Inhaltszusammenfassung:
6.1. Background
The subtrigonal approach for robotic assisted radical prostatectomy was first described in 2010 as the most anatomically preserving technique, in which the prostate can be completely removed through the Douglas pouch. This technique was introduced in the Urology Department of Tuebingen University Hospital in June 2013 after many years of performing the conventional transperitoneal robotic prostatectomy, however few data is available regarding its outcome.
6.2. Objectives
The aim of this study is to compare the functional and oncological outcomes of subtrigonal approach versus the conventional approach for robotic radical prostatctomy
6.3. Methods
Consecutive groups of patients who underwent TPRP (n=126) from 01/2012 to 05/2013, and those who switched and underwent STRP (n=62) from 01/2014 to 01/2015 were compared;. Functional outcomes were evaluated using ICIQ and IIEF of both groups by questionnaire and telephone protocols. Oncological outcomes were assessed regarding positive surgical margins and biochemical recurrence free survival (PSA ≥ 0.02 ng/ml) using the Kaplan Meier curve. Postoperative complications were classified using the Clavien-Dindo system. Statistical analysis was performed using the jmp v.12 software®. Mann-Whitney-U and Pearson x2 tests were employed to compare the continuous and categorical variables, respectively. The Kaplan Meier curve was applied to present the survival data
6.4. Results
The median age and follow-up time in the TPRP and STRP groups were 64 and 62.5 years and 34 and nine months, respectively. Within 7 days of catheter removal, 37/93 patients (40%) in group A were continent compared to 23/53 (43%) in group B (p-value = 0.67). At 3, 6 and 12-month intervals, the continence recovery rates were 71%, 73% and 87% in group A versus 76%, 89% and 96% in
group B. The p-values were 0.55, 0.02 and 0.054, respectively. 15 and 7 patients in group A and B, respectively, underwent bilateral nerve sparing surgery (NS). In group A, 2/15 (13%) could achieve enough erection for penetration versus 3/7 (43%) in group B; (p-value = 0.13). The overall positive surgical margin (PSM) rate was 16% in group A versus 8% in group B (p-value = 0.11). According to the pathological stage, PSM rates in pT2, pT3a and pT3b were 7.2%, 53% and 55.6% in group A compared to 2.2%, 11% and 60% in group B, respectively (p-values = 0.19, 0.03 and 0.87). PSM in pT3a was significantly lower in group B. When comparing the PSM rate at the prostatic apex, it was 9.8% in group A versus 1.6% in group B; with a significant difference (p-value = 0.02). The BCR 1y-free survival was 91% in group A versus 94% in group B (Log-rank p-value = 0.57).
6.5. Conclusion
The anatomical preservative sub-trigonal approach for RARP increases the post-operative continence recoverability. Our results approved the oncological safety of this technique even in locally advanced cases. Sub-trigonal approach displayed reduction of PSM especially at the apex and in tumors with extra- capsular extension. Prospective randomized studies including bigger cohorts of patients with longer follow up are mandatory to confirm these results.
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