Posterior Musculofascial Reconstruction Research Articles

"Single Knot-Single Running Suture" Vesicourethral Anastomosis with Posterior Musculofascial Reconstruction during Robot-Assisted Radical Prostatectomy: A Step-by-Step Guide of Surgical Technique.

Background: Our aim is to describe Gallucci's (VV-G) technique for vesicourethral anastomosis and posterior musculofascial reconstruction (PMFR) during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative outcomes. VV-G consists of a "single knot-single running suture" vesicourethral anastomosis with PMFR. Methods: Between September 2019 and October 2021, we prospectively compared VV-G vs. conventional Van Velthoven anastomosis (VV-STD) during RARP. We excluded patients with urinary incontinence, pelvic radiotherapy, and urethral and BPH surgery prior to RARP. Social continence (SC) recovery, perioperative complications, and length of hospital stay (LOS) were compared between VV-G vs. VV-STD. SC was defined as 0-1 pad/die. We applied 1:1 propensity score matching (PSM) adjusting for different covariates (age, Charlson Comorbidity Index, BMI, prostate volume, nerve-sparing and lymph node dissection). Results: From 166 patients, 1:1 PSM resulted in two equally sized groups of 40 patients each with no residual differences (all p ≥ 0.2). VV-G yielded higher 3-month SC rates than VV-STD (97.5 vs. 55.0%, p < 0.001). A tiny difference was still recorded at one-year follow-up (97.5 vs. 80.0%, p = 0.029, HR: 2.90, 95% CI: 1.74-4.85, p < 0.001). Conversely, we observed no differences in any perioperative complications (15.0 vs. 22.5%, OR: 0.61, 95% CI 0.19-1.88, p = 0.4) and LOS (3 vs. 4 days, Δ: -0.69 ± 0.61, p = 0.1). Conclusions: VV-G significantly improved early SC recovery without increasing perioperative morbidity. In our opinion, VV-G represents an easy-to-learn and easy-to-teach technique due to its single-suture, single-knot, and symmetrical design.

Posterior musculofascial reconstruction in robot-assisted laparoscopic prostatectomy for the treatment of clinically localised prostate cancer: a Cochrane Review.

To assess the effects of posterior musculofascial reconstruction robot-assisted laparoscopic prostatectomy (PR-RALP) compared to no PR during standard RALP (S-RALP) for the treatment of clinically localised prostate cancer. We performed a systematic search with no restrictions including randomised controlled trials (RCTs) comparing variations of PR-RALP vs S-RALP for clinically localised prostate cancer. The quality of evidence was assessed on outcome basis according to Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Our search identified 13 records of eight unique RCTs, of which six were published studies, and two were abstract proceedings. There were 1085 randomised patients, of whom 963 completed the trials. All patients had either cT1c or cT2 or cT3a disease. A PR-RALP may improve urinary continence 1 week after catheter removal compared to no PR (risk ratio [RR] 1.25, 95% confidence interval [CI] 0.90-1.73; I2 = 42%, five studies, 498 patients, low certainty of evidence [CoE]). A PR-RALP may have little to no effect on urinary continence 3 months after surgery compared to no PR (RR 0.98, 95% CI 0.84-1.14; I2 = 67%, six studies, 842 patients, low CoE). A PR-RALP probably results in little to no difference in serious adverse events compared to no PR (RR 0.75, 95% CI 0.29-1.92; I2 = 0%, six studies, 835 patients, moderate CoE). This review found evidence that PR-RALP may improve early continence 1 week after catheter removal but not thereafter. Meanwhile, adverse event rates are probably not impacted and positive surgical margin rates are likely similar. There was no difference in our subgroup analysis for all outcomes with anterior reconstruction technique when combined with PR vs only PR.

For men with clinically localized prostate cancer, how do posterior musculofascial reconstruction and standard robotic-assisted laparoscopic prostatectomy (RALP) compare?

For men with clinically localized prostate cancer, how do posterior musculofascial reconstruction and standard robotic-assisted laparoscopic prostatectomy (RALP) compare?

MP15-11 URETHRAL FIXATION: A NOVEL TECHNIQUE TO IMPROVE EARLY URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP15)1 Sep 2021MP15-11 URETHRAL FIXATION: A NOVEL TECHNIQUE TO IMPROVE EARLY URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY Vincenzo Ficarra, Marta Rossanese, Alessandro Crestani, Giuseppe Alario, Giuseppe Mucciardi, Antonino Isgrò, and Gianluca Giannarini Vincenzo FicarraVincenzo Ficarra More articles by this author , Marta RossaneseMarta Rossanese More articles by this author , Alessandro CrestaniAlessandro Crestani More articles by this author , Giuseppe AlarioGiuseppe Alario More articles by this author , Giuseppe MucciardiGiuseppe Mucciardi More articles by this author , Antonino IsgròAntonino Isgrò More articles by this author , and Gianluca GiannariniGianluca Giannarini More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001996.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We have previously proposed a novel technique based on the concept of fixing the urethral stump laterally and posteriorly instead of supporting it, and have shown that urethral fixation was associated with a significant improvement in early urinary continence recovery compared to standard vesico-urethral anastomosis (VUA) after retropubic radical prostatectomy. In this study, we compared early urinary continence recovery and complications in patients undergoing robot-assisted radical prostatectomy (RARP) with urethral fixation versus standard VUA. METHODS: A prospective single-center, single-surgeon cohort of 70 consecutive patients undergoing RARP between January and December 2019 was analyzed. A study group of 35 patients operated on with the urethral fixation technique was compared with a control group of 35 patients receiving standard VUA. In the study group, the urethral stump was fixed to the dorsal median raphe posteriorly and to the medial portion of levator ani muscle postero-laterally, so as to avoid urethral retraction or deviation, and maintain the urethral sphincter in its natural position in the pelvic floor. The same posterior musculofascial reconstruction incorporating the VUA was performed in both groups. Urinary continence recovery, defined as 0-1 daily safety pads, within 3 months after catheter removal, and perioperative complications were compared between the two groups. RESULTS: The two groups were comparable with regard to all demographic, clinical and pathological variables. Recovery of urinary continence at 3 months after catheter removal was reported by 34 (97.1%) patients in the study, and 28 (80%) patients in the control group (p=0.02). Patients in the study group reported significantly higher rates of urinary continence even at 1 week and 1 month after catheter removal compared to the control group (68.6% vs 45.7%, p=0.04, and 80% vs 54.3%, p=0.04, respectively). No intraoperative complications were observed in either group. Ninety-day postoperative complications were observed in 1 (2.9%) patient in the study, and in 4 (11.4%) in the control group (p=0.3). CONCLUSIONS: We observed a significant improvement in early urinary continence recovery with no increase in perioperative complications using the novel urethral fixation technique versus standard VUA during RARP. These preliminary data seem to corroborate the hypothesis that maintaining the urethral stump in its correct position in the pelvic floor may improve the probability of an earlier urinary continence recovery after RARP. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e268-e268 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vincenzo Ficarra More articles by this author Marta Rossanese More articles by this author Alessandro Crestani More articles by this author Giuseppe Alario More articles by this author Giuseppe Mucciardi More articles by this author Antonino Isgrò More articles by this author Gianluca Giannarini More articles by this author Expand All Advertisement Loading ...

Posterior musculofascial reconstruction in robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer.

Posterior musculofascial reconstruction in robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer.

Robot-assisted Radical Prostatectomy Using the Novel Urethral Fixation Technique Versus Standard Vesicourethral Anastomosis

BackgroundUrinary continence recovery after radical prostatectomy is a major issue even in the robotic era. Surgical techniques aimed at improving earlier return to continence are continuously sought. ObjectiveTo describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative complications. Design, setting, and participantsA prospective, single-center, single-surgeon cohort of 70 consecutive patients undergoing RARP between January and December 2019 was analyzed. A study group of 35 patients operated on with the urethral fixation technique was compared with a control group of 35 patients receiving standard vesicourethral anastomosis. Surgical procedureUrethral fixation versus standard vesicourethral anastomosis during RARP was evaluated. In the study group, the urethral stump was fixed to the dorsal median raphe posteriorly and to the medial portion of the levator ani muscle posterolaterally. The same posterior musculofascial reconstruction incorporating the vesicourethral anastomosis was performed in both groups. MeasurementsUrinary continence recovery, perioperative complications, operating room time, and estimated blood loss were recorded and compared between the two groups. Results and limitationsThe two groups were comparable with regard to all demographic, clinical, and pathological variables. Recovery of urinary continence at 3 mo after catheter removal was reported by 34 (97.1%) patients in the study and 28 (80%) patients in the control group (p = 0.02). Patients in the study group reported significantly higher rates of urinary continence even at 1 wk and 1 mo after catheter removal compared with the control group (68.6% vs 45.7%, p = 0.04, and 80% vs 54.3%, p = 0.04, respectively). No differences were observed in operating room time (p = 0.7) or estimated blood loss (p = 0.65). Ninety-day postoperative complications were observed in one (2.9%) patient in the study and in four (11.4%) in the control group (p = 0.3). The main limitation is the nonrandomized comparison of relatively small cohorts. ConclusionsIn our study, we observed a significant improvement in early urinary continence recovery, with no increase in operating room time or perioperative complications, using the novel urethral fixation technique compared with the standard vesicourethral anastomosis during RARP. Patient summaryWe describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy. Compared with the standard technique, utilization of our technique was found to be associated with an improved early recovery of urinary continence, with no increase in operating room time or perioperative complications.

Posterior musculofascial reconstruction versus no posterior reconstruction during robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

Posterior musculofascial reconstruction versus no posterior reconstruction during robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer

Posterior, Anterior, and Periurethral Surgical Reconstruction of Urinary Continence Mechanisms in Robot-assisted Radical Prostatectomy: A Description and Video Compilation of Commonly Performed Surgical Techniques

BackgroundRobot-assisted radical prostatectomy (RARP) is hampered by side effects that may have a serious impact on quality of life, particularly stress urinary incontinence. Continence rates may be improved by surgical reconstruction of the pelvic floor. ObjectiveVideo illustrations of different surgical techniques may be particularly worthwhile for practicing urologists in understanding the pelvic-floor anatomy and in the training of residents and fellows in urology. Design, setting, and participantsWe describe and video-illustrate commonly performed pelvic reconstructive techniques in RARP, as performed by experts in the field. Surgical procedureSurgical techniques have been described, such as posterior musculofascial reconstruction, anterior reconstruction and periurethral suspension, preservation of membranous urethral lengthening, bladder-neck reconstruction, and combinations. MeasurementsAn overview of continence rates of the different techniques is given. Results and limitationsAll reconstructive surgical techniques result in similar short-term continence rates and good-to-excellent outcomes 1yr after surgery. There are only a few randomized clinical trials comparing a reconstructive technique with “no reconstruction” or a different reconstructive technique, and outcomes are conflicting. ConclusionsAlthough many of the procedures report a benefit with respect to early continence, benefits seem to diminish with longer follow-up. Whether any of the reconstructive techniques is superior to another is a matter of study. Patient summaryEarly continence rates might be improved by surgical reconstruction of the pelvic floor.

Bidirectional barbed suture for posterior musculofascial reconstruction and knotless vesicourethral anastomosis during robot-assisted radical prostatectomy.

The aim of the work is to describe an original technique of posterior musculofascial reconstruction (PMFR) during robot-assisted radical prostatectomy (RARP). From January 2015 to June 2016, 121 consecutives patients underwent RARP and were submitted to a novel technique of PMFR, using a single 3/0 barbed bidirectional (Filblock®, Assut Europe) suture. The first step of this new technique of PMFR, is to approximate the posterior layer of Denonvilliers fascia (DF) to the posterior part of the sphincteric apparatus. Then, the second step consists in the anastomosis of the posterior blabber neck edge with the posterior urethra edge. We realize the completion of anastomosis clockwise from 7 to 12 o'clock and anticlockwise from 5 to 12 o'clock. No leakage of anastomosis was observed and the catheter was removed in the 5th day after surgery. After catheter removal, the urinary recovery of early continence at 3 days was 45% and at 7 days was 75%, while the urinary continence recovery at 1 month was 88% and at 3 months was 94%. In our experience this novel approach results feasible in all patient, without extending the operation time and gives a good safety in terms of reduction of bleeding and leakage with shorter urinary continence recovery's time. The aim of the combination of the PMFR and the vesicourethral anastomosis with one bidirectional barbed suture is to have all the advantages of both techniques plus the stability of a single running suture.

Combined bladder neck preservation and posterior musculofascial reconstruction during robotic assisted radical prostatectomy: effects on early and long term urinary continence recovery

BackgroundTo evaluate the effects of combined bladder neck preservation and posterior reconstruction techniques on early and long term urinary continence in patients treated by robotic assisted radical prostatectomy (RARP).MethodsTwo-hundred ninety-two patients who previously underwent radical prostatectomy were retrospectively selected for a case-control study, excluding those with anastomotic strictures and significant perioperative complications and re-called for a medical follow-up visit after their consent to participate the study. They were divided in 3 different groups according to the surgical technique previously received: radical retropubic prostatectomy (RRP) combined with bladder neck preservation (BNP), RARP with bladder neck resection, and RARP combined with BNP and posterior musculofascial reconstruction (PRec).Functional and oncologic outcomes evaluation were integrated by a questionnaire on urinary continence status, abdominal ultrasound scan, uroflowmetry and post-void urine volume measurement.Urinary continence definition included the terms “no pad” or “safety pad”.ResultsTwo hundred thirty-two patients responded to the phone call interview and were enrolled in the study. They presented comparable age, prostate volume and BMI. Differences in comorbidities, ASA score and medications, did not influence the postoperative functional results, focused on continence outcome.Early urinary continence was achieved in 49.38% and 24.73% of patients who previously underwent RARP + BNP + PRec and simple RARP respectively (p = 0.000)as well as late 12-months urinary continence was obtained in 92.59% and 79.56% of patients.(p = 0.01). Late urinary continence in the RRP + BNP group was comparable to the result obtained in the simple RARP group. The potential effects of nerve sparing technique on urinary continence have not been evaluated.ConclusionsThe combined technique of RARP + BNP + PRec seems to be effective to determine early and long term significant effects on urinary continence of patients with comparable body mass index, age and prostate volume. No statistically significant differences were found between the simple RARP and the RRP + BNP groups.

Posterior Muscolofascial Reconstruction Incorporated into Urethrovescical Anastomosis During Robot-Assisted Radical Prostatectomy

The rationale of posterior musculofascial plate reconstruction during radical prostatectomy is to shorten the time to reach urinary continence recovery and to reduce the risk of bleeding and anastomosis leakage. We describe our original technique incorporating the posterior muscolofascial reconstruction into urethrovesical anastomosis using robot-assisted radical prostatectomy (RARP). For this reconstructive step, we use a 30-cm V-Loc 90 3-0 barbed suture (V-20 tapered needle). Specifically, the free edge of the posterior layer of the Denonvilliers fascia is approximated to the posterior part of the sphincteric apparatus in a running fashion from left to right. The musculature of the urethral wall is incorporated in this first layer of the running suture. This suture is then continued back to the left in a second layer incorporating the anterior layer of the Denonvilliers fascia (or prostatovesical muscle), the bladder neck, and again the urethra, this time also with urethral mucosa. The urethrovesical anastomosis is completed using a second running barbed suture (15-cm V-Loc 90 3-0 barbed suture, V-20 tapered needle). No intraoperative complications were observed during this step of the procedure. Anastomotic leakages were observed only in 2% of cases. Only 12.5% showed urinary incontinence after catheter removal (1-2 pads). At mean follow-up of 9 months, the urinary continence recovery was 95%, and an anastomosis stricture necessitating an endoscopic incision developed in only three (1.5%) patients. Recent systematic reviews of the literature showed only a minimal advantage in favor of posterior musculofascial reconstruction in terms of urinary continence recovery within 1 month after radical prostatectomy. We support the use of this step of RARP because it is simple, reproducible, with a very limited increase in operative time, and with only a slight risk of potential harm to the patient. Moreover, it could improve hemostasis and provide greater support for a delicate anastomosis.

Impact of Posterior Musculofascial Reconstruction on Early Continence After Robot-Assisted Laparoscopic Radical Prostatectomy: Results of a Prospective Parallel Group Trial

BackgroundA significant proportion of patients develop urinary incontinence early after radical prostatectomy. Posterior reconstruction of supporting tissues has been found to reduce incontinence in open and conventional laparoscopic prostatectomy series. ObjectiveTo investigate whether our version of a posterior musculofascial reconstruction will reduce early incontinence and have a beneficial effect on patients’ quality of life (QoL). Design, setting, and participantsOne hundred seven consecutive patients undergoing primary robot-assisted radical laparoscopic prostatectomy (RALP) performed by a single surgeon at one tertiary referral oncology institution were alternately assigned (not randomised) to intervention (n=53) or control groups (n=54). Surgical procedureRALP with median fibrous raphe reconstruction (MFRR) followed by formation of the urethrovesical anastomosis (intervention group) versus standard anastomosis without posterior reconstruction (control group). MeasurementsMeasurements included incontinence at baseline and 3-mo intervals; QoL as measured by a simple questionnaire, the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life–Core 30 (QLQ-C30), and Prostate Cancer Module (PR25) questionnaires preoperatively and at 6 mo postprocedure; tumour characteristics; operative time; fascial preservation score; duration of catheterisation; and anastomotic leakage on cystogram. Results and limitationsFor intervention and control groups respectively, mean catheter duration was 11.74 d and 12.74 d (p=0.451); leakage on cystogram was present in six and eight cases (p=0.28); and incontinence (any involuntary urine loss) at 3 mo was 75% and 69% (p=0.391) and at 6 mo was 51% and 43% (p=0.686). Urinary retention occurred only in one case (control group). The percentage of cases returning to baseline in all QoL domains (except insomnia) was similar at 6 mo between the two groups. Short follow-up, lack of blinding, and probable small differences in our method of MFRR performed compared with other studies were identified as significant limitations. ConclusionsNo significant difference in any of the analysed outcome measures was observed. Posterior reconstruction of the musculofascial complex does not appear to improve early urinary incontinence after RALP.