‘Igloo’ technique for robot‐assisted radical prostatectomy – maximum nerve sparing for early recovery of continence and sexual function

Abstract

Robot-assisted radical prostatectomy (RARP) is a treatment option for men with localised prostate cancer. The challenge of RARP consists in competing oncological and functional goals. The most common side effects following RARP are urinary incontinence and erectile dysfunction, occurring in 74% and 79%, respectively, of participants in the PROTECT study, a prospective randomised trial conducted in the United Kingdom [1]. These results contrast with single-institution cohort studies from high-volume centres, which have reported urinary incontinence and erectile dysfunction in as few as 11% and 34% of participants, respectively, 3 years after RARP [2]. These differences may be attributable to patient selection, differences in outcome definitions, and/or differences in surgical technique. The hypothesis that the surgical technique influences the outcome has led to several modifications of RARP that aim to preserve and/or reconstruct the delicate periprostatic structures to improve functional outcomes. Previous surgical techniques have attempted to preserve or reconstruct several periprostatic structures, including the puboprostatic ligament complex, Denonvilliers' fascia, neurovascular bundles, bladder neck and urethra, endopelvic fascia, accessory pudendal arteries, and Santorini complex. Inspired by Dr. Richard Gaston's laparoscopic technique, we illustrate a robotic surgery technique that preserves all periprostatic structures to facilitate early return of continence and erectile function, after which the preserved periprostatic anatomical structure has the appearance of an igloo. Our primary aim in this study was to describe the surgical steps of the novel standardised ‘igloo’ technique (Video S1). The secondary aim was to present the early functional and oncological outcomes of this technique. Patients eligible for this surgical technique are men with histologically proven low- to intermediate-risk prostate cancer with a life expectancy of at least 10 years and intact continence and erectile function, who are eligible for bilateral intrafascial nerve sparing. Prior to surgery, patients are counselled about their diagnosis, prognosis, and different options for treatment, including active surveillance, external beam radiotherapy, brachytherapy and RARP. The expected benefits, risks, and likelihood of success for each option are given. Surgical complications are discussed, including urinary incontinence, erectile or sexual dysfunction, nerve injury resulting in altered skin sensation or pain, infection, injury to vessels leading to bleeding or thrombosis, cancer recurrence, inguinal hernia, infertility, seroma, lymphoedema, venous thromboembolic and arterial events, and general complications of anaesthesia. Patients are informed that any complication or disease recurrence may require further treatment. Written informed consent and video publication consent were obtained from all patients. A four-arm da Vinci Si Surgical System (Intuitive Surgical-ISRG, Sunnyvale, CA, USA) was used for all cases. All procedures were performed by a single experienced surgeon (A.M.) at least 6 weeks after prostate biopsy. During the procedure, the patient is placed supine, and a rectal catheter is introduced after general anaesthesia. After placement of a supraumbilical 12-mm optic trocar (Covidien, Dublin, Ireland), the abdominal cavity is inspected with a zero-degree 10-mm robotic laparoscope to exclude adhesions, and three 8-mm robotic trocars (da Vinci System; Intuitive Surgical-ISRG) are placed under vision, followed by another 12-mm and a 5-mm assistant port (Covidien). The 5-mm and 12-mm ports are positioned cranially two fingers' breadth from the right robotic port to allow triangulation. Next, the patient is positioned in a steep Trendelenburg position at approximately 25° incline, and the robotic system is docked as previously described [3-5]. No drains are used [7]. The supraumbilical incision is widened to remove the prostate, and the