Posterior Rhabdosphincter Reconstruction Research Articles

Posterior Rhabdosphincter Reconstruction During Robotic Assisted Radical Prostatectomy: Results From a Phase II Randomized Clinical Trial

Posterior rhabdosphincter reconstruction following radical prostatectomy was designed to improve early urinary continence. We executed a randomized clinical trial to test this conjecture in men undergoing robotic radical prostatectomy. We conducted a phase II randomized clinical trial intended to detect a 25% difference in 3-month continence outcomes defined by a patient response of 0 or 1 to question 5 of the Expanded Prostate Cancer Index Composite questionnaire urinary domain, comparing standard running vesicourethral anastomosis (controls) to posterior rhabdosphincter reconstruction followed by standard running vesicourethral anastomosis (posterior rhabdosphincter reconstruction treated). Patients had clinically localized prostate cancer and were blinded. Surgeons were notified of computer randomization after prostate excision. Further continence outcomes were assessed by analysis of Expanded Prostate Cancer Index Composite questionnaire questions 1 and 12, International Prostate Symptom Score and 24-hour pad weights. Statistical significance was defined as p <0.05 A total of 94 patients were randomized, 47 to each arm. Preoperative clinical and functional variables were equivalent between study arms. There were no complications associated with either anastomotic technique. Of the 87 evaluable patients 62 (71.3%) met our 3-month continence definition. The null hypothesis was not rejected as 33 (81%) controls and 29 (63%) posterior rhabdosphincter reconstruction treated patients were continent at 3 months (chi-square p = 0.07, Fisher exact p = 0.1). Likewise there was no significant difference between arms in 24-hour pad weights (p = 0.14), International Prostate Symptom Score (p = 0.4), absence of daily leaks (p = 0.4) or perception of urinary function (p = 0.4). In this randomized clinical trial posterior rhabdosphincter reconstruction offered no advantage for return of early continence after robotic assisted radical prostatectomy.

Editorial Comment

This is a nice review of the techniques of reconstruction of the posterior periurethral plate and their effect on continence. The clinical series reviewed were of 2 categories: cohort studies with historical controls 1 Rocco F. Carmignani L. Acquati P. et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007; 52: 376-383 Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar , 2 Rocco B. Gregori A. Stener S. et al. Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol. 2007; 51: 996-1003 Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar , 3 Tewari A. Jhaveri J. Rao S. et al. Total reconstruction of the vesicourethral junction. BJU Int. 2008; 101: 871-877 Crossref PubMed Scopus (166) Google Scholar , 4 Nguyen M.M. Kamoi K. Stein R.J. et al. Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int. 2008; 101: 1135-1139 Crossref PubMed Scopus (96) Google Scholar , 5 Woo J.R. Shikanov S. Zorn K.C. et al. Impact of posterior rhabdosphincter reconstruction during robot-assisted radical prostatectomy: retrospective analysis of time to continence. J Endourol. 2009; 23: 1995-1999 Crossref PubMed Scopus (22) Google Scholar and randomized clinical trials (1 published and 1 as an abstract). As the authors point out, the interpretation of the results is bedeviled by slight differences in technique, length of follow-up, and definitions of continence. The cohort studies showed a 30%-50% improvement of continence from a baseline of 30%-40% without reconstruction to 80%-85% with reconstruction, if using 0-1 pad were considered continent. If the definition of continence were no pads, the continence rates were much lower at about 40%. The 1 published randomized trial was powered to detect a 30% difference in continence rates. It showed that the 0-1 pad continence rate was 74% without reconstruction and 80% with reconstruction. 6 Menon M. Muhletaler F. Campos M. et al. Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol. 2008; 180: 1018-1023 Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar Thus, it did not show a significant difference in continence, primarily because the continence results were close to 80% without any reconstruction. The unpublished abstract showed no difference in continence or EPIC scores with reconstruction, although the overall continence rates were somewhat lower than in the other studies. 7 Sutherland D. Tacoma W.A. Hong M. et al. Posterior rhabdosphincter reconstruction after RARP: results from a phase 2 RCT. J Urol. 2009; 181: 457 Abstract Full Text PDF Google Scholar Posterior Rhabdosphincter Reconstruction During Robot-assisted Radical Prostatectomy: Critical Analysis of Techniques and OutcomesUrologyVol. 76Issue 3PreviewMany centers have recently implemented posterior rhabdosphincter reconstruction (PRR) into robot-assisted radical prostatectomy (RARP) with the objective of earlier continence recovery. We comprehensively review the anatomic and functional changes occurring post prostatectomy along with the reconstructive techniques and published outcomes of PRR. Several case control studies show a better continence rate within the first 3 months, whereas the only randomized control trial presents a conflicting conclusion. Full-Text PDF ReplyUrologyVol. 76Issue 3PreviewAlthough radical prostatectomy (RP) delivers excellent long-term survival outcomes, postoperative incontinence remains a potential complication. Increasing age, shorter pre- and postoperative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations in surgical technique, and previous prostate surgery have been reported as negative risk factors for delayed continence recovery after radical prostatectomy. Over the past decade, with increased use of robotic and laparoscopic technology, coupled with cadaveric and video urodynamic studies, there has been an increased interest in elucidating the functional anatomy and physiology of the male continence mechanism. Full-Text PDF

Impact of Posterior Rhabdosphincter Reconstruction During Robot-Assisted Radical Prostatectomy: Retrospective Analysis of Time to Continence

Posterior rhabdosphincter (PR) reconstruction during robot-assisted radical prostatectomy (RARP) was introduced in an attempt to improve postoperative continence. In the present study, we evaluate time to achieve continence in patients who are undergoing RARP with and without PR reconstruction. A prospective RARP database was searched for most recent cases that were accomplished with PR reconstruction (group 1, n = 69) or with standard technique (group 2, n = 63). We performed the analysis applying two definitions of continence: 0 pads per day or 0-1 security pad per day. Patients were evaluated by telephone interview. Statistical analysis was carried out using the Kaplan-Meier method and log-rank test. With PR reconstruction, continence was improved when defined as 0-1 security pad per day (median time of 90 vs 150 days; P = 0.01). This difference did not achieve statistical significance when continence was defined as 0 pads per day (P = 0.12). A statistically significant improvement in continence rate and time to achieve continence is seen in patients who are undergoing PR reconstruction during RARP, with continence defined as 0-1 security/safety pad per day. A larger, prospective and randomized study is needed to better understand the impact of this technique on postoperative continence.