Factors Influencing Outcomes After Robotic-Assisted Laparoscopic Radical Prostatectomy: The Search for the Trifecta

The three long-term goals of Radical Prostatectomy (RP) are complete removal of the cancer, recovery of urinary continence and recovery of sexual potency. However, these individual outcomes are not necessarily independent of each other, i.e., improvement in one outcome may come at the expense of the other two outcomes. Therefore, assessing individual results after RP may not truly inform the patient regarding what to expect in terms of overall cancer control and quality of life after surgery. This has led to the concept of reporting the likelihood of achieving the three outcomes concurrently after RP: the so called “trifecta”.Throughout our learning experience, we developed several technical modifications during Robotic-Assisted Radical Prostatectomy (RARP) which presently allow us to perform the procedure with improved functional outcomes while not compromising cancer control; as a result, excellent “trifecta” rates are currently reported in our series. These technical refinements, which will be fully described in this presentation, include the periurethral suspension stitch, athermal seminal vesicle dissection, early retrograde release of the neurovascular bundle, incremental/partial nerve-sparing, athermal apical dissection, transverse bladder neck plication/reconstruction and, finally, modified posterior reconstruction of the rhabdosphincter.Although each specific outcome of RP has been extensively described, few series analyzing the trifecta rates have been previously reported. We have recently reported our early trifecta outcomes after RARP. We evaluated prospectively 404 consecutive patients who were considered potent preoperatively and underwent bilateral full nerve-sparing. Baseline and postoperative urinary and sexual functions were assessed using self-administered validated questionnaires. Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times (with or without the use of oral PDE-5 inhibitors) and biochemical recurrence (BCR) was defined as two consecutive values of PSA > 0.2 ng/mL after RARP. Results were compared between three age groups (Group 1 ≤ 55 years, Group 2—56 to 65 years and Group 3 > 65 years). The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively, showing that RARP offers excellent short-term trifecta outcomes when performed by an experienced surgeon. No statistically significant difference was found in the continence and BCR-free rates between the three age groups at all postoperative intervals analyzed. Nevertheless, younger patients demonstrated shorter time to achieving the trifecta (group 1, median time 6 weeks vs. group 2, 12 weeks vs. group 3, 24 weeks, log-rank, P<0.001) and higher trifecta rates at 6 weeks (57.7% vs. 41.3% vs. 22.7%;P<0.01), 3 months (72.6% vs. 64.4% vs. 52.7%;P=0.041) and 6 months (85.5% vs. 75.2% vs. 66.6%; P=0.036) after RARP compared to elderly patients. These findings can be attributed to the earlier return of sexual function (group 1, median time 6 weeks vs. group 2, 6 weeks vs. group 3, 24 weeks, log-rank, P<0.01) and higher overall potency rates also reported by younger men at the same intervals after RARP in our series.