Retropubic Approach Research Articles

C-Clamp Technique: A Retrospective Review of a Novel Technique to Prevent Bladder Injury in Retropubic Midurethral Slings

ABSTRACT The original technique for mesh midurethral sling, which utilized a retropubic approach for sling placement, also recognized a risk of simultaneous iatrogenic bladder injury. While synthetic mesh midurethral slings have the criterion standard for SUI treatment, there is still no available technique that entirely eliminates the risk of bladder injury at the time of implantation. The retropubic approach holds a 0.7% to 34% rate of bladder injury. Some providers still opt for the transobturator approach because of a perceived decreased risk of intraoperative bladder perforation. This article describes the “C-clamp technique,” a method directly addressing the perceived key causes of bladder injury via the retropubic approach. This study aimed to determine bladder injury rates upon surgical implantation of retropubic synthetic mesh midurethral sling by 1 provider using the C-clamp technique. The article provides step-by-step instructions for this technique, as well as a link to a video (https://links.lww.com/FPMRS/A362). Briefly, the technique involves use of a deflecting catheter guide in steep Trendelenburg, “clamping” the pubis with the operator's nondominant hand to decrease the retropubic distance, and using the nondominant thumb on the inner curve of the trocar to guide the trocar passage toward the nondominant finger tips and suprapubic exit through the skin. This retrospective review identified 201 bottom-up retropubic synthetic mesh midurethral slings placed using the C-clamp technique between April 2012 and June 2022. General data collected included average age (51 years), average weight (46–139 kg), average body mass index (BMI, 15–57 kg/m2), and a range of prior surgical procedures and concomitant procedures. Approximately 15% of patients had a history of prior retropubic urethropexy or some form of midurethral sling. There were no lower urinary tract injuries in the entire cohort. Strengths of this study include its description of the C-clamp technique, the extremes and range of data points included within the study, and the 10-year range of the study. Limitations include its retrospective nature, the single surgeon provider, the vast majority of slings used produced by 1 manufacturer, and limited comprehensive data collection. Using data from 201 consecutive bottom-up synthetic mesh midurethral sling outcomes during a 10-year span, the authors argue that this technique addresses key anatomic issues contributing to bladder and urethral injury during placement of such slings, with a promising ability to eliminate bladder and urethral injury. Favorable data in a larger number of patients and by multiple providers could provide further support to this technique and support retropubic sling as a preferred method of midurethral sling.

MP80-16 BLACK PATIENTS HAVE WORSE CONTINENCE OUTCOMES AT 12 MONTHS FOLLOWING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP80-16 BLACK PATIENTS HAVE WORSE CONTINENCE OUTCOMES AT 12 MONTHS FOLLOWING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Findlay MacAskill, Majed Shabbir, Arun Sahai, Cathcart Paul, and Noel Jonathan Findlay MacAskillFindlay MacAskill More articles by this author , Majed ShabbirMajed Shabbir More articles by this author , Arun SahaiArun Sahai More articles by this author , Cathcart PaulCathcart Paul More articles by this author , and Noel JonathanNoel Jonathan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: It is known that racial disparities exist for oncological outcomes following prostate cancer, with black patients having a higher mortality. There remains a paucity of specific data regarding functional outcomes and ethnicity in robotic-assisted radical prostatectomy (RARP). The aim of this study was to investigate if racial disparity exists in outcomes following RARP at our institution, which covers a diverse population. METHODS: This single site study utilised an institution approved (10128) prospective database of patients that underwent primary RARP from 2020-2021 with a minimum follow up of 12 months. All 5 surgeons perform a retropubic approach. Logistic regression was performed to investigate the continence rate at 3, 6 and 12 months for significance (p<0.05). Continence is defined as 0 pads/24 hours. Further analysis was performed using propensity score matching for 12-month continence rate only. RESULTS: In this study, 232 men were included of which 37% (86) were black. On average black men underwent surgery at a younger age (59 versus 63 year). However, no difference was observed between black and white men for mean prostate volume, ISUP grade or T stage. While difference in urinary continence recovery was not significant at 3 months (36% versus 52%) and 6 months (49% versus 63%), recovery of urinary continence recovery was inferior for black men at 12 months after surgery (57% versus 75%, p=0.01). After propensity score matching, 95 white and 95 black patients were evaluated. Mean age was 61 (44-67) and 59 (43-73) years, ISUP grade 2.55 and 2.6, MRI 39 (16-112) and 28 (12-112) cc for white and black patients, respectively. Continence rate at 12 months was 76% and 60% (p=0.02), for respectively. CONCLUSIONS: The study demonstrates a racial disparity for return of urinary continence following robotic-assisted laparoscopic prostatectomy with black men having inferior recovery of urinary continence. Further work is required to investigate the reasons for the different outcome. Source of Funding: FM, MS and AS have received an unrestricted educational grant from Boston Scientific © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1159 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Findlay MacAskill More articles by this author Majed Shabbir More articles by this author Arun Sahai More articles by this author Cathcart Paul More articles by this author Noel Jonathan More articles by this author Expand All Advertisement PDF downloadLoading ...

Retropubic slings are more efficient than transobturator at 10-year follow-up: a Swedish register-based study

Introduction and hypothesisLong-term performance of mid-urethral slings (MUS) and potential differences between the retropubic and the transobturator technique for insertion are scarcely studied. This study aims to evaluate the efficacy and safety 10 years after surgery and compare the two main surgical techniques used.MethodsWomen who underwent surgery with a MUS between 2006 and 2010 were identified using the Swedish National Quality Register of Gynecological Surgery and were invited 10 years after the operation to answer questionnaires regarding urinary incontinence and its impact on quality-of-life parameters (UDI-6, IIQ-7) and impression of improvement, as well as questions regarding possible sling-related complications and reoperation.ResultsThe subjective cure rate reported by 2421 participating women was 63.3%. Improvement was reported by 79.2% of the participants. Women in the retropubic group reported higher cure rates, lower urgency urinary incontinence rates and lower UDI-6 scores. No difference was shown between the two methods regarding complications, reoperation due to complications or IIQ-7 scores. Persisting sling-related symptoms were reported by 17.7% of the participants, most commonly urinary retention. Mesh exposure was reported by 2.0%, reoperation because of the tape by 5.6% and repeated operation for incontinence by 6.9%, significantly more in the transobturator group (9.1% vs. 5.6%). Preoperative urinary retention was a strong predictor for impaired efficacy and safety at 10 years.ConclusionsMid-urethral slings demonstrate good results for the treatment of stress urinary incontinence and tolerable complication profiles in a 10-year perspective. The retropubic approach displays higher efficacy than the transobturator, with no difference regarding safety.

Does trocar puncture of the bladder during midurethral sling impact postoperative urinary storage and voiding symptoms?

The incidence of trocar bladder puncture during midurethral sling (MUS) surgery varies widely. We aim to further characterize risk factors for bladder puncture and examine its long-term impact on storage and emptying. This is an Institutional Review Board-approved, retrospective chart review of women who underwent MUS surgery at our institution from 2004 to 2018 with ≥12months of follow-up. Unless prolonged catheterization was necessary, a voiding trial was performed prior to discharge, or the next morning in outpatients, regardless of puncture. Preoperative and postoperative details were obtained from office charts and operative records. Of 1,500 women, 1,063 (71%) had retropubic (RP) and 437 (29%) had transobturator MUS surgery. Mean follow-up was 34months. Thirty-five women (2.3%) sustained a bladder puncture. RP approach and lower BMI were significantly associated with puncture. No statistical association was found between bladder puncture and age, previous pelvic surgery, or concomitant surgery. Mean day of discharge and day of successful voiding trial were not statistically different between the puncture and nonpuncture groups. There was no statistically significant difference in de novo storage and emptying symptoms between the two groups. Fifteen women in the puncture group had cystoscopy during follow-up and none had bladder exposure. Level of the resident performing trocar passage was not associated with bladder puncture. Lower BMI and RP approach are associated with bladder puncture during MUS surgery. Bladder puncture is not associated with additional perioperative complications, long-term urinary storage/voiding sequelae, or delayed bladder sling exposure. Standardized training minimizes bladder punctures in trainees of all levels.

A kismedencei szervek süllyedésének és a női terheléses vizeletvesztésnek a konzervatív és sebészi kezelése Magyarországon.

As clinical guidelines are available for the treatment of stress urinary incontinence, but not pelvic organ prolapse, in Hungary, the treatment of pelvic organ prolapse varies widely throughout the country and is not standardized. Due to the establishment of the Hungarian Continence and Urogynecological Association, we aimed to determine current conservative and surgical treatment trends and strategies for these conditions in Hungary and compare them with international practice. An online questionnaire consisting of 20 multiple-choice, checkbox, multiple-choice grid, and short-answer items was sent to 40 urology and 65 gynecology departments in Hungary in September and October 2021. The overall response rate was 24.76%. Almost all (96.15%) respondents reported that conservative treatment options were offered as first-line therapy to patients with symptomatic pelvic organ prolapse. For symptomatic anterior-wall prolapse, anterior repair, and laparoscopic sacrohysteropexy/sacrocolpopexy were the preferred surgical options (by 28.96% and 27.42% of respondents, respectively). For apical prolapse, laparoscopic sacrofixation was the first-choice treatment (35.88%). For stress urinary incontinence, mid-urethral sling insertion with a transobturator (61.53%) or retropubic (15%) approach was the preferred intervention. The low overall response rate in this study alone reflects the current condition of Hungarian urogynecology. Our findings might provide a good basis for the improvement and refinement of diagnosis and therapy for female urinary incontinence and pelvic organ prolapse in the country. As Hungary is a new affiliated partner of the European Urogynecological Association, we hope that this goal can be achieved soon. In addition, a curriculum for urogynecological specialization is needed. Orv Hetil. 2022; 163(52): 2072-2078.

Robot-assisted laparoscopic abdominoperineal resection with en bloc prostatectomy using the Retzius-sparing robot-assisted radical prostatectomy technique.

The best surgical technique for rectal cancer invading the prostate remains controversial. Rectal resection with en bloc prostatectomy using a standard retropubic approach is an option but has disadvantages. We report a new surgical procedure applying Retzius-sparing robot-assisted radical prostatectomy. First, the rectum was mobilized mainly at its dorsal side. Next, the prostate was separated from the bladder and urethra via the pouch of Douglas approach without opening the Retzius cavity, after which the surgical specimen was extracted through the perineal wound. Lateral pelvic lymph node dissection was performed after vesicourethral anastomosis. This new robotic procedure minimizes surgical trauma and preserves normal pelvic anatomy. Furthermore, this approach makes it easy to perform subsequent lateral pelvic lymph node dissection.

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence.

To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m2), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

PD22-04 LONG-TERM FOLLOW-UP AND FUNCTIONAL OUTCOMES OF THE T PLASTY FOR RECALCITRANT BLADDER NECK STENOSES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (PD22)1 Sep 2021PD22-04 LONG-TERM FOLLOW-UP AND FUNCTIONAL OUTCOMES OF THE T PLASTY FOR RECALCITRANT BLADDER NECK STENOSES Frederik König, Roland Dahlem, Phillip Marks, Lennart Kühnke, Maryam Khonsari, Margit Fisch, and Malte W. Vetterlein Frederik KönigFrederik König More articles by this author , Roland DahlemRoland Dahlem More articles by this author , Phillip MarksPhillip Marks More articles by this author , Lennart KühnkeLennart Kühnke More articles by this author , Maryam KhonsariMaryam Khonsari More articles by this author , Margit FischMargit Fisch More articles by this author , and Malte W. VetterleinMalte W. Vetterlein More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002011.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is a non-negligible proportion of men with recalcitrant bladder neck stenoses following treatment for benign prostatic hyperplasia (BPH) refractory to transurethral resections. We here present the long-term follow-up of our T-shaped modification of the YV plasty. METHODS: We included men with recurrent bladder neck stenoses following transurethral treatment for BPH who underwent the T plasty between 2008-19. Via a retropubic approach, the anterior bladder wall is opened by a T-shaped incision after scar excision and two well-vascularized bladder wall flaps are connected to the prostatic apex. This is supplemented by dorsal mucomucosal anastomosis of trigone and the prostatic cavity. We assessed clinical and surgical parameters to characterize our cohort. Validated patient-reported outcomes (ICIQ-UI SF, 6-item LUTS score, and treatment satisfaction) were assessed and recurrence was defined as surgical re-intervention due to recurrence at the bladder neck. RESULTS: Overall, 48 men underwent T plasty at a median age of 69 yr and 26 men (54%) had a Charlson index of 0. Median number of prior bladder neck resections was 3 (IQR 2–4) and median time from last resection was 5 mo (IQR 4–8). Of all patients, 9 (18%) had a hx of previous open urethral reconstruction and 4 (8.4%) were redo procedures with hx of previous YV plasty. At admission, 36 (75%) had a suprapubic catheter and median preoperative Qmax was 7.3 ml/s. Median operative time was 98 min, the procedure was performed by two experienced reconstructive surgeons, and median postoperative Qmax was 25 ml/s. At a median follow-up of 67 mo, treatment success was 94%. Of 3 recurring patients, 1 received a suprapubic catheter and 2 were treated endoscopically. PROMs were available in 43 men. According to the ICIQ-UI SF, 27 men (63%) reported full continence and median ICIQ-UI sum score (0-21) was 0 (0-4). Overall, 37 men (86%) were (very) satisfied with the surgical outcome and 19 (45%) reported normalization of urinary stream. Median 6-item LUTS score (0-24) was 2 (IQR 2–3), indicating a restored postoperative voiding function. CONCLUSIONS: We confirm the durable efficacy of the T plasty as salvage therapeutical approach in men who suffer from recurrent bladder neck stenoses refractory to conventional endoscopic interventions. Through the utilization of a bilateral bladder flap after T-shaped incision, a wide and tension-free bladder neck may be established leading to excellent and durable outcomes. The T plasty is a valid last resort alternative to permanent urinary diversion and warrants robotic adoption and validation. Source of Funding: n/a © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e381-e381 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Frederik König More articles by this author Roland Dahlem More articles by this author Phillip Marks More articles by this author Lennart Kühnke More articles by this author Maryam Khonsari More articles by this author Margit Fisch More articles by this author Malte W. Vetterlein More articles by this author Expand All Advertisement Loading ...

Robotic-assisted radical prostatectomy following colo-rectal surgery: a user's guide.

To assess the feasibility and operative outcomes of RARP following colo-rectal surgery. A prospective database of patients undergoing RARP is maintained at our Institution since January 2015. We reviewed all patients undergoing RARP after previous colo-rectal surgery. Overall, 49 (7.4%) of 658 RARPs were performed after previous pelvic surgery, 14 (2.1%) of which following colo-rectal surgery after an interval of 5years. (a) Colo-rectal surgery. Previous colo-rectal surgery included resection of the left colon (n = 6), and right colon (n = 4), and rectum (n = 4). Histopathology showed pT0-T2N0 in 5, pT3N0-1 in 3, and benign conditions in 4. Prostate-specific antigen (PSA) was elevated (4ng/ml or greater) or slightly elevated (3.5-4ng/ml) in 9 (65%) of 14 cases at the time of colo-rectal surgery. (b) Prostatectomy. Overall prostatectomy and adhesiolysis median operative times were 235 and 42min, respectively. A robotic approach was accomplished in 11 cases with previous uncomplicated colo-rectal surgery; open conversion occurred in 3 cases. Risk factors for open conversion during RARP were: history of multiple or complicated abdominal surgery, previous open conversion, and hospital stay > 10days. Postoperative complications included: anemization (n = 2), persistent drain output (n = 1), and urinary tract infection (n = 1). The robotic approach was successful in the case of previous uncomplicated colo-rectal surgery. The risk of intestinal injury during conversion might suggest a direct retropubic approach in case of previous multiple or complicated abdominal surgery. A planned elective colo-rectal surgery should include a thorough urologic evaluation, considering the risk of a subsequent prostate surgery.

Recurrent Incontinence After Transvaginal Partial Sling Excision in Patients with Prior Mid-Urethral Sling.

IntroductionPatients may develop recurrent urinary tract infections, pain syndromes, dyspareunia, and voiding difficulty after mid-urethral sling placement that can be treated by partial sling excision.ObjectiveThe primary objective of this study was to evaluate the incidence of de novo incontinence and voiding difficulty after partial sling excision. A secondary objective was to assess risk factors associated with future incontinence surgery in this subset of patients.MethodsFrom 2009 to 2017, 95 female patients with subjective complaints of pelvic pain, dyspareunia, or voiding difficulty following synthetic mid-urethral sling placement for stress urinary incontinence underwent partial sling excision at a single institution. The incidence of urinary incontinence was assessed 6 months after partial sling excision. Patients were also assessed for resolution of voiding difficulty and future incontinence surgery. Primary endpoints were examined by Pearson’s Chi-square test and interval data by t-test. A p < 0.05 was significant.ResultsAbout 72% of patients were more likely to be continent after partial sling excision irrespective of initial symptoms prior to surgery. No difference was seen in voiding difficulty between the continent and incontinent patients after partial sling excision (p=0.09). Patients with a retropubic mid-urethral sling were more likely to be continent after partial sling excision (p=0.03). Preoperative maximum flow rate >16 mL/sec was associated as an independent variable to develop incontinence surgery after partial sling excision (p=0.009).ConclusionIn conclusion, partial sling excision poses a low risk for de novo urinary incontinence regardless of preoperative symptoms. Stress urinary incontinence may be less likely to reoccur in those patients having a retropubic approach. A preoperative maximum flow rate of >16 mL/sec is a risk factor for future incontinence surgery after partial sling excision and should be taken into consideration when formulating a treatment plan.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review.

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery. A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries. Twenty-six studies on 292,606 patients (n= 9077 for POP surgery and n= 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17months for POP surgery and 39.33 ± 27.68months for SUI surgery. Overall, the POP group were older (p< 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p< 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p< 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31days. The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

What to do after a mid-urethral sling fails.

After the Food and Drug Administration Public Health Notification in 2011 regarding transvaginal mesh, there has been a decline in the use of mid-urethral slings (MUS). However, they are an effective treatment option for stress urinary incontinence (SUI) with minimal complications. The management of recurrent SUI after sling continues to be debated. Long-term follow-up after primary MUS confirms its efficacy and safety. There remains no level 1 evidence for the best next step after a failed MUS. Preferred treatment strategies include placing a repeat MUS with more recent evidence demonstrating no difference in cure rates between transobturator tape and retropubic approach. Pubovaginal slings (PVS) and urethral bulking agents are also acceptable treatment options. A newer bulking agent, polyacrylamide hydrogel, demonstrated excellent short-term success rates in patients after a failed sling. MUS is an effective treatment option for SUI. Patients who develop recurrent urinary incontinence are a heterogeneous population who must be evaluated for detrusor overactivity, misplaced sling, unrecognized ISD. Patients with ISD are more likely to benefit by a PVS. Other patients with demonstrated recurrent SUI will likely do well with a repeat MUS.

Retzius-sparing Robotic-assisted Radical Prostatectomy Facilitates Early Continence Regardless of Neurovascular Bundle Sparing.

Retzius-sparing robotic-assisted radical prostatectomy (RARP) has had better results in early continence rate and comparable oncological safety compared to the retropubic approach. However, the role the neurovascular bundle (NVB) sparing plays in the rate of early continence after catheter removal remains unclear. In this study, we sought to compare the early continence rate between Retzius-sparing RARP and the retropubic approach RARP to assess whether NVB sparing affects the continence rate in patients with prostate cancer. This was a retrospective case series of 133 patients who underwent RARP from 2004 to 2017. 92 patients underwent retropubic RARP and 41 patents underwent Retzius-sparing RARP. All procedures were performed by a single surgical team in a single institution. Baseline patient characteristics were recorded and analyzed. Continence results and oncological outcomes were compared between the two groups. Continence outcome of Retzius-sparing RARP with NVB sparing was also analyzed. No differences in age, prostate size, pathology T stage, PSA, and NVB sparing were found between the two groups. The oncological results including surgical margin and biochemical recurrence rate at one year showed no difference between the two groups. With respect to immediate continence results, the Retzius-sparing group showed a better continence result compared to the retropubic approach (75.6% vs. 26.1 %, respectively, p<0.001) after catheter removal. However, there was no difference between the two groups after 6 months. Furthermore, no significant difference in immediate continence result was found in the Retzius-sparing group between patients with NVB sparing (75 %) and those without (75 % vs. 78%, respectively, p=1.00). Retzius-sparing RARP may provide a better immediate continent result compared to retropubic RARP. In Retzius-sparing RARP, NVB sparing did not enhance immediate continence after the operation.

Risk Factors for Polypropylene Midurethral Sling Extrusion: A Case–Control Study

OBJECTIVETo identify risk factors associated with surgical revision of midurethral sling (MUS) due to mesh extrusion. MATERIALD AND METHODSThis is a case–control study identifying women who underwent primary surgical revision of polypropylene MUS for vaginal mesh extrusion from 2001 to 2016. Cases of surgical revision were compared to a randomly selected control group in a 1:5 ratio. Patient demographics and clinical characteristics were compared and multivariate logistic regression modeling was performed to analyze the relationships between risk factors and vaginal mesh extrusion. RESULTSIn total, 64 cases were identified and compared to 400 controls. The average subject was 51.7 years old (range, 30-78) with a body mass index (BMI) of 27.9 kg/m2 (range, 23.6-30.2) at the time of surgical revision. The median time to MUS revision was 318 days (interquartile range, 144-1355 days). Surgical revision was associated with current smokers (odds ratio [OR] = 5.43 [95% confidence interval [CI] 2.86, 10.31]), a BMI under 30 kg/m2 (OR = 4.37 [95% CI = 2.05, 9.36]), age under 55 years (OR = 2.02, [95% CI = 1.13, 3.61]), a retropubic sling (OR = 2.10 [95% CI = 1.14, 3.88]), and fibromyalgia (OR = 3.33 [95% CI 1.12, 9.95]). CONCLUSIONSmoking status, age under 55 years, BMI below 30 kg/m2, fibromyalgia, and retropubic approach were factors associated with surgical revision of MUS due to vaginal mesh extrusion. These findings may improve counseling and patient selection.

Онкологическая безопасность нервосберегающей техники радикальной простатэктомии: оценка патоморфологических результатов и безрецидивной выживаемости

To evaluate histopathological outcomes and biochemical recurrence (BCR) free survival in patients after nerve-sparing radical prostatectomy (nsRP). Prospective study group comprised 313 patients who underwent uni- or bilateral nsRP from 2014 to 2018; control group included 592 patients with clinically localized prostate cancer who underwent non-nsRP from 2014 to 2018. Mann-Whitney U-test was performed to assess continuous variables; chi-squared test was used for comparative analysis of categorical data. BCR free survival was evaluated with Kaplan-Meier method, log-rank test was used to compare survival outcomes. Adverse histopathological findings were lower in the study group: extracapsular extension was found in 9,4% and 18,75% (p<0,001), grade group upgrade in 23% and 29,3% (p=0,04), positive surgical margins (PSM) in 15% and 22,1% (p=0,01). Subanalysis according to cancer risk groups showed lower PSM rates in high-risk patients (15,6% and 30,3%, p=0,017) and tendency for higher PSM rates in low-risk patients in the study group with no significant difference (12,6% and 7%, p=0,16). BCR free survival after 12 months was 100% and 88,2%, after 20 months - 92,3% and 86,4%, p=0,04. PSM ratesin the study group were notsignificantly different depending on the type of surgery: 13,9% in robotic-assisted approach and 15,4% in retropubic approach, p=0,75. Relatively favorable histopathological outcomes and BCR free survival can be achieved after nsRP. However, obtained results could not be considered optimal and clearly indicate the need for further improvement of preoperative planning and intraoperative quality control of surgical treatment.

Analysis of Retropubic and Laparoscopic Radical Prostatectomy for Localized Prostate Cancer

Objective：To analysis of treatment effects and safety of retropubic approach and laparoscope approach of radical prostatectomy in localized prostate cancer. Methods：The observation group underwent radical prostatectomy by laparoscope approach,while the control group underwent radical prostatectomy by retropubic approach, after that, to analysis the operation indexes and complications of patients. Results：The intraoperative blood loss,length of stay and postoperative NRS score of observation group were less than control group, the operation time of the observation group was longer than that of the control group. with statistical significance (P＜0.05). The postoperative complication rate of observation group was lower than control group,with statistical significance (P＜0.05). Conclusion：Comparing with retropubic approach, laparoscope approach of radical prostatectomy for localized prostate cancer can improve the safety of surgical treatment and optimize surgical indicators,which is worthy of promotion.

The evolution and resurgence of perineal prostatectomy in the robotic surgical era.

To review the recent advances in terms of surgical technique and new robotic platforms applied to radical perineal prostatectomy (RPP). A literature review was performed focusing on original articles on perineal prostatectomy searching via Medline/Pubmed and Embase. The entire spectrum was covered such as development of surgical technique including pelvic lymphadenectomy, adoption of novel surgical platforms, learning curve and future directions. Surgical removal of the prostate plays a significant role on the treatment of localized prostate cancer (PCa). RPP was the first surgical approach described for radical prostatectomy. This technique declined in popularity secondary to the development of the retropubic approach. Recently, the appearance of novel robotic technology has generated renewed interest in the perineal approach. There has been a recent resurgence on the interest of radical perineal prostatectomy for the treatment of localized PCa driven by the advent of new robotic surgical technologies into the field. Future studies are needed to better determine the learning curve of the perineal approach and its current role in the treatment of prostate cancer.

Complicaciones intraoperatorias y posoperatorias de las cintas medio uretrales libres de tensión en incontinencia urinaria de esfuerzo

Antecedentes: La colocación de cintas medio uretral son actualmente el tratamiento de primera línea para la incontinencia urinaria de esfuerzo. El objetivo fue evaluar las complicaciones intra y posoperatorias de las cintas transobturadora y retropúbica; y los factores de riesgo asociados.&#x0D; Material y métodos: Estudio de cohorte retrospectivo en 105 mujeres durante el 2016 a 2018. Se dividió en dos grupos: TVT (n=28) y TOT (n=77). Se analizaron variables demográficas, factores de riesgo, complicaciones intra y posoperatorias. Se realizo estadística descriptiva y correlación de variables con programa SPSS v17.0, y p ≤ 0.05 estadísticamente significativo.&#x0D; Resultados: La edad promedio fue 56.7 ± 8.8 años; 31.4% (n=33) con incontinencia de esfuerzo, 65.7% (n=69) con incontinencia mixta (IUM) y 2.9% (n=3) con incontinencia oculta. La tasa de complicación global fue de 29.5% (n=31). La complicación intraoperatoria común fue la perforación vesical 3.8% en el grupo TVT asociada a obesidad (OR 12.9). Las complicaciones posoperatorias estuvieron relacionadas con la TOT (p=0.049), compuestas por infección de vías urinarias (11.4%), inguinodinea (7.6%) y otras (6.9%). El riesgo de infección urinaria posoperatorio estuvo asociado con incontinencia de esfuerzo (p=0.03), ausencia de tratamiento de incontinencia urinaria mixta (p=0.04); aumentado la tasa de incontinencia urinaria de urgencia de novo.&#x0D; Conclusiones: El enfoque transobturador tiene bajos índices de complicaciones transoperatorias en comparación con la retropúbica. La complicación más común en nuestra serie fue la infección urinaria por lo que se requieren estudios prospectivos aleatorizados.

Comparación entre abordaje retropúbico con malla vaginal libre de tensión (TVT) y el abordaje transobturador (TVT-O/TOT) en el tratamiento de incontinencia urinaria de esfuerzo: Un metaanálisis de efectividad y complicaciones

Introducción: La Incontinencia Urinaria de Esfuerzo es una condición potencialmente tratable que puede ser causa significativa de angustia y disminución en la calidad de vida para muchas mujeres. Hace aproximadamente una década surge el abordaje transobturador como una alternativa quirúrgica que evite las complicaciones asociadas al abordaje retropúbico. El objetivo de este estudio fue comparar la efectividad de ambos abordajes además de la aparición de complicaciones asociadas a dichos procedimientos. Metodología: Se realizó un metanálisis mediante la búsqueda sistemática de literatura disponible en PUBMED, LILACS y CENTRAL; se identificaron inicialmente 117 estudios, de los cuales 14 fueron incluidos en el presente análisis según los criterios de inclusión/exclusión establecidos. Como resultados de interés, se analizó la tasa de cura objetiva y subjetiva, y la tasa de complicaciones asociadas a ambos abordajes, mediante la estimación del riesgo relativo con un intervalo de confianza del 95%. Resultados: Se incluyó un total de 3022 mujeres sometidas a intervenciones quirúrgicas anti-incontinencia; a 1496 mujeres se les practicó el abordaje transobturador y a 1526 mujeres se les realizó abordaje retropúbico. Se realizó un análisis comparativo al subgrupo de abordaje transobturador tipo TVT-O (malla medio-uretral con abordaje transobturador IN-OUT-de adentro hacia afuera) versus el tipo TVT ( malla medio-uretral retro púbica con abordaje vaginal libre de tensión), sin encontrarse mayores diferencias. Se determinó que la tasa de cura objetiva entre abordaje transobturador versus retropúbico es similar, con una tendencia a favorecer a la cura en el grupo de TVT, siendo esta diferencia estadísticamente significativa únicamente a los 12 meses postquirúrgico. La tasa de curación subjetiva, por otro lado, no alcanza diferencia significativa entre ambos abordajes quirúrgicos en ninguno de los periodos analizados. Dentro de las complicaciones observadas se halló mayor incidencia de dolor postquirúrgico en abordaje transobturador (RR: 2,14; IC 95%, 1,42-3,22); sin embargo, se encontró una mayor aparición de trastornos de vaciamiento en las pacientes sometidas a TVT (TVT-O VS TVT, RR: 0,61, IC 95%: 0,39-0,94); y en relación a la tasa de lesión vesical, se evidenció menor incidencia luego del abordaje trans-obturador (RR: 0,20, IC 95%: 0,11-0,37). Ninguna otra complicación alcanzó diferencias estadísticamente significativas. Conclusión: En consistencia con la literatura existente, al comparar los abordajes transobturador y retropúbico no se encontró diferencia entre las tasas de cura objetiva ni subjetiva, aunque se evidencia una clara tendencia a favorecer la tasa de cura objetiva en las pacientes sometidas a TVT. Por otro lado, sí existe una mayor incidencia de dolor postquirúrgico en relación al abordaje transobturador y una mayor tasa de lesión vesical y de trastornos de vaciamiento luego del abordaje retropúbico.

Dr Jekyll and Mr Hyde.

On the 10 July 2018, the UK Independent Medicines and Medical Devices (IMMD) safety review led by Baroness Cumberlege implemented a hiatus in the use of vaginal meshes for incontinence and prolapse because of concerns about complications. The use of vaginal mesh for prolapse has seen a natural decline over the past decade (Jha Int Urogynecol J 2018;29:795–801) with robust evidence available to suggest outcomes for native tissue repair are not significantly inferior to mesh-reinforced repair (Glazener Lancet 2017;389:381–92). However, there was considerable concern in relation to incontinence that patients would be exposed to more complex procedures with a greater complication rate because they would no longer have access to synthetic slings. The two synthetic sling procedures performed for stress urinary incontinence (SUI) are the tension-free vaginal tape (TVT) retropubic and the TVT obturator. Recently, these two devices have been referred to in the press interchangeably. The devices are made from identical mesh and are the same in their composition, size and the amount that is embedded in the patient, with similar success rates. However, that is where the similarity ends. So how did the two types of synthetic tapes become the Jekyll and Hyde of continence surgery? The Scottish review of the use of transvaginal mesh implants found greater adverse effects with obturator synthetic tapes than with retropubic tapes (https://www.gov.scot/publications/scottish-independent-review-use-safety-efficacy-transvaginal-mesh-implants-treatment-9781786528711/). The review also identified a greater need for repeat SUI surgery following the transobturator approach beyond 12 months. In addition, the number of cases under review for litigious reasons was three times greater in the obturator group than in the retropubic group. In the 2006 National Institute of Health and Care Excellence (NICE) clinical guidance (CG 40) on the management of urinary incontinence, there was only a brief mention of obturator tapes and the advice was to make women aware of the ‘lack of long term data’. When this guidance was updated in 2013 (CG 171), this advice remained unchanged. In the recent NICE consultation document published in October 2018, the advice is more directive: ‘do not offer a transobturator approach unless there are specific clinical circumstances (for example, multiple previous abdominal procedures) in which the retropubic approach should be avoided’. Obturator tapes were developed to reduce the risk of bladder injury but have been associated with groin pain and obturator neuropathies. These present as pain and restricted mobility of the thigh and hip adduction, along with sensory loss and pain across the anterior thigh. Foot drop is another rare presentation. However, the greatest problem with obturator tapes is the difficulty of complete removal, which is hampered by their placement deep in the obturator foramen, requiring dissection of the groin (usually by a plastic surgeon). In the largest series of vaginal mesh removals for all indications, the commonest type of mesh removed was the obturator tape for incontinence (Miklos Surg Technol Int 2016;29:185–9) and the removal of these meshes also had the highest complication rates. Clinicians who traditionally undertook obturator tape placement should be aware that even if the temporary ban is lifted, they will have to change their practice, as this procedure has acquired the mantle of Mr Hyde and will be off limits in most future circumstances. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.