Posterior Reconstruction Research Articles

Impact of Intraoperative Prognostic Factors on Urinary Continence Recovery Following Open and Laparoscopic Radical Prostatectomy

Background and Objectives: Radical prostatectomy (RP) stands as the predominant instigator of postoperative stress urinary incontinence. Techniques such as the preservation of the neurovascular bundles, bladder neck preservation, and ensuring longer postoperative urethral length have shown positive impacts on continence. The posterior reconstruction is another method that aids in early continence recovery. Anterior suspension as simulator of puboprostatic ligaments is another factor. Materials and Methods: This study was conducted in the Clinic of Urology, University Clinical Center of Serbia, between December 2014 and January 2020, employing a prospective, non-randomized comparative design. Data were meticulously gathered from 192 consecutive patients. The process of regaining continence was monitored at intervals of 1, 3, 6, 12, and 24 months after surgery. The main criterion for assessing the level of urinary continence was the number of pads used daily. Results: The distribution of overall continence rates in the BNP vs. no-BNP group at 3, 6 and 12 months was 86% vs. 60% (p < 0.0001), 89% vs. 67% (p < 0.0001), 93% vs. 83% (p = 0.022). Continence rates in non-posterior reconstruction group (10%, 22%, 34%, and 54% at 1, 3, 6, and 12 months) were statistically significantly lower (p < 0.0001). The patients who underwent urethral suspension exhibited significantly higher rates of overall continence at 1 mo (73% vs. 29%, p < 0.0001), 3 mo (85% vs. 53%, p < 0.001), 6 mo (89% vs. 62%, p < 0.0001), 12 mo (95% vs. 76%, p < 0.0001), and 24 mo (93% vs. 81%, p = 0.007). Patients who underwent urethral suspension had a four-fold greater likelihood of regaining continence (p = 0.015). Conclusions: Patients who underwent urethral suspension or BNP or posterior reconstruction had higher continence rates. Only the urethral suspension was found to be a significant prognostic factor of continence recovery.

Proximal lumbar anterior column realignment for iatrogenic sagittal plane adult spinal deformity correction: a retrospective case series

Anterior column realignment (ACR) is a powerful minimally invasive surgery (MIS) technique to restore sagittal alignment in adult spinal deformity (ASD). This can accomplish similar segmental lordosis restoration as 3-column osteotomy with less blood loss and comparable complication rates. ACR can be performed at adjacent disease segments in the proximal lumbar spine in revision cases. However, two-thirds of physiologic lordosis occurs between L4-S1, and concerns remain about altered lumbar morphology. We evaluated patients who underwent proximal lumbar ACR for iatrogenic flatback deformity. A total of 19 consecutive patients who underwent L1-2 or L2-3 ACR were retrospectively analyzed. All patients were treated with lateral MIS interbody technique, followed by posterior reconstruction with Smith-Peterson osteotomy (SPO). Pre- and post-operative radiographic and clinical outcomes were obtained. Mean follow-up was 19-months. All but one patient had a history of prior lumbar or lumbo-sacral fusion. SVA and PI-LL decreased from 11.9 cm to 6.1 cm (p<0.0001) and 34.2° to 12.8° (p<0.0001). Segmental lordosis increased from -2.7° to 21.9° (p<0.0001). Proximal lumbar lordosis (PLL) increased from -0.4° to 22.6° (p<0.0001), and lordosis distribution index (LDI) decreased from 79.5% to 48.9% (p<0.0001). Mean ODI and NPRS back pain decreased from 58.0 to 36.2 (p=0.0041) and 7.9 to 3.4 (p<0.0001). PROMIS-10 Physical and Mental Health T-scores increased from 34.1 to 43.3 (p=0.0049) and 40.4 to 45.0 (p=0.0993). Major complication rate was 15.8%. One patient required revision for mechanical failure. There were no permanent neurological or vascular injuries. Proximal lumbar ACR plus SPO can achieve sagittal correction with low major complication rates in patients with ASD and prior distal fusion. Differentially increasing PLL and lowering LDI did not have deleterious effects on radiographic or clinical outcomes. Further work is needed to understand the effect of proximal ACR in the surgical management of ASD.

Clinical Analysis of Improved Lateral Approach Lesion Clearance, Autologous Iliac Bone Interbody Fusion, and Posterior Internal Fixation for Lumbar Tuberculosis

Objective: To explore the clinical efficacy of improved lateral approach lesion clearance, autologous iliac bone interbody fusion, and posterior internal fixation for treating lumbar tuberculosis. Methods: Thirty lumbar tuberculosis patients enrolled from January 2022 to June 2023 were selected and divided into two groups based on the surgical method. The control group (15 cases) underwent traditional posterior open lesion clearance and conventional lumbar posterior reconstruction surgery. The observation group (15 cases) received improved lateral approach lesion clearance, autologous iliac bone interbody fusion, and posterior internal fixation. Comparisons were made on surgical conditions, time to ambulation after surgery, complication rates, laboratory test results, ASIA scores, VAS scores, ODI index, and cure rates. Results: The observation group had superior surgical outcomes compared to the control group, with shorter time to ambulation after surgery (P &lt; 0.05). The complication rate in the observation group was lower than in the control group (P &lt; 0.05). Laboratory test results post-surgery were better in the observation group (P &lt; 0.05). ASIA scores were higher in the observation group (P &lt; 0.05). There were no significant differences in VAS scores and ODI index between the two groups (P &gt; 0.05). The cure rate was higher in the observation group (P &lt; 0.05).Conclusion: Improved lateral approach lesion clearance, autologous iliac bone interbody fusion, and posterior internal fixation for lumbar tuberculosis resulted in a smooth surgical process, faster recovery, and better safety. This method improved laboratory results, neurological function, and cure rates.

Editorial Comment on “Effect of a Modified Technique of Posterior Reconstruction by Iliopectineal Ligament Suspension During Robot-assisted Laparoscopic Radical Prostatectomy on Early Continence: A Randomized Controlled Trial”

Editorial Comment on “Effect of a Modified Technique of Posterior Reconstruction by Iliopectineal Ligament Suspension During Robot-assisted Laparoscopic Radical Prostatectomy on Early Continence: A Randomized Controlled Trial”

Giant Cell Tumor of the Rib: A Report of Two Patients.

Giant cell tumor of the bone is a locally aggressive and rarely metastasizing tumor that typically affects the ends of long bones. Less than 1% of giant cell tumor of bone occur in the ribs. Our patients were a 32-year-old woman and a 45-year-old man and were detected following chest traumas. No bone alterations were detected in radiological studies performed immediately after local trauma. Six- and one- months, respectively, following chest trauma, both giant lytic heterogeneous masses arising on an anterior rib arc were radiologically observed. In the computerized tomography-guided needle biopsy, giant cell tumor of bone were diagnosed. Both tumors were completely removed by bloc resection including the adjacent ribs and posterior reconstruction were performed. One patient was preoperatively treated with denosumab. Neither local recurrences nor metastasis have been detected in follow-up. Despite its low frequency and its low degree of suspicion, giant cell tumor of bone should be included in the differential diagnosis of a rapid growing chest mass.

Urinary continence following extraperitoneal radical prostatectomy: impact of surgical technique and pelvic fascial spaces reconstruction

Introduction. Urinary incontinence is a common complication of radical prostatectomy. The development of surgical techniques when performing radical prostatectomy that improve the function of urinary continence after surgery is actual.Objective. To compare urinary continence functions in long-term follow-up after open and laparoscopic radical prostatectomy when only posterior or combined (anterior + posterior) reconstruction of the pelvic fascial spaces is performed.Materials &amp; methods. The study included 130 patients aged 63.0 [59.0; 68.0] years with local prostate cancer (сT1a-2сN0-xM0; 1 – 4 ISUP groups), subjected to non-nerve-sparing retropubic radical prostatectomy with posterior reconstruction and non-nerve-sparing extraperitoneal laparoscopic radical prostatectomy with isolated posterior or combined (anterior + posterior) fascial reconstruction of the pelvic fascial spaces. Postoperative continence function was studied at 1, 3, 6, and 12 months following surgery using a standard pad test.Results. The incidence of urinary continence was higher at all follow-up periods during laparoscopic surgery. From the 6-months follow-up, these patients did not have severe urinary incontinence. At the same time, the rate of growth of some patients who began to retain urine did not depend on the method of reconstruction of the pelvic fascial spaces. The use of combined reconstruction of the pelvic fascial spaces at 12-months follow-up showed an advantage in urinary continence over performing only posterior reconstruction. Such patients achieved urinary continence in 90% of cases compared to 80.0% of cases. At the same time, the restoration of urinary continence at all periods of observation had a relatively uniform linear rate of increase in the indicator.Conclusion. Reconstruction of the pelvic fascial spaces during open and laparoscopic radical prostatectomy allows one to achieve satisfactory continuation in the postoperative period. However, higher efficiency is achieved when using a combined reconstruction technique.

Effect of a Modified Technique of Posterior Reconstruction by Iliopectineal Ligament Suspension During Robot-assisted Laparoscopic Radical Prostatectomy on Early Continence: A Randomised Controlled Trial

ObjectivesTo evaluate the effect of a modified technique of posterior reconstruction by iliopectineal ligament suspension during robot-assisted radical prostatectomy (RARP) on recovery of early continence. MethodsA prospective, single surgeon, single center, randomized controlled trial was performed from August 2018 to March 2020 with 171 patients (92 control vs. 79 experimental). The posterior reconstruction was done using a standard technique in the control group and was modified for the experimental group by incorporating not only the “Rocco” stitch between Denonvilliers’ fascia and the rhabdosphincter but also the iliopectineal ligaments bilaterally to further improve posterior support with this suspensory ‘hammock’. Both groups of patients were followed for a year with questionnaires and 24-hour pad tests. ResultsBoth groups were comparable in terms of baseline demographic, clinical and pathological characteristics. With regards to recovery of urinary continence, no statistically significant differences were found for socially continent (0-1 pads per day) or fully continent (0 pads per day) rates at all time points examined (1, 3, 6, 12 months). Moreover, there was no statistically significant differences between the groups for presence of urinary symptoms, bowel symptoms, sexual function, and hormonal symptoms. ConclusionsThe modified technique of posterior reconstruction by iliopectineal ligament suspension is not associated with improved early continence as compared to the standard posterior reconstruction technique during RARP. Future studies may want to explore other variations of suspensory sutures that could strengthen posterior urethral support to achieve earlier recovery of continence.

Formulation and Characterization of New Experimental Dental Composites with Zirconium Filling in Different Forms.

Short glass fibers are generally used in posterior dental restorations to enhance the mechanical properties and improve the material microstructure. Two resin-based composites (S0 and SF) were formulated and characterized to investigate the influence of zirconium in their characteristics and properties. The organic part of the investigated materials was the same (BisGMA, TEGDMA, and a photochemical polymerization system), and in the inorganic part, besides quart, glassA, and hydroxylapatite with Zn, sample S0 contained strontium glass with zirconium and sample SF contained fiber powder of chopped zirconium. The samples were characterized by the degree of conversion (DC), mechanical properties, water sorption (WS), scanning electron microscopy (SEM), atomic force microscopy (AFM) before and after the WS test, and antimicrobial properties. The results obtained were subjected to one-way ANOVA and Tukey's statistical tests. Both samples had a high DC. Regarding the mechanical properties, both samples were very similar, except DTS, which was higher for the composite without fibers. After 14 days, the WS value of the SF sample was lower than that of the S0 sample. Water caused significant changes in the topography of the SF sample, but thanks to its antimicrobial properties and the diffusion phenomenon, SF had a more pronounced antimicrobial effect. This study shows that the addition of appropriate amounts of Sr-Zr-glass powder gives the material in which it is added similar properties to material containing chopped zirconium glass fiber powder. According to the antimicrobial test results, resin composites containing experimental zirconia fillings can be considered in future in vitro clinical studies for posterior reconstructions with significantly improved mechanical properties.

State of art of robotic prostatectomy: the way we do it in Catalonia, Spain

Introduction and objectiveRobotic-assisted laparoscopic prostatectomy (PLAR) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the PLAR “state of art” in Catalonia, Spain. Material and methodsThis was a cross-sectional survey-based study conducted among urologists across Catalonia, Spain. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v20. Results59 urologists completed the survey, revealing PLAR as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the Airseal technology. The intraperitoneal approach is performed in >90% of cases. Endopelvic fascia preservation is not routinely performed. 34.5% of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. 34% performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage.Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95%CI 0.07−0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95%CI 1.07−127.60) and endopelvic fascia preservation (OR 13.64, 95%CI 1.087–201.27), but there was no correlation with time the bladder catheter or days hospitalized. ConclusionsThe study provides an overview of the state of PLAR in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Los últimos avances en prostatectomía robótica: ¿cómo lo hacemos en Cataluña, España?

Introduction and objectiveRobotic-assisted laparoscopic prostatectomy (RALP) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the RALP “state of art” in Catalonia, Spain. Material and methodsThis was a cross-sectional survey-based study conducted among urologists across Catalonia. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v. 20. ResultsFifty-nine urologists completed the survey, revealing RALP as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the AirSeal® technology. The intraperitoneal approach is performed in more than 90% of cases. Endopelvic fascia preservation is not routinely performed. A percentage of 34.5 of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. Thirty-four percent performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage. Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95% CI 0.07-0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95% CI 1.07-127.60) and endopelvic fascia preservation (OR 13.64, 95% CI 1.087-201.27), but there was no correlation with time the bladder catheter or days hospitalized. ConclusionsThe study provides an overview of the state of RALP in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Functional assessment of daily living activities following surgical management of young-burgess lateral compression type-II pelvic fractures with combined anterior and posterior internal fixation

Background: Fractures of the ischiopubic bones, S-I joint, and sacrum are among the most common bony injuries. Various procedures are available for managing this condition. Biomechanically, internal fixation of both the posterior and anterior lesions can offer complete stability to the pelvic ring. This study aimed to assess the functional assessment of daily living activities following surgical management of young-burgess lateral compression type-II pelvic fractures with combined anterior and posterior internal fixation. Methods: This descriptive observational study was conducted at the Department of Orthopedics &amp; Traumatology, Dhaka Medical College &amp; Hospital, Dhaka, Bangladesh from July 2016 to June 2018. A total of 44 patients with pelvic injuries admitted to the respective department were purposively enrolled as the study population. Data analysis was performed using the MS Office tools. Results: Most patients (68.18%) continued their jobs with reduced performance, while 22.72% maintained both job and performance levels. Regarding functional assessment, 54.54% could sit pain-free, with only 13.63% experiencing discomfort. None reported painful sexual intercourse. Mobility-wise, no one was bedridden or could only walk a few meters, and 0% needed walking sticks. Additionally, 18.81% could walk for one hour with a stick, while 63.63% had a normal walking distance for their age. No limitations in walking time or distance were observed in 63.63% of cases. Conclusions: This study concludes that stabilization of LC type-II pelvic ring fractures by anterior, combined, or posterior reconstruction plate provides a good result concerning daily living activities.

PRIME: Posterior Reconstruction of the Input for Model Explanations

Artificial intelligence (AI) has developed rapidly in the past few decades, but the corresponding explaining techniques do not keep up with the pace of development. This state of low interpretability leads developers to improve model performance by continuously increasing the use of features when training machine learning models, but it is difficult for them to judge the contribution of features to the prediction. Therefore, it is particularly important to evaluate features. Most of the existing research on model explaining focuses on characterizing the output space and ignored the research on the input space. In this paper, we propose a model-agnostic method to evaluate the feature importance by analyzing the change in the input space. The motivation is to come up with a flexible, general, and computationally efficient method of model explaining. The experiments on the synthetic datasets, standard datasets, and industrial dataset verify the effectiveness of our algorithm. At the same time, we compare our methods to the classic and late model explaining methods, such as SHAP, LIME, and Marginal Contribution Feature Importance (MCI) to further demonstrate the feasibility of our method.

Biomechanical Analysis of 2 Versus 4 Rods Across the Cervicothoracic Junction in a Human Cadaveric Model.

Posterior reconstruction of the cervicothoracic junction poses significant biomechanical challenges secondary to transition from the mobile cervical to rigid thoracic spines and change in alignment from lordosis to kyphosis. After destabilization, the objectives of the current investigation were to compare the rod strain and multidirectional flexibility properties of the cervicothoracic junction using a 4-rod vs traditional 2-rod reconstructions. Ten human cadaveric cervicothoracic specimens underwent multidirectional flexibility testing including flexion-extension, lateral bending, and axial rotation. After intact analysis, specimens were destabilized from C4 to T3 and instrumented from C3 to T4. The following reconstructions were tested: (1) 3.5-mm titanium (Ti) 2-rod, (2) 3.5-mm Ti 4-rod, (3) 4.0-mm cobalt chrome (CoCr) 2-rod, (4) 4.0-mm CoCr 4-rod, and (5) Ti 3.5- to 5.5-mm tapered rod reconstructions. The operative level range of motion and rod strain of the primary and accessory rods were quantified. The addition of accessory rods to a traditional 2-rod construct improved the biomechanical stability of the reconstructions in all three loading modalities for Ti ( P < .05). The accessory CoCr rods improved stability in flexion-extension and axial rotation ( P < .05). The addition of accessory rods in Ti or CoCr reconstructions did not significantly reduce rod strain ( P < .05). CoCr 2 and 4 rods exhibited less strain than both Ti 2 and 4 rods. Supplemental accessory rods affixed to traditional 2-rod constructs significantly improved stability of Ti alloys and CoCr alloy materials. The 4.0-mm CoCr rods provided greater stability than 3.5-mm Ti rods in flexion-extension, lateral bending, and axial rotation. While rod strain was not significantly reduced by the addition of accessory rods, it was reduced in CoCr rod treatment groups compared with the Ti rods.

Continence-Sparing Techniques in Radical Prostatectomy: A Systematic Review of Randomized Controlled Trials.

Background: Numerous continence-sparing radical prostatectomy techniques have been developed to enhance postoperative early continence (EC) recovery; however, evidence regarding the best approach remains controversial. The objectives are to provide a critical appraisal of various prostatectomy techniques, based on the evidence of quality-assessed randomized control trials (RCTs); to summarize the immediate continence and the EC reported; and to propose a new standardization for continence outcomes reporting. Methods: Data acquired from five medical registries were reported to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Evidence from published, English, full-text RCTs reporting postoperative urinary continence outcomes within 6 months from surgery was included. The heterogeneity of surgical techniques and continence definitions did not allow a meta-analysis. All RCTs were critically appraised, and quality assessed. Results: In total, 39 RCTs were included: 19 of 39 studies were low-quality RCTs, presenting small cohort, monocentric, or single-surgeon data. The best RCT-supported evidence is in favor of robot-assisted radical prostatectomy (RARP) compared with laparoscopic radical prostatectomy (LRP) and of the Retzius-sparing (RS) technique over the traditional prostatectomy. Other techniques such as bladder neck and puboprostatic ligament (PPL) preservation, posterior reconstruction with or without combination of anterior suspension technique, and nerve-sparing (NS) approach seem to enhance EC. Oppositely, the endopelvic fascia preservation, bladder neck mucosa eversion/plication/slings, and the selective ligature of dorsal venous complex (DVC) were not significantly associated with EC improvements. RCTs are lacking on pubovesical complex-sparing, seminal vesicle preservation, anterior reconstruction of the puboprostatic collar, musculofascial reconstruction, and DVC suspension to the periosteum of the pubic bone techniques. Conclusions: RARP and RS have high-quality evidence supporting their ability to enhance postoperative EC recovery. NS, bladder neck, and PPL preservation may contribute to better EC recovery, although the evidence level is low. Further multicenter RCTs are needed to establish the optimal combination of standard surgical techniques. A new continence outcome-reporting standardization was proposed.

A matched-analysis on short-term and long-term (up to 5 years of follow-up) urinary incontinence outcomes after robot-assisted radical prostatectomy with and without anterior and posterior reconstruction: data on 1358 patients

PurposeWe report a comparative monocentric study with a short and long-term follow-up with the aim to assess differences about urinary continence outcomes in patients treated with Robot-Assisted Radical Prostatectomy (RARP) with two different techniques: with anterior and posterior reconstruction and without any kind of reconstruction.Materials and methodsFrom January 2016 to September 2021, at the Department of Urology of the “F. Miulli” Hospital of Acquaviva delle Fonti, in Italy, 850 eligible patients underwent extraperitoneal RARP with anterior and posterior reconstruction and 508 without reconstructions.ResultsIn patients undergoing RARP with reconstructions 1 month after surgery the urinary continence was preserved in 287/850 patients (33.8%), 3 months after surgery in 688/850 (81%), 6 months in 721/850 (84.8%), 12 months in 734/850 (86.3%), 18 months in 671/754 (89%), 24 months in 696/754 (92.3%), 36 months in 596/662 (90%), 48 months in 394/421 (93.6%), 60 months in 207/212 (97.6%). In patients undergoing RARP without reconstruction 1 month after surgery urinary continence was preserved in 99/508 (19.4%), after 3 months in 276/508 (54.3%), 6 months in 305/508 (60%), 12 months in 329/508 (64.7%), 18 months in 300/456 (65.7%), 24 months in 295/456 (64.7%), 36 months in 268/371 (72.3%), 48 months in 181/224 (81%), 60 months in 93/103 (90.3%).ConclusionIn our case study, the RARP with anterior and posterior reconstruction technique is associated with a statistically significant higher rate (up to 48 months of follow-up) and a faster recovery of urinary continence compared to the technique without reconstructions.

MP61-06 IMPACT OF POSTERIOR RECONSTRUCTION URETHROVESICAL ANASTOMOSIS ON 5-YEAR INCIDENCE OF UNDERGOING CONTINENCE IMPROVING PROCEDURES AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY: A RANDOMIZED CONTROLLED TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP61-06 IMPACT OF POSTERIOR RECONSTRUCTION URETHROVESICAL ANASTOMOSIS ON 5-YEAR INCIDENCE OF UNDERGOING CONTINENCE IMPROVING PROCEDURES AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY: A RANDOMIZED CONTROLLED TRIAL Braden Millan, Jen Hoogenes, Michael Uy, Raees Cassim, and Bobby Shayegan Braden MillanBraden Millan More articles by this author , Jen HoogenesJen Hoogenes More articles by this author , Michael UyMichael Uy More articles by this author , Raees CassimRaees Cassim More articles by this author , and Bobby ShayeganBobby Shayegan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003319.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Posterior reconstruction of the Denonvilliers’ musculofascial plate also known as the Rocco stitch, have shown mixed results on early return to urinary continence, yet little data exist on long-term outcomes. The objective of this study was to evaluate the long-term need for incontinence improving procedures post robot-assisted radical prostatectomy (RARP) comparing posterior reconstruction urethrovesical anastomosis (PR-UVA) versus conventional urethrovesical anastomosis (C-UVA). METHODS: Consecutive patients with clinically localized prostate cancer undergoing RARP were randomized to PR-UVA or C-UVA groups. Return to continence outcomes were assessed using a validated questionnaire (Expanded Prostate Cancer Index Composite [EPIC] Short Form-26) at baseline, 2, 3, 4, 6, 8, and 12-month follow-up. Five-year outcomes were assessed by frequency of continence-improving procedures. RESULTS: A total of 163 patients were randomized from April 2014 to July 2015 and 140 patients completed follow-up. Pre-operative clinical and functional variables were equivalent between study arms. Using a continence definition of 0-1 pads/day, the continence rates for PR-UVA versus the C-UVA were 39% versus 38% at 2 months (p=1.0), and 93% versus 86%, respectively, at 12 months (p=0.3). Frequency of urine leak, quantity of pad use, subjective urinary control, and overall bother improved significantly in all patients during the 12-month study period (p<0.001); however, no difference was demonstrated between groups. Five-year results showed no difference in the number of patients undergoing a continence-improving procedure (HR 0.90, 95% CI 0.29-2.80; p=0.09). CONCLUSIONS: PR-UVA failed to show a benefit in short-term return to urinary continence or need for an incontinence improving procedure at 5-year follow-up post RARP. Source of Funding: The Masonic Foundation of Ontario © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e854 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Braden Millan More articles by this author Jen Hoogenes More articles by this author Michael Uy More articles by this author Raees Cassim More articles by this author Bobby Shayegan More articles by this author Expand All Advertisement PDF downloadLoading ...

V10-03 OUTCOMES OF PRECISION PROSTATECTOMY PROCEDURE FOR LOCALIZED PROSTATE CANCER, AND STEP-BY-STEP TECHNIQUE OF SINGLE PORT TRANSVESICAL PRECISION PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023V10-03 OUTCOMES OF PRECISION PROSTATECTOMY PROCEDURE FOR LOCALIZED PROSTATE CANCER, AND STEP-BY-STEP TECHNIQUE OF SINGLE PORT TRANSVESICAL PRECISION PROSTATECTOMY Sohrab Arora, Samantha Wilder, Mohit Butaney, Craig Rogers, and Wooju Jeong Sohrab AroraSohrab Arora More articles by this author , Samantha WilderSamantha Wilder More articles by this author , Mohit ButaneyMohit Butaney More articles by this author , Craig RogersCraig Rogers More articles by this author , and Wooju JeongWooju Jeong More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Whole-gland therapy is the mainstay of treatment for high-volume, low risk patients with prostate cancer (PCa), however it is associated with functional side effects. Precision prostatectomy is a surgical technique that removes >90% of prostatic tissue while preserving functional recovery. We describe a case of single port transvesical precision prostatectomy and report outcomes of patients who have received multiport precision prostatectomy at our institution. METHODS: A 72-year-old man with prior appendectomy and umbilical and hernia repair on active surveillance for left Grade Group 2 PCa elected to undergo surgery due to rising PSA. The following surgical steps are described: (1) transvesical access and robot docking, (2) anterograde bladder neck dissection, (3) standard dissection and nerve sparing on radical side, (4) development of precision plane, (5) apical dissection, (6) urethral transection, (7) posterior reconstruction, and (8) urethrovesical anastomosis. Oncological and functional outcomes of 88 patients with localized PCa undergoing multiport precision prostatectomy are reported. RESULTS: The patient underwent an uncomplicated single port transvesical precision prostatectomy, was discharged on post op day (POD) 1, and passed trial of void on POD 8. He was fully continent by 4 weeks post foley removal. The patient has not yet tried sexual activity postoperatively due to life events. 11-month follow-up shows a stable PSA of 0.7. All 88 patients undergoing multiport precision prostatectomy were alive and metastasis free at a median follow up of 25 months. At 36 months, 93% of patients were free from clinically significant residual PCa, 91% had not undergone additional treatment, and 100% were alive and metastasis-free. Two patients had biochemical failure according to Phoenix criteria, and 25 using the more stringent AUA post-RP criterion. However, detectable PSA was due to prostate cancer in only 10 patients as detected on biopsy of the remnant. Six patients underwent removal of the remnant and were free from biochemical failure at median follow-up of 10.2 months. At 12 months, 91% of patients were pad free, and 90% of the preoperatively potent patients had a SHIM score of 17+. CONCLUSIONS: Precision prostatectomy offers excellent postoperative functional results while minimizing PCa undertreatment. Single port transvesical precision prostatectomy is feasible and safe in select patients. Close patient follow-up and investigation into long-term oncological outcomes are necessary. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e926 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sohrab Arora More articles by this author Samantha Wilder More articles by this author Mohit Butaney More articles by this author Craig Rogers More articles by this author Wooju Jeong More articles by this author Expand All Advertisement PDF downloadLoading ...

V06-04 ROBOTIC-ASSISTED INTRACORPOREAL NEOBLADDER RECONSTRUCTION WITH Y-SHAPED RESERVOIR: VIDEO DESCRIPTION AND CLINICAL OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023V06-04 ROBOTIC-ASSISTED INTRACORPOREAL NEOBLADDER RECONSTRUCTION WITH Y-SHAPED RESERVOIR: VIDEO DESCRIPTION AND CLINICAL OUTCOMES Bernardo Rocco, Simone Assumma, Tommaso Calcagnile, Filippo Turri, Mattia Sangalli, Luca Sarchi, Giulia Garelli, Daniele Stroppa, Enrico Panio, Giorgio Bozzini, Salvatore Micali, Paolo Marcangeli, Angelica Grasso, Matteo Maggioni, Alberto Del Nero, Paolo Dell'Orto, and Maria Sighinolfi Bernardo RoccoBernardo Rocco More articles by this author , Simone AssummaSimone Assumma More articles by this author , Tommaso CalcagnileTommaso Calcagnile More articles by this author , Filippo TurriFilippo Turri More articles by this author , Mattia SangalliMattia Sangalli More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Giulia GarelliGiulia Garelli More articles by this author , Daniele StroppaDaniele Stroppa More articles by this author , Enrico PanioEnrico Panio More articles by this author , Giorgio BozziniGiorgio Bozzini More articles by this author , Salvatore MicaliSalvatore Micali More articles by this author , Paolo MarcangeliPaolo Marcangeli More articles by this author , Angelica GrassoAngelica Grasso More articles by this author , Matteo MaggioniMatteo Maggioni More articles by this author , Alberto Del NeroAlberto Del Nero More articles by this author , Paolo Dell'OrtoPaolo Dell'Orto More articles by this author , and Maria SighinolfiMaria Sighinolfi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003274.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: One of the hardest surgical challenges for robotic surgeon is intracorporeal neobladder reconstruction during robotic radical cystectomy (RARC). In the present video, we illustrate a step-by-step description of the technique and the clinical outcomes from a single center series. METHODS: Overall, 40 RARC were performed between July 2021 and October 2022: 20/40 patients underwent intracorporeal neobladder reconstruction and were enrolled in the study. When RARC is completed, a 40-50 cm ileal segment is isolated and the part with adequate mesenteric length is approximated to the urethral stump. A modified posterior reconstruction is conducted. Anastomosis with a barbed suture is finalized. Ileal segments at each side are isolated using robotic staplers and ileal-ileal anastomosis is accomplished. Ileum's reverse tubular U-segment is detubularized to create the neobladder. Posterior plane is first sutured; then, the orhotopic reservoir with two lateral limbs is created. After negative leakage test, a direct uretero-neobladder anastomosis of each spatulated ureter is performed in the dorsal part of the limbs. Ureteral stents are placed and brought out through the abdominal wall. Anterior plate is finally sutured. RESULTS: Mean age was 64.5 years (48-75). Seventeen out of 20 patients were males; 3 were females. One non-surgical intra-operative complication (myocardial infarction requiring an acceleration of operative time) was recorded. During post-op course, two cases of urinary leakage at the neovescical-urethral anastomosis were evident and required prolonged catheterization. Mean length of stay was 17 days (12-27), excluding a single case of prolonged hospitalization due to C. Albicans superinfection. The 30-day readmission rate was 20% (4/20) due to febrile urinary tract infections; 90-day readmission rate was just 5% (1 symptomatic lymphocele requiring percutaneous drainage). Most male patients (14/17) reported daytime continence with insignificant post-voided residual. Between those patients in which nerve-sparing approach was pursued – and have more than 90 days of follow up – 3/5 referred potency. Regarding female patients, incomplete voiding is reported in a case and urinary incontinence (2 pads/day) in another. CONCLUSIONS: Intracorporeal neobladder reconstruction is a complex procedure even for expert robotic surgeons. Nevertheless, the standardization of the surgical approach – as displayed in the video – facilitates a rapid implementation of the procedure with positive surgical and clinical outcomes. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e509 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bernardo Rocco More articles by this author Simone Assumma More articles by this author Tommaso Calcagnile More articles by this author Filippo Turri More articles by this author Mattia Sangalli More articles by this author Luca Sarchi More articles by this author Giulia Garelli More articles by this author Daniele Stroppa More articles by this author Enrico Panio More articles by this author Giorgio Bozzini More articles by this author Salvatore Micali More articles by this author Paolo Marcangeli More articles by this author Angelica Grasso More articles by this author Matteo Maggioni More articles by this author Alberto Del Nero More articles by this author Paolo Dell'Orto More articles by this author Maria Sighinolfi More articles by this author Expand All Advertisement PDF downloadLoading ...

Urinary Continence Recovery after Robotic Radical Prostatectomy without Anterior or Posterior Reconstruction: Experience from a Tertiary Referral Center

The aim of our study is to evaluate the prevalence and predictive factors of short- (30 d) and mid-term continence in a contemporary cohort of patients treated with robotic-assisted laparoscopic prostatectomy (RALP) without any posterior or anterior reconstruction at our referral academic center. Data from patients undergoing RALP between January 2017 and March 2021 were prospectively collected. RALP was performed by three highly experienced surgeons following the principles of the Montsouris technique, with a bladder-neck-sparing intent and maximal preservation of the membranous urethra (if oncologically safe) without any anterior/posterior reconstruction. (Self-assessed urinary incontinence (UI) was defined as the need of one or more pads per die (excluding the need for a safety pad/die. Univariable and multivariable logistic regression analysis was used to assess the independent predictors of early incontinence among routinely collected patient- and tumor-related variables). A total of 925 patients were included; of these, 353 underwent RALP (38.2%) without nerve-sparing intent. The median patient age and BMI were 68 years (IQR 63-72) and 26 (IQR 24.0-28.0), respectively. Overall, 159 patients (17.2%) reported early (30 d) incontinence. In multivariable analysis adjusting for patient- and tumor-related features, a non-nerve-sparing procedure (OR: 1.57 [95% CI: 1.03-2.59], p = 0.035) was independently associated with the risk of urinary incontinence in the short-term period, while the absence of cardiovascular diseases before surgery (OR: 0.46 [95% CI: 0.320.67], p ≤ 0.01) was a protective factor for this outcome. At a median follow-up of 17 months (IQR 10-24), 94.5% of patients reported to be continent. In experienced hands, most patients fully recover urinary continence after RALP at mid-term follow-up. On the contrary, the proportion of patients who reported early incontinence in our series was modest but not negligible. The implementation of surgical techniques advocating anterior and/or posterior fascial reconstruction might improve the early continence rate in candidates for RALP.

Reproducibility of a modified posterior reconstruction during robotic intracorporeal neobladder reconfiguration.

Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.