Igloo-technique for robotic radical prostatectomy—maximum nerve sparing for very early recovery of continence and sexual function

Abstract Background : We describe a surgical technique to facilitate very early return of continence and erectile function after robotic-assisted radical prostatectomy (RARP) for prostate cancer. Objective : To describe the “igloo technique” for RARP. Design, setting, and participants : Prospective study of the first 13 patients to be treated with the igloo technique at a major urban hospital. Only patients without suspected invasion of the neurovascular bundle were included. Surgical procedure : RARP was performed using “igloo technique” to preserve all periprostatic structures, including the puboprostatic ligament complex, neurovascular bundles, Santorini complex, endopelvic and periprostatic fascia, and accessory pudendal arteries. Outcome measurements and statistical analysis : Descriptive analysis of the perioperative, pathological, and short-term oncological outcomes. Results and limitations : The median operative time was 200 minutes [inter-quartile range (IQR): 188–210]. The transurethral catheter was removed after a median of 3 days post-RARP. In the first 24 hours after catheter removal, the median urine loss was 4g/24h[IQR: 2–10g/24h]. Ten days after surgery, 3 patients had urine loss of 10g/24h, and 10 patients had urine loss of 0g/24h. At 6 weeks after surgery, only 1 patient had urine loss of 10g/24h, and the remaining 12 patients all reported urine loss of 0g/24h. The median IIEF-15 decrease after surgery was 19[IQR: 5–36]. Positive surgical margins were reported for 4 participants(31%), and biochemical recurrence was observed in 1 subject who did not have a positive surgical margin. Conclusions: The igloo technique is a technically demanding technique for RARP that spares most periprostatic structures with very early return of continence and erectile function after surgery. Despite case selection, a considerable proportion of participants showed a positive surgical margin. Patient summary: Through improved preservation of the anatomical structures around the prostate, we achieved very early return of urinary continence and erectile function after surgical removal of the prostate.