Xi Nerve-sparing Robotic Radical Perineal Prostatectomy: European Single-center Technique and Outcomes

BACKGROUND: Radical prostatectomy (RP) represents the standard of care for the treatment of patients with organ-confined prostatic cancer. Historically, perineal RP has been described as the first surgical approach for the complete removal of the prostatic gland. In the past years, robotic techniques provided some technical advantages that allow resuming alternative approaches, such as robotic radical perineal prostatectomy (r-RPP). OBJECTIVE: To present in detail the technique of Xi nerve-sparing r-RPP and to report perioperative, oncological, and functional outcomes from a European tertiary center. DESIGN, SETTING, AND PARTICIPANTS: Patients with low- or intermediate-risk prostatic cancer not suitable for active surveillance and prostate volume up to 60 ml who underwent r-RPP between November 2018 and December 2020 were identified. SURGICAL PROCEDURE: All patients underwent Xi nerve-sparing r-RPP. MEASUREMENTS: Baseline characteristics and intraoperative, pathological, and postoperative data were collected and analyzed. The complications were reported according to the standardized methodology to report complications proposed by European Association of Urology guidelines. RESULTS AND LIMITATIONS: Overall, our series included 26 patients who underwent r-RPP. Patients’ median age was 62.5 yr. Thirteen (50%) and eight (30.7%) patients showed a body mass index (BMI) of 25–30 and >30, respectively. A history of past surgical procedures was present in seven (26.8%) patients. The median prostate volume was 40 (interquartile range [IQR]: 28–52) ml. The median operative time and blood lost were 246 (IQR: 230–268) min and 275 (IQR: 200–400) ml, respectively. Overall, four (15.4%) patients reported intraoperative complications and five (19.2%) reported postoperative complications, with one (3.8%) reporting major complications (Clavien-Dindo ≥3). No patient with biochemical recurrence (BCR) was reported at 1 yr of follow-up. Continence rates were 73.0%, 84.6%, and 92.3%, respectively, at 3, 6, and 12 mo after surgery. Erectile potency recovery rates were 57.1%, 66.6%, and 80.9% at 3, 6, and 12 mo of follow-up, respectively. CONCLUSIONS: Xi r-RPP is a challenging but safe minimally invasive approach for selected patients. No patient reported BCR at 12 mo. The choice of the surgical approach for RP is likely to be based on the patient’s characteristics as well as the surgeon’s preferences. PATIENT SUMMARY: Our study suggests that Xi radical perineal prostatectomy is a safe minimally invasive approach for patients with low- or intermediate-risk prostatic cancer, and complex abdominal surgical history or comorbidities.