Improvements in surgical technique: past and more recent


Nearly 3 years ago now, we first mentioned a surgical technique known as “Retzius-sparing” radical prostatectomy on this web site. The degree to which this has been adopted into standard urologic surgical practice around the world is still unclear. However, what is clear is that the urologic surgical community is still seeking ways to improve patient outcomes after removal of the prostate for first-line treatment of localized prostate cancer, and the three things that they are most focused on are these:

  • Elimination of the cancer itself
  • Rapid and complete recovery of normal urinary function
  • Reasonably rapid recovery of erectile function — at least the the same extent as prior to the surgeryt for each specific patient

This set of three objectives is often referred to by prostate cancer specialists as the “trifecta”.

To be blunt, it remains relatively rare for all three goals to be accomplished for the majority of patients. From the surgical perspective, the primary objective is elimination of the cancer. The next is recovery of at least decent urinary function. The recovery of good erectile function still comes in as a relatively poor third.

On the other hand, we should be clear that some of the world’s best prostate cancer surgeons are constantly seeking ways to improve their personal skills and techniques and then to pass these along to others. The latest such potential advance seems to be coming from the group led by Dr. Ash Tewari at the Mount Sinai Health System and the Icahn School of Medicine in New York.

In a recent article in European Urology, Wagaskar et al. report on what they are describing as a new “hood technique” for the conduct of robot-assisted laparoscopic prostatectomy. We aren’t going to try to get into all the details of how they conduct this type of surgery, but it appears to combine aspects of the “Retzius-sparing” surgical technique with the preservation of other periurethral anatomical structures (e.g., the “pouch of Douglas”). The abstract of the actual paper is available at the prior link and there is also a summary write-up on their research on the Healio web site.

Basically, Tewari and his colleagues report data from 300 patients with localized prostate cancer, and with an average (median) age of 64 years, who were treated using this new “hood” technique between April 2018 and March 2019.

According to Tewari, as quoted by Healio:

Using the hood technique, we were able to preserve tissue which, after prostate removal, has the appearance of a hood comprising of the detrusor apron, arcus tendineus, puboprostatic ligament, anterior vessels and some fibers of the detrusor muscle. This hood surrounds and safeguards the membranous urethra, external sphincter and supportive structures.

The authors claim that among 299 of their 300 patients, 21 percent (63/299) were continent within 1 week and 95 percent (284/299) were continent within 48 weeks (nearly a year) after removal of their urinary catheters post-surgery. They further state that just 6 percent of these patients (18/299) had positive surgical margins.

Now we do need to be clear that these are data from a single center and this was not a randomized study. We also need to be clear that (as far as we are aware) there are no reports of data on recovery of erectile function from this study (as yet).

On the other hand, we also need to be clear that, just as the radiation oncology community has slowly and surely improved their abilities to target radiation therapy and reduce the number of cycles of therapy while improving the likelihood of good long-term outcomes after radiation treatment, the urologic surgical community has also — slowly but surely — been seeking to improve outcomes post-surgery — from Dr. Walsh’s introduction of nerve-sparing surgery in the early 1980s to the introduction of laparoscopic and then robot-assisted laparoscopic techniques in the last 1990s and early 2000s to the “Retzius-sparing” and “hood” techniques of the late 2010s.

It is hard to be able to say that we will ever reach a point at which any surgical technique will be able to pretty much “guarantee” a high-quality trifecta outcome for the majority of “good” patients with localized but clinically significant prostate cancer. However, progress is still being made as we gain more and more knowledge about the anatomical functionalities of the male urogenital system.

Between the recognition that large numbers of men with lower-risk forms of localized prostate cancer can be initially (at least) well-managed on active surveillance and without any immediate need for invasive therapy, and the gradual expansion of invasive treatment options and clear improvements in the use of surgery and radiation therapy, we are making strides toward the better and safer management of localized prostate cancer. The progress may be slower than we would like, but it is still progress.

One Response

  1. Had surgery in April, 2019, by Dr. Tewari. No urinary issues. Was back commuting to New York City at 3 weeks. Did wear a pad but never needed it (peace of mind). Back in the gym on the treadmill at 4 weeks and resumed firing at 8 weeks. Never had a problem (was 66 at the time of surgery).

    ED takes longer. But the pills and shots (thought much worse than doing it) helps.

    Luckily all margins and nodes clean. Don’t know if Dr. Tewari used the method described in the article, but I was anticipating urinary issues so not having any was a huge plus.

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