Dottorato in TECNOLOGIE AVANZATE IN CHIRURGIA

Titolo della tesi: NEAR-INFRARED FLUORESCENCE IMAGING-GUIDED ROBOT-ASSISTED MADIGAN SIMPLE-PROSTATECTOMY: SURGICAL TECHNIQUE, PERIOPERATIVE AND MID-TERM FUNCTIONAL OUTCOMES

Introduction: Despite an increasing adoption of novel minimally-invasive technologies and anatomical techniques, the main pitfall of BPH surgery in sexually active men remains ejaculatory dysfunction (EjD), which permanently affects quality of life. The aim of this study was to detail a novel technique for marking the intraprostatic urethra through a retrograde injection of indocyanine green to enhance selective dissection of prostatic lobes during urethra-sparing robot-assisted simple prostatectomy (US-RASP) with the use of near- infrared fluorescence imaging (NIFI) and to evaluate different surgical techniques of RASP (Freyer, Millin and US) performed at a single-centre according to BPH6 achievement at a mid-term follow-up. Material and Methods: Between January 2011 and December 2020 out of a total of 105 patients who underwent RASP at a single institution, 73 (69.5%) with available data for BPH6 assessment (namely symptom relief, quality of recovery, erectile function preservation, ejaculatory function preservation, continence preservation and safety, follow-up≥12 months) were eligible for inclusion, including 37 Millin (group A) 18 Freyer (group B) and 18 US (group C), respectively. Descriptive analyses were used. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQRs) were reported for continuously coded variables. Differences between continuous variables were assessed with the one-way ANOVA test, while Pearson’s χ2 test was used for categorical data. Cox regression analyses were used to identify predictors of BPH6 achievement. For all analyses, a two-sided p<0.05 was considered significant. Results: In group C patients showed significant younger age at surgery (p=0.052) and increased mean operative time (p=0.02), while the length of hospital stay and % of preoperative indwelling catheter were significantly increased in the A and B groups (each p<0.05). All other baseline and perioperative data were comparable between groups (each p>0.5). At a median follow-up of 35 months (IQR 14-57.9) in group B and C patients showed a significantly increased preservation of erectile function (p=0.04) while the ejaculatory function was significantly spared only in the C group (p<0.001) (Table 2). Overall BPH6 achievement was 21.9%. On multivariable analysis prostate weight of 80-120 mL (HR 0.25; 95% CI 0.07-084; p=0.02) and Madigan technique (HR 20.6; 95% CI 2.21-191.5; p=0.008) were both independent predictors of BPH6 composite endpoint. Conclusions: We described a novel NIFI-guided technique to perform US-RASP. This technique showed promising mid-term functional results, suggesting a significant role of intraprostatic urethral integrity for the preservation of ejaculatory function. By comparing different RASP techniques with a standardized metric system urologist and patients can better understand the net benefit when selecting a urethral-sparing option over other techniques. A prostate weight of 80 is an independent prognostic factor of BPH6 achievement after RASP.