Rassweiler Jens, Sander Sara
Lehrstuhl für Urologie und Andrologie, Danube Private University, Krems Steiner Landstraße 124, 3500, Krems-Stein, Österreich.
Senior Consultant, Urologische Klinik, Klinikverbund Südwest, Sindelfingen, Deutschland.
Urologie. 2025 Jun 16. doi: 10.1007/s00120-025-02627-0.
Since robot-assisted laparoscopic prostatectomy (RALP) has become widely accepted in German-speaking countries, there needs to be an agreement on the most efficient surgical techniques. This should be based on the video-anatomy of the prostate and a summary of the actual literature.
Based on video material of different surgical techniques, a systematic literature search in PubMed has been performed focusing on preservation of continence and minimal rates of positive margins. This is based on the anatomy of the male pelvis applying a standard nomenclature. The original 3825 publications could be reduced to 604 articles according to the inclusion criteria (randomized controlled trials, meta-analyses, systematic reviews, and clinical studies). When expanding the search to encompass individual operation techniques, we identified 27 relevant articles.
Crucial surgical details include preserving the levator fascia, the puboprostatic collar, a long urethral stump with protection of the urethral lissosphincter and posteriorly reconstruction of the rectourethralis with the prostatovesical muscle. Fascial preservation for the levator ani muscle results in 1‑year continence between 78.0 and 98.3%, preservation of the puboprostatic collar and detrusor apron between 95.6 and 100%, maximal functional urethral length between 90.5 and 97.5%. Posterior reconstruction leads to a 3-month continence between 92.3 and 96.9%. Preserving the Retzius' space and thus the total anterior sphincter apparatus results in 1‑year continence of 95.8%; however, it is associated with a higher rate of positive surgical margins (14-42 vs. 10-29%).
Based on the increase of knowledge and the feasibility to translate this into novel surgical techniques, the continence rates could be significantly improved. This includes approaches to spare anatomical structures of the sphincter apparatus, such as preservation of the levator fascia, the puboprostatic collar, the urethral lissosphincter, but also reconstructive techniques, such as posterior reconstruction of the vesicoprostatic and rectourethralis muscle. Demanding techniques, such as the Retzius-sparing approach result in higher continence rates, but are also associated with a higher rate of surgical margins.
由于机器人辅助腹腔镜前列腺切除术（RALP）在德语国家已被广泛接受，因此需要就最有效的手术技术达成共识。这应该基于前列腺的视频解剖学以及当前文献的总结。
基于不同手术技术的视频资料，在PubMed上进行了系统的文献检索，重点关注控尿的维持和切缘阳性率最低。这是基于男性骨盆的解剖结构并应用标准命名法。根据纳入标准（随机对照试验、荟萃分析、系统评价和临床研究），最初的3825篇出版物可缩减至604篇文章。当扩大检索范围以涵盖个体手术技术时，我们确定了27篇相关文章。
关键的手术细节包括保留提肌筋膜、耻骨前列腺环、带有尿道平滑括约肌保护的长尿道残端以及用前列腺膀胱肌对直肠尿道肌进行后方重建。保留肛提肌的筋膜可使1年控尿率在78.0%至98.3%之间，保留耻骨前列腺环和逼尿肌围裙的控尿率在95.6%至100%之间，最大功能性尿道长度在90.5%至97.5%之间。后方重建可使3个月控尿率在92.3%至96.9%之间。保留Retzius间隙从而保留整个前部括约肌装置可使1年控尿率达到95.8%；然而，其手术切缘阳性率较高（14 - 42%对1日 - 29%）。
基于知识的增加以及将其转化为新型手术技术的可行性，控尿率可得到显著提高。这包括保留括约肌装置解剖结构的方法，如保留提肌筋膜、耻骨前列腺环、尿道平滑括约肌，也包括重建技术，如前列腺膀胱肌和直肠尿道肌的后方重建。要求较高的技术，如保留Retzius间隙的方法，可使控尿率更高，但也与更高的手术切缘阳性率相关。
