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

Apical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery.

To describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs).

A total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center.

rates of apical PSMs; secondary outcome: urinary continence.

The urethral sphincter complex is incised 2-3mm 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.

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.

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).

The collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter.

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.