Urinary continence and erectile dysfunction results in robot-assisted radical prostatectomy with endopelvic fascia preservation Resultados de continencia urinaria y disfunción eréctil en la prostatectomía radical robótica con preservación de la fascia endopélvica

Introduction: Radical prostatectomy is the treatment of choice for patients with organ-confined prostate cancer due to its oncological benefits and survival. With the advancement of technology, surgical techniques have been modified, and robot-assisted radical prostatectomy (RARP) is currently the procedure with the most advanced technology. Due to its multiple advantages, such as short-term functional and surgical results, shorter hospital stay and minimal invasiveness, it constitutes a valid therapeutic option to consider for this group of cancer patients. Objective: To compare the results obtained in urinary continence and erectile dysfunction after RARP with a standard da Vinci® system with 4 arms, between a group of 43 patients who underwent said procedure, without preservation of the endopelvic fascia in 2018, and 68 patients who underwent the same procedure with endopelvic fascia preservation, between January 2019 and February 2021, all at the Hospital Carlos Andrade Marín, in Quito. Methodology: A retrospective longitudinal descriptive observational study was made, with the comparison of 68 prostate cancer patients who underwent radical surgery with endopelvic fascia preservation at the Hospital Carlos Andrade Marín, between January 2019 and February 2021, and 43 patients who had the same surgery but without endopelvic preservation, in the year 2019. Results: One hundred eleven surgeries for prostate cancer with the robot-assisted radical prostatectomy technique were performed. Forty-three (37.8%) surgeries were made without endopelvic fascia preservation, and 68 (61.3%) were made with endopelvic fascia preservation. At the first month of follow-up, 25 (58%) patients of the RARP without endopelvic fascia preservation group, presented with severe erectile dysfunction, 11 (26%) with moderate erectile dysfunction, 6 (14%) with moderate to mild erectile dysfunction, and 1 (2%) with mild erectile dysfunction. At 6 months follow-up, of the 25 patients with severe dysfunction, 2 presented with moderate dysfunction and 23 remained with severe dysfunction. Of the patients who underwent RARP with endopelvic fascia preservation, 54 (80%) presented with mild incontinence, and 3 (4%) were completely continent making use of this technique. Furthermore, at 9 months follow-up, 90% of the patients had complete continence and 10% mild incontinence. Fifty six percent of the RARP patients with endopelvic fascia preservation presented severe sexual dysfunction at the first postoperative month. However, after pharmacological treatments, only 19% remained with erectile dysfunction. Conclusion: RARP is a safe and minimally invasive technique, it improves surgical and functional results, in the short and long terms, with respect to continence and sexual function. Endopelvic fascia preservation could improve results in the long term for continence and erectile dysfunction.


Introduction
Cancer is a global health problem and its incidence and mortality rates vary between countries. Prostate neoplasia can stay asymptomatic for several years, and its natural history is not completely clear. Its most frequent symptoms are not exclusive to it, and when they are apparent, the disease may have spread out from the prostate. (1) About 1 in 9 men will be diagnosed with prostate cancer during their lifetime, and it is more frequent in older men and in black men. Approximately, 6 out of 10 cases are diagnosed in men of 65 years of age or more, and it appears before 40 years of age on few occasions. The average age of onset is 66. (2) Cancer is the second cause of death worldwide. In 2015, there were 17.5 million cases of cancer. Prostate cancer was the most common type in men (1.6 million cases). (3) The incidence of prostate cancer in Ecuador is in a medium-high range, with 18.3% in 2017. ( The indications for laparoscopic radical prostatectomy are localized prostate adenocarcinoma (T1-T2), without metastasis, and locally advanced (T3) without metastasis, both in patients with life expectancy of more than 10 years. Patients need to be informed that it may be necessary to complement the treatment with radiotherapy. (8) In order to perform laparoscopic radical prostatectomy, it is convenient that the patient hasn't undergone any previous abdominal surgery, hence the indication of this technique for patients between 70 and 75 years of age. (9) RARP is a better technique when comparing functional, oncologic and perioperative results with conventional therapy in localized prostate cancer. (10) Robotic surgery is a (minimally invasive) laparoscopic procedure, in which the surgeon operates a set of four robotic arms (three of which hold surgical instruments and the fourth holds a 3D camera).
This robotic system is known as da Vinci, and from the surgeons' perspective, it has advantages over other techniques, such as image enlargement, articulated instrumentation, better ergonomics, filtering of tremors, wider range of movements, and a shorter learning curve, compared to laparoscopy. (11) This leads to an improved surgeon precision when extracting the prostate, and to a decrease of the likelihood of leaving positive (oncologic) margins, as well as to a reduction of surgical times, and functional and perioperative complications. (12) Regarding sexual dysfunction, a randomized controlled trial (RCT) (13) showed that there was an improvement in the recovery rate of erectile function (63% vs 13%, p < 0.01), 3 months after surgery with RARP, in comparison with laparoscopic surgery. Another RCT, (14) did not find significant differences (40% vs 60%, p=0.09). At 6 months postoperative, according to the same study, (14) RARP was better than laparoscopic surgery to improve the erectile function recovery rate (75% vs 22%, p<0.01), but another RCT did not find evidence for said differences (48.5% vs 65.7%, p=0.14, for laparoscopy and RARP, respectively). (15) At 3 months postoperative, an RCT couldn't find evidence for urinary continence recovery significant differences, (16) when comparing RARP to laparoscopy (69% vs 63%, respectively, p=0.51), on the other hand, another RCT did show significant differences in favor of RARP (80% vs 61.6%, p=0.044). (17) An RCT, (18) showed that at 6 months, RARP was not different than laparoscopic surgery to recover urinary continence (75% vs 88%, p=0.06). The meta-analysis of these two RCTs found an advantage for RARP (RR: 1.14; CI 95%: 1.04-1.24). (19) As the understanding of the anatomy of the male pelvis has advanced, the technique for the preservation of the endopelvic fascia has been developed, with excellent results. Several case series have shown free surgical margins (13%), 50% of the patients with preserved sexual function at 1 month postoperative, and 86% after 1 year. Also, 85.9% had immediate continence, and 98.4 after 1 year. (20) Another study showed that the preservation of the endopelvic fascia improved continence and erectile function results at 12 months in a 95.6% and 75%, respectively. (20) For all these reasons, a retrospective longitudinal descriptive observational study was made, to evaluate functional results in 111 patients who underwent RARP, comparing the procedure with preservation of endopelvic fascia, and without it.

Objective
To evaluate and compare results for sexual dysfunction and urinary continence after RARP with

Materials and methods
A descriptive retrospective study was designed for 111 patients with prostate cancer, who underwent radical surgery at the same hospital, the Carlos Andrade Marín, in the city of Quito, in the period between 2019 and 2021. The data was obtained from the clinical records of the information system AS 400, and from continence and sexual dysfunction questionnaires, pre-and post-surgery, from each patient.

Results
One hundred eleven surgeries for localized prostate cancer were performed, using the RARP technique. In 43 patients (38.7%) the procedure was made without endopelvic fascia preservation, while in 68 (61.3%), it was made with said fascia preservation.
Fifty eight percent of the patients who underwent the RARP, were between 61 and 70 years of age, and only 3% under 50 years of age. Figure 1.   The results for urinary continence in patients who underwent RARP with endopelvic fascia preservation showed that the percentage was higher in patients with mild incontinence (80%), while 4% (3 patients) had complete continence after using said technique, as shown in Table 3. At 9 months postoperative, 90% of the patients had total continence, and 10% had mild incontinence, which however, did not affect their lifestyle. Tabla 3

Conclusions
It was shown that, for urinary continence, at 1 month follow-up, there was mild incontinence in 79% of the patients in the RARP without endopelvic fascia preservation group, and in 80% of the patients in the RARP with endopelvic fascia preservation. At the end of the 9 months follow-up, 98% of the patients in the group without fascia preservation had total continence, while for the group with fascia preservation it was 90%.