Effect of bladder neck sparing at robot-assisted laparoscopic prostatectomy on postoperative continence rates and biochemical recurrence

ObjectivesPrevious studies reported improved continence recovery by bladder neck sparing (BNS) in prostate cancer patients treated with robot-assisted laparoscopic radical prostatectomy (RALP), without compromising biochemical recurrence (BCR). We compared the continence outcomes, surgical margin rates, and BCR risk of BNS vs. bladder neck reconstruction (BNR) patients during RALP.MethodsOverall, 1,512 patients who underwent RALP with BNS or BNR between 2010 and 2017 in a single high-volume center, were identified. Logistic regression models tested the effect of BNS on continence and surgical margin rates. Cox regression models tested the effect of BNS on BCR. Continence was defined as the use of 0 or 1-safety pad per day.ResultsThree hundred and eighty-two vs. 1,130 patients underwent BNS vs. BNR. The median time to catheter removal was significantly shorter (5 vs. 8 days) in patients with BNS. Pad-free rates at 7 days after catheter removal were 60.0% vs. 54.5%, continence rates were 80.1% vs. 78.3% after 3 months and 85.3% vs. 89.6% after 1 year for BNS and BNR, respectively. Multivariable models revealed that BNS is an independent predictor to be pad-free at 7 days after catheter removal (OR: 1.39, P = 0.04), but no predictor for continence at 3 months (OR: 1.02, P = 0.9) and 1 year (OR: 0.78, P = 0.4) after RALP, as well as for positive surgical margin (OR: 0.95, P = 0.8) and BCR (Hazard ratio: 0.95, P = 0.9).ConclusionPatients with BNS had a better chance to be pad-free at 7 days after catheter removal and had a significant shorter time to catheter removal. However, this beneficial effect disappeared with time and no differences in continence rates at 3 months and 1 year were recorded. Moreover, BNS did not negatively affect positive margin or BCR rates.     

Posterior Reconstruction and Outcomes of Laparoscopic Radical Prostatectomy in a High-Risk Setting

Background and Objectives:

To detail the technique and evaluate the impact of a personal modified posterior reconstruction technique (PDR) on the outcomes of extrafascial laparoscopic radical prostatectomy (eLRP) in a consecutive series of 52 patients affected by high-risk prostate cancer (HRPCa).

Methods:

From October 2007 to March 2012, 52 patients underwent PDR during eLRP for HRPCa. Fifty-four patients who underwent eLRP for HRPCa with no PDR were considered as historical controls. Mean operative time (MOT), mean catheterization time (MCT), % continence and quality of life (QoL) at a scheduled follow-up, % anastomotic leakage, % adjuvant therapy were compared between the groups. Percentage of continence and QoL were prospectively assessed by self-administered validated questionnaires (ICI-Q-SF; SF-36) at 1, 3, 6, and12 months.

Results:

PDR was associated wither higher continence rates at 1 and 3 mo (P = .028, P = .006), a lower incidence of cystographic leakage (P = .002), and an increased adjuvant radiotherapy rate (P = .008). At 1- and 3-mo interval, in the PDR group, we found a higher number of patients reporting better general health, (P = .01, P = .03) reduced role limitations due to physical health, (P = .02, P = .001), and emotional problems (P = .001, P = .02).

Conclusions:

PDR is associated with a lower degree of anastomotic leakage, and it significantly enhances urinary continence at 1 and 3 mo. The increased adjuvant radiotherapy rate and quality of life after surgery observed with our technique suggest that in the high-risk setting an early functional recovery may substantially influence the oncologic outcome of eLRP.     

Predictors of positive surgical margins at open and robot-assisted laparoscopic radical prostatectomy: a single surgeon series

Robot-assisted laparoscopic radical prostatectomy (RALRP), increasingly used to treat localized prostate cancer, has advantages over open radical prostatectomy (ORP) in terms of reduced bleeding and quicker convalescence. However, debate continues over whether RALRP provides superior or at least equivalent surgical outcomes. This study compares positive surgical margins (+SM), as a surrogate for long-term cancer control, at RALRP and ORP performed by a single experienced surgeon during the process of taking up RALRP. 400 consecutive patients undergoing surgery for prostate cancer under a single surgeon (DW) between November 1999 and July 2009 were studied. Prior to July 2005, all patients underwent ORP; after this date, most patients were treated by RALRP. Data were collected by retrospective chart review and analysed independently of the treating surgeon. +SM were defined as the presence of cancer at an inked surface. Overall, 23 (11.5%) of 200 patients undergoing RALRP had +SM, compared to 40 (20.0%) of 200 patients undergoing ORP (P?<?0.05). On univariate logistic regression analysis, in addition to surgical approach (odds ratio [OR]?=?1.92), patient age (OR?=?1.05), pathologic stage (OR?=?3.93) and specimen Gleason (GS) score (OR?=?1.86) were significant predictors of +SM. On multivariate analysis, surgical approach, p-stage and specimen GS remained significant predictors of +SM. RALRP is associated with lower rates of +SM compared to ORP, even after adjusting for other known risk factors. Of note, the RALRP in this study were part of the surgeon??s learning curve.     

Focal brachytherapy for localized prostate cancer: 5.7-year clinical outcomes and a pair-matched study with radical prostatectomy

ObjectivesTo report experience with focal brachytherapy (FB) and compare its clinical outcomes with those of radical prostatectomy (RP) in localized prostate cancer.MethodsFifty-one patients with low- to intermediate-risk prostate cancer underwent low-dose-rate FB. Survival rates free from biochemical failure (BF), additional treatment (AT) including re-FB, and whole-gland or systemic salvage therapy (ST) were calculated and oncological risk factors were investigated. Patient-reported outcomes on genitourinary function were also assessed. Using propensity scoring, 51 pair-matched RP patients were selected. Oncological control, urinary continence, and ejaculation status after FB and RP were compared.ResultsDuring a median 5.7-year follow-up, BF, AT, and ST occurred in 12 (24%), 10 (20%), and 4 FB patients (8%), respectively. 6 of 10 AT patients were managed with re-FB alone. In the RP cohort, 3 patients (6%) underwent ST. 5-year BF-free survival rate after FB was 79%. Compared to 5-year ST-free survival rate of 94% after RP, ST-free and AT-free survival rates after FB were 93% (P = 0.813) and 87% (P = 0.049), respectively. Multivariate analyses of FB-treated patients showed that time to PSA nadir was negatively associated with BF and AT (hazard ratio 0.84 and 0.83, respectively, P <0.001 for each). The difference in oncological outcomes between low- and intermediate-risk categories was not significant. At 2 years after FB and RP, pad-free continence rates were 100% and 81%, respectively (P = 0.001). Ejaculation was preserved in 67% and 0% of patients who had been capable of ejaculation at baseline, respectively (P <0.001).ConclusionIn low- to intermediate-risk prostate cancer, FB-treated patients achieved superior genitourinary function compared to pair-matched RP patients. The need for ST was not substantially different between the 2 treatment cohorts. Over half of patients requiring AT could be managed by re-focal treatment rather than whole-gland ST. Early PSA nadir may predict poor oncological control after FB.     

Validation of “patient-reported outcomes via online questionnaire” as a urinary continence assessment and quality improvement tool following radical prostatectomy

BackgroundSecuring reliable data on functional outcomes following radical prostatectomy (RP) is paramount to patient follow-up and management.ObjectiveTo validate an email-based patient-reported outcomes tracking system in assessing pad-free continence rates and time-to continence recovery following RP.Patients and Methods483 men undergoing RP by a single surgeon from November 2013 to March 2019 were prospectively assigned to 1 of 3 tracking systems: 1) a preaddressed paper packet containing a pad-free card and daily urinary pad log, (N = 249); 2) an automated email questionnaire, (N = 234) or 3) both (N = 51). Patients tracked electronically received electronic Research Electronic Data Capture surveys 30 days after catheter removal, with up to 3 reminders sent automatically if no response was received within 2 days. Response rates and continence rates were compared in group 1 vs. group 2 via student t-tests; time-to pad-free status was assessed for concordance among men in group 3 via linear regression.ResultsThirty-day response rates in group 1 (paper) vs. group 2 (electronic) were 80.7% (201/249) and 94.0% (220/234), (P < 0.0001); pad-free rates were 64.2% (129/201) and 64.1% (141/220), (P = 0.9847), respectively. Similarly, 1-year response rates in group 1 and 2 were 87.6% (218/249) vs. 94.0% (220/234), (P = 0.0146); pad-free rates were 91.7% (200/218) vs. 96.4% (212/220), (P = 0.0411), respectively.In group 3, time to pad-free continence recovery assessed via Patient Reported Outcomes via Online Questionnaire (PROVOQ) was highly concordant in 89.6% (43/48) of patients ± 5 days (Figure 1, R² = 0.9893). No significant bias was found for subsequent reporting in either group.ConclusionThe use of automated email survey questionnaires via PROVOQ for the assessment of patient-reported post-RP continence recovery facilitates increased response rates, timeliness of response, and accuracy. PROVOQ significantly reduce the labor of tracking continence outcomes, improve quality improvement efforts, and enables surgeons to more clearly differentiates risk of long-term incontinence.     

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

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

Early continence in patients with localized prostate cancer. A comparison between open retropubic (RRPE) and endoscopic extraperitoneal radical prostatectomy (EERPE)

ObjectiveThe study examined and compared continence rates in prostate cancer patients who had undergone either open retropubic prostatectomy (RRPE) or endoscopic extraperitoneal radical prostatectomy (EERPE). The core question was whether the surgical approach had an effect on the patients' continence status 3 months after surgery.MethodsWe conducted a multicentric, longitudinal study in 7 German hospitals. Three hundred fifty prostate cancer patients (166 EERPE, 184 RRPE) were asked to self-assess symptoms associated with urinary incontinence (UI) 1 day before and 3 months after prostatectomy. Symptoms of UI were assessed using the EORTC QLQ-PR25 questionnaire. Urinary continence was defined according to (1) the use of no protective pad, (2) the use of up to a single protective pad in a 24-hour period, and (3) according to the patient's self-assessment. A binary regression model was employed to predict early continence status.ResultsThree months after prostatectomy, 44% of patients who underwent EERPE and 40% of patients who underwent RRPE were completely continent. Patients who underwent nerve-sparing prostatectomy and patients younger than 65 years had a better chance of regaining urinary continence earlier. The surgical approach had no significant impact on the patients' continence status. Limitations of the study are a drop-out rate of 39% and sociodemographic and clinical differences between both treatment groups.ConclusionsThree months after prostatectomy, there were no significant differences between both treatment groups regarding urinary continence. The surgical approach had no significant effect on the patients' continence status. Higher age and non-nerve-sparing surgery are associated with a longer period of convalescence.     

Significance of postbiopsy hemorrhage observed on preoperative magnetic resonance imaging in performing robot-assisted laparoscopic radical prostatectomy

Objectives

Due to lack of tactile feedback, dissection of surgical planes during delicate procedures of nerve-sparing robot-assisted laparoscopic radical prostatectomy (RALRP) can be hampered more by postbiopsy hematomas or adhesions compared with open surgery. Thus, we investigated association between extent of postbiopsy hemorrhage observed via preoperative magnetic resonance (MR) imaging with surgical difficulty of RALRP.

Methods

We reviewed records of 154 men who received prostate biopsy, MR imaging, and subsequently, nerve-sparing RALRP for clinically localized prostate cancer within 2 weeks of MR imaging. We scored degree of postbiopsy hemorrhage as shown on T1-weighted MR imaging (hemorrhage score) and analyzed potential association of hemorrhage score with variables representative of surgical difficulty (operative time, estimated blood loss, and margin positivity) and functional outcomes (urinary continence and erectile function).

Results

Among our subjects, total hemorrhage score demonstrated no significant associations with interval from biopsy to MR imaging (p = 0.210). In multivariate analyses, prostate volume and total hemorrhage score were observed to be significantly associated with operative time (p = 0.004 and 0.039, respectively) and estimated blood loss (p = 0.009 and 0.023, respectively). Patients’ age and total hemorrhage score was observed to be independent predictor of the return of erectile function sufficient for vaginal intercourse at 6 months following RALRP (p = 0.003 and 0.036, respectively).

Conclusions

Degree of postbiopsy hemorrhage observed in preoperative MR imaging may be predictive of surgical difficulty for RALRP. Such findings provide concrete evidences that aftereffects of prostate biopsy have significant impact on performing RALRP.     

Evaluation of combined oncologic and functional outcomes after robotic-assisted laparoscopic extraperitoneal radical prostatectomy: Trifecta rate of achieving continence,potency and cancer control

ObjectivesOutcomes of continence, erectile function, and oncologic control are well-described in isolation especially for the retropubic open approach. However, only few series have yet reported combined results after radical prostatectomy. To determine the proportion of men who are continent, potent, and cancer-free (trifecta rate) 2 years after robot-assisted laparoscopic radical prostatectomy (RALRP).Materials and methodsWe included patients who underwent a RALRP at our department and who were followed during at least 2 years. Men who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 500 men were included. All patients prospectively completed validated questionnaires (IIEF-5, ICS) before the medical visit and concerning their voiding and sexual disorders, preoperatively, 3, 6, 12, 18, and 24 months after RALRP. Biochemical recurrence was defined as any detectable serum PSA (≥0.2 ng/ml). The study end point was the trifecta rate (cancer control, continence, and potency) at 2 years of the surgery. Predictive factors of the trifecta outcome were assessed in univariate and multivariate analyses.ResultsMedian age and PSA level were 62.2 years and 9.7 ng/mL. A trifecta outcome was achieved in 44% and 53% of men at 12 and 24 months, respectively. The 2-year trifecta rate reached 62% in men undergoing bilateral nerve-sparing surgery and 71% in men < 60 years. Age < 60 years, PSA level < 10 ng/ml, organ-confined disease, and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome.ConclusionTwo years after RALRP, the trifecta outcome is achieved in 53% of preoperatively potent and continent men.     

Prostatectomies for localized prostate cancer: a mixed comparison network and cumulative meta-analysis

No consensus has been attained regarding the utility of open retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) for localized prostate cancer (PCa). We carried out a network meta-analysis and cumulative meta-analysis comparing RRP, LRP and RALRP on peri-operative and functional outcome measures. Electronic databases were searched for either randomized clinical trials or cohort studies comparing RALRP either with LRP or RRP in patients with localized PCa. Outcome measures were as follows: overall, pT2 and pT3-positive surgical margins (PSMs); biochemical recurrence (BCR); complication rates; estimated blood loss; blood transfusion rate; continence and potency rates; duration of catheterization and hospital stay. Publication bias, risk of bias and inconsistency were assessed. Inverse heterogeneity model was used for analysis. A total of 45 studies were included for the final analysis. We observed that RALRP and LRP did not differ significantly from RRP with regard to the following outcomes: overall PSM; pT2 and pT3 PSMs; OT; complication rate; continence and potency rates; total blood loss and hospital stay. Duration of catheterization was significantly shorter in RALRP than LRP and RRP while significant reductions in the need for blood transfusion and BCR were observed for both RALRP and LRP in comparison with RRP. To conclude, similar functional, operative and oncologic outcomes were observed for both RALRP and LRP compared to RRP.     

Robot-assisted laparoscopic radical prostatectomy after previous open transvesical adenomectomy

Introduction

Robot-assisted laparoscopic radical prostatectomy (RALRP) is one of the best treatment for patients with localized prostate cancer. RALRP is currently performed in patients without previous surgical treatment for benign prostatic hyperplasia. This paper presents a successfully performed RALRP after previous open transvesical adenomectomy (TVA).

Case report

A 68-year-old patient underwent nerve-sparing RALRP for prostate cancer revealed by transrectal ultrasound guided prostate biopsy, 7 years after TVA.

Results

Postoperatively, a regular diet was allowed on day 1. The Foley catheter was removed on day 7. At 3 months’ follow-up, the patient complained of moderate stress incontinence but erectile function was responsive to Tadalafil^®. Serum prostate-specific antigen was undetectable. Quality of life was satisfactory.

Conclusions

A history of previous prostatic surgery does not appear to compromise the outcome of RALRP. Nerve sparing is still indicated. Long-term follow-up is necessary to define RALRP as a gold standard also in patients with previous TVA.     

La prostatectomía radical retropúbica abierta es todavía una técnica quirúrgica bien establecida para el tratamiento del cáncer de próstata

IntroductionThe surgical treatment options for prostate cancer have changed rapidly, given the expansion of robotics. However, open retropubic radical prostatectomy (ORP) will continue to be performed in areas with financial limitations or with limited access to robotics. The purpose of this study was to determine the long-term oncological outcomes, to categorize complication rates and to examine the early continence rates in patients treated with ORP.MethodsWe identified all patients who underwent ORP at our institution between 2000 and 2020. A standardized pad test was used to determine the early continence rates upon catheter removal, the late continence around a year after surgery was determined by the number of pads per day. The Clavien-Dindo classification was used to report the complication rates. The biochemical recurrence (BCR)-free survival and overall survival (OS) rates were defined using the Kaplan-Meier method and log-rank analysis. Multivariable Cox-regression models were used to test the effect of different factors on biochemical recurrence.ResultsWe analyzed 1095 patients. The median follow-up was 93.4 months. An overall 10-year BCR-free survival and OS of 73% and 82% respectively was found. A complication rate for Clavien Dindo ≥ 3 was seen in 4.8% of patients. The early continence rate was 81.4% and the late continence 89.1%. Preoperative PSA level, Gleason score sum, pT stage, lymph node status, and surgical margin status were independent predictors of BCR (P < .001). Limitations include retrospective and single centre study design.ConclusionsORP is a surgical procedure that provides excellent oncological- and early continence-rates.     

Application of fibrin sealant at the urethrovesical anastomosis in robotic assisted radical prostatectomy: does it enable earlier Foley catheter and Jackson–Pratt drain removal?

Leakage at the urethrovesical anastomosis in the post-operative period can result in morbidity including ileus. We examined the effectiveness of using a fibrin sealant at the anastomosis to limit urine leakage thereby facilitating earlier Jackson–Pratt drain and Foley catheter removal following robotic assisted laparoscopic prostatectomy (RALRP). Forty consecutive patients underwent RALRP by one surgeon at our institution. The first 20 patients underwent standard operation and served as the control group. The subsequent 20 patients underwent the same operation with addition of fibrin sealant following a running absorbable sutured urethrovesical anastomosis. The two groups were compared for age (60.5 vs. 58.2 years), pre-operative PSA (5.23 vs. 4.71), Gleason score (6.3 vs. 6.5), stage at resection, and prostate size at resection (51.7 vs. 47.7 g). Wilcoxon rank sum test determined no statistically significant differences in the groups. Patients in the fibrin sealant group had 1.3 versus 2.1 days with a Jackson–Pratt drain, 9.75 versus 12.1 days with a catheter, and an average of 38.6 versus 63.2 cc of drainage per shift. Catheters were removed when a cystogram demonstrated no extravasation of contrast. Two patients in the control group and no patients in the fibrin sealant group had large-volume leakage and ileus post-operatively. In patients undergoing RALRP, application of fibrin sealant at the urethrovesical anastomosis appears to facilitate sealing, thereby allowing earlier removal of the JP drain, by 0.8 days, and the Foley catheter, by 2.35 days, than in controls. No patients in the fibrin sealant group suffered post-operative ileus. This adjunct may be especially useful early in the learning process to reduce morbidity.     

A comparative study of laparoscopic and robotic assisted radical prostatectomy performed by a single surgeon

ObjectiveTo present the transition from laparoscopic radical prostatectomy (LRP) to robotic-assisted laparoscopic radical prostatectomy (RALP) over 10 years in a medium volume center by a single surgeon.Materials and methodsWe retrospectively reviewed 140 prostate cancer patients who underwent LRP (100 patients) or RALP (40 patients) between May 2005 and May 2015. Preoperative parameters included age, body mass index, and serum prostate specific antigen. Operative course parameters included operative time, estimated blood loss, intraoperative blood transfusion, conversion to open surgery, hospitalization days, duration of Foley catheterization, and complications. Pathological stage, surgical margin status, biochemical recurrence (BCR) rate, and continence rate at 12 months after surgery were reviewed and compared between the LRP and RALP groups.ResultThe operative outcomes revealed significantly less blood loss (143 mL vs. 306 mL, p < 0.001), shorter hospital stay (6.9 days vs. 8.7 days, p = 0.006), and shorter duration of Foley catheterization (9.3 days vs. 11.3 days, p < 0.001) in patients who underwent RALP. Major perioperative complications occurred in four LRP patients (4%), and none were observed in RALP patients. LRP and RALP had similar positive surgical margin rates (p = 0.285) and BCR rates (p = 0.88). RALP resulted in better continence recovery than LRP (55% vs. 82.5%, p = 0.003).ConclusionPatients who underwent RALP had better perioperative and functional outcomes. Oncologic outcomes were similar compared to patients who underwent LRP.     

Comparación entre la prostatectomía con preservación del espacio de Retzius y la prostatectomía radical estándar asistida por robot para el cáncer de próstata

Introduction and objectivesWe aim to compare the first year oncological and functional outcomes of Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) and standard robot-assisted radical prostatectomy (RARP).Materials and methodsEighty-eight patients who underwent robotic radical prostatectomy between 2018-2019 were included. We compared the minimum one-year follow-up results of patients who underwent Rs-RARP or RARP in terms of oncological and functional outcomes. Potency was assessed with the Sexual Health Inventory for Men (SHIM) score and was defined as an erection sufficient for penetration. Continence was defined as the absence of urinary incontinence with no safety pad. Patients were evaluated in the first month of follow-up and subsequently, every three months.ResultsForty-six patients in Rs-RARP and 42 patients in the RARP group were enrolled. Catheter removal time was shorter in the Rs-RARP group (12 vs. 14 days, P = .001). At the 1^st month visit, 41 patients (%89) were continent (no pads) in the Rs-RARP group while 25 patients (%59) were continent in the RARP group (P = .001). Patients who underwent Rs-RARP achieved faster recovery of urinary continence (Log-rank, P = .001). After one year of follow-up, 43 patients (93%) in Rs-RARP group and 38 patients (90%) in RARP group were continent (P = .6). Potency rates were 38.7% in Rs-RARP and 34.4% in RARP group (P = .28). There were no cases of biochemical recurrence in any group.ConclusionsRs-RARP is a feasible technique, providing early return of continence. However, overall continence rates were similar at the end of the one-year follow-up.     

The value of cystography in the prediction of early urinary continence after radical prostatectomy

ObjectiveTo determine the association between vesicourethral anastomosis level (VUAL) and the condition of the bladder neck with early recovery of urinary continence on cystography after radical prostatectomy.Materials and methodsThis was a retrospective analysis of 116 patients who underwent radical prostatectomy at our hospital from 2008 to 2013. On cystography, the VUAL in the pelvic cavity was defined according to the upper margin of the pubic symphysis; above the upper margin was considered a higher VUAL and below it was considered a lower VUAL. The condition of the bladder neck was determined by whether or not there was contrast flow into the proximal urethra. Early recovery of urinary continence was defined as not requiring pads within 3 months. We determined the predictive factors for the early recovery of continence.ResultsAmong all patients, 68.1% achieved an early recovery of urinary continence. The patients with a higher VUAL were younger and had a shorter time to continence than those with a lower VUAL. The early recovery rates were 88.9% and 58.8% with a higher and lower VUAL, respectively (p < 0.001). The patients with a closed bladder neck also had better results of early continence than those with an open bladder neck (82.9% vs. 45.7%, respectively). VUAL level and bladder neck condition were independent predictors of an early recovery of urinary continence [odds ratio 5.821 (95% confidence interval: 1.632–20.75) higher vs. lower VUAL, p = 0.007; and odds ratio 5.828 (95% confidence interval: 2.259–15.036) closed vs. open bladder neck, p < 0.0001] after adjusting for age, risk of recurrence, operative method, prostate volume, and nerve sparing procedure.ConclusionPostoperative cystography can provide information on VUAL and bladder neck condition which can predict recovery of urinary continence after radical prostatectomy. A higher VUAL and bladder neck closure were associated with a higher rate of early recovery of urinary continence.     

Technical Refinements in Superextended Robot-assisted Radical Prostatectomy for Locally Advanced Prostate Cancer Patients at Multiparametric Magnetic Resonance Imaging

BackgroundThe feasibility and efficacy of robot-assisted radical prostatectomy (RARP) in locally advanced prostate cancer (PCa) patients with iT3 lesion at magnetic resonance imaging (MRI) are currently not explored.ObjectiveTo describe our revised RARP technique (ie, superextended RARP [SE-RARP]) for PCa patients with posterior iT3a or iT3b at MRI.Design, setting, and participantsData from 89 patients with posterior iT3a or T3b disease who underwent SE-RARP at a single high-volume centre between 2015 and 2018 were analysed.Surgical procedureRARP was performed using a DaVinci Xi system. The surgical approach provided an inter- or extrafascial RARP where Denonvilliers’ fascia and perirectal fat were dissected free and left on the posterior surface of the seminal vesicles.MeasurementsPerioperative outcomes, and intra- and postoperative complications were assessed. Postoperative outcomes were assessed in patients with complete follow-up data (n = 78). Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values of ≥0.2 ng/ml. Urinary continence (UC) recovery was defined as the use of zero or one safety pad. Kaplan-Meier and multivariable Cox regression models were used.Results and limitationsThe median operative time, blood loss, and length of stay were 204 min, 300 ml, and 5 d, respectively. The median bladder catheterisation time was 5 d. Overall, 28%, 28%, and 27% of patients had pathological grade group (GG) 4–5, pT3b, and positive surgical margins (PSMs), respectively. Three patients (3.4%) experienced intraoperative complications. Among patients with available follow-up data (n = 78), 14 (18%) experienced 30-d postoperative complications. The median follow-up was 19 mo. Overall, 11 patients received additional treatment. At 2 yr of follow-up, BCR-free and additional treatment–free survival were 55% and 66%, respectively. Pathological GG 4–5 (hazard ratio [HR] 3.2) and PSM (HR 5.8) were independent predictors of recurrence, as well as of additional treatment use (HR 5.6 for GG 4–5 and 5.2 for PSM). The 1-yr UC recovery was 84%.ConclusionsWe presented our revised RARP technique applicable to patients with posterior iT3a or iT3b at preoperative MRI. This technique is associated with good morbidity and continence recovery rates, and might guarantee biochemical control of the disease and postpone the use of additional treatments in patients with low-grade and negative surgical margins.Patient summaryA revised robot-assisted radical prostatectomy technique applicable to prostate cancer patients with posterior iT3a or iT3b lesion at magnetic resonance imaging was described. This novel technique is feasible and safe in expert hands.     

The preoperative pad test as a predictor of urinary incontinence and quality of life after robot-assisted radical prostatectomy: a prospective,observational, clinical study

Purpose

To assess whether the preoperative 1-h pad test could predict postoperative urinary incontinence and quality of life after robot-assisted radical prostatectomy.

Methods

A total of 329 patients who underwent robot-assisted radical prostatectomy between 2013 and 2016 were prospectively enrolled in this study. These patients were divided into the preoperative urinary continence group and the preoperative urinary incontinence group according to the 1-h pad test. The time to achieve urinary continence, lower urinary tract function evaluated by uroflowmetry and post-voided residual urine volume, and quality of life evaluated by King’s Health Questionnaire and International Consultation on Incontinence Questionnaire-Short Form were compared between these two groups.

Results

There were 190 patients (58%) in the preoperative urinary continence group (1-h pad test?≤?2 g) and 139 patients (42%) in the preoperative urinary incontinence group (1-h pad test > 2 g). In the preoperative urinary continence/incontinence groups, 83%/76% of patients achieved continence within 12 months, respectively, and urinary incontinence remained significantly longer in the preoperative incontinence group than in the preoperative continence group (P? =?0.042). Although there were no significant differences in all quality of life items between the two groups before surgery, several items were significantly higher in the preoperative urinary continence group.

Conclusion

Achievement of urinary continence and improvement of urinary quality of life are delayed in patients with preoperative urinary incontinence assessed by the 1-h pad test. The preoperative 1-h pad test could be a useful predictor of prolonged urinary incontinence and poor quality of life after robot-assisted radical prostatectomy.

     

Pilot study of an adult bowel management program for fecal incontinence

ObjectiveBowel management programs are efficacious in pediatric patients with fecal incontinence or intractable constipation unresponsive to standard treatment. No studies have been done examining outcomes in adults. The objective of this study was to assess continence and quality of life outcomes in adults who have underwent bowel management program.MethodsA retrospective review of patients 16 or older at the time they underwent a bowel management program for fecal incontinence or constipation was performed. Data collected included intake and follow-up stool and urinary continence, patient-reported outcomes measures (Cleveland Clinic Constipation Score, Baylor Continence Scale, Vancouver Symptom Score for Dysfunctional Elimination), and an age-adjusted health-related quality of life measure.ResultsThe cohort included 38 patients with a median age of 19 years (range: 16-55) when they underwent our program. 50% of patients were female and the majority (33, 87%) were White. The most common diagnosis was anorectal malformation (16, 42%) followed by functional constipation (10, 27%). Stool continence rates improved after undergoing the program (52.7% prior to 87.6% at follow-up, p<0.01). There was significant improvement in the Baylor Continence Scale, Cleveland Clinic Constipation Score, and PedsQL (p<0.05).ConclusionsAdult patients who underwent a bowel management program for severe fecal incontinence or constipation show significant improvement in stool continence rates, patient-reported outcomes measures, and quality of life. A bowel management program (in-person or via telemedicine) is a feasible treatment strategy for adult patients who fail standard management of fecal incontinence or constipation and should be offered when appropriate.Level of evidence: III.     

Urodynamic evaluation of a suspension technique for rapid recovery of continence after radical retropubic prostatectomy

BACKGROUND: We investigated urodynamic findings involved in the rapid recovery of urinary continence after radical retropubic prostatectomy with a suspension technique. METHODS: A total of 45 consecutive patients (mean age 67.6 years) who had undergone radical retropubic prostatectomy for localized prostate cancer were evaluated with multichannel urodynamics including the maximal urethral pressure (MUP), functional urethral length (FUL), maximal cystometric capacity (MCC) and abdominal leak point pressure (ALPP) at base line, 1 week, 1 month, and 3 months postoperatively. The suspension of vesicourethral anastomosis preserving anterior attachments of puboprostatic ligaments to pubic bone was performed in 33 patients. Twelve patients did not undergo the suspension technique. RESULTS: The continence rates at 1 week, 1 month, and 3 months after radical prostatectomy in the suspension group were significantly higher than those in the non-suspension group: 67% versus 0% at 1 week (P < 0.001), 82% versus 25% at 1 month (P < 0.001), and 91% versus 50% at 3 months (P < 0.01), respectively. Postoperative ALPP at all points of measurement was significantly higher in the suspension group than in the non-suspension group (P < 0.0002). There was no difference in MUP, FUL or MCC at each point following radical prostatectomy between the two groups. CONCLUSIONS: These observations suggest that preserving anterior attachments of puboprostatic ligaments to pubic bone and fixation of urethral hyper-mobility by the suspension of vesicourethral anastomosis promotes rapid recovery of urinary continence after radical retropubic prostatectomy.