Is Retzius-sparing radical prostatectomy the surgical wave of the future?

Back in the early 1980s, Dr. Patrick Walsh at the Johns Hopkins Medical Center in Baltimore changed the nature of surgical treatment for prostate cancer when he first started to conduct so-called nerve-sparing radical prostatectomies.

Then, in the late 1990s and early 2000s, there were two other major changes to prostate cancer surgery, with the introduction of — first — laparoscopic forms of radical prostatectomy (LRP) and then robot-assisted laparoscopic radical prostatectomy (RALP).

In a new blog post on the SantisHealth web site, Mr. Christopher Eden — a well-known British surgeon who was the first to start carrying out LRP in the UK — discusses what seems (at least potentially) to be yet another major advance in the conduct of the radical prostatectomy — so-called Retzius-sparing radical prostatectomy. He gives details about going to South Korea to learn how to carry out this procedure under the guidance of Prof. K. H. Rha, and he reports that his first 20 patients treated back in the UK using this technique were all (yes 100 percent) either completely continent (pad free, 80 percent) or used just one small safety pad per day (20 percent) at 4 weeks following surgery.

He also expresses his considered opinion that within a decade Retzius-sparing surgery — which can be carried out using a robot-assisted, laparoscopic technique — will be the standard method of conducting radical prostatectomies among all high-volume surgeons who specialize in the treatment of prostate cancer.

For those who are interested, the two most experienced surgeons in the world in the use of this technique at this time are:

  • Prof. A. M. Bocciardi of the Ospedale Niguarda in Milan, Italy, who reported the 1-year outcomes on his first 200 patients using the Retzius-sparing technique back in 2013.
  • Prof. K. H. Rha, of Yonsei University College of Medicine, Seoul, South Korea, who first reported data on his use of this technique in 2014, and has now published five papers reporting the outcomes of patients treated using this technique.

Here in the US, Dr. Mani Menon and colleagues at the Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan, have reported data from a randomized trial of his so-called anterior surgical technique as compared to the “Bocciardi” Retzius-sparing technique and has stated that, at least in the hands of his surgical group,

… differences in urinary continence seen at 3 months were muted at 12 months follow-up, while sexual function recovery, postoperative complications and biochemical recurrence rates were comparable 1-year postoperatively.

The “New” Prostate Cancer InfoLink is only too well aware how difficult it is to learn to carry out a new and different form of radical prostatectomy. We suspect it may take time for even experienced surgeons to learn how to carry out this new technique with a high degree of skill and reproducibility. Mr. Eden is clear in his blog post that Retzius-sparing surgery is very different to standard forms of RALP and requires even the most experienced prostate cancer surgeon to stop, think, and re-learn how to carry out this procedure.

It will probably be a while before the Retzius-sparing procedure becomes commonplace here in America. However, there are strong suggestions from the data published by Rha and by Bocciardi that this technique can result in significantly faster recovery of good erectile function post-surgery — in addition to the faster recovery of continence. We are going to need data from larger, longer-term studies before we can be certain about the potential benefits of this technique.

Editorial note: Our thanks to one of our regular British readers for bringing Mr. Eden’s blog post to our attention. Also — for those not aware of this British eccentricity — male surgeons in the UK are always referred to as Mr. X or Mr. Y (as opposed to Dr. X or Dr. Y). You want to know why? See here.

7 Responses

  1. It would be “Shavian unreasonable” to insist on it. So…

    I reckon (and hope on behalf of others more “reasonable”) it will be less than a decade. The interesting thing is the data suggest the lead time is short. So I would actually be happy to be patient zero of a skilled RALRP surgeon. It would have the decided advantage of keeping the interns out.

    So I will tell my guy tomorrow that RSRALRP might be what is needed to get me off AS: I would regard this as ample reward for my 15 months of patience. Dream scenario: him, me as patient zero, and Eden “sitting right”.

  2. I’d like to thank the sitemaster and participants for the broad liberal education one receives here. Case in point:

    * Background of surgeons addressed as Mr. (or Ms.) in the UK.
    * “Shavian unreasonableness” (but isn’t that redundant?)

    But BTW, it appears that RSRALRP may be referred to as simply RSP, for short.

  3. If the Retzius-sparing radical prostatectomy would really reduce the side effects that much, this would provide a great advantage for robotic prostatectomy versus open surgery.

    Also it would not make much sense to use focal therapies if the side effects of Retzius-sparing robotic prostatectomy would be equal or even less compared with these therapies.

  4. So just a data point on Mr Eden’s 10 years and my hope that it is an overestimate.

    I shall not name names but cognoscenti will have a short shortlist. Yesterday’s consult was with the registrar of one of London’s most prominent urologists, who is known for overhauling the urology practice at one of the top London teaching hospitals in a way that has gone on to become standard. (Specialist clinics, template biopsy — sadly not universal here yet, MRI-guided biopsy, etc.)

    He (the consultant) has started doing RSP (thank you @Casey) in some cases in order to assess results. Assuming this is worth the candle, which I think is fair, then it will propagate from there. But not become universal; as the registrar stressed, there is a possible issue in oncological outcomes in the anterior region; they will use imaging to narrow down.

  5. Who is doing this in the United States today (i.e., as of December 2020).

    Thank you.

  6. Dear Art:

    In all honesty I don’t know this yet. I am pretty sure it is a relatively small number of surgeons, however.

  7. Art,

    I’ve seen trials by Mani Menon at Henry Ford in Detroit. There are also trials of covering the neurovascular bundles with various substances (e.g., amniotic sacs, chitosan membranes, and other synthetic films).

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