What is Retzius-Sparing Robotic Prostatectomy (RSP)?
Retzius-sparing robotic prostatectomy (RSP) is an advanced approach for treating prostate cancer by removal of the prostate gland. It is based on conventional Robot-assisted laparoscopic radical prostatectomy (RALP) and offers significant advantages over standard RALP.
In RSP, the cave of Retzius (containing fat and connective tissue) as well as the puboprostatic ligaments are preserved. This preservation of normal pelvic anatomy results in better urinary continence outcomes and reduced bladder neck descent. Not all patients are necessarily suitable, but it can be extremely valuable for those who are.
Features and Benefits of Surgery
The main advantages of RSP include:
- Faster Return to Continence: Men experience a significantly faster return to continence compared to the standard technique (around 70 - 90% of men are continent or pad-free within 1 month of surgery, compared to 20 - 30% with standard robotic techniques).
- Improved Patient Comfort: Often a suprapubic catheter placed through the abdomen is used to drain the bladder after surgery rather than a catheter placed into the penis.
- Minimally Invasive Precision: As a robotic procedure, it provides enhanced surgical precision, less bleeding, and reduced post-operative pain compared to open techniques.
Surgical Development & Local Expertise
The Retzius-Sparing approach was originally developed by Prof. Aldo Bocciardi and Dr. Antonio Galfano at the ASST Grande Ospedale Metropolitano Niguarda in Milan, Italy.
A/Prof Gianduzzo has been doing this procedure in Brisbane since 2018 and pioneered its development in Australia in collaboration with his colleague Dr. Philip Dundee from Melbourne. Both have been impressed at the improvement in continence outcomes compared to the standard technique.
A/Prof Gianduzzo undertook sabbaticals with Prof. Bocciardi in Milan and Prof. Christopher Eden in London to learn and refine this technique. He also hosted a Retzius-Sparing robotic radical prostatectomy workshop at the Wesley Hospital, featuring international expert faculty including Prof. Eden and Prof. Koon Rha (Yonsei University, South Korea).
Preparation Before Surgery
In order to prepare for surgery, the patient is adequately counselled to ensure informed consent is fully understood. The doctor runs a series of tests to confirm fitness for surgery, including:
- Blood work and urine analysis
- PSA testing and physical examination
- Imaging scans (as required)
The physician makes the final decision on eligibility based on examination and lab results. As this is major surgery, patients are advised to fast (no food or drink) for eight hours prior to the procedure. Some hospitals may admit the patient the evening before surgery.
Steps in Surgery & Technical Demonstration
The surgery is performed using the da Vinci robotic surgical system. The doctor may show the robot to the patient beforehand to relieve anxiety and answer any questions.
General Surgical Workflow:
- Anesthesia & Access: An IV line is placed for fluids, and general anesthesia is administered. Keyhole incisions are made in the abdomen for the robotic arms and camera.
- Dissection: The robotic arms manipulate tissue to reach the prostate gland. The prostate tissue is dissected in sequence and removed while strictly sparing the Retzius cave.
- Catheter Placement & Closure: A suprapubic catheter is placed temporarily (for about 1 week) to assist healing. The robotic instruments are removed, and the small incisions are sutured.
- Post-Op Transition: The patient is awakened from anesthesia and transferred to post-operative recovery.
Case Demonstration Video
This video is a demonstration of this technique by mentor Prof. Christopher Eden, the UK's leading prostate cancer surgeon.
- Case Profile: A 55-year-old potent man with a PSA of 4.3 and Gleason 3+4 T2aN0M0 adenocarcinoma of the prostate undergoing a complete Retzius-sparing interfascial nerve-preserving robotic radical prostatectomy.
- Procedure Nuance: After the anastomosis is complete, a suprapubic catheter is inserted, and the urethral catheter is removed. The topical haemostatic powder Arista is applied over both neurovascular bundles at the end of the case. (Video has no audio).
Post-Operative Care & Recovery
Immediate Post-Op
- The patient is monitored in the recovery room before transfer to a hospital room.
- NSAIDs and paracetamol are provided for pain management.
- Light liquids can usually be started by the evening of surgery.
- Patients are typically discharged once mobile, usually within about three days.
Recovery & Long-Term Care Plan
- Wound Care: Wounds must be kept clean, and mild analgesics (e.g., paracetamol) can be taken as needed.
- Return to Activity: Patients are generally expected to return to normal activities within 6 weeks.
- Follow-Up: The doctor will establish a structured care plan involving follow-up appointments several weeks apart and routine PSA testing to monitor progress.
