A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The "Collar" Technique

Background: Apical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery. Objective: To describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs). Design, setting, and participants: A total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center. Primary outcome: rates of apical PSMs; secondary outcome: urinary continence. Intervention: The urethral sphincter complex is incised 2-3 mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter. Outcome measurements and statistical analysis: Mann-Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs. Results and limitations: Fourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p = 0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p = 0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n = 43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p <= 0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p = 0.009). Conclusions: The collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter. Patient summary: We describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery. (c) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.