Abstract
PurposeOur primary aim was to present a combined technique to protect the anatomic integrity of distal urethral sphincter complex (DUSC) during minimally invasive radical prostatectomy (RP) and discuss its impact on urinary continence (UC) recovery. The second aim was to define the learning curve of the combined technique.MethodsWe conducted a non-randomized retrospective study. There were 314 consecutive patients who received RP by the same urologist surgeon with more than 2,000 prior cases in Shanghai Ruijin Hospital between March 2017 and April 2020. Included in this study were 263 patients with clinical T1–T2 stage. We modified a combined RP (Comb-RP) technique including endopelvic fascia no-incising technique, dorsal venous complex (DVC) no-ligation technique, intrafascial dissection technique, and anterior reconstruction technique so as to preserve the anatomic integrity of DUSC. The patients were assigned to two groups: a Comb-RP group and a conventional RP (Conv-RP) group. Continence rates were assessed every 3 months after removal of the catheter. UC was defined as 0 pad per day. Peri-operative variables of the patient including operation time, estimated blood lost (EBL), positive surgical margin (PSM), and postoperative complications were also collected. Scatter-graphs of learning curves were drawn using locally weighted scatterplot smoothing (LOWESS).ResultsRP was accomplished smoothly in all 263 cases. The pad-free UC rates in Conv-RP group and Comb-RP group were 17.3 vs. 27.8% (P = 0.048) at the removal of the catheter, 35.8 vs. 50.0% (P = 0.027) at 1 month, 60.5 vs. 76.1% (P = 0.012) at 3 months, 87.7 vs. 96.5% (P = 0.022) at 6 months, and 94.7 vs. 97.7% (P = 0.343) at 12 months. Kaplan–Meier analysis showed significantly higher and faster continence recovery in the Comb-RP group (mean 4.9 vs. 2.6 months, Log Rank P = 0.001). There was no significant difference in PSM rate between the Comb-RP and Conv-RP group (31.1 vs. 31.2%, P =0.986). The learning curves of peri-operative variables, oncological and functional outcomes achieved the lowest point or plateau at the 20th–60th cases.ConclusionsThe anatomic integrity and intact pelvic floor interplay of DUSC is important for its function. Our combined technique was a safe and feasible technique for improving early UC in RP with no significantly increased PSM rate and no significant difference in long-term UC.
Highlights
Radical prostatectomy (RP) is one of the most important methods for the treatment of localized prostate cancer (PCa)
There were no significant differences in age, BMI, American Society of Anesthesiologists (ASA) classification, PSA level, lower urinary tract symptom (LUTS), and prostate volume between the two groups (Table 1)
There were no significant differences in estimated blood loss (EBL), International Society of Urological Pathology (ISUP) group, positive surgical margin (PSM), and postoperative complication between the two groups
Summary
Radical prostatectomy (RP) is one of the most important methods for the treatment of localized prostate cancer (PCa). On the premise of ensuring the effect of tumor control, protection of urinary continence (UC) has long been the crux in RP. Various techniques for early UC recovery have emerged in recent years. The early UC recovery rate of the above techniques is reportedly 23–84% [1,2,3,4,5,6,7,8]. Among different UC theories, the urethral sphincter has been widely accepted as a significant factor for improving early continence. In addition to the functional-length, the anatomic fixation and integrity of the urethral sphincter are essential to preserving UC after RP [4]
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