion to an open procedure. Perioperative complications were only Clavien-Dindo grade II. RA completion of prostatectomy was feasible in the four cases with cancer recurrence.
  
  
  
  PZ prostate-sparing RA-APP for isolated APC is feasible and safe, and represents an option for highly selected men with APCs as an alternative to other focal ablative therapy.
authors.affiliation: Department of Urology, CHU Lille, Université de Lille, Lille, France.
authors.forename: Arnauld
authors.initials: A
authors.lastname: Villers
authors.affiliation: Department of Urology, CHU Lille, Université de Lille, Lille, France.
authors.forename: Vincent
authors.initials: V
authors.lastname: Flamand
authors.affiliation: Clinica INDISA, Facultad de Medicina, Universidad Andrés Bello, Santiago, Chile.
authors.forename: Rodríguez-Carlin
authors.initials: RC
authors.lastname: Arquímedes
authors.affiliation: Department of Radiology, CHU Lille, Université de Lille, Lille, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Puech
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.affiliation: USC Institute of Urology, Catherine & Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA.
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.affiliation: Urology and Transplantation Department, Edouard Herriot Hospital, Université de Lyon, Lyon, France.
authors.forename: Sebastien
authors.initials: S
authors.lastname: Crouzet
authors.affiliation: Department of Urology, CHU Lille, Université de Lille, Lille, France.
authors.forename: Adil
authors.initials: A
authors.lastname: Ouzzane
authors.affiliation: USC Institute of Urology, Catherine & Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA.
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D065287:Robotic Surgical Procedures
keywords: #PCSM; #ProstateCancer; focal therapy; prostate MRI; robot-assisted surgery