Technique Of Radical Prostatectomy Research Articles

Commentary on: Does Surgeon Subjective Nerve Sparing Score Predict Recovery Time of Erectile Function Following Robot-Assisted Radical Prostatectomy?

In spite of the recent advances in the treatment modalities for prostate cancer, functional outcomes of these procedures remain a major concern [1]. Although robotic-assisted radical prostatectomy (RARP) has enthusiastically become the treatment of choice because of the large promotional campaigns, the outcomes of this costly procedure have failed to meet the expectations of both physicians and patients alike. Despite recent reports suggesting that RARP may be associated with more favorable erectile function outcomes when compared with open radical prostatectomy (RP) [2], erectile dysfunction continues to be the most commonly reported health-related quality of life issue among prostate cancer survivors [1]. Since the introduction of the neurovascular bundle (NVB) and nerve-sparing (NS) RP technique by Walsh and Donker [3] in 1982, this area has become the major focus of surgeons looking to preserve erectile function in patients undergoing RP. Numerous studies have demonstrated that NVB preservation is associated with improved erectile function outcomes after RP. However, those studies typically grouped the NS status into one of three categories: bilateral, unilateral, or none. This method of classification has been criticized for its validity and reliability in predicting post-RP erectile function, and several authors have proposed that the surgeons’ subjective sense of intraoperative NVB sparing quality may actually be a more precise predictor of erectile function preservation and recovery.

Landmarks in erectile function recovery after radical prostatectomy.

The description of the nerve-sparing technique of radical prostatectomy by Walsh was one of the major breakthroughs in the surgical treatment of prostate cancer in the 20(th) century. However, despite this advance and consequent technological refinements to nerve-sparing surgery, a large proportion of men still suffer from erectile dysfunction (ED) as a complication of prostatectomy. A plethora of therapeutic approaches have been proposed to optimize erectile function recovery in these patients. Several preclinical and translational studies have shown benefits of therapies including PDE5 inhibitor (PDE5I) treatment, immunomodulation, neurotrophic factor administration, and regenerative techniques, such as stem cell therapy, in animal models. However, most of these approaches have either failed to translate to clinical use or have yet to be studied in human subjects. Penile rehabilitation with PDE5Is is currently the most commonly used clinical strategy, in spite of the absence of solid clinical evidence to support its use.

V11-14 LAPARO-ENDOSCOPIC SINGLE SITE (LESS) PLUS ONE PORT (POP) RADICAL PROSTATECTOMY

You have accessJournal of UrologyAdrenal/Single Port Surgery/LESS/NOTES1 Apr 2015V11-14 LAPARO-ENDOSCOPIC SINGLE SITE (LESS) PLUS ONE PORT (POP) RADICAL PROSTATECTOMY Alexander Tsivian, Roman Bass, Yury Stanevsky, Matvey Tsivian, Mohammed Shahwan, Dmitry Khunovitch, Shalva Benjamin, and Ami Sidi Alexander TsivianAlexander Tsivian More articles by this author , Roman BassRoman Bass More articles by this author , Yury StanevskyYury Stanevsky More articles by this author , Matvey TsivianMatvey Tsivian More articles by this author , Mohammed ShahwanMohammed Shahwan More articles by this author , Dmitry KhunovitchDmitry Khunovitch More articles by this author , Shalva BenjaminShalva Benjamin More articles by this author , and Ami SidiAmi Sidi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2612AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical prostatectomy is the gold standard treatment for prostate cancer. In recent years, technological advances have permitted to decrease the number of ports used in laparoscopic surgeries down to a single port. Still, there is a technical difficulty performing these surgeries due to lack of triangulation of the instruments and their clashing outside and within the patient's body. Herein, we present a video that demonstrates the surgical technique of LESS POP radical prostatectomy. METHODS From February to August 2014, 19 consecutive patients underwent radical prostatectomy by this technique. We describe the surgical technique as well as tips and tricks for this procedure. RESULTS Patients' age ranged between 55-75 years (mean-63.3). The surgery duration was between 165-300 minutes (mean-240). One patient underwent concomitant umbilical hernia repair. The average hospital stay was 3 days (range 2-7). In 15 patients (79%), the catheter was removed after 7 days. In 4 other patients, the catheter was left indwelling longer- in 3 due to urine leak and in 1 because of rectal injury and lymphorrhea. Positive margins were identified in 6 patients. There were no conversions to standard laparoscopic or open surgery. In 4 cases an additional 5 mm trocar was used. In 2 -due to difficulty to progress with dissection. In one case due to the need to expedite the surgery in a patient with anesthesia difficulties (patient with severe COPD) and in another it was required for suturing a rectal injury. Pathology: Gleason 6,7,8,9 was in 7,9,1 and 2 cases respectively, stage pT2b, pT3a and pT3b was in 13,3 and 3 respectively. Ten patients underwent lymph node dissection ( mean 15.4 nodes ). In the follow-up period that ranged between 1 to 7 months continence rate is 80% CONCLUSIONS We described a new and innovative laparoscopic technique for treating prostate cancer. This technique has the advantages of a minimally invasive procedure without oncological rules compromise. It enables the triangulation of the instruments and is ergonomically better and more comfortable for the surgeon. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e911 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Tsivian More articles by this author Roman Bass More articles by this author Yury Stanevsky More articles by this author Matvey Tsivian More articles by this author Mohammed Shahwan More articles by this author Dmitry Khunovitch More articles by this author Shalva Benjamin More articles by this author Ami Sidi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP42-20 PATHOLOGIC OUTCOMES OF CANDIDATES FOR ACTIVE SURVEILLANCE UNDERGOING RADICAL PROSTATECTOMY: RESULTS FROM A CONTEMPORARY TURKISH PATIENT COHORT

You have accessJournal of UrologyProstate Cancer: Localized I1 Apr 2015MP42-20 PATHOLOGIC OUTCOMES OF CANDIDATES FOR ACTIVE SURVEILLANCE UNDERGOING RADICAL PROSTATECTOMY: RESULTS FROM A CONTEMPORARY TURKISH PATIENT COHORT Ilker Tinay, Guven Aslan, Ali Riza Kural, Haluk Ozen, Bulent Akdogan, Asif Yildirim, Ozdal Dillioglugil, Tarik Esen, Ferruh Zorlu, and Levent Turkeri Ilker TinayIlker Tinay More articles by this author , Guven AslanGuven Aslan More articles by this author , Ali Riza KuralAli Riza Kural More articles by this author , Haluk OzenHaluk Ozen More articles by this author , Bulent AkdoganBulent Akdogan More articles by this author , Asif YildirimAsif Yildirim More articles by this author , Ozdal DillioglugilOzdal Dillioglugil More articles by this author , Tarik EsenTarik Esen More articles by this author , Ferruh ZorluFerruh Zorlu More articles by this author , and Levent TurkeriLevent Turkeri More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1605AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate the pathological outcomes of Turkish men meeting criteria for AS, who elected immediate radical prostatectomy (RP) to assess the risk of under-grading and under-staging in candidates for AS. METHODS Criteria for potential AS was defined as: clinical stage T2 or lower, PSA 15 ng/mL or lower, Gleason sum 6 or lower(without 4 as primary or secondary), total biopsy cores 8 or more, 33.3% or lower tumor positive cores on biopsy pathology and with at least 2 years follow-up after RP. The primary outcomes were pathological up-staging, defined as the occurrence of extracapsular extension (T3a) or seminal vesicle involvement (T3b), and pathological up-grading, defined as a Gleason sum 7 or higher. Regarding the study design, all data were submitted online by the investigator of participating instutition to the database, which is created specifically for this study within the “Association of Urooncology, Turkey”. RESULTS Of the 1,212 patients, 981 met study inclusion criteria. Mean PSA level was 6.89 (0.51-15) ng/mL and mean biopsy core number was 12 (8-47). Mean tumor positive cores on final biopsy pathology were 1.95 (1-6) cores [16.6%(2.1-33.3%)]. The RP technique was open, laparoscopic and robotic surgery in 744, 24 and 134, respectively. A total of 368 men (37.5%) underwent pelvic lymph node dissection and only 1 patient (0.2%) had tumor invasion at the final RP pathology. Overall 30.6 % of the men experienced a Gleason sum upgrade and 11.5% had pathological up-staging (figure). A total of 24 men (2.7%) died during follow-up from other causes. A total of 10 patients (1%) underwent radiotherapy with hormonal treatment and had a higher mean PSA level (7.85 vs. 6.89) with higher mean tumor positive core percentage (20.2% vs. 16.6%). A total of 22 patients (2.4%) received only adjuvant radiotherapy and had a higher mean PSA level (7.3 vs. 6.89) but lower mean tumor positive core percentage (15.6% vs. 16.6%). In the remaining 863 patients, who did not received any adjuvant treatment, 26 (3%) experienced PSA failure at a mean time of 35 months (12-88) after the surgery. CONCLUSIONS In conclusion, up-grading and up-staging at RP is common among Turkish men with low-risk PCa, who are candidates for AS. Most Turkish men with low-risk PCa treated with RP experience long-term PSA control. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e517 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ilker Tinay More articles by this author Guven Aslan More articles by this author Ali Riza Kural More articles by this author Haluk Ozen More articles by this author Bulent Akdogan More articles by this author Asif Yildirim More articles by this author Ozdal Dillioglugil More articles by this author Tarik Esen More articles by this author Ferruh Zorlu More articles by this author Levent Turkeri More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP83-05 THE EFFECT OF NERVE-SPARING ON URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY: IS IT THE PRESERVATION OF THE NEUROVASCULAR BUNDLES OR THE SURGICAL TECHNIQUE WHICH LEADS TO IMPROVED CONTINENCE RATES?

You have accessJournal of UrologyProstate Cancer: Localized IX1 Apr 2015MP83-05 THE EFFECT OF NERVE-SPARING ON URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY: IS IT THE PRESERVATION OF THE NEUROVASCULAR BUNDLES OR THE SURGICAL TECHNIQUE WHICH LEADS TO IMPROVED CONTINENCE RATES? Derya Tilki, Sascha Ahyai, Pierre Tennstedt, Markus Graefen, Hartwig Huland, and Uwe Michl Derya TilkiDerya Tilki More articles by this author , Sascha AhyaiSascha Ahyai More articles by this author , Pierre TennstedtPierre Tennstedt More articles by this author , Markus GraefenMarkus Graefen More articles by this author , Hartwig HulandHartwig Huland More articles by this author , and Uwe MichlUwe Michl More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1880AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The effect of the preservation of the neurovascular bundles (NVB) during radical prostatectomy (RP) on continence remains controversial. We hypothesized that the differing surgery techniques of nerve-sparing versus non nerve-sparing RP and not the preservation of the NVB itself may be responsible for differences in continence rates. METHODS A total of 16734 who underwent RP from 2002 to 2014 in a single high-volume center were retrospectively analyzed. The following three patient groups were studied: Patients with bilateral nerve-sparing (NS) RP, patients with primary non nerve-sparing (NNS) RP and patients with bilateral secondary resection of the NVBs for positive frozen section results after an initial bilateral nerve-sparing (secNNS) RP. Propensity score-matched analysis adjusting for age, prostate volume and year of surgery was performed to assess differences in continence rates 1 week, 3 months and 12 months after RP between the different study groups. Continence was defined as the use of 0 or 1 safety pad per day. RESULTS Urinary continence rates at 1 week / 3 months / 12 months after surgery were 50.0%/77.4%/88.7%, 32.1%/52.8%/75.5% and 39.6%/61.3%/86.8% in the NS, NNS and secNNS groups, respectively. In the propensity score matched analysis, urinary continence rates at 12 months post-surgery did not significantly differ between patients who had bilateral NS and patients who had resection of both NVBs after an initial nerve-sparing technique (secNNS). In contrast, when comparing the non nerve-sparing study groups with initial NNS versus secondary NNS (secNNS), the secNNS group had significantly higher continence rates even after 12 months. CONCLUSIONS Our results indicate that the meticulous apical dissection associated with the nerve-sparing RP technique rather than the preservation of the NVBs itself may have a positive impact on long-term urinary continence rates. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1051 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Derya Tilki More articles by this author Sascha Ahyai More articles by this author Pierre Tennstedt More articles by this author Markus Graefen More articles by this author Hartwig Huland More articles by this author Uwe Michl More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Recent Developments in Minimally Invasive Radical Prostatectomy

Minimally invasive surgery has gained a dominant status in prostate cancer surgery during the last decade. The benefits of minimally invasive prostatectomy were demonstrated by pioneers of conventional laparoscopic prostatectomy, however, the real domination of laparoscopy in radical prostatectomy (RP) started after the dissemination of robotic surgery. Robot-assisted surgery still remains the most widespread method to perform minimally invasive RP, although the recent evolution of laparoscopic technology and instruments has evoked interest in conventional laparoscopy again. The recent developments in the technique of RP are focused on decreasing invasiveness and complications. The recent methods to improve postoperative functional outcome of RP can be utilised without compromising the oncological results.

Urinary Continence Outcomes after Puboprostatic Ligament Preserving Open Retropubic Radical Prostatectomy at a Sub-Saharan Hospital.

Background. Open retropubic radical prostatectomy is a commonly performed procedure for clinically localized prostate cancer. The demand for high level functional outcomes after therapy is increasing especially for young age patients; in this regard refinements in the surgical technique have been made. There is limited data to show the success of some of these refinements in resource limited settings. Methods. A retrospective clinical study was performed over a 2-year period at Mengo Hospital, Urology Unit. Men with clinically localized prostate cancer and who consented to the procedure were eligible and were recruited. Consequently excluded were those that turned out to have advanced disease and those with severe comorbidities. Patients were followed up for 3 months after surgery. Data was entered using SPSS version 17 and analyzed. Results. A total of 24 men with clinically localized prostate cancer underwent open retropubic puboprostatic ligament preserving radical prostatectomy technique. Mean age was 66, range 54–75 years. Outcome. Two patients had stress incontinence and three were incontinent at 3 months. The urinary continence recovery rate was 19/24 (79%) at 3 months. Conclusion. Preservation of the puboprostatic ligament in open retropubic radical prostatectomy was associated with rapid and a high rate of return to urinary continence among men with clinically localized disease.

Association of anesthesia technique for radical prostatectomy with biochemical recurrence: a retrospective cohort study.

Anesthesia technique has been associated with cancer outcomes after radical prostatectomy (RP). These studies are limited by variability in surgeon experience, bias in patient selection, and in some cases, sample size. We evaluated the impact of anesthesia technique for RP on biochemical recurrence (BCR) using a large cohort of patients operated on by a single experienced surgeon. We retrospectively reviewed data from a prospective institutional oncologic database on 929 patients treated with RP by a single surgeon from 1999-2008. Spinal anesthesia was used for patients from 2002-2006. We compared outcomes of these patients (n = 264) with outcomes of patients who underwent general anesthesia (n = 665) at Memorial Sloan-Kettering Cancer Center from 1999-2001 and 2006-2008. Cox proportional hazards regression was used to assess differences in BCR rates between the anesthesia groups adjusting for differences in postoperative factors related to anesthetic technique and tumour pathologic characteristics associated with BCR after RP. Median follow-up among patients free from BCR was 4.6 yr. On multivariable analysis, spinal anesthesia did not independently predict the rate of BCR (hazard ratio = 1.10; 95% confidence interval 0.7 to 1.74; P = 0.7). Independent predictors of BCR were preoperative prostate-specific antigen (PSA), pathologic Gleason grade, extracapsular extension, and seminal vesicle invasion. We did not find an association between anesthesia technique and disease recurrence in men with prostate cancer treated with RP. Anesthesia technique is unlikely to alter disease recurrence following RP independent of surgical and pathological factors.

Preservation of the internal vesical sphincter and proximal urethra during retropubic radical prostatectomy may improve earlier recovery of continence in selected patients

ObjectivesTo evaluate the influence of preservation of the muscular internal sphincter and proximal urethra on continence recovery after radical prostatectomy (RP). Materials and methodsFifty-five consecutive patients with organ confined prostate cancer were submitted to RP with the preservation of muscular internal sphincter and the proximal urethra (group 1) and compared to 55 patients submitted to standard procedure (group 2). Continence rates were assessed using a self-administrated questionnaire at 3, 7, 30 days and 3, 12 months after removal of the catheter. ResultsGroup 1 had a faster recovery of continence than group 2 at 3 days (50.9% vs. 25.5%; p=.005), at 7 days (78.2% vs. 58.2%; p=.020), at 30 days (80.0% vs. 61.8%; p=.029) and at 3 months (81.8% vs. 61.8%; p=.017); there were no statistical difference in terms of continence at 12 months among the two groups. Multivariate logistic regression analysis of continence showed that surgical technique was significantly associated with earlier time to continence at 3 and 7 days. The two groups had no significant differences in terms of surgical margins. ConclusionsOur modified technique of RP with preservation of smooth muscular internal sphincter as well as of the proximal urethra during bladder neck dissection resulted in significantly increased early urinary continence at 3, 7, 30 days and 3 months after catheter removal. The technique does not increase the rate of positive margins and the duration of the procedure.

Urologist 2.0: how to lead the change

Modern urology started about 150 years ago in France, with a strong contribution made by other European countries including Italy. The figure of the modern urologist is linked to a technological evolution but also to the contribution made by great men who have played a crucial role in the evolution of the surgical technique and in the clinical approach to the discipline. An analysis of the evolution of the surgical technique of radical prostatectomy can be paradigmatic in describing the development and, above all, the direction of the hyper-specialization concerning the urologic discipline. To this kind of centrifugal fragmentation is associated a fragmentation at the scientific level which can be defined as centripetal, with a multiplicity of national societies that ultimately complicate the management of the urology discipline. This pathway, made up of divisions and hyper-specializations, contrasts with another less travelled one, which foresees a drastic revision of the figure of the urologist and of the urological discipline in its totality. One which places the patient at the center of the scene, and not only his pathology. Urology cannot become the mere execution of surgical acts, and the objective of our National Residency Programmes should not be solely to form the "perfect surgeon", but to produce a complete specialist able to manage prevention and a correct diagnosis and to guarantee a therapeutic approach including the uro-andrological follow-up of the patient. It is necessary that both basic research and translational research become an integral part of the formative baggage of the young urologist.

The effects of retropubic and perineal radical prostatectomy techniques on postoperative urinary continence after surgery: Results of 196 patients.

The aim of this study was to examine the effects of the retropubic and perineal radical prostatectomy techniques on postoperative urinary continence. This study included patients who had undergone radical retropubic (RRP) (n=54) or radical perineal prostatectomies (RPP) (n=142) in our clinic between December 2006 and December 2010 with the indication of localized prostate cancer. Preoperative, and postoperative continence levels of the patients were evaluated on the day of catheter removal, and at 3., 6. or 12. months using University of California-Los Angeles (UCLA) prostate cancer index query forms completed by the patients themselves in outpatient clinics. Mean ages of the perineal, and retropubic groups were 62.3 (48-77), and 62.5 (50-74) years, respectively. The absolute urinary control rates of the RPP patients on the first days, and the first, third, sixth, and twelfth months were 44.3, 63.6, 76.2, 79.5, and 86.1%, respectively. The same rates were 51.4, 75.7, 78.4, 89.2, and 91.9% for the RRP group, respectively. There was no significant difference between RRP groups as for the frequency of urinary incontinence.

A Literature-Based Analysis of the Learning Curves of Laparoscopic Radical Prostatectomy

There is a trend for the increased adoption of minimally invasive techniques of radical prostatectomy (RP) – laparoscopic (LRP) and robotic assisted (RARP) – from the traditional open radical retropubic prostatectomy (ORP), popularised by Partin et al. Recently there has been a dramatic expansion in the rates of RARP being performed, and there have been many early reports postulating that the learning curve for RARP is shorter than for LRP. The aim of this study was to review the literature and analyse the length of the LRP learning curves for the various outcome measures: perioperative, oncologic, and functional outcomes. A broad search of the literature was performed in November 2013 using the PubMed database. Only studies of real patients and those from 2004 until 2013 were included; those on simulators were excluded. In total, 239 studies were identified after which 13 were included. The learning curve is a heterogeneous entity, depending entirely on the criteria used to define it. There is evidence of multiple learning curves; however the length of these is dependent on the definitions used by the authors. Few studies use the more rigorous definition of plateauing of the curve. Perioperative learning curve takes approximately 150-200 cases to plateau, oncologic curve approximately 200 cases, and the functional learning curve up to 700 cases to plateau (700 for potency, 200 cases for continence). In this review, we have analysed the literature with respect to the learning curve for LRP. It is clear that the learning curve is long. This necessitates centralising LRP to high volume centres such that surgeons, trainees, and patients are able to utilise the benefits of LRP.

Challenges of managing elderly men with prostate cancer.

The incidence of prostate cancer increases with age. Current evidence suggests that prostate cancer is under treated in patients aged ≥70 years, despite evidence of efficacy and acceptable toxicity. Radical cystectomy and definitive radiotherapy are often denied owing to fears of post-operative complications and radiotherapy-associated gastrointestinal and genitourinary toxicity. However, modern radical prostatectomy techniques provide excellent clinical outcomes with low perioperative morbidity. Moreover, volume-restricted intensity-modulated radiation therapy is a significant improvement over previous 2D conformal radiotherapy with similar efficacy and lower toxicity. Androgen-deprivation therapy is also under-prescribed among the elderly, owing to concerns of increases in cardiac deaths and osteoporosis acceleration. However, prospective trials have not identified any increase in cardiovascular mortality among elderly men receiving androgen-deprivation therapy compared to age-matched controls. Most patients on androgen deprivation eventually progress to a castration-resistant state. At this stage, the disease still responds to newer agents that target the androgen pathway and to chemotherapy. Among the elderly, chemotherapy is under-prescribed even though it has been demonstrated to be palliative and improve survival. We describe the trends in prostate cancer management in the elderly and the importance of assessing comorbidity status, tumour characteristics, and health status, including a complete geriatric evaluation, before making treatment recommendations.

Do we need the nerve sparing radical prostatectomy techniques (intrafascial vs. interfascial) in men with erectile dysfunction? Results of a single-centre study

To report effect of different nerve sparing techniques (NS) during radical prostatectomy (RP) (intrafascial-RP vs. interfascial-RP) on post-RP incontinence outcomes (UI) in impotent/erectile dysfunction (ED) men. A total of 420 impotent/ED patients (International Index of Erectile Function-score <15) with organ-confined prostate cancer were treated with bilateral-NS [intrafascial-RP (239) or interfascial-RP (181)] in our institution. Intrafascial-RP was indicated for biopsy Gleason score ≤6 and PSA ≤10 ng/ml while interfascial-RP for Gleason score ≤7 and higher serum PSA. Seventy-seven patients with bilateral non-NS-RP were taken for comparison. No patient received pre-/postoperative radiation/hormonal therapy or had prostatic enlargement surgery. UI was assessed 3, 12 and 36 months postoperatively by third party. Continence was defined as no pads/day, safety 1 pad/day as separate group, 1-2 pads/day as "mild-incontinence" and >2 pads/day as "incontinence". All groups had comparable perioperative criteria without significant preoperative morbidities. International Prostate Symptom Score showed severe symptoms in 5 % of patients without correlation to UI. UI-recovery increased until 36 months. Full continence was reported from 56 versus 62 and 53 % patients after intrafascial-RP versus interfascial-RP and wide excision at 3 months, respectively (p = 0.521). Corresponding figures at 12 months were 70 versus 61 versus 51 % (p = 0.114) and at 36 months 85 versus 75 versus 65 % (p = 0.135), respectively. After 12 and 36 months, there was tendency to better UI-results in advantage of NS-technique; best results were achieved in intrafascial-RP group. UI-recovery was age-dependant. Advantage was found in NS-group compared with non-NS-group in older patients (>70 years, p = 0.052). Impotent/ED patients have higher chances of recovering full continence after NS-RP. NS should be planned independently of preoperative potencystatus whenever technically and oncologically feasible. Age and lower urinary symptoms are not restrictions. Current data should be considered in preoperative patient counselling.

La preservación del esfínter interno vesical y la uretra proximal durante la prostatectomía radical retropúbica puede mejorar la recuperación temprana de la continencia en pacientes seleccionados

ObjectivesTo evaluate the influence of preservation of the muscular internal sphincter and proximal urethra on continence recovery after radical prostatectomy (RP). Material and methodsFifty-five consecutive patients with organ confined prostate cancer were submitted to RP with the preservation of muscular internal sphincter and the proximal urethra (group 1) and compared to 55 patients submitted to standard procedure (group 2). Continence rates were assessed using a self-administrated questionnaire at 3, 7, 30 days and 3, 12 months after removal of the catheter. ResultsGroup 1 had a faster recovery of continence than group 2 at 3 days (50.9% vs. 25.5%; P=.005), at 7 days (78.2% vs. 58.2%; P=.020), at 30 days (80.0% vs. 61.8%; P=.029) and at 3 months (81.8% vs. 61.8%; P=.017); there were no statistically difference in terms of continence at 12 months among the two groups. Multivariate logistic regression analysis of continence showed that surgical technique was significantly associated with earlier time to continence at 3 and 7 days. The two groups had no significant differences in terms of surgical margins. ConclusionsOur modified technique of RP with preservation of smooth muscular internal sphincter as well as of the proximal urethra during bladder neck dissection resulted in significant increased early urinary continence at 3, 7, 30 days and 3 months after catheter removal. The technique does not increase the rate of positive margins and the duration of the procedure.

Bladder neck contracture-incidence and management following contemporary robot assisted radical prostatectomy technique

Purpose:Bladder neck contracture (BNC) is a well-recognized complication following robot-assisted radical prostatectomy (RARP) for treatment of localized prostate cancer with a reported incidence of up to 1.4%. In this series, we report our institutional experience and management results.Methods:A prospectively collected database of patients who underwent RARP by a single surgeon from 2006 to 2012 was reviewed. Watertight bladder neck to urethral anastomosis was performed over 18-French foley catheter. BNC was diagnosed by flexible cystoscopy in patients who developed symptoms of bladder outlet obstruction. Subsequently, these patients underwent cold knife bladder neck incisions. Patients then followed a strict self regimen of clean intermittent catheterization (CIC). We identify the patient demographics, incidence of BNC, associated risk factors and success of subsequent management.Results:Total of 930 patients who underwent RARP for localized prostate cancer was identified. BNC was identified in 15 patients, 1.6% incidence. Mean patient age and preoperative prostate-specific antigen was 58.8 years old and 7.83 ng/mL (range, 2.5–14.55 ng/mL) respectively. Mean estimated blood loss was 361±193 mL (range, 50–650 mL). Follow-up was mean of 23.4 months. Average time to BNC diagnosis was 5.5 months. In three patients, a foreign body was identified at bladder neck. On multivariate analysis, estimated blood loss was significantly associated with development of BNC. All patients underwent cystoscopy and bladder neck incision with a 3-month CIC regimen. Out of 15 index patients, none had a BNC recurrence over the follow-up period.Conclusions:BNC was identified in 1.6% of patients in our series following RARP. Intraoperative blood loss was a significant risk factor for BNC. In 20% of BNC patients a migrated foreign body was noted at vesicourethral anastomosis. Primary management of patients with BNC following RARP should be bladder neck incision and self CIC regimen.

Impact of surgical case order on perioperative outcomes for robotic-assisted radical prostatectomy.

Objectives:Since its introduction, there have been many refinements in the technique and implementation of robotic-assisted radical prostatectomy (RARP). However, it is unclear whether operative outcomes are influenced by surgical case order. We evaluated the effect of case order on perioperative outcomes for RARP within a large health maintenance organization.Materials and Methods:We conducted a retrospective review of RARP cases performed at our institution from September 2008 to December 2010 using a single robotic platform. Case order was determined from surgical schedules each day and surgeries were grouped into 1st, 2nd and 3rd round cases. Fourth round cases (n = 1) were excluded from analysis. We compared clinicopathological variables including operative time, estimated blood loss (EBL), surgical margin rates and complication rates between groups.Results:Of the 1018 RARP cases in this cohort, 476 (47%) were performed as 1st round cases, 398 (39%) 2nd round cases and 144 (14%) 3rd round cases by a total of 18 surgeons. Mean operative time was shorter as cases were performed later in the day (213 min vs. 209 min vs. 180 min, P < 0.0001) and similarly, EBL also decreased with surgical order (136 mL vs. 134 mL vs. 103 mL, P = 0.01). Transfusion rates, surgical margin rates and complication rates did not significantly differ between groups. Patients undergoing RARP later in the day were much more likely to have a hospital stay of 2 or more days than earlier cases (10% vs. 11% vs. 32%, P = 0.01).Conclusions:Surgical case order may influence perioperative outcomes for RARP with decreased operative times and increased length of hospital stay associated with later cases. These findings indicate that select perioperative factors may improve with ascending case order as the surgical team “warms up” during the day. In addition, 3rd round cases can increase hospital costs associated with increased lengths of hospital stay. Knowledge of these differences may assist in surgical planning to improve outcomes and limit costs.

Robot-assisted radical prostatectomy: modified ultradissection reduces pT2 positive surgical margins on the bladder neck.

The purpose of this study was to compare the positive surgical margin (PSM) rates of 2 techniques of robot-assisted radical prostatectomy (RARP) for pT2 (localized) prostate cancer. A retrospective analysis was conducted of 361 RARP cases, performed from May 2005 to September 2008 by a single surgeon (KHR) at our institution (Yonsei University College of Medicine). In the conventional technique, the bladder neck was transected first. In the modified ultradissection, the lateral border of the bladder neck was dissected and then the bladder neck was transected while the detrusor muscle of the bladder was well visualized. Perioperative characteristics and outcomes and PSM rates were analyzed retrospectively for pT2 patients (n＝217), focusing on a comparison of those undergoing conventional (n＝113) and modified ultradissection (n＝104) techniques. There was no difference between the conventional and modified ultradissection group in mean age, BMI, PSA, prostate volume, biopsy Gleason score, and D'Amico prognostic criteria distributions. The mean operative time was shorter (p＜0.001) and the estimated blood loss was less (p＜0.01) in the modified ultradissection group. The PSM rate for the bladder neck was significantly reduced by modified ultradissection, from 6.2% to 0% (p＜0.05). In conclusion, modified ultradissection reduces the PSM rate for the bladder neck.

Modified radical retropubic prostatectomy: Personal technical variation “tension free continuum-urethral anastomosis (T.F.C.U.A)” with optical magnification in the preservation of the bladder neck, and estimation of the urinary continence

To reassess the double continence technique for open retropubic radical prostatectomy, proposed by Malizia and employed by Pagano et al., with the "tension free continuum-urethral anastomosis" (T.F.C.U.A.) personal modification and the use of image magnification optical systems and appropriate and delicate surgical tools. A total of 173 radical retropubic prostatectomies, performed by the same surgeon, were evaluated in terms of early and late continence. The presence of residual prostate cancer cells within the muscle layer was always excluded by the histopathological examination that also demonstrated that the muscle layer was well represented; satisfactory outcomes were obtained in terms of both early urinary continence (60%) and urinary continence at 6-12 month follow-up (92.4% for the whole series and 97.2% for the last series of patients). The "tension free" anastomosis obtained by the suspension of the anterior bladder wall to the the pubis along the median line allowed to achieve satisfactory outcomes in terms of urinary continence, even if these data obviously need to be confirmed by other series and comparative trials.

Assessing the extirpative quality of a radical prostatectomy technique: categorisation and mapping of technical errors

To examine the extirpative quality of an open radical prostatectomy (RP) technique by first categorising and mapping all intraprostatic incisions into benign tissue and then determining a cumulative technical error rate given by all intraprostatic incisions into benign and malignant tissue. We performed a retrospective review of prospectively collected data relating to 1065 men with clinically localised prostate cancer who underwent open retropubic RP (70.6% nerve-sparing surgery [NSS]) by a single surgeon (January 2005 to December 2011). We recorded all intraprostatic incisions: (i) iatrogenic positive surgical margins (PSMs), (ii) deep or superficial benign capsular incisions (BCIs), (iii) incisions into benign prostate glands at the prostate apex or bladder neck (benign glandular tissue incisions [BGTIs]), and determined incision location, length and nature (solitary/multiple). We evaluated: (i) associations between benign incisions, NSS and PSMs, (ii) significant predictors for PSM risk by multivariate analysis, (iii) postoperative biochemical recurrence (BCR)-free survival (Kaplan-Meier method). Intraprostatic incision rates were 2.3% pT2 PSMs, 6.0% BCIs and 5.4% BGTIs. There were slight variations in rate over time and with NSS technique. Benign incisions were located as follows: 46.8% right posterolateral, 37.5% left posterolateral, and 15.7% bilateral for BCIs; 58.6% bladder neck and 41.4% apical for BGTIs. The median (range) incision length, for solitary and multiple incisions respectively, was 4 (1-13) and 9 (2-25) mm for BCIs and 1 (1-5) and 2 (2-6) mm for BGTIs. BCI rate, but not BGTI rate, was significantly associated with NSS (P = 0.004) and PSM (P = 0.005), and increased PSM risk 3.6-fold. A PSM increased BCR risk two-fold (odds ratio 2.078, 95% confidence interval 1.383-3.122). BCR-free survival decreased significantly even for short PSMs (<1 mm; P < 0.001). Although the pT2 PSM rate was low (2.3%), the cumulative technical error rate (patients with at least one pT2 PSM, BCI or BGTI) was five-fold higher (12.5%). Categorising and mapping intraprostatic incisions is a tool surgeons can use in self-audits to identify areas of potential improvement, reduce errors, and improve surgical skills.