Rhabdosphincter Reconstruction Research Articles

World’s first known reported complete female urinary rhabdosphincter reconstruction after iatrogenic injury

World’s first known reported complete female urinary rhabdosphincter reconstruction after iatrogenic injury

Continence definition and prognostic factors for early urinary continence recovery in posterior rhabdosphincter reconstruction after robot-assisted radical prostatectomy. Post-hoc analysis of a randomised controlled trial

IntroductionUrinary incontinence after radical prostatectomy (RP) is an adverse event with high impact on patient’s quality of life. Nowadays there is no standardized method for urinary continence measurement. Posterior rhabdosphincter reconstruction (PRR) is a surgical step that can improve early urinary continence after RP. Our objective was to analyse different continence definitions and predictors of urinary continence recovery after robot-assisted RP (RARP). Material and methodsWe conducted a double-blind, randomised controlled trial (NCT03302169) including 152 consecutive patients with localized prostate cancer subjected to RARP. Patients were randomised to single urethrovesical anastomosis (control arm) or PRR before urethrovesical anastomosis (PRR arm). Urinary continence was measured with the EPIC-26 and ICIQ-SF validated questionnaires, and pad use (0-1 pads and no pads), at 7, 15, 30, 90, 180 and 365 days after catheter removal. Prognostic factors for early urinary continence recovery were analysed. Results72 patients were included in the control arm and 80 in the PRR arm. Baseline characteristics were similar between arms, except body mass index, which was higher in PRR arm. “No pad” was the only definition assessing the benefit of PRR at 30 days, 33.8% in PRR arm and 18.1% in control arm, p = 0.022; and at 90 days, 58.8 and 43.1% respectively, p = 0.038. Questionnaires did not detect differences in terms of continence recovery. PRR was the only predictor for early continence recovery, p = 0.03. ConclusionsPRR increased early urinary continence recovery after RARP. Continence definition was critical to assess benefit. The only predictive factor for early continence recovery was PRR.

Definición de continencia y factores pronósticos para la recuperación temprana de la continencia urinaria en la prostatectomía radical robótica con reconstrucción posterior del rabdoesfínter. Análisis post hoc de un ensayo clínico aleatorizado

IntroductionUrinary incontinence after radical prostatectomy (RP) is an adverse event with high impact on patient's quality of life. Nowadays there is no standardized method for urinary continence measurement. Posterior rhabdosphincter reconstruction (PRR) is a surgical step that can improve early urinary continence after RP. Our objective was to analyse different continence definitions and predictors of urinary continence recovery after robot-assisted RP (RARP). Materials and methodsWe conducted a double-blind, randomised controlled trial (NCT03302169) including 152 consecutive patients with localized prostate cancer subjected to RARP. Patients were randomised to single urethrovesical anastomosis (control arm) or PRR before urethrovesical anastomosis (PRR arm). Urinary continence was measured with the EPIC-26 and ICIQ-SF validated questionnaires, and pad use (0-1 pads and no pads), at 7, 15, 30, 90, 180 and 365 days after catheter removal. Prognostic factors for early urinary continence recovery were analysed. Results72 patients were included in the control arm and 80 in the PRR arm. Baseline characteristics were similar between arms, except body mass index, which was higher in PRR arm. “No pad” was the only definition assessing the benefit of PRR at 30 days, 33.8% in PRR arm and 18.1% in control arm, p=0.022; and at 90 days, 58.8 and 43.1% respectively, p=0.038. Questionnaires did not detect differences in terms of continence recovery. PRR was the only predictor for early continence recovery, p=0.03. ConclusionsPRR increased early urinary continence recovery after RARP. Continence definition was critical to assess benefit. The only predictive factor for early continence recovery was PRR.

Reconstruction of the Denonvillier's fascia and posterior ligament of the external urethral sphincter: Assessment of its effect on urinary continence after laparoscopic radical prostatectomy.

Some studies have shown that rhabdosphincter reconstruction provides an earlier return to continence after radical prostatectomy. We aim to study the impact of this procedure in urinary continence along with comparing two specific surgical techniques for posterior reconstruction. We studied a group of patients who were submitted to LRP with No Rhabdosphincter Reconstruction (NRR) and another group with Posterior Reconstruction of the Rhabdosphincter (PRR). The latter was further divided into two groups: "Rocco type stitch" group and "Bollens type stitch" group. We used three questionnaires (IIEF-5, ICIQ-SF and IPSS) to assess urinary continence and erectile function 90 days after surgery. Patients of PRR group had a better full continence rate than patients of NRR group at 90 days (96.6% vs 33.3%, p < 0.001). Concerning urinary incontinence (p = 0.116), lower urinary tract symptoms (p = 0.543) and postoperative complication rates (p = 0.738), our results suggested that there were no differences between the techniques studied. Posterior reconstruction of the rhabdosphincter has significant benefits for urinary continence recovery on patients undergoing radical prostatectomy. No differences were observed in continence recovery between the two techniques analyzed. Additionally, reconstruction of the rhabdosphincter appears to be a safe procedure with no increased risk of postoperative complications.

P1158 - A randomised controlled trial to assess the benefit of posterior rhabdosphincter reconstruction in early urinary continence recovery after robot assisted radical prostatectomy

P1158 - A randomised controlled trial to assess the benefit of posterior rhabdosphincter reconstruction in early urinary continence recovery after robot assisted radical prostatectomy

A Randomised Controlled Trial to Assess the Benefit of Posterior Rhabdosphincter Reconstruction in Early Urinary Continence Recovery after Robot-assisted Radical Prostatectomy

Posterior rhabdosphincter reconstruction (PRR) has been proposed to improve early urinary continence (UC) recovery after radical prostatectomy (RP). In order to generate level 1b evidence, we designed a double-blind randomised controlled trial powered to detect a 20% increase in early UC recovery after robot-assisted RP (RARP). A group of 153 patients with cT1c–3a N0M0 prostate cancer were randomised (73 to control arm and 80 to PRR arm) and 152 completed 12-mo follow-up. For UC defined as no pad use, the recovery hazard ratio at 1-mo follow-up was 2.312 (95% confidence interval [CI] 1.081–4.937; p = 0.030). UC recovery was observed in 33.8% of patients in the PRR arm and 18.1% of patients in the control arm (p = 0.022). At 3-mo follow-up the corresponding rates were 58.8% and 43.1% (p = 0.038). The median time to UC recovery was 106 d (95% CI 73–139) in the control arm and 64 d (95% CI 39–89) in PRR arm (p = 0.897). No differences in pathological outcomes or early and late surgical complications were observed between the arms. We conclude that PRR is safe and increases early UC recovery after RARP. Patient summaryWe investigated reconstruction of a muscular ring that controls the flow of urine, called the rhabdosphincter, after removal of the prostate in robot-assisted surgery. The procedure is safe and increases early recovery of urinary continence.This trial is registered at ClinicalTrials.gov as NCT03302169.

The position of urethrovesical anastomosis after robotic radical prostatectomy assessed by MRI predicts early functional recovery: A cohort analyses from a randomized clinical trial

PurposeFunctional and anatomical changes associated with prostate removal coincide with alterations in pelvic structures. Posterior rhabdosphincter reconstruction was designed to improve urinary continence after radical prostatectomy. The aim of this study was to determine magnetic resonance anatomic predictors of urinary recovery after radical prostatectomy, and to assess their relation to the type of reconstruction. Material and MethodsForty patients were randomly selected from a trial (NCT03302169). Two independent radiologists determined the situation of the anastomosis in the pelvis according to MRI performed a month after the radical prostatectomy: vertical situation assessed as the distance to the line coccyx-inferior pubic margin (ACPv) and anteroposterior situation as the distance from the pubis (Distance A), and from the coccyx (Distance B). ResultsThe Pearson correlation of ACPv, Distance A, and B between readers were 0.975, 0.940, and 0.711, p < 0.001. Patients with the reconstruction presented more cephalic situation of the anastomosis (higher ACPv) than patients with standard reconstruction technique. A multivariate analysis was performed including age, BMI, prostate volume, PRRS, and the MRI parameters. ACPv and Distance B were the only two independent predictors of no need for any urinary protection at 6 months after the surgery. ConclusionsThis is the first study that suggests positional differences according to the type of reconstruction after radical prostatectomy related to early urinary recovery. Magnetic resonance measurements to determine anastomosis positioning are reliable and have a strong correlation between readers. Anatomic MRI features are independent predictors of urinary recovery after robotic radical prostatectomy.

PT030 - Should we change how to assess early continence after rhabdosphincter reconstruction in patients undergoing robotic prostatectomy? Results of a randomized controlled trial

PT030 - Should we change how to assess early continence after rhabdosphincter reconstruction in patients undergoing robotic prostatectomy? Results of a randomized controlled trial

PT043 - MRI confirms different position of the vesicourethral anastomosis after rhabdosphincter reconstruction in patients undergoing robotic prostatectomy: A cohort analyses from a randomized controlled trial

PT043 - MRI confirms different position of the vesicourethral anastomosis after rhabdosphincter reconstruction in patients undergoing robotic prostatectomy: A cohort analyses from a randomized controlled trial

Robotic radical prostatectomy in 93 cases: Outcomes of the first ERUS robotic urology curriculum trained surgeon in Turkey.

This study presents the surgical, oncological, and functional outcomes of the first 93 robotic radical prostatectomy (RARP) procedures performed in Erzurum, Turkey. These procedures were performed by a single surgeon who had completed the European Association of Urology Robotic Urology Section (ERUS) RARP curriculum in an ERUS-certified training center in Ankara. The study present the results of 93 RARP procedures performed by a single surgeon. The surgeon performing the operations completed an ERUS training program structured for RARP by two robotic surgeons holding ERUS training certificates in an ERUS-approved academic robotic surgery training center in Ankara. The RARP cases performed by the surgeon after completion of the training between April 2016 and August 2018 were retrospectively evaluated. The mean patient age was 63.62±7.04 years, and the mean preoperative serum prostate-specific antigen level was 8.34±4.96 ng/mL. Preoperatively, 82 and 4 patients had prostate biopsy Gleason scores of 3+3 and 4+3, respectively. Bilateral neurovascular bundle (NVB) sparing, unilateral NVB-sparing, and non-NVB-sparing surgery were performed in 21, 13, and 59 cases, respectively. The mean prostate weight was 85.34±47.57 g. Posterior rhabdosphincter reconstruction was performed in 60 (64.5%) cases. Mean console time, intraoperative blood loss, duration of hospital stay, and urethral catheter removal time were 170.49±36.50 min, 100.70±34.08 cc, 6.84±2.28 days, and 7.40±3.11 days, respectively. During the perioperative period (0-30 days), five minor (prolonged drain output, n=3; rectocele, n=1; gout arthritis, n=1) and six major (inguinal hernia, n=1; incisional hernia, n=2; anastomotic urinary leakage, n=2; myocardial infarction, n=1) complications were identified. No complication was detected during postoperative days 31-90. Postoperative pathological stages included pT2a, pT2b, and pT2c disease in 77 (82.8%), 9 (9.7%), and 7 (7.5%) patients, respectively. The positive surgical margin (SM) rate was 10.7% (n=10), including patients with pT2a (n=6) and pT2c (n=2) diseases. Eleven (11.8%) patients underwent pelvic lymph node (LN) dissection. The mean LN yield was 16.45±4.29. The mean length of follow-up was 11.17±8.01 months. Biochemical recurrence was observed in two patients, one of whom received maximal androgen blockage (MAB), and the other one received pelvic radiotherapy+MAB. All the patients with at least one-year follow-up (n=48, 51.6%) were fully continent (0 pads/day). Of the 40 (43%) patients with no preoperative erectile dysfunction (ED) and with at least three-month follow-up, 18 (45%) had no ED, with or without any additional medication including phosphodiesterase-5 (PDE5) inhibitors. RARP is a safe minimally invasive procedure with acceptable morbidity, excellent operative, pathological and oncological outcomes, and satisfactory functional results. The ERUS RARP curriculum provides effective and sufficient training.

Bidirectional Barbed Only vs Poliglecaprone Suture with Rhabdosphincter Reconstruction for Urethrovesical Anastomosis During Robotic Radical Prostatectomy: Does It Make Any Difference?

We investigated the use of bidirectional barbed suture only vs poliglecaprone suture with posterior rhabdosphincter reconstruction for urethrovesical anastomosis (UVA) during robot-assisted radical prostatectomy (RARP) on cystographic leakage, duration of catheterization, and early urinary continence. Bidirectional double-armed barbed suture only was used for UVA (n = 50) in Group 1. Two 3/0 poliglecaprone 25 sutures were tied to each other to form a double-armed suture used for UVA with posterior rhabdosphincter reconstruction in Group 2 (n = 50). Groups were similar regarding patient demographics and operative parameters. Groups were compared regarding leakage on cystography, duration of urethral catheterization after RARP, immediate urinary continence (continence at the time of urethral catheter removal), and continence rates at first and third-month follow-up. Leakage on cystography was detected in 4 (8%) and 10 (20%) of the patients in Group 1 and 2, respectively (p = 0.08). Urinary catheter removal duration was 7.8 and 8.5 days in Group 1 and 2, respectively (p = 0.1). Immediate urinary continence was achieved in 38 (76%) and 20 (40%) of the patients in Group 1 and 2, respectively (p = 0.002). Urinary continence in first-month follow-up was achieved in 46 (92%) and 38 (76%) of the patients in Group 1 and 2, respectively (p = 0.02). Urinary continence in third-month follow-up was achieved in 48 (96%) and 47 (94%) of the patients in Group 1 and 2, respectively (p = 0.64). Mean UVA time was 16.8 and 21.2 minutes, respectively, in Group 1 and 2 (p < 0.001). Because of our experience, use of a barbed suture for UVA during RARP seems to lead to better immediate and early (first month) urinary continence rates and a shorter UVA time.

The Impact of Lateral Bladder Neck Preservation on Urinary Continence Recovery After Robot-Assisted Radical Prostatectomy

Urinary incontinence is one of the most bothersome adversities after robot-assisted radical prostatectomy (RARP). The aim of this study was to investigate the urinary continence recovery and the effect of various surgical techniques. We previously reported that posterior rhabdosphincter reconstruction and nerve-sparing were independent predictors of urinary continence recovery 1 month after catheter removal in 199 patients who underwent RARP. Retrospectively, we further reviewed those 199 patients for urinary continence recovery at 3 months or later after RARP. The relationships of urinary continence with perioperative findings, including surgical procedures, were evaluated at 3 to 12 months after RARP. The Fisher exact test and Mann-Whitney rank sum test were used for evaluating variables between the groups. Multivariate logistic regression analysis was performed to investigate the association between urinary continence and perioperative factors. On univariate analyses, surgeon experience, lateral bladder neck preservation (BNP), anterior reconstruction, and posterior reconstruction were significantly associated with urinary continence recovery 3 months after RARP, but only lateral BNP was independently associated with urinary continence recovery in a multivariate analysis. Similarly, on univariate analyses, surgeon experience, lateral BNP, and posterior reconstruction were significantly associated with continence recovery at 6 months or later after surgery. However, multivariate analyses showed that only lateral BNP was significantly associated with urinary continence recovery 6 months or later after surgery. Although the lateral BNP technique did not affect immediate urinary continence recovery, this procedure was significantly associated with continence recovery 3 months or later after RARP.

PJY05 - Use of bidirectional barbed suture only versus PDS suture with posterior rhabdosphincter reconstruction for urethro-vesical anastomosis during robotic radical prostatectomy: Any impact on cystographic leakage, duration of catheterization and urinary conti

PJY05 - Use of bidirectional barbed suture only versus PDS suture with posterior rhabdosphincter reconstruction for urethro-vesical anastomosis during robotic radical prostatectomy: Any impact on cystographic leakage, duration of catheterization and urinary conti

PD18-01 RANDOMIZED STUDY EVALUATING SHORT-TERM FUNCTIONAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN LOW-RISK PROSTATE CANCER PATIENTS

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III1 Apr 2017PD18-01 RANDOMIZED STUDY EVALUATING SHORT-TERM FUNCTIONAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN LOW-RISK PROSTATE CANCER PATIENTS Alexander Govorov, Dmitry Pushkar, Konstantin Kolontarev, Pavel Rasner, and Vladimir Dyakov Alexander GovorovAlexander Govorov More articles by this author , Dmitry PushkarDmitry Pushkar More articles by this author , Konstantin KolontarevKonstantin Kolontarev More articles by this author , Pavel RasnerPavel Rasner More articles by this author , and Vladimir DyakovVladimir Dyakov More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.861AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Many techniques have been described to optimize functional outcomes of robot-assisted radical prostatectomy (RARP). Our objective was to test the impact of surgical technique on post-operative urinary continence recovery (UCR), urinary bother symptoms and erectile function (EF) recovery in a randomized study in high-volume center. METHODS From July to December 2015 89 low-risk PCa patients signed the IC and were randomized in Group 1 (n=45, RARP with full bilateral nerve sparing (NS) and lateral prostatic fascia preservation with amniotic membrane allograft nerve wrap) and Group 2 (n=44, conventional RARP with bilateral NS). Posterior rhabdosphincter reconstruction (PRR) was performed in all cases. Patients started tadalafil 5 mg OAD from Day of catheter removal. Groups were comparable for clinical and pathological variables. We evaluated: 1) UCR rate, defined as the use of 0 pad/day; 2) post-op urinary bother symptoms measured using the QoL question in the IPSS questionnaire (no bother, score 0-2; bother, score 3 and more); 3) EF recovery rate, defined as IIEF-5>17. RESULTS Patients with full NS, preservation of lateral prostatic fascia and amniotic membrane use had significantly higher rates of UCR at 1 week, 1 and 3 months and EF recovery rates at 3 and 6 months. Urinary bother scores were lower in these men at 1, 3 and 6 months post-RARP (table 1). There was no difference in positive surgical margins and intra- /post-RARP complication rate. Results were confirmed on multivariable analyses (odds ratio for Group 1 vs. Group 2 - 2.2 for UCR [p=0.006], 1.8 for EF recovery [p=0.004] and 3.6 for urinary bother [p=0.01]). CONCLUSIONS Lateral prostatic fascia preservation with amniotic membrane allograft nerve wrap significantly improved the rate of post-RARP urinary continence, urinary bother and EF recovery in a group of low-risk PCa patients with bilateral NS and PRR in a randomized study. This in turn can translate into a higher post-operative QoL and/or patient satisfaction. The definition of surgical Pentafecta describing intraoperative technical manoeuvers optimizing functional outcomes may include 1) bilateral nerve sparing, 2) preservation of lateral prostatic fascia, 3) PRR, 4) amniotic membrane allograft use and 5) watertight anastomosis. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e359 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Alexander Govorov More articles by this author Dmitry Pushkar More articles by this author Konstantin Kolontarev More articles by this author Pavel Rasner More articles by this author Vladimir Dyakov More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V4-01 OUR SUCCESSFUL EXPERIENCE UTILIZING POSTERIOR RHABDOSPHINCTER RECONSTRUCTION DURING ROBOTIC PROSTATECTOMY

You have accessJournal of UrologyRobotics – Prostate/Novel Imaging1 Apr 2016V4-01 OUR SUCCESSFUL EXPERIENCE UTILIZING POSTERIOR RHABDOSPHINCTER RECONSTRUCTION DURING ROBOTIC PROSTATECTOMY Mona Yezdani, Ben Katz, Sylvia Yu, daniel maas, Alexa Lee, Alice McGill, Kelly Monahan, and David Lee Mona YezdaniMona Yezdani More articles by this author , Ben KatzBen Katz More articles by this author , Sylvia YuSylvia Yu More articles by this author , daniel maasdaniel maas More articles by this author , Alexa LeeAlexa Lee More articles by this author , Alice McGillAlice McGill More articles by this author , Kelly MonahanKelly Monahan More articles by this author , and David LeeDavid Lee More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1805AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There have been numerous techniques employed to maximize continence after robot-assisted radical prostatectomy (RARP), including posterior rhabdosphincter reconstruction (PRR). However optimum PRR stitch location remains relatively undefined. We aimed to apply our modified posterior reconstruction of the rhabdosphincter (M-PRR) in 570 consecutive patients undergoing RARP for adenocarcinoma of the prostate. In this video, we demonstrate our technique for M-PRR performed during RARP. METHODS This patient had his prostate removed in the standard fashion as previously described. The M-PRR uses the posterior layer of whitish connective tissue that may by reproducibly seen on dissection after division of the posterior bladder wall during the bladder neck transection, and prior to identification of the vasa deferentia and seminal vesicles. This retrotrigonal layer anchor tissue is in clear distinction to Denonvilliers’ fascia, which should not be encountered until after division of the vasa deferentia and seminal vesicles. RESULTS Patient and intraoperative variables were similar between the PRR and M-PRR groups, and there were no surgical technique differences between the two groups. Weeks to 0 PPD was statistically different at the three month interval (p=0.0466). Mean weeks to 1 PPD was 13.1 weeks in the control group and 11.76 weeks in the intervention arm. There were no significant differences in post-operative AUASS or EPIC scores between groups. Console time in this case was 112 minutes. Estimated blood loss was 100 ml. Hospital stay was 26 hours. The foley catheter was removed 6 days after surgery. By also utilizing preoperative kegel exercises, our patient was continent on urethral catheter removal. CONCLUSIONS Retrotrigonal stitch placement during PRR resulted in statistically significant improvement in time to reach total continence post-operatively. Our M-PRR robotic approach for radical prostatectomy is safe and effective. This study is one of the largest to date examining the effect of varied stitch location at the time of RARP on continence outcomes. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e516 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Mona Yezdani More articles by this author Ben Katz More articles by this author Sylvia Yu More articles by this author daniel maas More articles by this author Alexa Lee More articles by this author Alice McGill More articles by this author Kelly Monahan More articles by this author David Lee More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effects of bladder neck preservation and reconstruction of rhabdosphincter on urinary continence recovery after laparoscopic radical prostatectomy

To retrospectively analyze the effects of bladder neck preservation (BNP) and reconstruction of rhabdosphincter (RS) on urinary continence recovery for patients after laparoscopic radical prostatectomy (LRP). Bladder neck preservation plus reconstruction of rhabdosphincter (BNP+RS) was employed in 18 prostate cancer patients after LRP from January 2011 to December 2012. Eighteen contemporary cases of routine LRP were selected for control group. The operative duration, blood loss volume, postoperative surgical margins, urine leakage and continence rate were compared between two groups. LRP was successfully performed through extraperitoneal space in all 36 cases. There was no conversion into open surgery. The median operative duration, blood loss volume, positive surgical margins and urine leakage rate in BNP+RS and control groups were 164 (125-245) versus 142 (95-210) min, 195 (80-550) versus 230 (120-400) ml, 3 versus 2 cases and 0 versus 2 cases respectively. At 3, 6, 12 months, the continence rates in BNP+RS and control groups were 12 cases (66.7%) versus 5 cases (13.9%, P = 0.044) , 15 cases(83.3%) versus 11 cases (30.6%, P = 0.264) and 16 cases (88.9%) versus 13 cases (36.1%, P = 0.402) respectively. A significant higher continence rate in the first 3 months postoperatively was found in BNP+RS group than control group. BNP plus RS reconstruction after LRP can significantly improve continence in the first 3 months after operation.

Editorial Comment

In this article, the authors examine the effect of a bladder sling (created using a single suspending Vicryl suture) on the early return of continence after robotic prostatectomy. The study was a well-devised blinded prospective randomized study, involving 27 patients in the sling group and 30 patients in the control group. All patients had puboprostatic preservation and double-layered posterior rhabdosphincter reconstruction. For assessing continence, the study has included both subjective and objective measures.

285 POSTOPERATIVE CYSTOGRAM FINDINGS USED TO PREDICT PERSISTENT INCONTINENCE FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyBladder and Urethra: Anatomy, Physiology and Pharmacology (I)1 Apr 2013285 POSTOPERATIVE CYSTOGRAM FINDINGS USED TO PREDICT PERSISTENT INCONTINENCE FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY Daniel Han, Damien Smith, Robert Torrey, Caroline Wallner, Gene Huang, Steven Engebretsen, and D. Duane Baldwin Daniel HanDaniel Han Loma Linda, CA More articles by this author , Damien SmithDamien Smith Loma Linda, CA More articles by this author , Robert TorreyRobert Torrey Loma Linda, CA More articles by this author , Caroline WallnerCaroline Wallner Loma Linda, CA More articles by this author , Gene HuangGene Huang Loma Linda, CA More articles by this author , Steven EngebretsenSteven Engebretsen Loma Linda, CA More articles by this author , and D. Duane BaldwinD. Duane Baldwin Loma Linda, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1669AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Incontinence is a dreaded complication following robot-assisted radical prostatectomy (RARP). The ability to predict a slow return of continence would allow appropriate expectations to be set and also allow early, targeted therapy with Kegel exercises, physiotherapy, and biofeedback. The purpose of this study is to determine whether a low bladder neck position on postoperative cystogram predicts subsequent incontinence at 3 and 12 months. METHODS A retrospective review of 611 consecutive RARP patients at a single institution from 2005 to 2011 was performed. In 263 patients, a postoperative cystogram allowed the anatomic position of the bladder neck in relation to the symphysis to be calculated using a ratio called the Bladder Neck to Pubic Symphysis ratio (BNPS). 215 patients had complete 3 and 12 month continence data. The BNPS ratio was defined as the distance from the superior aspect of the pubic symphysis to the bladder neck on antero-posterior cystogram divided by the total pubic symphysis height, and was reported as a percentage. Continence was assessed by the number of pads used in a 24-hour period at 3 and 12-months follow-up. Patients using no pads or 1 pad for protection were considered continent. Continent and incontinent groups were compared with StudentÆs t-test and Chi-square analyses. RESULTS Mean patient age was 62 years and body mass index 29 kg/m2. At 3 months follow-up, continent patients had a higher position of the bladder neck with a mean BNPS ratio of 39.2% versus 48.7% in incontinent patients (p = 0.01). Similarly, at 12 months, continent patients had a higher position of the bladder neck, mean BNPS 40.3% versus 60.3% in incontinent patients (p = 0.001). At 3 months, patients with a BNPS ratio greater than 50% were significantly more likely to be incontinent (OR 2.23). Similarly, patients at 12 months with a BNPS ratio of greater than 40% were more likely to be incontinent (OR 8.24). Upon subanalysis, when posterior rhabdosphincter reconstruction was performed, there was a 95.8% continence rate at 12 months compared to 86.0% when reconstruction was not performed (p=0.019). Furthermore, when the pubovesical fascia was preserved, BNPS was significantly decreased from 53.9% to 31.5% (p = 0.01). CONCLUSIONS Post-prostatectomy bladder neck location defined by the BNPS ratio correlates with incontinence and may predict patients at risk for prolonged incontinence. Furthermore, this study suggests that efforts designed to preserve or reestablish support of the bladder neck may improve both early and late continence following RARP. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e116 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Han Loma Linda, CA More articles by this author Damien Smith Loma Linda, CA More articles by this author Robert Torrey Loma Linda, CA More articles by this author Caroline Wallner Loma Linda, CA More articles by this author Gene Huang Loma Linda, CA More articles by this author Steven Engebretsen Loma Linda, CA More articles by this author D. Duane Baldwin Loma Linda, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Preliminary results of robot‐assisted laparoscopic radical prostatectomy (RALP) after fellowship training and experience in laparoscopic radical prostatectomy (LRP)

• To ascertain whether prior experience in laparoscopic radical prostatectomy (LRP) shortens the 'learning curve' and therefore improves early patient outcomes when transitioning to robot-assisted laparoscopic RP (RALP). • Retrospective analysis of prospectively collected data of the most recent 87 cases of LRP compared with the initial 73 cases of RALP. • LRP was performed via a five-port extraperitoneal approach, while transperitoneal RALP was performed using a four-arm da Vinci S unit. • The median operative duration for RALP (skin-to-skin, including docking time) rapidly reduced, although never exceeded 3.5 h, for each consecutive set of 10 cases. • Oncological outcomes were preserved with no cases of pT2 positive surgical margins (PSMs) in any group. pT3 PSM rates were not significantly different at 50% and 38% for LRP and RALP, respectively. • Penetrative intercourse rates at 3 months for bilateral nerve-sparing procedures in preoperatively potent patients were similar, at 50% for LRP (median Sexual Health Inventory for Men [SHIM] 17) and 48.1% for RALP (median SHIM 18). The pad-free rate at 3 months was significantly better for RALP at 59.7%, compared with 39.8% for LRP (P= 0.043). • Complications were minimal and comparable for the two groups except for a higher LRP radiological anastomotic leak rate of 16 vs 1% (P= 0.004). • In this comparative series fellowship training and prior experience in LRP resulted in no significant RALP learning curve with regards to oncological and functional outcomes, while maintaining a low complication rate. • A short learning curve existed for operative duration but this improved rapidly and there were no prolonged cases. • Differences in early continence and radiological leaks may reflect changing from an interrupted anastomosis (LRP) to a continuous anastomosis with posterior rhabdosphincter reconstruction (RALP).

The Powerful Impact of Double-Layered Posterior Rhabdosphincter Reconstruction on Early Recovery of Urinary Continence After Robot-Assisted Radical Prostatectomy

The usefulness of posterior rhabdosphincter reconstruction (PR) during robot-assisted radical prostatectomy (RARP) has still been controversial. We investigated the association of several factors, including the Rocco original double-layered PR, with early recovery of urinary continence after RARP. Between August 2006 and April 2011, a single surgeon at Tokyo Medical University Hospital performed 206 RARPs. Of these 206 patients, 199 eligible patients were enrolled in this study. We retrospectively analyzed the correlation of several perioperative factors, including surgical techniques, with early recovery of urinary continence 1 month after catheter removal. Continence was defined as no use or the use of only one safety pad. Univariate analysis showed that surgeon experience, lateral approach of bladder neck preservation, bladder neck reconstruction, anterior reconstruction, and the Rocco double-layered PR were significantly associated with early recovery of urinary continence 1 month after catheter removal. Preoperative prostate-specific antigen level, body mass index, and attempted nerve-sparing (NS) procedures, however, were not significantly associated with early recovery of urinary continence. Multivariate logistic regression analysis showed that the Rocco PR and attempted NS were the only independent predictive factors of urinary continence recovery 1 month after catheter removal (odds ratio [OR], 15.01; 95% confidence interval [CI], 3.413-66.67; P=0.0003 and OR, 2.248; 95% CI, 1.048-4.975; P=0.0402, respectively). When we applied NS as well as the Rocco PR, the recovery rates of continence at 1 month after catheter removal was 85.3%. The Rocco double-layered PR and attempted NS and not surgeon experience were the significant independent predictive factors of early recovery of urinary continence after RARP. NS procedures positively influenced early recovery of urinary continence only when they were applied with the PR technique.