The Evolution of Retzius-Sparing Robot-Assisted Laparoscopic Prostatectomy: An Idea, Development, Evolution, Assessment, and Long-Term Study Perspective

Purpose: The Retzius-sparing (RS) approach represents an important surgical innovation in how robot-assisted laparoscopic prostatectomy (RALP) is performed. The aim of this study was to examine to what extent its development has followed the idea, development, evolution, assessment, and long-term study (IDEAL) recommendations. Materials and Methods: We conducted a comprehensive literature search for studies up to the 18th of March 2021. Abstracted data points included authorship, year of publication, study design, reported endpoints, and length of follow-up. We mapped each study to the five IDEAL stages of surgical innovation using published criteria. Results: Of 415 references, 118 were included in our analysis. Five academic centers authored >50% of all study reports, with the groups from Seoul (24; 20.3%), Milan (15; 12.7%), and Ninjang (10; 8.5%) being the main contributors. Approximately 40% of studies (50/118) were reported as full-text publications. Most of the reports mapped to retrospective studies (97/118; 82.2%) with approximately one-third (31/97; 32.0%) reporting the use of prospectively collected data. Cumulatively, 17,974 were reported on RS-RALP. Of those, 13,929 were unique cases. Approximately 23% of cases were reported in multiple publications (4045/17,974). We mapped 2, 12, and 3 studies to the idea, assessment, and long-term study stages, respectively, and no study to the development and evaluation stages. Conclusions: Few reported studies followed the IDEAL stages for surgical innovation; none addressed the stages of development and evaluation. Future systematic prospectively planned assessments would be helpful to refine the approach and address issues related to the surgical learning curve.