Early Continence Recovery Research Articles

The posterior approach of robot-assisted laparoscopic radical prostatectomy

Objective To explore the feasibility and safety of the posterior approach of robot-assisted laparoscopic radical prostatectomy and to the approach. Methods From November 2001 to April 2017, 32 patients underwent posterior approach of robot-assisted laparoscopic radical prostatectomy. Patients aged 53 to 81 years, with mean of 66.9 years old. Their prostate volumes were 12.0-73.7 ml with an average of 32.9 ml. All patients were diagnosed by prostate biopsy before surgery. The operation time, blood loss and length of hospital stay were recorded. Results All the operations were completed by robotic assisted laparoscopy with no transition to open surgery. The surgery time was 129-210 minutes with an average of 163.6 minutes. The estimated blood loss was 20-200 ml with an average of 59.3 ml. The hospital stay was 8-21 days with an average of 12.8 days. The postoperative hospital stay was 3-13 days with an average of 6.9 days. The time of postoperative catheter removal was 4-14 days with an average of 7.5 days. Postoperative follow-up was 1-6 months. Twenty-four (75%) patients had early recovery of continence, and all (100%) patients regained continence 3-month postoperatively. Conclusion The posterior approach of robotic assisted laparoscopic radical prostatectomy was a safe and effective surgical technique, which was beneficial in early continence recovery. Key words: Prostatic neoplasms; Robotic surgery; Radical prostatectomy; Posterior approach

Quantitative assessment of fascia preservation improves the prediction of membranous urethral length and inner levator distance on continence outcome after robot-assisted radical prostatectomy.

To determine whether preoperative prostate/pelvic anatomical structures and intraoperative fascia preservation (FP) predict continence recovery after robot-assisted radical prostatectomy (RARP). Between January 2012 and March 2016, 439 prostate cancer (PCa) patients with normal preoperative continence were retrospectively included. FP score was defined as the extent of FP from base to apex of the prostate, quantitatively assessed by the surgeon. Anatomical prostate structures were measured on endorectal preoperative Magnetic Resonance Imaging. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess urinary incontinence (UI). Cox analysis was used to determine predictive factors for early continence recovery. Finally a binary logistic regression analysis was performed to develop a risk calculator. At a median follow up of 12.1 months 50.8% of men reported UI. In the Cox multivariate analysis longer membranous urethral length (MUL; P < 0.0001; OR 1.309; CI 1.211, 1.415) and shorter inner levator distance (ILD; P < 0.0001; OR 0.904; CI 0.85, 0.961) were predictors of earlier continence recovery. In the multivariate binary logistic regression analysis longer MUL (P < 0.0001; OR 1.565, CI 1.362, 1.798), shorter ILD (P < 0.0001; OR 0.819, CI 0.742, 0.904) and higher FP score (P = 0.024; OR 1.089, CI 1.011, 1.172) were independent predictors of continence outcome. The risk calculator predicted continence recovery between 1.3% and 99%. Preoperative longer MUL and shorter ILD, but also intraoperative FP independently improve continence recovery after RARP. The risk calculator could be used to identify patients at high risk of UI.

MP46-02 RADICAL PROSTATECTOMY AND RECOVERY OF URINARY CONTINENCE IN PATIENTS WITH LOCALLY ADVANCED PROSTATE CANCER

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy1 Apr 2017MP46-02 RADICAL PROSTATECTOMY AND RECOVERY OF URINARY CONTINENCE IN PATIENTS WITH LOCALLY ADVANCED PROSTATE CANCER Jung Keun Lee, In Jae Lee, Tae Jin Kim, Hakmin Lee, Jong Jin Oh, Sangchul Lee, Jeong Hyun Kim, Sung Kyu Hong, Seok-Soo Byun, Sang Eun Lee, and Seong Jin Jeong Jung Keun LeeJung Keun Lee More articles by this author , In Jae LeeIn Jae Lee More articles by this author , Tae Jin KimTae Jin Kim More articles by this author , Hakmin LeeHakmin Lee More articles by this author , Jong Jin OhJong Jin Oh More articles by this author , Sangchul LeeSangchul Lee More articles by this author , Jeong Hyun KimJeong Hyun Kim More articles by this author , Sung Kyu HongSung Kyu Hong More articles by this author , Seok-Soo ByunSeok-Soo Byun More articles by this author , Sang Eun LeeSang Eun Lee More articles by this author , and Seong Jin JeongSeong Jin Jeong More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1441AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Few studies have been reported on the evaluation for recovery of urinary continence after radical prostatectomy in patients with locally advanced prostate cancer. We conducted a study of ≥pT3 patients to improve understanding of the natural history of continence state and to identify predictors useful in patient selection for incontinence management. METHODS We reviewed the data ofpatientswith prostate cancer managed by open retropubicor robotic radical prostatectomyfrom January 2004 to May 2015. Excluding patients requesting short-term follow-up (< 12 months), 1,859 subjects were eligible for the study. Achievement of continence was defined as no pads or an occasional security pad. A total of 547 patients were diagnosed ≥pT3 disease. Multivariate logistic regression analyses were used to determine predictors for early continence (recovery within 3 months) or for persistent incontinence (no recovery after 12 months). Furthermore, ≤ pT2 patients were matched 1:1 to ≥pT3 patients based on the propensity score. Predictors of recovery of urinary continence were compared between ≥pT3 and ≤ pT2 patients. RESULTS Of the 547 patients with ≥pT3, 63% underwent robotic surgery and 42%received bilateral nerve sparing procedure. Continence recovery at 1 month, 3 months, 6 months, 9 months, and 12 months was observed in 27%, 76%, 89%, 92%, and 95% of patients, respectively. Age (OR 0.967, p = 0.045), membranous urethra length (OR 1.120, p = 0.004), and bilateral nerve saving (OR 1.956, p = 0.006) had the significant predictive value for early continence. Additionally, open surgery (vs. robotic) was an independent risk factor for persistent incontinence (OR 3.146, p = 0.002). Of the ≤ pT2 patients, age, membranous urethra length, and bilateral nerve saving were also statistically associated with early continence recovery. However, open surgery did not show a significance to predict persistent incontinence (OR 0.656, p = 0.305) (table). CONCLUSIONS Urinary continence was achieved in most patients with ≥pT3 prostate cancer managed by radical prostatectomy. Our results highlight the advantage of robotic surgery for continence outcomes in patients with ≥pT3 prostate cancer compared with ≤ pT2. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e619 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jung Keun Lee More articles by this author In Jae Lee More articles by this author Tae Jin Kim More articles by this author Hakmin Lee More articles by this author Jong Jin Oh More articles by this author Sangchul Lee More articles by this author Jeong Hyun Kim More articles by this author Sung Kyu Hong More articles by this author Seok-Soo Byun More articles by this author Sang Eun Lee More articles by this author Seong Jin Jeong More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis.

To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP); an updated systematic review of the literature. A systematic review of the literature was performed in June 2015, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the 'Title' and 'Abstract' fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta-analysis of the risk ratios estimated using data from the selected studies was performed. In all, 21 studies were identified, including three randomised controlled trials. The overall analysis of comparative studies showed that PR improved early continence recovery at 3-7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after PR. There were no significant differences for positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. The analysis confirms the benefits at 30 days after catheter removal already discussed in the review published in 2012, but also shows a significant advantage in terms of urinary continence recovery in the first 90 days. A multicentre prospective randomised controlled trial is currently being conducted in several institutions around the world to better assess the effectiveness of PR in facilitating an earlier recovery of postoperative urinary continence.

AB010. “Total reconstruction” of the urethrovesical anastomosis contributes to early urinary continence in laparoscopic radical prostatectomy

BackgroundTo improve early recovery of continence after radical prostatectomy, we present our experience with total reconstruction in urethrovesical anastomosis after extraperitoneal laparoscopic radical prostatectomy (ELRP).MethodsELRP was performed using a standard urethrovesical anastomosis in 79 consecutive patients (group A) from June 2011 to October 2012, and using a total reconstruction procedure in 82 consecutive patients (group B) from June 2012 to June 2013. The primary outcome measure was urinary continence assessed at 1, 2, 4, 12, 24 and 52 weeks after catheter removal. Other data recorded were patient age, body mass index (BMI) (kg/m2), International Prostate Symptoms Score (IPSS), prostate volume, preoperative PSA, Digital Rectal Examination (DRE) for T stage evaluation, Gleason score, neurovascular bundle preservation, operation time, blood loss, complications and positive margin rate.ResultsIn group A the continence rates at 1, 2, 4, 12, 24 and 52 weeks were 7.59%, 20.25%, 37.97%, 58.22%, 81.01% and 89.87% respectively. In group B the continence rates were 13.41%, 32.92%, 65.85%, 81.71%, 90.24% and 95.12% respectively. Group B had significantly higher continence rates at 4 and 12 weeks after ERLP (P<0.001 and P=0.001). There were no significant differences between the groups with respect to patients age, BMI, prostate-specific antigen level, prostate volume, IPSS, estimated blood loss, number of nerve-sparing procedures and postoperative complications.ConclusionsTotal reconstruction of the urethrovesical anastomosis during ELRP improved early recovery of continence.

"Total reconstruction" of the urethrovesical anastomosis contributes to early urinary continence in laparoscopic radical prostatectomy.

ABSTRACTPurpose:To demonstrate the effect of total reconstruction technique on postoperative urinary continence after laparoscopic radical prostatectomy (LRP).Material and Methods:LRP was performed using a standard urethrovesical anastomosis in 79 consecutive patients (Group-A) from June 2011 to October 2012, and a total reconstruction procedure in 82 consecutive patients (Group-B) from June 2012 to June 2013. The primary outcome measurement was urinary continence assessed at 1, 2, 4, 12, 24 and 52 weeks after catheter removal. Other data recorded were patient age, body mass index, International Prostate Symptoms Score, prostate volume, preoperative PSA, Gleason score, neurovascular bundle preservation, operation time, estimated blood loss, complications and pathology results.Results:In Group-A, the continence rates at 1, 2, 4, 12, 24 and 52 weeks were 7.59%, 20.25%, 37.97%, 58.22%, 81.01% and 89.87% respectively. In Group-B, the continence rates were 13.41%, 32.92%, 65.85%, 81.71%, 90.24% and 95.12% respectively. Group––B had significantly higher continence rates at 4 and 12 weeks after surgery (P<0.001 and P=0.001). There were no significant differences between the groups with respect to patient's age, body mass index, prostate-specific antigen level, prostate volume, IPSS, estimated blood loss, number of nerve-sparing procedures and postoperative complications.Conclusions:Total reconstruction technique in the procedure of urethrovesical anastomosis during LRP improved early recovery of continence.

MP80-13 ROLE OF PREOPERATIVE MAGNETIC RESONANCE IMAGING IN PREDICTING THE EARLY RECOVERY OF URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VII1 Apr 2016MP80-13 ROLE OF PREOPERATIVE MAGNETIC RESONANCE IMAGING IN PREDICTING THE EARLY RECOVERY OF URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY Myungchan Park, Seung-Kwon Choi, Myong Kim, Won Hee Park, Jongwon Kim, Cheryn Song, Tai young Ahn, and Hanjong Ahn Myungchan ParkMyungchan Park More articles by this author , Seung-Kwon ChoiSeung-Kwon Choi More articles by this author , Myong KimMyong Kim More articles by this author , Won Hee ParkWon Hee Park More articles by this author , Jongwon KimJongwon Kim More articles by this author , Cheryn SongCheryn Song More articles by this author , Tai young AhnTai young Ahn More articles by this author , and Hanjong AhnHanjong Ahn More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2045AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The predictive value of membranous urethral length (MUL) and shape of the prostatic apex (PA) for early recovery of urinary continence after radical prostatectomy (RP) were evaluated by preoperative magnetic resonance imaging (MRI). METHODS Three-hundred three patients who underwent RP at our institute were prospectively analyzed. The MUL and shape of PA were measured by preoperative MRI. The urethral pressure profiles (UPP) were assessed preoperatively in all patients. The pre- and postoperative UPP were measured in a subgroup of 100 patients to assess the effect of change in UPP on early recovery of continence. Continence, defined pad-free state with no leakage of urine, was assessed at 3 months and 1 year after surgery. RESULTS Of 303 patients, 213 patients (70.3%) initially achieved urinary continence 3moths after surgery, and a total of 251 (82.8%) patients achieved urinary continence 1 year after surgery. The MUL was longer in the continent group than in the incontinent group (11.2 mm vs. 12.4 mm, p=0.001). Patients with the PA covering the membranous urethra on the anterior side (type 1 PA) showed worse urinary continence rates than those without (type 2 PA) (57.9% vs. 89.2%, p<0.001). The subgroup analysis showed that the postoperative percent change in MUCP was higher in patients with type 1 PA (24.4% vs. 14.2%, p = 0.042). Patients with a MUL >12 mm and type 2 PA, showed a markedly increased probability of continence recovery compared to patients with a MUL =12 mm and type 1 PA (odds ratio 27.430, p<0.001). In all patients, the MUL (odds ratio 1.135, p=0.016) and shape of the PA (odds ratio 5.621, p<0.001) were independent preoperative predictors of early continence recovery after RP. The inclusion of MUL and prostatic apical shape on MRI increased the predictive accuracy of the base model from 0.621 to 0.770 (p=0.012). CONCLUSIONS The MUL and shape of the PA on preoperative MRI significantly enhance the prediction of early continence recovery after RP. Maximal preservation of MUL is important during RP, especially for patients with a short MUL or a PA covering the membranous urethra on the anterior side. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1048 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Myungchan Park More articles by this author Seung-Kwon Choi More articles by this author Myong Kim More articles by this author Won Hee Park More articles by this author Jongwon Kim More articles by this author Cheryn Song More articles by this author Tai young Ahn More articles by this author Hanjong Ahn More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V4-05 A NOVEL TECHNIQUE OF DYNAMIC LATERAL SUSPENSION OF POSTERIOR RECONSTRUCTION SUTURE (DLSPRS) AFTER VESICO-URETHRAL ANASTOMOSIS DURING ROBOTIC RADICAL PROSTATECTOMY- IMPROVES EARLY CONTINENCE

You have accessJournal of UrologyRobotics – Prostate/Novel Imaging1 Apr 2016V4-05 A NOVEL TECHNIQUE OF DYNAMIC LATERAL SUSPENSION OF POSTERIOR RECONSTRUCTION SUTURE (DLSPRS) AFTER VESICO-URETHRAL ANASTOMOSIS DURING ROBOTIC RADICAL PROSTATECTOMY- IMPROVES EARLY CONTINENCE Yuvaraja Thyavihally, Abhinav Pednekar, Santosh Waigaonkar, Nikhil Gulavani, Nikhil Dharmadhikari, and Tirathram Kaushik Yuvaraja ThyavihallyYuvaraja Thyavihally More articles by this author , Abhinav PednekarAbhinav Pednekar More articles by this author , Santosh WaigaonkarSantosh Waigaonkar More articles by this author , Nikhil GulavaniNikhil Gulavani More articles by this author , Nikhil DharmadhikariNikhil Dharmadhikari More articles by this author , and Tirathram KaushikTirathram Kaushik More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1809AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Search for techniques to achieve maximum continence after robotic radical prostatectomy (RRP) is ongoing. We describe a novel technique DLSPRS after vesico-urethral anastomosis during robotic radical prostatectomy in the accompanying video and comparing early continence rates in patients who underwent DLSPRS versus those with only posterior reconstruction group (PRS). METHODS Continence rates of 25 consecutive patients who underwent DLSPRS was compared with 25 patients with PRS. In brief technique include posterior rocco repair of sphincter complex. After urethrovesical anastomosis is completed, needles of posterior suture are passed through levator ani muscle and lateral arcuate ligament pulled to elevate the entire sphincter complex. It is presumed that while contracting pelvic floor muscles the entire complex elevates still further helping continence mechanism. Early continence was assessed with self-administrated questionnaires (Expanded Prostate Cancer Index Composite) at 1, 3 and 6 months. RESULTS Patients' characteristics and perioperative outcomes were comparable. In DLSPRS group, the continence rates at 1, 3 and 6 months were 65%, 76% and 88% in PRS group it was 38%, 60% and 69% respectively. DLSPRS group had significantly higher continence at 1 and 3 months with p value of 0.04. There were no complications related to suspension of posterior suture. CONCLUSIONS Dynamic lateral suspension of the posterior reconstruction sutures may acts like bladder neck sling. Our very early experience performing this suspension technique at the time of RRP had better early continence recovery. Further prospective non randomized study is underway in our institute to give further insight. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e518 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Yuvaraja Thyavihally More articles by this author Abhinav Pednekar More articles by this author Santosh Waigaonkar More articles by this author Nikhil Gulavani More articles by this author Nikhil Dharmadhikari More articles by this author Tirathram Kaushik More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD01-03 VIDEOURODYNAMIC CHANGES AND THE PREDICTORS OF EARLY RECOVERY ON URINARY CONTINENCE AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2016PD01-03 VIDEOURODYNAMIC CHANGES AND THE PREDICTORS OF EARLY RECOVERY ON URINARY CONTINENCE AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY Hsu-Che Huang, Yuan-Hong Jiang, and Hann-Chorng Kuo Hsu-Che HuangHsu-Che Huang More articles by this author , Yuan-Hong JiangYuan-Hong Jiang More articles by this author , and Hann-Chorng KuoHann-Chorng Kuo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2023AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although laparoscopic radical prostatectomy (LRP) is effective in treatment of localized prostate cancer, patients might suffer from stress urinary incontinence (SUI) after LRP. This study investigated the changes of videourodynamic parameters after LRP and impact on urinary incontinence METHODS A total of 48 male patients underwent LRP received videourodynamic study (VUDS) at baseline, 3 months and 6 months after operation. The changes of urodynamic parameters including detrusor pressure (Pdet), voided volume, cystometric bladder capacity (CBC), maximum flow rate (Qmax), postvoid residual (PVR), maximal urethral closure pressure (MUCP) and functional profile length (FPL) were measured at 3 and 6 months after opeation. The bladder neck (BN) level to the superior margin of the symphysis pubis (SMSP) after LRP was also measured 7 to 10 days after opeartion by retrigrade cystography. The BN level at or above SMSP was defined as 0, and BN level below SMSP more than 2 cm was defined as -2, otherwise, the BN level was -1. The SUI condition was evaluated by questionare during out-patient clinic follow up. RESULTS The overall SUI rate was 66.7%,47.9%, and 16.7% at 3,6,12 months after LRP, respectively. MUCP, FPL and Pdet significantly declined from 62.6cmH2O, 48.7mm and 41.8cmH2O, which was measured at baseline, to 46.4cmH2O,16.8mm and 25.4cmH2O at 6 months, respectively. Among patients with SUI at 3 months and 6 months after operation, the MUCP level at 3 months and bladder neck level were significantly lower than patients without SUI. For patients with prolonged SUI (12 months postoperatively), the MUCP at 3 months showed significant association. (Table.1 and Table. 2) CONCLUSIONS BN level and MUCP can strongly predict the early continence recovery after LRP. The BN level not below the symphysis pubis and higher MUCP level at 3 months after operation are associated with an early recovery of SUI after LRP © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e46 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Hsu-Che Huang More articles by this author Yuan-Hong Jiang More articles by this author Hann-Chorng Kuo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP80-07 POSTERIOR RECONSTRUCTION OF THE RHABDOSPHINCTER IMPROVES EARLY RECOVERY OF URINARY CONTINENCE AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VII1 Apr 2016MP80-07 POSTERIOR RECONSTRUCTION OF THE RHABDOSPHINCTER IMPROVES EARLY RECOVERY OF URINARY CONTINENCE AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY Dmitry Pushkar, Alexander Govorov, Pavel Rasner, Konstantin Kolontarev, and Bernardo Rocco Dmitry PushkarDmitry Pushkar More articles by this author , Alexander GovorovAlexander Govorov More articles by this author , Pavel RasnerPavel Rasner More articles by this author , Konstantin KolontarevKonstantin Kolontarev More articles by this author , and Bernardo RoccoBernardo Rocco More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2039AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Meta-analyses have recently demonstrated that posterior reconstruction of the rhabdosphincter (PRR) offers an advantage in terms of early continence recovery in the first 30-45 days after radical prostatectomy. At the same time, large variability in results of PRR use was documented. The aim of our study was to prospectively evaluate the efficacy of PRR (Rocco stich) in prostate cancer patients undergoing robot-assisted radical prostatectomy (RARP) in terms of early recovery of urinary continence. METHODS From January 2012 to June 2014 398 consecutive patients with biopsy proven prostate cancer (PCa) were randomized to PRR (n=201) vs No PRR (n=197) groups. The inclusion criteria were age 40-75 years, clinically localized PCa (cT1c to cT2cN0M0), informed consent signed, RARP pre-planned, no urinary incontinence pre-surgery. Patients after TURP or neoadjuvant hormones, as well as salvage cases were not included. Barbed sutures were used for both PRR and anastomosis. Urinary continence was defined as the No pad usage (assessed by Question 5 of the Expanded Prostate Cancer Index Composite (EPIC) Urinary assessment). RESULTS The mean patients age was 61.2+-6.2 years, BMI 27.3+-2.8, total PSA 8.1 (1.8-23) ng/ml, and prostate volume 36.5 (18-135) cc. According to D Amico risk classification 32% (n=127), 27% (n=107) and 41% (n=164) of men were from low, intermediate and high-risk groups respectively. Biopsy Gleason score of 6 (3+3), 7 (3+4), 7 (4+3) and 8 was detected in 49% (n=195), 24% (n=95), 16% (n=64) and 11% (n=44) of patients. Basic patients characteristics did not differ between PRR vs no PRR group. After the exclusion of men with EBRT indicated (n=45) and non-compliant patients (n=38) 315 participants had full data collected. After 1, 2, 3, 6 and 12 months the percentage of men reporting 0 pad use in PRR vs No PRR group was 57.9% vs 39.1% (p<0.01), 69.2% vs 60.9% (p=0.01), 78.6% vs 71.8% (p=0.02), 90.6% vs 89.7% (NS) and 95% vs 94.2% (NS). There was no difference in overall complications rate, potency recovery (IIEF-5 scores at 6 and 12 months) or biochemical recurrence rates (PSA>0.2 ng/ml at 6 and 12 months) between groups. The anastomotic time was slightly longer in PRR vs no PRR group (14 vs 9 min, p<0.01). Limitations of the study are: 1) single center trial, 2) follow-up performed by physicians and not third party. CONCLUSIONS Restoration of the posterior aspect of the rhabdosphincter improves the urinary continence recovery comparing to No reconstruction of the rhabdosphincter group at 1, 2 and 3 months after RARP. After 6 to 12 months follow-up, the difference between groups became statistically insignificant, although the advantage of earlier continence recovery is of great importance for many men. Larger international prospective randomized study evaluating the same topic (with more parameters planned for assessment) is ongoing. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1045-e1046 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Dmitry Pushkar More articles by this author Alexander Govorov More articles by this author Pavel Rasner More articles by this author Konstantin Kolontarev More articles by this author Bernardo Rocco More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urinary continence and pathological outcome after bladder neck preservation during radical prostatectomy: a systematic review and meta-analysis

Objective To conduct a systematic review to evaluate efficacy and safety of bladder neck preservation techniques during radical prostatectomy. Methods We searched PubMed, Embase, Medline, Central (the Cochrane Library, Issue 1, 2013), CNKI, CBM from the inception to July 2015 for randomized or observational studies assessing the influence of preservation of bladder neck on the continence recovery and cancer control outcomes after radical prostatectomy. Two researchers evaluated the quality of included studies. A meta-analysis was conducted using Review Manager 5.0 software. Results Twelve observational and two randomized studies were analyzed. BNP group had a faster recovery of early continence than non-BNP group at 1 month[OR=2.88, 95%CI 1.80-4.60, P<0.05], 3-4 months [OR=2.32, 95%CI 1.42-3.80, P<0.05]. However there was no statistically significant difference in terms of continence rate at 6 months [OR=1.49, 95%CI 0.97-2.29, P=0.07] and 12 months[OR=0.99, 95%CI 0.70-1.39, P=0.93] among two groups. There was no significant difference in terms of PSM rate [OR=0.92, 95%CI 0.71-1.19, P=0.52] between BNP and non-BNP groups. Conclusions We found that preservation of the bladder neck result in earlier return of urinary continence without adversely affecting cancer control. Key words: Prostatectomy; Urinary incontinence; Bladder neck; Prostatic neoplasms

661 Surgical expertise represents a strong determinant of early continence recovery after robot-assisted radical prostatectomy

661 Surgical expertise represents a strong determinant of early continence recovery after robot-assisted radical prostatectomy

The value of cystography in the prediction of early urinary continence after radical prostatectomy

ObjectiveTo determine the association between vesicourethral anastomosis level (VUAL) and the condition of the bladder neck with early recovery of urinary continence on cystography after radical prostatectomy. Materials and methodsThis was a retrospective analysis of 116 patients who underwent radical prostatectomy at our hospital from 2008 to 2013. On cystography, the VUAL in the pelvic cavity was defined according to the upper margin of the pubic symphysis; above the upper margin was considered a higher VUAL and below it was considered a lower VUAL. The condition of the bladder neck was determined by whether or not there was contrast flow into the proximal urethra. Early recovery of urinary continence was defined as not requiring pads within 3 months. We determined the predictive factors for the early recovery of continence. ResultsAmong all patients, 68.1% achieved an early recovery of urinary continence. The patients with a higher VUAL were younger and had a shorter time to continence than those with a lower VUAL. The early recovery rates were 88.9% and 58.8% with a higher and lower VUAL, respectively (p < 0.001). The patients with a closed bladder neck also had better results of early continence than those with an open bladder neck (82.9% vs. 45.7%, respectively). VUAL level and bladder neck condition were independent predictors of an early recovery of urinary continence [odds ratio 5.821 (95% confidence interval: 1.632–20.75) higher vs. lower VUAL, p = 0.007; and odds ratio 5.828 (95% confidence interval: 2.259–15.036) closed vs. open bladder neck, p < 0.0001] after adjusting for age, risk of recurrence, operative method, prostate volume, and nerve sparing procedure. ConclusionPostoperative cystography can provide information on VUAL and bladder neck condition which can predict recovery of urinary continence after radical prostatectomy. A higher VUAL and bladder neck closure were associated with a higher rate of early recovery of urinary continence.

The Therapeutic Effect of Solifenacin Succinate on the Recovery From Voiding Dysfunction After Radical Prostatectomy in Men With Clinically Localized Prostate Cancer: A Prospective, Randomized, Controlled Study

To evaluate whether anticholinergic medication contributes to early recovery of continence and improvement of other voiding symptoms after radical prostatectomy (RP). A total of 78 patients with clinically localized prostate cancer who had incontinence at 1 week after RP were enrolled prospectively. The patients were allocated to one of the 2 groups: group 1 (α-adrenergic agonist [midodrine] plus an anticholinergic [solifenacin]) or group 2 (α-adrenergic agonist only). A urodynamic study and the International Continence Society male Short Form questionnaire were completed preoperatively and 4 months after RP. One-hour pad test and 3-day frequency volume chart at 1 and 4 months after medication were also analyzed. The rate of continence, defined as being pad free, did not differ between the groups at 4 months (both 71.8%; P >.05). However, the decreased value of mean weight of daily pads worn by groups 1 and 2 were 51.5 vs 11.7 g, respectively (P = .005). The incontinence (P = .008) and quality of life (P = .044) subscale scores significantly worsened in group 2, whereas they remained unchanged in group 1. Maximal detrusor pressure and maximal urethral closure pressure significantly decreased in both groups, whereas maximal cystometric capacity increased significantly in group 1 only (290.8-332.0 cm H2O; P <.001). Anticholinergics may facilitate early recovery from incontinence and prevent worsening of quality of life, which might be attributed to increased cystometric capacity after their use.

Narrowing of the dorsal vein complex technique during laparoscopic radical prostatectomy: a simple trick to simplify the control of venous plexus.

The control of the Dorsal Venous Complex (DVC) is crucial to the recovery of urinary continence during Laparoscopic Radical Prostatectomy (LRP). The size of DVC may affect the venous control. We developed a trick to simplify the suturing of the DVC. Forty-seven patients with localized prostate cancer were divided in two groups: group 1 (n = 24) underwent LRP with a conventional ligature of DVC, and in group 2 (n = 23) the venous control was done with "Narrowing" of DVC technique (N-DVC). Our technique involves maintaining pressure on a metallic urethral sound inserted into the urethra, just at the time of ligature. The width of DVC in group 2 was measured before and after applying the technique. The numbers of attempts to place the stitch adequately were recorded and compared in both groups. The demographic dates, perioperative dates and results were compared retrospectively. Operative time, estimated blood loss, prostate weight, positive surgical margins rates and potency results showed no significant differences between the groups. The immediate 1-month, and 3-month continence rates were significantly greater in group 2 (30.4% vs. 12.5%, P = .048; 73.9% vs. 50%, P = .037, respectively). For all patients in group 2, width of DVC decreased and the ligation stitch was effective at the first attempt. In 37.5% of patients in group 1, the controlling of the DVC was obtained in more than one attempt. The N-DVC simplifies the control of DVC during LRP and may contribute to the early recovery of continence.

Effects of New 1-Step Posterior Reconstruction Method on Recovery of Continence after Robot-Assisted Laparoscopic Prostatectomy: Results of a Prospective, Single-Blind, Parallel Group, Randomized, Controlled Trial

We devised a 1-step posterior reconstruction technique that opposes the median dorsal raphe only to the posterior counterpart of the detrusor apron rather than to Denonvilliers' fascia. In a retrospective study we previously found that during robot-assisted laparoscopic prostatectomy this new technique could significantly shorten continence recovery time. We designed a prospective clinical trial to confirm this. We designed a single-blind, parallel group, randomized, controlled trial. A total of 100 men who underwent robot-assisted laparoscopic prostatectomy performed by a single surgeon at a referral center were randomly allocated to the intervention group (50) or the control group (50) from October 2012 through August 2013. The intervention group underwent posterior reconstruction with this new technique before vesicourethral anastomosis. All patients in each group were treated with anterior reconstruction. The study primary end point was time to continence recovery, defined as no pad use. Secondary outcomes were time to recovery of social continence, defined as 0 or 1 pad used per day. One control was excluded from analysis due to open conversion and 4 patients were excluded since they withdrew from participation. Median time to complete continence recovery did not differ significantly between the intervention and control groups (106 and 119 days, respectively, p = 0.890). However, time to social continence recovery was significantly shorter in the intervention group than in controls (median 18 vs 30 days, p = 0.024). One-step posterior reconstruction did not significantly shorten time to complete continence recovery. However, it seemed to have a marginal benefit on early recovery of social continence.

Impact of Prostatic Apical Shape and Protrusion on Early Recovery of Continence After Robot-assisted Radical Prostatectomy

To investigate the impact of prostatic apical shape from preoperative magnetic resonance imaging on early recovery of urinary continence after robot-assisted radical prostatectomy (RARP). We reviewed the records of 1011 patients who underwent RARP at a tertiary center from October 2007 to March 2013. Patients were stratified into 4 different groups by prostatic apical shapes as shown on preoperative magnetic resonance imaging (groups A-D). The early recovery of urinary continence was defined as 0 or 1 security pad/d within 12 weeks after the surgery. The association between early recovery of continence and various factors was analyzed. Overall, 807 patients (79.8%) showed early recovery of urinary continence. The numbers of patients in groups A, B, C, and D were 88 (8.7%), 478 (47.3%), 167 (16.5%), and 278 (27.5%), respectively. There were no significant differences in the rates of early recovery of urinary continence between different groups (P = .257). On multivariate analysis, the patient's age (odds ratio [OR], 0.960; P = .004), preoperative International Index of Erectile Function-5 score (OR, 1.029; P = .009), neurovascular bundle preservation (OR, 1.586; P = .013), and membranous urethral length (OR, 1.104; P = .001) were revealed as independent prognostic factors in the early recovery of urinary continence. The results of our study showed that the prostatic apical shape does not influence the early recovery of urinary continence. We believe this is another strong point of RARP compared with conventional open surgery, particularly for patients with complex type of apical shape.

Retzius‐sparing robot‐assisted laparoscopic radical prostatectomy: combining the best of retropubic and perineal approaches

ObjectiveTo compare the early peri‐operative, oncological and continence outcomes of Retzius‐sparing robot‐assisted laparoscopic radical prostatectomy (RALP) with those of conventional RALP.Materials and MethodsData from 50 patients who underwent Retzius‐sparing RALP and who had at least 6 months of follow‐up were prospectively collected and compared with a database of patients who underwent conventional RALP. Propensity‐score matching was performed using seven preoperative variables, and postoperative variables were compared between the groups.ResultsA total of 581 patients who had undergone RALP were evaluated in the present study. Although preoperative characteristics were different before propensity‐score matching, these differences were resolved after matching. There were no significant differences in mean length of hospital stay, estimated blood loss, intra‐ and postoperative complication rates, pathological stage of disease, Gleason scores, tumour volumes and positive surgical margins between the conventional RALP and Retzius‐sparing RALP groups. Console time was shorter for Retzius‐sparing RALP. Recovery of early continence (defined as 0 pads used) at 4 weeks after RALP was significantly better in the Retzius‐sparing RALP group than in the conventional RALP group.ConclusionsThe present results suggest that Retzius‐sparing RALP, although technically more demanding, was as feasible and effective as conventional RALP, and also led to a shorter operating time and faster recovery of early continence. Retzius‐sparing RALP was also reproducible and achievable in all cases.

Are early continence recovery and oncologic outcomes influenced by use of different devices in prostatic apex dissection during laparoscopic radical prostatectomy?

Treatment of patients with prostate cancer has evolved considerably in the last decade, especially in terms of minimization of the negative impacts on erectile function and continence to ensure good quality of life for treated patients. New surgical devices, such as dissectors and hemostatic scalpels, allow precise definition of the surgical field with finer dissection of the anatomic structures, with subsequent reductions in operative times and better oncologic and functional outcomes. Although monopolar scissors (MS) are still widely used, radiofrequency (RF) and ultrasound (US) scalpels have been introduced recently in laparoscopic radical prostatectomy (LRP). Despite the widespread use of these scalpels, however, few studies have compared these devices in terms of oncologic and functional outcomes after radical prostatectomy. The present study aimed to prospectively assess the impact of MS, RF, and US scalpels on margin status at apex, and recovery of urinary continence and erectile function in patients undergoing extraperitoneal LRP. A total of 150 men were prospectively enrolled between September 2009 and April 2013 and postoperatively evaluated for continence and clinical factors. There were no differences in terms of operative times (P=0.9433), blood loss (P=0.9681), apical margin positivity (P=0.3965) or postoperative hospital stay (P=0.9257) among the groups. Moreover, no differences in the functional outcome scores, as evaluated by the International Consultation on Incontinence self-administered Questionnaire, at 1, 3, and 6 months postsurgery were observed. Our study represents the first evaluation of continence recovery in LRP with respect to different devices used for prostatic apex dissection. We found that the oncologic, functional, and operative outcomes were similar between these different devices during LRP, with no scalpel demonstrating superiority in continence recovery.

Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra during retropubic radical prostatectomy: a technical modification to improve the early recovery of continence.

We describe our technique for preservation of the smooth muscular internal (vesical) sphincter and proximal urethra during radical retropubic prostatectomy (RRP) and present our preliminary clinical results. The first steps of the prostatectomy reflect the standard RRP, while for the final phases the procedure continues in an anterograde manner with incision of the fibers of the detrusor muscle at the insertion of the ventral surface of the base of the prostate. At this level, the inner circular muscle of the bladder neck forms a sphincteric ring of smooth muscle that covers the longitudinally oriented smooth muscle component of the urethral musculature that extends distally to the verumontanum. These two proximal structures represent the internal sphincter that envelopes and locks the proximal urethra. A blunt dissection is continued until the ring shaped vesical sphincter is separated from the prostate and the longitudinally oriented smooth muscle component of the urethral musculature is identified. The base of the prostate is then gently separated from the urethra and from the bladder until the maximal length of the urethral musculature is isolated and preserved. After 30 initial set-up procedures, 40 consecutive patients with organ confined prostate cancer were submitted to radical retropubic prostatectomy with the preservation of muscular internal sphincter and the proximal urethra and compared to 40 patients submitted to standard procedure who served as control group. The group of patients submitted to our technical modification had a faster recovery of early continence than control group at 3 and 7 days. The described technique is a feasible and safe method for preservation of the internal urethral sphincter and allows improving the early recovery of urinary continence. The technique does not increase the rate of positive margins and the duration of the procedure.