Vesicourethral Reconstruction Research Articles

Modified three-layer vesicourethral reconstruction in robot-assisted radical prostatectomy can change cystography pattern and improve early recovery of continence.

To determine early continence outcomes after three-layer vesicourethral reconstruction during robot-assisted radical prostatectomy (RARP) and the role of postoperative cystography pattern. Between May 2015 and January 2019, a total of 170 consecutive patients with localized prostate cancer who underwent RARP, were divided into one- and three-layer groups based on the method of vesicourethral reconstruction. Continent status, preoperative, intraoperative, postoperative, clinicopathological variables, and cystography parameters were analyzed. The patients were followed up for at least 12 months. Of the 170 consecutive patients, 85 with one-layer vesicourethral anastomosis, and 85 with three-layer reconstruction. The continence rates immediately after catheter removal, 4, 12, and 24 weeks after RARP were 47.1%, 75.3%, 92.9%, and 98.8% in the three-layer group; compared to 15.3%, 60%, 78.8%, and 90.6% in the one-layer group, respectively. In the multivariate analysis, three-layer reconstruction was the only independent variable with a 42% risk reduction of postprostatectomy incontinence (hazard ratio (HR): 0.58, 95% confidence interval (CI) = 0.42-0.80, p = 0.001). Cystography in the three-layer group revealed less anastomotic leakage, less sharp bladder neck angle, and higher bladder neck level category. Three-layer anatomical reconstruction demonstrated promising early continence outcomes, and postoperative cystography revealed a specific pattern more associated with continence.

V10-02 SINGLE-PORT TRANSVESICAL PARTIAL PROSTATECTOMY: PREOPERATIVE SURGICAL PLANNING USING A 3D PRINTED MODEL

You have accessJournal of UrologyCME1 Apr 2023V10-02 SINGLE-PORT TRANSVESICAL PARTIAL PROSTATECTOMY: PREOPERATIVE SURGICAL PLANNING USING A 3D PRINTED MODEL Ethan Ferguson, Jason Scovell, Roxana Ramos, Albert Geskin, Jay Chavali, Andres Purysko, and Jihad Kaouk Ethan FergusonEthan Ferguson More articles by this author , Jason ScovellJason Scovell More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Jay ChavaliJay Chavali More articles by this author , Andres PuryskoAndres Purysko More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003328.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical simulation using 3D printed prostate and kidney models has been developed with proposed benefits in pre-operative planning, training, and patient education. Single-port (SP) transvesical partial prostatectomy has been performed in highly selected patients with localized intermediate risk prostate cancer as an alternative to focal therapy. We sought to record our experience and outcomes of SP transvesical partial prostatectomy using a 3D printed model of the bladder and prostate. METHODS: An otherwise healthy and potent 59 year-old patient was selected with localized Gleason 3+4=7 prostate cancer, arising from a MRI-visible lesion in the left anterior prostate gland and no other positive biopsies. Segmentation of the preoperative prostate MRI was done to isolate the bladder, prostate, prostatic urethra, and DVC. Using this information, a 1:1 scale 3D printed model was created. A rehearsal procedure was performed on the model using the DaVinci SP surgical system prior to the patient’s operation. RESULTS: Transvesical access, docking, catheter insertion, partial prostate excision, and vesico-urethral reconstruction were able to be simulated using the 3D model. On the day of surgery, lesion excision was carried out with assistance of fused MRI and ultrasound images for intraoperative guidance. Pathology showed Gleason 3+4 disease. The patient achieved negative margins despite incidental focal extraprostatic extension and was discharged on the same day of the procedure. The foley catheter was removed on postoperative day 3. He was fully continent immediately following foley catheter removal and regained full potency within one week of surgery. CONCLUSIONS: A 3D printed model of the bladder and prostate can be used to simulate partial prostatectomy prior to the in-vivo operation. This has potential benefits in surgical planning and education, though challenges include simulation of patient physiology such as bleeding and the cost of materials. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e926 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Ferguson More articles by this author Jason Scovell More articles by this author Roxana Ramos More articles by this author Albert Geskin More articles by this author Jay Chavali More articles by this author Andres Purysko More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

Perineoscopic vesicourethral reconstruction: A novel surgical technique for anastomotic stricture following radical prostatectomy.

Vesicourethral anastomotic stenosis (VUAS) is frequently seen after prostate surgery because of various operative and postoperative factors. In this study, we aimed to present our results of perineoscopic bladder neck reconstruction, which is a new technique of the perineal approach in the treatment of patients with VUAS after prostate cancer surgery. Sixteen consecutive patients who underwent perineoscopic bladder neck reconstruction in our clinic between July 2017 and March 2019 were included in the study. Demographic characteristics, surgical history, postoperative continence status, and additional treatment requirements were recorded. Perineoscopic surgery is defined as the visualization of the surgical site with instruments used in laparoscopy and the surgeon performing the entire operative procedure through the screen. The mean number of preoperative endoscopic bladder neck resections of the patients was 7±5.1, with a history of suprapubic cystostomy in 7 (43.7%) and radiotherapy in 5 (31.2%) patients before surgery. The mean surgical time was 126.2±13.1 min. The mean follow-up period was 13.2±6.8 months, and the success rate was 81.25%. During follow-up, two (12.5%) patients received perineoscopic re-do reconstruction because of stricture recurrence, and one (6.2%) patient was included in a urethral dilatation program. Improving visualization and ergonomics with the perineoscopic approach can increase the success rate of bladder neck reconstruction in comparison with the standard approach. In addition, the lack of need for expanded dissection (corporal separation, inferior pubectomy) reduces postoperative complication rates.

Open retropubic radical prostatectomy.

Radical prostatectomy (RP) is a common treatment choice for localized prostate cancer. While there is increasing utilisation of robotic assisted RP in some centres, open RP (ORP) remains well established and commonly performed in many parts of the world. The goals of modern ORP are to remove the prostate en-bloc with negative surgical margins, while minimising blood loss and preserving urinary continence and erectile function. We present a technical review of ORP incorporating contemporary techniques for control of the deep venous complex, additional haemostatic measures, nerve-sparing and vesicourethral reconstruction.

Extraperitoneal Robot-Assisted Vesicourethral Reconstruction to Manage Anastomotic Stricture Following Radical Prostatectomy

To demonstrate the feasibility of robot-assisted vesicourethral reconstruction. Vesicourethral anastomotic stricture following radical prostatectomy is a real challenge for reconstructive surgery when facing several endoscopic management failures. This is a case series of robot-assisted vesicourethral reconstruction for anastomotic stricture failing endoscopic management. The procedure was performed with an extraperitoneal approach. The fibrotic anastomotic region was resected and a new vesicourethral running suture was performed with well-vascularized tissue. Bladder catheter was removed after 7 days. Six procedures were performed from April 2013 to May 2018 at our department. One patient had a robot-assisted radical prostatectomy at our department; the 5 others were referred from other institutions after receiving open prostatectomies. Three patients had salvage radiation therapy before reconstruction. Mean age was of 73.8 years (68-82). There was no peroperative complication. Mean operative time was of 108 minutes (60-180)], with a mean estimated blood loss of 130 mL (50-300). After surgery, 3 patients presented recurrences managed endoscopically without recurrence after 3, 5, and 11 months. Three patients presented incontinence treated with artificial sphincter implantation. One patient had no residual symptom after 5 years of follow-up. Robot-assisted vesicourethral reconstruction is a safe procedure. It is an option to consider when facing recurring anastomotic stricture following radical prostatectomy. It is an alternative to the perineal approach and an option before urinary diversion. Patients should be informed of the risks of incontinence and recurrence before surgery especially if they had radiation therapy.

64 Early continence outcomes after robotic radical prostatectomy – Impact of vesicourethral reconstruction

64 Early continence outcomes after robotic radical prostatectomy – Impact of vesicourethral reconstruction

Total reconstruction of the vesico‐urethral junction

We describe a novel technique of total vesico-urethral reconstruction, which combines the tactics of previous surgeons, and compare the outcome of our innovative changes for return to early continence with prostatectomies with no or partial reconstruction of the vesico-urethral junction. Between 1 January 2005 and 5 June 2007 a cohort of 700 patients undergoing robotic radical prostatectomy were prospectively evaluated. Patients in 2005 (214) served as a control group, they received no additional methods to provide support to the vesico-urethral junction; a standard anastomosis was made. Patients in 2006 (304) received an anterior reconstruction only, to provide additional vesico-urethral anastomotic support. Patients in 2007 (182) received the total reconstructive procedure, which included an anterior reconstruction and posterior reconstruction. Outcome data were collected using standardized health-related quality-of-life measures, which included the Expanded Prostate Cancer Index Composite survey, International Prostate Symptom Score, International Index of Erectile Function, and then re-verified by telephone interview with a standardized questionnaire. The follow-up intervals were 1, 6, 12, 24 and 52 weeks. Continence was defined as no pad usage or one small liner used for security purposes only. Baseline variables were also collected. The percentage of patients who had achieved continence in the control group were: 13%, 35%, 50%, 62% and 82% at the 1-, 6-, 12-, 24- and 52-week follow-up, respectively. The percentage of patients who had achieved continence in the anterior reconstruction group were 27%, 59%, 77%, 86%, and 91%, respectively. The total reconstruction group had continence rates of 38%, 83%, 91%, and 97% at 1, 6, 12, and 24 weeks, respectively. At all the follow-up intervals the continence rate was significantly less in the control group than in the anterior reconstruction group and the total reconstruction group (P < 0.01). The total reconstruction procedure is a safe and effective way to achieve an early return to continence. No adverse effects have been observed because of its employment and our data validates that it does provide a statistically significant early return to continence compared with no reconstructive efforts or with only anterior reconstructive efforts.

Laparoscopic Radical Prostatectomy

Objectives: In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In our study, we describe our operative technique and assess our results in terms of oncologic cure, continence and potency. Methods: 200 patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy. 66 of these patients were either referred, or operated during surgical demonstrations. Thus, complete evaluation is based on a homogenous personal series of 134 patients and was performed by an independent clinical analyst. There were 91 T1 and 43 T2. We did not perform pelvic lymph node excision in 78 patients whose PSA was less than 10 ng/ml and the Gleason score of endorectal biopsies was below 7. The surgical procedure recapitulated the steps of traditional retropubic prostatectomy with one basic difference however: the first step of the technique consisted in a rectoprostatic cleavage, which was done transperitoneally. Except for the first 10 patients, the vesicourethral reconstruction was performed either with two hemi–circumferential or a single circumferential running suture. Results: All interventions were performed as planned, no conversions were necessary, and only 4 patients required blood transfusion. Operating time decreased with growing experience; after the first 20 patients the usual operating time was 3.5 h without and 4 h with lymphadenectomy. The surgical complication rate was 22.5% in the first 40 patients, and 3.2% in the remaining 94 patients. Except for the first 10 patients, the mean hospital stay was 6.1 days and bladder catheterization 4.8 days. Median catheterization time was 4 days. Histological study of the specimen showed pT2 disease in 101 patients and pT3 in 33 patients, the rate of positive margins was 16.8 and 48.8%, respectively. At 1 year, overall erection rate (with or without sexual intercourse) was 56%, the rate of patients without pad was 86.2% during the day and 100% during the night. Conclusions: Laparoscopic environment seems to comply with the oncologic goals of radical prostatectomy. Improved intraoperative visualization and magnification may provide benefits for the preservation of continence and potency by allowing a more precise dissection and vesicourethral reconstruction. Despite longer operative times and the steep learning curve this new technique is currently proliferating due to expectations of decreased postoperative morbidity and better quality of life.

Laparoscopic radical prostatectomy: preliminary results

Objectives. To evaluate our preliminary experience with laparoscopic radical prostatectomy. The indications for laparoscopy are currently being extended to complex oncologic procedures. Methods. Forty-three men underwent laparoscopic radical prostatectomy. We used five trocars. The surgical technique replicates the steps of traditional retropubic prostatectomy, except that the rectoprostatic cleavage plane is developed transperitoneally at the beginning of the procedure. In the first 10 patients, we performed the vesicourethral reconstruction with interrupted sutures; in the remaining 33 patients, we performed it with two hemicircumferential running sutures. The specimen was removed through the umbilical port site. Results. Once the developmental phase with the first 10 patients was concluded, the median operating time was 4.3 hours without pelvic lymphadenectomy, and the median postoperative bladder catheterization was 4 days. Two (4.7%) of 43 patients underwent transfusion. Twelve patients (27.9%) had positive surgical margins; all patients had a postoperative prostate-specific antigen level of less than 0.1 ng/mL at 1 month. Rectal injury occurred in 1 patient, requiring colostomy, and 4 patients had urethrovesical anastomotic leakages requiring surgical repair. One month postoperatively, 36 patients (84%) were fully continent (no leakage). Six patients had had erections, and four stated they had had sexual intercourse. Conclusions. Laparoscopic radical prostatectomy has evolved to a fully standardized and reproducible procedure. The short-term oncologic and functional efficacy rates are equivalent to those for open surgery. The operating time is reasonable once the learning curve is over, and postoperative morbidity is diminished. Because of the improved visual accuracy, permitting more precise dissection, this technique has the potential to become an important advancement in urologic surgery.

VESICOURETHRAL RECONSTRUCTION IN RADICAL RETROPUBIC PROSTATECTOMY: AN ALTERNATIVE TECHNIQUE

Purpose We review an alternative method of vesicourethral reconstruction in patients undergoing radical retropubic prostatectomy for adenocarcinoma of the prostate. Materials and Methods A total of 91 consecutive patients were prospectively evaluated for an alternative technique for vesicourethral reconstruction which incorporates specific principles of direct suture anastomosis and the modified Vest technique. Perioperative and postoperative complications were reviewed. Results Total continence was reported in 80 of 91 patients (87.9%). Persistent moderate to severe incontinence was present in 1 patient and anastomotic stricture was identified in 7 (7.7%). Prolonged urinary extravasation was rare. Conclusions This method of vesicourethral reconstruction appears to offer an efficient, reproducible alternative to direct suture anastomosis with acceptable complication rates.

Comparison of techniques for vesicourethral anastomosis: Simple direct versus modified vest traction sutures

Radical retropubic prostatectomy has become a mainstay surgical procedure in the treatment of cancer of the prostate. There has been controversy, however, regarding the most appropriate method of vesicourethral reconstruction. We examined the records of 692 consecutive patients who underwent a radical retropubic prostatectomy from 1978 through 1984 at the Mayo Clinic. Of these, 416 patients underwent a modified Vest procedure, and in 276 patients a direct simple anastomosis was fashioned. In comparing these two methods, our review showed no substantial difference in complications, including the rate of urinary incontinence.

Reevaluation of vest technique of vesicourethral reconstruction in radical retropubic prostatectomy

Vesicourethral reconstruction after radical retropubic prostatectomy was done by the Vest technique in 36 patients and by direct vesicourethral anastomosis in 100 patients. Complications resulting from the two methods of vesicourethral reconstruction were similar. Incontinence after radical retropubic prostatectomy appears not to be related to the method of vesicourethral reconstruction but occurs because of damage during surgery or postoperative scarring of the distal sphincteric mechanism.