Salvage Retzius-Sparing Radical Prostatectomy: A Review of Complications, Functional Outcomes, and Oncologic Outcomes

Round 1

Reviewer 1 Report

In this interesting review the authors offer an overview about the few published studies which demonstrated that the Retzius-sparing approach in the robotic-assisted radical prostatectomy in patients with prostate cancer is a safe treament  which can improve continence outcomes. 

The review is well written and is suitable for publication after few minor changes.

Explain the acronym EBL in Table 2.

To strengthen the main hypothesis of the paper that the anterior approach may reduce the rate of urinanry incontinence, you may add to the discussion the theory that the periprostatic neurovascular bundle involved in the mechanism of urinary continence run also on the anterior surface of the bladder and of the prostate (not only on the posterior side), as demonstrated by pathological and imaging recent published study. Please, add the reference "Di Paola V et al, Depiction of periprostatic nerve fibers by means of 1.5 T diffusion tensor imaging. Abdom Radiol (NY). 2021 doi: 10.1007/s00261-020-02682-5." to the discussion.  

 

Author Response

Thank you for your comments. We have clarified the acronym EBL (estimated blood loss) in the Abbreviations section as well as in the table caption. We have additionally reviewed the suggested citation and have incorporated it into our discussion section. It is a valuable addition to our study and we appreciate your thoughts.

Reviewer 2 Report

This is a review of the comparison of the Retius-sparing and standard methods of salvage prostatectomy.

The all Tables are difficult to read, so please try to summarize them by report.

There seem to be many items related to postoperative evaluation. Are there any comments regarding intraoperative difficulty? For example, in the case of brachytherapy, the risk of leaving the seeds on the anterior side during RSRARP.

Author Response

Thank you for your comments. We have edited the tables to be more easily read, and have added a summary caption beneath. There was unfortunately very little commentary from the source material on intraoperative difficulty though multiple sources mention radiation effects including tissue fibrosis and obliteration of surgical planes. We have added comments into our discussion section to address this point.

Reviewer 3 Report

  The subject of the work is of interest; however, some issues have to be raised:

 

1) Please provide the keywords based on MeSH terms. (http://www.nlm.nih.gov/mesh/MBrowser.html)

 

2)      The INTRODUCTION section does not cover sufficient literature review.

3)      Is it likely that all relevant studies (published and unpublished) were identified?

4)      Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

 

5)      Were the criteria used to select articles for inclusion predetermined, clearly stated, and appropriate?

6)      Were the included studies sufficiently valid?

7)      Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis.

 

 

Author Response

Hello, thank you for your comments. Below are our numbered responses 

1. We have updated the keywords to reflect the corresponding MeSH terms. 
2. The introduction has been updated with a larger scope of literature review, including recent studies on robotic salvage prostatectomy and meta-analyses on salvage prostatectomy (Valle, Kenney, Yuh, Chauhan, Kaffenberger, Sanderson, Heidenreich, Nguyen)  and we look forward to any additional comments. 
3. After extensive literature search it is likely that all published and abstract-only studies were identified and we have included only those with data for review. There was one study that was a video abstract only (doi: 10.1590/S1677-5538.IBJU.2021.0260), as well as one study which met the search criteria however did not include any data on salvage RS-RARP (doi: 10.1186/s12894-019-0550-9). There was an unpublished work reviewed however was excluded due to lack of reportable data (doi: 10.1590/S1677-5538.IBJU.2021.0260). The unpublished study in question was an expert opinion piece.
4. We have clarified and added in our PICOS question as stated here: We hypothesize that patients who undergo salvage Retzius-sparing robotic-assisted radical prostatectomy will have similar complication rates and oncologic outcomes with improved functional outcomes when compared to standard salvage RARP. 
5. We aimed to review studies comparing RS-RARP to S-RARP in the salvage setting. Given the rarity of sRS-RARP, we were only able to identify six sources covering the subject; however, we have now specified our inclusion/exclusion criteria in the Methods section. 
6. These studies are internally valid based on their prior review and publication, however the external validity of these studies may be questioned as the SRS performed are done at high-volume centers with experienced surgeons. Thus, these results may not be applicable to urologists who rarely perform this surgery. The discussion and conclusion have been updated to reflect this.
7. Given the low number and heterogeneity of studies involved, we were unable to perform meta-analysis. The P-values listed are per each individual study.

Round 2

Reviewer 2 Report

There are several sentences with similar content in the introduction. Please correct them appropriately.