RARP is considered the gold standard for surgical management of localized prostate cancer. In 2010, Galfano et al described the RS-RARP (Bocciardi technique) using a completely posterior approach through the pouch of Douglas (Fig.3). With the dissection inherently proceeding from inside-out, the neurovascular bundle is pushed out and remains attached to lateral pelvic fascia while dissection of prostate proceeds intra-fascially. This is unlike the outside-in anterior approaches where one has to move from outside the fascial sheath inwards, potentially putting traction on nerve fibers and neuropraxia. Option to move extra-fascial remains open with the surgeon in RS-RARP as well, if needed.Surgically this advantage has been shown to translate to early continence recovery as this technique also allows for the preservation of puboprostatic ligaments, the endopelvic fascia and deep venous complex (Santorini plexus).
Technique
Once the parietal peritoneum is incised in the rectovesical pouch, the seminal vesicles and vasa deferentia are identified and dissected. The posterior and lateral dissection is then carried out caudally till the apex of prostate (P). Bladder (UB) neck is identified, incised and divided; posterior followed by anterior (Fig.4(a&b)). The anterior prostatic dissection also proceeds in similar fashion till the prostatic apex with or without the ligation of dorsal venous complex (DVC) followed by division of urethra (U) (Fig.4(c&d)) The vesicourethral anastomosis is then completed as a mirror image of standard RARP (S-RARP).
Outcomes
The complication rates tend to be similar as with S-RARP.There have been concerns regarding inferior oncological outcomes with RS-RARP having positive surgical margin rates from 14% - 42% as opposed to standard RARP which have positive margin rates from 10%-29%. This larger PSM rates are especially relevant when anterior tumors are taken into consideration.However, recent literature shows trend towards similar PSM rates which may reflect the better expertise with time. With paucity of literature on BCR free survival, RS-RARP and S-RARP tend to fare similarly.Several studies have shown that the time to continence recovery is significantly quicker with early (1-4 week) continence rates ranging from 38%-92% with RS-RARP as compared to 30%-85% with S-RARP.However, this does not translate to persistent advantage in continence beyond 6-12 months.With limited data, the potency rates appear to be similar (RS-RARP vs S-RARP – 65-86.5% vs 62-69.2%).
To summarize, RS-RARP is a reliable and safe technique with an advantage of early continence recovery. There is a concern regarding PSMs especially in anterior tumors which seems to come down as expertise develops.
Figure 3: Key steps of RS-RARP: 1) Posterior dissection 2) identification & incision of bladder neck 3) Division of urethra & completion of anastomosis
Figure 4: Intra-operative images depicting bladder neck and urethral division
Authored by Dr Prashant Singh, AIIMS,New Delhi
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