Systematic Review and Meta-analysis of Studies Reporting Urinary Continence Recovery After Robot-assisted Radical Prostatectomy

A risk grouping algorithm for predicting factors of persistently elevated prostate-specific antigen in patients following robot-assisted radical prostatectomy

OBJECTIVE

After radical prostatectomy, prostate-specific antigen(PSA) value measuring ≥0.1 ng/mL is defined as persistent PSA(pPSA) and in many studies, it was found to be associated with aggressive disease and poor prognosis. Our aim in this study is to point out the pathological and clinical factors affecting pPSA among the patients who underwent robot-assisted radical prostatectomy(RARP) in an experienced academic centre and to make a useful risk grouping algorithm that can predict pPSA value based on operative data.

METHODS

We examined records of 1273 patients who underwent RARP retrospectively. Preoperative, operative and postoperative data were collected. Based on the PSA values (ng/mL) measured after 4-to-8 weeks of RARP, patients were divided into two groups as pPSA group (Group1)(n = 97) with PSA values ≥0.1 ng/mL and undetectable PSA group (Group2)(n = 778) with PSA values <0.1 ng/mL. Later on, Group1 was further divided into Group1a (PSA:0.1-0.2 ng/mL) and Group 1b (PSA≥0.2 ng/mL) to evaluate biochemical recurrence(BCR).

RESULTS

Multivariate logistic regression analyses of the collected data revealed that preoperative PSA≥20 ng/mL, operation time, a postoperative international society of urological pathology (ISUP) grade of ≥4, pT 3-4 and pN were independently associated with pPSA. Based on these results, a risk grouping algorithm predicting pPSA was developed. By looking at the risk grouping algorithm pPSA was found in 98.9% of the cases with a preoperative PSA value of ≥20 ng/mL, an operation time of 150 min, a postoperative ISUP grade of 4-5, a positive lymphovascular invasion (LVI) status, pT3-T4, and pN+; while pPSA was found in 25.5% of the cases with a preoperative PSA value of <20 ng/mL, an operation time of 100 min, a postoperative ISUP grade of <4-5, a negative LVI status, pT<3-4 and pN-. The estimated BCR-free survival time was 16.3 months in Group 1a and 57.0 months in Group2 (P < .001). Adjuvant treatment ratio was 64.9% in Group1 and 7.1% in Group2 (P < .001).

CONCLUSION

For the patients who underwent RARP, factors associated with aggressive disease can predict the PSA persistence. To plan our treatment modalities accurately, an applicable risk grouping algorithm in daily practice would be useful.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

Functional and Oncological Outcomes After Open Versus Robot-assisted Laparoscopic Radical Prostatectomy for Localised Prostate Cancer: 8-Year Follow-up

BACKGROUND

Radical prostatectomy reduces mortality among patients with localised prostate cancer. Evidence on whether different surgical techniques can affect mortality rates is lacking.

OBJECTIVE

To evaluate functional and oncological outcomes 8 yr after robot-assisted laparoscopic prostatectomy (RALP) and open retropubic radical prostatectomy (RRP).

DESIGN, SETTING, AND PARTICIPANTS

We enrolled 4003 patients in a prospective, controlled, nonrandomised trial comparing RALP and RRP in 14 Swedish centres between 2008 and 2011. Data for functional outcomes were assessed via validated patient questionnaires administered preoperatively and at 12 and 24 mo and 8 yr after surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was urinary incontinence. Functional outcomes at 8 yr were analysed using the modified Poisson regression approach.

RESULTS AND LIMITATIONS

Urinary incontinence was not significantly different at 8 yr after surgery between RALP and RRP (27% vs 29%; adjusted risk ratio [aRR] 1.05, 95% confidence interval [CI] 0.90-1.23). Erectile dysfunction was significantly lower in the RALP group (66% vs 70%; aRR 0.93, 95% CI 0.87-0.99). Prostate cancer-specific mortality (PCSM) was significantly lower in the RALP group at 8 yr after surgery (40/2699 vs 25/885; aRR 0.56, 95% CI 0.34-0.93). Differences in oncological outcomes were mainly seen in the group with high D'Amico risk, with a lower risk of positive surgical margins (21% vs 34%), biochemical recurrence (51% vs 69%), and PCSM (14/220 vs 11/77) for RALP versus RRP. The main limitation is the nonrandomised design.

CONCLUSIONS

In this prospective multicentre controlled trial, PCSM at 8 yr after surgery was lower for RALP in comparison to RRP. A causal relationship between surgical technique and mortality cannot be inferred, but the result confirms that RALP is oncologically safe. Taken together with better short-term results reported elsewhere, our findings confirm that implementation of RALP may continue.

PATIENT SUMMARY

Our study comparing two surgical techniques for removal of the prostate for localised prostate cancer shows that a robot-assisted minimally invasive technique is safe in the long term. Together with previous results showing some better short-term effects with this approach, our findings support continued use of robot-assisted surgery.

Impact of Bladder Neck Angle Measured by Postoperative Magnetic Resonance Imaging on Midterm Recovery of Urinary Continence in Prostate Cancer Patients Undergoing Robot-Assisted Radical Prostatectomy

Introduction: MRI has helped clarify the relationship between pelvic anatomical structures and functional outcomes after robot-assisted radical prostatectomy (RARP). The objective of this study was to assess the impact of the bladder neck angle (BNA) measured by postoperative MRI on midterm recovery of urinary continence (UC) in patients undergoing RARP. Patients and Methods: This study retrospectively included 200 consecutive patients with prostate cancer who were treated by RARP and received MRI 3 months after RARP. Based on postoperative MRI, the BNA was measured as the angle between the anterior and posterior bladder walls. The midterm recovery of UC was defined as the use of either no pad or an occasional security pad at 6 months after RARP. Results: One hundred forty-four of the 200 patients (72.0%) achieved midterm recovery of UC and the median BNA was 70°. There were no significant differences in several parameters, including age, body mass index, total prostate volume, preservation of the neurovascular bundle, and postoperative membranous urethral length (MUL), between patients with BNA ≥70° and <70°. Of these parameters, only the BNA and postoperative MUL were independently associated with the midterm recovery of UC. The optimal cutoff points of the BNA and MUL (65° and 9 mm, respectively) were calculated by the receiver operating characteristics curve, and a scoring model for the prediction of midterm recovery of UC was developed according to the logistic regression analysis. This scoring model was demonstrated to be satisfactorily calibrated (p for Hosmer-Lemeshow test = 0.49) and provide good discrimination (area under the curve: 0.723; p < 0.001). Conclusions: These findings suggest that midterm recovery of UC after RARP is favorably affected by the large BNA and long postoperative MUL, and our scoring model can be used as a reliable tool for predicting the midterm continence status after RARP.

Myosteatosis as a novel predictor of urinary incontinence after robot-assisted radical prostatectomy

OBJECTIVES

To evaluate the impact of sarcopenia and myosteatosis on urinary incontinence after prostatectomy.

METHODS

We retrospectively reviewed consecutive patients who underwent robot-assisted radical prostatectomy without nerve sparing between December 2012 and March 2019. Psoas muscle index and average total psoas density, which were measured on preoperative computed tomography images at level L3, were used to evaluate sarcopenia and myosteatosis, respectively. In addition, several magnetic resonance imaging variables associated with pelvic muscles, the urethra and the prostate were measured. Urinary continence was defined as non-use or use of just one incontinence pad per day. Logistic regression analyses aimed to identify the predictors of urinary incontinence 3 and 12 months after surgery.

RESULTS

Overall, 121 patients were included in the analysis. The incidence rates of urinary incontinence 3 and 12 months after surgery were 42% (51/121 cases) and 16% (19/121 cases), respectively. Logistic multivariable analysis showed that low average total psoas density was the only significant independent predictor of urinary incontinence 3 months after surgery (P < 0.01), and low obturator internus muscle thickness (P = 0.01), short membranous urethral length (P = 0.01) and low average total psoas density (P < 0.01) were significant independent predictors of urinary incontinence 12 months after surgery. By contrast, psoas muscle index was not statistically associated with urinary incontinence after surgery.

CONCLUSIONS

Myosteatosis (low average total psoas density) could be a novel predictor of urinary incontinence after robot-assisted radical prostatectomy.

Angiogenesis and Anti-Angiogenic Treatment in Prostate Cancer: Mechanisms of Action and Molecular Targets

Prostate cancer (PC) is the most common cancer in men and the second leading cause of cancer-related death worldwide. Many therapeutic advances over the last two decades have led to an improvement in the survival of patients with metastatic PC, yet the majority of these patients still succumb to their disease. Antiagiogenic therapies have shown substantial benefits for many types of cancer but only a marginal benefit for PC. Ongoing clinical trials investigate antiangiogenic monotherapies or combination therapies. Despite the important role of angiogenesis in PC, clinical trials in refractory castration-resistant PC (CRPC) have demonstrated increased toxicity with no clinical benefit. A better understanding of the mechanism of angiogenesis may help to understand the failure of trials, possibly leading to the development of new targeted anti-angiogenic therapies in PC. These could include the identification of specific subsets of patients who might benefit from these therapeutic strategies. This paper provides a comprehensive review of the pathways involved in the angiogenesis, the chemotherapeutic agents with antiangiogenic activity, the available studies on anti-angiogenic agents and the potential mechanisms of resistance.

Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis

Purpose:

To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center.

Materials and Methods:

We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m²). They were grouped according to the age, PSA level, D’Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders.

Results:

Among the obese patients, mean BMI was 32.8kg/m², ranging 30 - 45.7kg/m². Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927).

Conclusions:

Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review

The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.

Feasibility and outcome of radical prostatectomy following inductive neoadjuvant therapy in patients with suspicion of rectal infiltration

OBJECTIVE

To determine the feasibility and outcome of radical prostatectomy (RP) following neoadjuvant therapy (NAT) in patients with initial inoperable, rectum-infiltrating cT4 prostate cancer (PCa).

METHODS

From 01/2018 to 12/2020, 26 patients with clinical (DRE) or radiographical (mpMRI) suspicion of rectum infiltrating PCa at diagnosis and NAT prior to RP were retrospectively identified from our prospective institutional database. Two patients were still inoperable after NAT. Downsizing was administered for at least 20 weeks and RP was performed after excluding ongoing rectal infiltration.

RESULTS

At diagnosis, median PSA was 42.5 ng/ml (IQR: 23.0-66.1). Inductive NAT consisted of androgen deprivation therapy (ADT) in combination with chemotherapy (n = 9) or without chemotherapy (n = 14). Median preoperative PSA was 0.93 ng/ml (IQR: 0.24-0.40). Median time from NAT to RP was 6 months (IQR: 5-7). Two patients were still inoperable after NAT. Of 24 patients undergoing RP, abortion of surgery due to inoperability was observed in 2 patients (8.4%), demonstrating a total failure rate of NAT in 4 out of 26 patients (15.4%). One patient suffered a rectal injury with consecutive colostomy (4.2%). No Clavien-Dindo complication Grade IV or V were observed. Urinary continence was achieved in 16 patients (84.2%). Sufficient erection for sexual intercourse was present in 2 patients (10.5%). All patients received adjuvant ADT with or without radiation therapy. Median PSA at 13 months was 0.08 ng/ml (IQR: 0.01-0.74).

CONCLUSION

RP of initially rectum infiltrating PCa is feasible and safe after inductive NAT, however complications rates tend to be higher compared to standard RP.

Improvement of quality of life and symptom burden after robot-assisted radical prostatectomy in patients with moderate to severe LUTS

The aim of this study was to assess clinically meaningful differences of preoperative lower urinary tract symptoms (LUTS) and quality of life (QoL) before and after robot-assisted radical prostatectomy (RARP). Therefore we identified 5506 RARP patients from 2007 to 2018 with completed International Prostate Symptom Score (IPSS) and -QoL questionnaires before and 12 months after RARP in our institution. Marked clinically important difference (MCID) was defined by using the strictest IPSS-difference of − 8 points. Multivariable logistic regression analyses (LRM) aimed to predict ∆IPSS ≤ − 8 and were restricted to RARP patients with preoperatively moderate (IPSS 8–19) vs. severe (IPSS 20–35) LUTS burden (n = 2305). Preoperative LUTS was categorized as moderate and severe in 37% (n = 2014) and 5.3% of the complete cohort (n = 291), respectively. Here, a postoperative ∆IPSS ≤ − 8, was reported in 38% vs. 90%. In LRM, younger age (OR 0.98, 95%CI 0.97–0.99; p = 0.007), lower BMI (OR 0.94, 95%CI 0.92–0.97; p < 0.001), higher preoperative LUTS burden (severe vs. moderate [REF.] OR 15.6, 95%CI 10.4–23.4; p < 0.001), greater prostate specimen weight (per 10 g, OR 1.12, 95%CI 1.07–1.16; p < 0.001) and the event of urinary continence recovery (OR 1.66 95%CI 1.25–2.21; p < 0.001) were independent predictors of a marked LUTS improvement after RARP. Less rigorous IPSS-difference of − 5 points yielded identical predictors. To sum up, in substantial proportions of patients with preoperative moderate or severe LUTS a marked improvement of LUTS and QoL can be expected at 12 months after RARP. LRM revealed greatest benefit in those patients with preoperatively greatest LUTS burden, prostate enlargement, lower BMI, younger age and the event of urinary continence recovery.

Patient reported outcome measures concerning urinary incontinence after robot assisted radical prostatectomy: development and validation of an online prediction model using clinical parameters, lower urinary tract symptoms and surgical experience

The prediction of post-prostatectomy incontinence (PPI) after robot-assisted radical prostatectomy (RARP) depends on multiple clinical, anatomical and surgical factors. There are only few risk formulas, tables or nomograms predicting PPI that may assist clinicians and their patients in adequate risk counseling on postoperative side-effects. Prospective data collection of 1814 patients who underwent RARP between 2009 and 2017 was done. Pre-operative parameters were age, body mass index (BMI), prostate volume, the American Society of Anesthesiologists (ASA) score, severity of Lower Urinary Tract Symptoms (LUTS), type of planned nerve-sparing surgery and surgical experience. The continence status was reported using Patient Reported Outcome Measurements (PROMs) using the validated pad-use questionnaire EPIC26. Continence was defined as either the use of zero pads or one safety pad. Multivariable logistic regression analysis was performed to identify predictors of PPI within one year after RARP. An online prediction tool was developed and validated. The median follow-up was 36 months (range 12-108). The response rate was high at 85.2%. A total of 85% (1537/1814) of patients was continent on follow-up. One-year continence rate was 80.1% (95% CI 78.3-81.9%) (1453/1814) and increased to 87.4% (95% CI 85.4-89.4%) after 5 years. On multivariable analysis, severity of LUTS (OR = 0.56 p = 0.004), higher age (OR = 0.73 p = 0.049), extend of nerve-sparing surgery (OR = 0.60 p = 0.001) and surgeon experience (OR = 1.48 p = 0.025) were significant independent predictors for PPI. The online prediction model performed well in predicting continence status with poor discrimination and good calibration. An intuitive online tool was developed to predict PPI after RARP that may assist clinicians and their patients in counseling of treatment.

Treatment of post-prostatectomy urinary incontinence and erectile dysfunction: there is insufficient utilisation of care in German cancer survivors

PURPOSE

Treatment of post-prostatectomy urinary incontinence (UI) and erectile dysfunction (ED) increases quality of life (QoL). Aim of our study was to evaluate the utilisation of care among patients with post-prostatectomy UI and ED in Germany.

METHODS

The HAROW study documented treatment of patients with localised prostate cancer (≤ T2c) in Germany. 1260 patients underwent radical prostatectomy (RP). Patients answered validated questionnaires after a median follow-up of 6.3 years. Response rate was 76.8%.

RESULTS

Median age at RP was 65 (IQR 60-69) years. 14% (134/936) used more than one pad per day for UI. 25% (26/104, 30 missing) of UI patients underwent surgery to improve continence. Of patients without surgery, 41% (31/75) reported a moderate-to-severe issue concerning their incontinence with worse mental health and QoL. 81% (755/936) patients were unable to have an erection firm enough for sexual intercourse. Of all ED patients, 40% (319/793) used ED treatment regularly or tried it at least once. 49% (243/499) of patients with interest in sex never tried ED treatment. In multivariate analysis, patients not using ED treatments were older (≥ 70 years OR 4.1), and more often had preoperative ED (OR 2.3) and less interest in sex (OR 2.2). Nevertheless, 30% (73/240) of these patients had moderate-to-severe issues with their ED reporting worse mental health and QoL.

CONCLUSION

Almost half of the patients without post-prostatectomy UI and ED treatment reported moderate-to-severe issues with a significant decrease in QoL. This indicates an insufficient utilisation of care in Germany.

Early Revision after Artificial Urinary Sphincter Implantation Does Not Impair the Long-Term Treatment Success

INTRODUCTION

After implantation of an artificial urinary sphincter (AUS) due to stress urinary incontinence, in some cases revision procedures may be necessary. This is mostly due to device infection or cuff erosion in the long term. The aim of this study was to evaluate the impact of early revision procedures (prior to or immediately after AUS activation) on the long-term outcome.

METHODS

We retrospectively evaluated patients who underwent primary AUS implantation between 2006 and 2019. Patients with previous radiotherapy, urethroplasty, urethral stent placement, or repeat AUS implantation were excluded. Early revision was defined as prior to or immediately after AUS activation and comprised pump repositioning or cuff size adaptation due to difficulties in using the pump, persistent urinary incontinence, or urinary retention. Patients were compared with regard to complication rates, functional outcome, and patient satisfaction. Univariable and multivariable logistic regression analyses were performed to analyze risk factors for early AUS revision. Kaplan-Meier analysis evaluated explantation-free survival.

RESULTS

A total of 250 patients were included. Twenty patients (8%) required early revision (pump repositioning in 15 cases [75%], cuff downsizing in 3 cases [15%], and cuff upsizing in 2 cases [10%]). Mean follow-up was 78.6 months. 96.4% of all patients were objectively continent at the time of last follow-up without differences between both groups, and patient satisfaction was high in both groups. No differences with regard to mechanical implant failure, tissue atrophy, and AUS explantation due to cuff erosion or implant infection were observed. Explantation-free survival was comparable in both groups. On univariable logistic regression analysis, coronary artery disease and transcorporal cuff placement were associated with early AUS revision.

CONCLUSION

Early revision after AUS implantation can be performed without negative impact on the long-term outcome.

To sling or not to sling? Impact of intraoperative sling procedures during radical prostatectomy on postoperative continence outcomes: A systematic review and meta‐analysis

Purpose

This systematic review and meta‐analysis investigates the efficacy of intraoperative sling procedures in reducing postprostatectomy urinary incontinence compared to having no slings.

Methods

A comprehensive search of PubMed, Medline, Embase, and the Cochrane library from inception to November 2020 was performed. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized studies and Newcastle‐Ottawa Scale for nonrandomized studies. The GRADE approach was used for critical appraisal of evidences and meta‐analyses were conducted using random‐effects models.

Results

Ten studies were included (n = 1,447). Quality of evidence ranged from moderate to very low. Sling procedure was generally favorable for short‐term continence outcomes, although discrepancies exist due to variability in continence definition. Sling procedure resulted in reduced urinary pad weight at 1 month postoperatively (MD: 21.55; 95%CI: 12.58 to 30.52). Patient‐reported questionnaires were also favorable for the sling group for up to 3 months (IPSS; (MD: 1.44; 95%CI: 0.14 to 2.74), ICIQ‐SF; (MD: 2.25; 95%CI: 1.26 to 3.24), EPIC‐U; (MD: 5.30; 95%CI: 1.12 to 9.39)) postoperatively. Sling procedure improved the number of continent patients at 1 month with continence definition of zero pad use/day (RR:1.41; 95%CI: 1.10 to 1.83) but not with the definition of ≤ 1pad/day. Similarly, it reduced the time to continence with the ≤ 1 pad/day definition (MD: 0.5; 95%CI: 0.1 to 0.9) but not with the zero pad/day definition.

Conclusion

The current literature suggests that intraoperative sling procedures during radical prostatectomy may promote early return of continence compared to having no sling, however, there are no long‐term differences.

A Bibliometric Analysis of Overall and Top 100 Most-Cited Studies About Robotic Surgery Versus Open Surgery

BACKGROUND

In the last 30 years, significant progress in the field of surgery has been achieved with the advent of robotic surgery. In this study, we aimed to conduct a bibliometric analysis to identify the distribution and characteristics overall and of the top 100 most-cited studies about robotic surgery versus open surgery.

METHODS

A systematic search was conducted on March 26, 2021 using Web of Science Core Collection. Two reviewers independently screened documents, and the top 100 most-cited studies were identified. Excel 2019 and VOSviewer were used to collect the data, and visual information was obtained.

RESULTS

A total of 2306 documents were searched from the Web of Science Core Collection, and 1065 journals and 2913 institutes were extracted. A significant growth was observed in the last 15 years. The number of citations from the United States accounted for 33.31% of the total number of citations. There were nine American institutes and one Swedish institute in the top 10 institutes. Four journals in the field of urology or gynecology were present in the top 10 published journals. Few global communications between authors, institutes, and countries authors were observed.

CONCLUSION

The lack of close cooperation among scientific research institutions may have affected the industrialization process of surgical robots. Some developing countries, including South America and Africa, should seize the development opportunity of robotic surgery to improve the level of domestic research on robotic surgery.

Measuring Quality of Life Following Robot-Assisted Radical Prostatectomy

BACKGROUND

Prostate cancer (PCa) represents the most common solid organ malignancy in men. Fortunately, at the time of diagnosis, the majority of cases are staged as localized or regional disease, conferring excellent 5- and 10-year cure rates. There are several first line treatment options including surgical approaches such as robot-assisted radical prostatectomy (RARP) and radiation therapy (RT) available to patients with localized disease that offer similar PCa oncologic outcomes but are associated with potentially significant side effects which may impact health-related quality of life (HRQOL) domains. Recently, clinicians and investigators have sought to better understand these changes in HRQOL metrics with the utilization of patient-reported outcomes (PRO). Given that RARP represents the most common surgical treatment for PCa in the United States, there has been a particular interest in assessing these outcomes derived by patient perspectives to more fully appreciate treatment-related impact on quality of life following RARP.

OBJECTIVE

This narrative review sought to explore the instruments available to measure quality of life after RARP, a review of the PRO data after RARP, and future directions for assessing and improving quality of life outcomes following this surgery.

CLINICAL USE

There are several treatment options for men diagnosed with local and regional prostate cancer with similar oncologic outcomes but differing patterns of side effects affecting post-treatment quality of life. Understanding data reported directly by patients following RARP about their side effects and quality of life gives providers additional information for appropriate preoperative counseling for patients choosing between treatment options for their prostate cancer.

Contemporary trends in radical prostatectomy and predictors of recovery of urinary continence in men aged over 70 years: comparisons between cohorts aged over 70 and less than 70 years

We evaluated contemporary trends in radical prostatectomy (RP) in men aged >70 years and investigated associations of selected variables with recovery of urinary continence (UC) in two age groups: >70 and ≤ 70 years. A retrospective cohort of 2301 eligible patients attending our institution from 2004 to 2015 was reviewed. Patients were divided into two groups based on age at surgery (>70 years [n = 610] vs 7 0 years [n = 1691]) and four groups by year of surgery. Over the study period, the proportion of patients aged >70 years gradually increased up to 30.0%, and the rate of robot-assisted RP and neurovascular bundle (NVB) saving increased continually to 80.0% and 67.4% of older patients, respectively. Although the rate of recovery of UC within 12 months (3 months) in patients aged >70 years was lower than that in those aged ≤ 70 years (81.5% [52.6%] vs 88.6% [60.9%], respectively; both P < 0.001), the gap between age groups in the rate of recovery within 12 months narrowed from the second quarter of the study period. Among younger patients, age, robot-assisted RP, prostate volume, membranous urethral length (MUL), and NVB saving were predictors of recovery of UC within 3 or 12 months. In contrast, only age and MUL were predictors of recovery of UC within 3 and 12 months in patients aged >70 years. Therefore, unlike younger patients, only variables (age and MUL), possibly associated with the inherent function of the urinary sphincter, were predictors of recovery of UC in patients aged >70 years.

Implementation of radioguided surgery in prostate cancer

With the development of new imaging technologies and tracers, the applications of radioguided surgery for prostate cancer are growing rapidly. The current paper aims to give an overview of the recent advances of radioguided surgery in the management of prostate cancer. We performed a literature search to give an overview of the current status of radioguided surgery for prostate cancer. Three modalities of radioguided surgery, the sentinel node procedure, Cerenkov Luminescence / beta-radio-guided surgery and radio-guided salvage surgery in recurrent prostate cancer, were reviewed in detail. Radioguided surgery for prostate cancer has shown promising value in the treatment of primary diagnosed prostate cancer and recurrent loco-regional lymph node positive prostate cancer. Advances have been made into minimal invasive (robot-assisted) laparoscopic surgery. The sentinel node procedure for prostate cancer has been further developed and is currently performed with high diagnostic sensitivity. Cerenkov luminescence imaging is a feasible and encouraging technique for intraoperative margin assessment in prostate cancer. Radioguided surgery in recurrent prostate cancer has shown to be feasible, yielding high sensitivity and specificity for detecting small local recurrences and metastases. With the availability of different new tracers, the road has been paved towards clinically feasible radioguided surgery for prostate cancer. Novel technologies now being developed for minimal invasive surgery are speeding up clinical research. Currently, none of the radioguided surgery techniques mentioned have been accepted as standard of care.

Robotic Radical Prostatectomy at the Egyptian National Cancer Institute: Overcoming the Challenges in the Initial Case Series

BACKGROUND: Robotic prostatectomy is showing progressive worldwide spread owing to potential clinical benefits, but at a higher cost. AIM: This article describes the challenges and clinical outcomes of the first group of patients undergoing robotic prostatectomy in Egypt. DESIGN, SETTING, PARTICIPANTS: From 2017 to 2019, the data of all (55) patients undergoing robotic radical prostatectomy at the National Cancer Institute of Egypt were retrospectively analyzed. OUTCOME EVALUATION: Short-term operative outcomes, complications, technical difficulties, pathologic data, and biochemical recurrence were reported. RESULTS: Average blood loss was 296 ml; one patient required blood transfusion. One case required open conversion, another required re-docking of the robot. Setup time was significantly improved from an average of 27.7 min in the first 27 cases to an average of 17.3 min in the final 28 cases (p < 0.0001). Complications developed in 27% of our patients. Continence recovery at catheter removal, 1st, 3rd, 6th, and 12th months were 32.7%, 50.9%, 65.5%, 74.5%, and 96%, respectively. CONCLUSIONS: Results from the first series of robotic radical prostatectomy were encouraging. Technical challenges can be overcome in a short period using a dedicated team supplemented by institutional support. Acceptable complication rate and satisfactory outcomes regarding continence and blood loss were observed.

Radical Prostatectomy: Sequelae in the Course of Time

Objective: Radical prostatectomy (RP) is a frequent treatment for men suffering from localized prostate cancer (PCa). Whilst offering a high chance for cure, it does not come without a significant impact on health-related quality of life. Herein we review the common adverse effects RP may have over the course of time. Methods: A collaborative narrative review was performed with the identification of the principal studies on the topic. The search was executed by a relevant term search on PubMed from 2010 to February 2021. Results: Rates of major complications in patients undergoing RP are generally low. The main adverse effects are erectile dysfunction varying from 11 to 87% and urinary incontinence varying from 0 to 87% with a peak in functional decline shortly after surgery, and dependent on definitions. Different less frequent side effects also need to be taken into account. The highest rate of recovery is seen within the first year after RP, but even long-term improvements are possible. Nevertheless, for some men these adverse effects are long lasting and different, less frequent side effects also need to be taken into account. Despite many technical advances over the last two decades no surgical approach can be clearly favored when looking at long-term outcome, as surgical volume and experience as well as individual patient characteristics are still the most influential variables. Conclusions: The frequency of erectile function and urinary continence side effects after RP, and the trajectory of recovery, need to be taken into account when counseling patients about their treatment options for prostate cancer.

Irreversible Electroporation for Prostate Cancer

Although it can be lethal in its advanced stage, prostate cancer can be effectively treated when it is localised. Traditionally, radical prostatectomy (RP) or radiotherapy (RT) were used to treat all men with localised prostate cancer; however, this has significant risks of post-treatment side effects. Focal therapy has emerged as a potential form of treatment that can achieve similar oncological outcomes to radical treatment while preserving functional outcomes and decreasing rates of adverse effects. Irreversible electroporation (IRE) is one such form of focal therapy which utilises pulsatile electrical currents to ablate tissue. This modality of treatment is still in an early research phase, with studies showing that IRE is a safe procedure that can offer good short-term oncological outcomes whilst carrying a lower risk of poor functional outcomes. We believe that based on these results, future well-designed clinical trials are warranted to truly assess its efficacy in treating men with localised prostate cancer.

Change of preoperative symptoms of the late-onset hypogonadism syndrome after robot-assisted radical prostatectomy

Background:

As prostate cancer (PCa) is a common cancer among older men, patients with PCa often show aging male symptoms (AMSs). This study aimed to investigate the preoperative AMSs of the late-onset hypogonadism (LOH) syndrome and the effects on them after robot-assisted radical prostatectomy (RARP).

Materials and methods:

One hundred eighty-eight patients who underwent RARP without androgen deprivation therapy were measured for serum free and serum total testosterone, and were preoperatively assessed for symptoms of the LOH syndrome using a questionnaire containing an AMS score. Patients with a preoperative AMS score higher than 37 and a serum free testosterone level lower than 8.5 pg/mL were classified as Group A, with the remaining classified as Group B. AMS scores were measured at 1, 3, 6, 9, and 12 months after surgery.

Results:

Of the 188 patients, 49 and 139 patients were classified as Groups A and B, respectively. Preoperative AMS scores were 44.5 ± 8.2 in Group A and 28.6 ± 5.3 in Group B (p < 0.0001). AMS scores in Group A significantly improved 1 month after RARP (30.6 ± 8.4, p < 0.0001) compared with their preoperative scores and remained at the same level from 3 to 12 months postoperatively, whereas those in Group B became significantly worse (32.0 ± 7.8, p < 0.0001) than their preoperative ones. There were no differences between AMS scores in Groups A and B at every postoperative period (p = 0.3259, 0.2730, 0.2429, 0.4629, 0.1771 at 1, 3, 6, 9, and 12 months after surgery, respectively).

Conclusions:

Our results indicate that AMSs in PCa patients with the LOH syndrome can expect the same level of improvement as patients without it.

Patient- and Tumour-related Prognostic Factors for Urinary Incontinence After Radical Prostatectomy for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

While urinary incontinence (UI) commonly occurs after radical prostatectomy (RP), it is unclear what factors increase the risk of UI development.

OBJECTIVE

To perform a systematic review of patient- and tumour-related prognostic factors for post-RP UI. The primary outcome was UI within 3 mo after RP. Secondary outcomes included UI at 3-12 mo and ≥12 mo after RP.

EVIDENCE ACQUISITION

Databases including Medline, EMBASE, and CENTRAL were searched between January 1990 and May 2020. All studies reporting patient- and tumour-related prognostic factors in univariable or multivariable analyses were included. Surgical factors were excluded. Risk of bias (RoB) and confounding assessments were performed using the Quality In Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were performed for all prognostic factor, where possible.

EVIDENCE SYNTHESIS

A total of 119 studies (5 randomised controlled trials, 24 prospective, 88 retrospective, and 2 case-control studies) with 131 379 patients were included. RoB was high for study participation and confounding; moderate to high for statistical analysis, study attrition, and prognostic factor measurement; and low for outcome measurements. Significant prognostic factors for postoperative UI within 3 mo after RP were age (odds ratio [OR] per yearly increase 1.04, 95% confidence interval [CI] 1.03-1.05), membranous urethral length (MUL; OR per 1-mm increase 0.81, 95% CI 0.74-0.88), prostate volume (PV; OR per 1-ml increase 1.005, 95% CI 1.000-1.011), and Charlson comorbidity index (CCI; OR 1.28, 95% CI 1.09-1.50).

CONCLUSIONS

Increasing age, shorter MUL, greater PV, and higher CCI are independent prognostic factors for UI within 3 mo after RP, with all except CCI remaining prognostic at 3-12 mo.

PATIENT SUMMARY

We reviewed the literature to identify patient and disease factors associated with urinary incontinence after surgery for prostate cancer. We found increasing age, larger prostate volume, shorter length of a section of the urethra (membranous urethra), and lower fitness were associated with worse urinary incontinence for the first 3 mo after surgery, with all except lower fitness remaining predictive at 3-12 mo.

Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Comparative effectiveness of robotic and open radical prostatectomy

Radical prostatectomy (RP) has undergone a remarkable transformation from open to minimally-invasive surgery over the last two decades. However, it is important to recognize there is still conflicting evidence regarding key outcomes. We aimed to summarize current literature on comparative effectiveness of robotic and open RP for key outcomes including oncologic results, health-related quality of life (HRQOL) measures, safety and postoperative complications, and healthcare costs. The bulk of the paper will discuss and interpret limitations of current data. Finally, we will also highlight future directions of both surgical approaches and its potential impact on health care delivery.

Contemporary outcomes following robotic prostatectomy for locally advanced and metastatic prostate cancer

While radical prostatectomy (RP) plays a prominent role in the management of localized prostate cancer, its role in high risk or metastatic disease is less clear. Due to changes in prostate cancer screening patterns, particularly those made by the United States Preventive Services Task Force, data is suggesting increasing incidences of high risk and metastatic disease, underlying the importance of continued research in this area. While past approaches to management may have discouraged surgical intervention, more contemporary approaches have attempted to evaluate its effectiveness and utility. The purpose of this review is an updated discussion of the current literature regarding surgical approaches to high risk prostate cancer. The PubMed and Medline databases were queried for English language articles related to the surgical management of high-risk prostate adenocarcinoma. In this review, we examine the utility of surgery as a single or multimodal approach to management with patients with high risk, locally advanced, and metastatic prostate cancer. Outcomes measures are reviewed including data on survival and recurrence rates. Functional outcomes are an important consideration in prostate cancer management and while data is more limited, this review examines some of the key findings. Finally, a discussion regarding surgical complication rates and ongoing clinical trials is addressed. While surgery appears to be promising in this patient cohort, there remains significant heterogeneity in the data that ongoing trials may be able to address. At its current level of understanding, surgery should be considered as a potential tool in patient management, but may play a more prominent role in a multi-modality setting for optimal outcomes.

Salvage Versus Primary Robot-assisted Radical Prostatectomy: A Propensity-matched Comparative Effectiveness Study from a High-volume Tertiary Centre

Background

Salvage robot-assisted radical prostatectomy (sRARP) is a potential treatment option for locally recurrent prostate cancer (PCa) after nonsurgical primary treatment. There are minimal data comparing outcomes between propensity-matched sRARP and primary robot-assisted radical prostatectomy (RARP).

Objective

The primary objective is to compare perioperative, oncological, and functional outcomes of sRARP with primary RARP, and the secondary is to compare outcomes between sRARP after whole and focal gland therapy.

Design, setting, and participants

A 1:1 propensity-matched comparison was carried out of 135 sRARP cases with primary RARP cases from a cohort of 3852 consecutive patients from a high-volume tertiary centre.

Outcome measurements and statistical analysis

Perioperative, oncological, and functional outcomes including complication rates, positive surgical margins, biochemical recurrence (BCR), continence, and erectile dysfunction (ED) were retrospectively collected.

Results and limitations

There were no significant differences in patient characteristics between sRARP and primary RARP groups. In the salvage and primary groups, median (interquartile range) follow-up periods were 521 (304–951) and 638 (394–951) d, grade III–V Clavien-Dindo complication rates were 1.5% and 0% (p = 0.310), BCR rates were 31.9% and 14.1% (p < 0.001) at the last follow-up, pad-free continence rates were 78.8% and 84.3% at 2 yr (p = 0.337), and ED rates were 94.8% and 76.3% (p < 0.001), respectively. Comparing the whole and focal gland groups, BCR rates were 36.7% and 29.1% (p = 0.687) at follow-up, pad-free continence rates were 53.1% and 89.3% at 2 yr (p < 0.001), and ED rates were 98% and 93% (p = 0.214), respectively.

Conclusions

Salvage RARP has similar perioperative outcomes to primary RARP with inferior potency rates. Post–focal therapy sRARP has similar recurrence and continence rates to primary RARP. Post–whole gland therapy, complication, and recurrence rates are higher, and there is a higher risk of urinary incontinence.

Patient summary

We report the largest propensity-matched comparison of salvage robot-assisted radical prostatectomy (RARP) after focal and whole gland therapy. Salvage RARP is a feasible procedure for the treatment of locally recurrent prostate cancer in high-volume centres; however, patients should be counselled appropriately as to the different outcomes.

Anatomical predictors of long-term urinary incontinence after robot-assisted laparoscopic prostatectomy: A systematic review

AIMS

There is scarce evidence of anatomical risk factors that might affect long-term post-prostatectomy incontinence (PPI) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). This systematic review aims to identify anatomical measurements in preoperative magnetic resonance imaging (MRI) that might be associated with increased risk of urinary incontinence (UI) 1 year after RALP.

METHODS

A comprehensive search on Pubmed and Scopus databases up to November 2020 was performed. Eight articles met the inclusion criteria and were finally selected.

RESULTS

The selected studies included 1146 patients. Seven articles focused on membranous urethral length (MUL); all of them related MUL to long-term PPI in univariate analysis and five of them in multivariate analysis. Four studies presented MUL difference to measure the magnitude of the effect. Average MUL (mm) was 15.9 (SD, 2.6), 16.1 (95% confidence interval [CI]: 13.9-18.9), 12.1 (95% CI 9.7-14.9) and 14.5 in continent patients and 13.9 (SD, 2.9), 10 (95% CI: 8.7-12.1), 10.3 (95% CI: 8.7-12.4) and 9.3 in incontinent patients, with statistically significant differences in all cases. Five studies presented the odds ratio as a result; although there was substantial heterogeneity in the methods used to obtain it, there was consistency in finding an inverse association between MUL and PPI. Other measurements including prostatic-urethral angle, membranous urethral thickness, intraprostatic urethral length and intravesical prostatic protrusion have been reported in few studies, and no association with long-term PPI was found. Levator ani muscle thickness was related to long-term PPI in one article.

CONCLUSION

Greater MUL on preoperative MRI is associated with lower risk of UI 1 year after RALP.

Urodynamic evaluation before and after to RARP to identify pre and intraoperative factors affecting postoperative continence

AIMS

To investigate factors contributing to pre and postoperative urethral function in male patients who underwent robot-assisted radical prostatectomy (RARP) using the urethral pressure profile (UPP).

METHODS

Study A A total of 313 patients who underwent RARP between April 2013 and March 2015 were prospectively investigated. UPP was performed preoperatively in all patients. Correlation and multiple regression analyses were performed to investigate predictive factors for low preoperative maximum urethral closure pressure (MUCP). Study B To validate the predictive factors for low preoperative MUCP obtained in Study A, 755 patients who underwent RARP between May 2010 and October 2017 were retrospectively examined. Relationships between the time to pad-free status and the following factors were investigated: number of predictive factors, nerve-sparing surgery, and vesicourethral anastomosis (VUA) methods (barbed vs. nonbarbed suture).

RESULTS

Study A A total of 187 patients were enrolled. Multivariate analysis revealed that older age, large prostate volume, low erectile function domain scores in International Index Erectile Function 15, and use of calcium channel blockers were significantly associated with low preoperative MUCP. Study B A total of 515 patients were included. Cox proportional hazard regression showed that the number of predictive factors and VUA method were significantly associated with the time to pad-free status.

CONCLUSIONS

Our study demonstrated that older age, larger prostate volume, poor erectile function, and calcium channel blocker use could be predictive markers for recovery from postprostatectomy urinary incontinence.

Treatment of Stress Urinary Incontinence with Muscle Stem Cells and Stem Cell Components: Chances, Challenges and Future Prospects

Urinary incontinence (UI) is a major problem in health care and more than 400 million people worldwide suffer from involuntary loss of urine. With an increase in the aging population, UI is likely to become even more prominent over the next decades and the economic burden is substantial. Among the different subtypes of UI, stress urinary incontinence (SUI) is the most prevalent and focus of this review. The main underlying causes for SUI are pregnancy and childbirth, accidents with direct trauma to the pelvis or medical treatments that affect the pelvic floor, such as surgery or irradiation. Conservative approaches for the treatment of SUI are pelvic physiotherapy, behavioral and lifestyle changes, and the use of pessaries. Current surgical treatment options include slings, colposuspensions, bulking agents and artificial urinary sphincters. These treatments have limitations with effectiveness and bear the risk of long-term side effects. Furthermore, surgical options do not treat the underlying pathophysiological causes of SUI. Thus, there is an urgent need for alternative treatments, which are effective, minimally invasive and have only a limited risk for adverse effects. Regenerative medicine is an emerging field, focusing on the repair, replacement or regeneration of human tissues and organs using precursor cells and their components. This article critically reviews recent advances in the therapeutic strategies for the management of SUI and outlines future possibilities and challenges.

Use of isotonic contrast solution in the artificial urinary sphincter does not impact device longevity

AIMS

The artificial urinary sphincter (AUS), the gold standard for treatment of male stress urinary incontinence, can be filled with normal saline (NS) or isotonic contrast solution. Surgeons have voiced concerns about the impact on device malfunction and longevity, but no studies address this issue. We used industry data to identify differences in outcomes between NS and contrast-filled AUS.

METHODS

Our analysis included all men patients in the industry who maintained the AUS database (Boston Scientific) from 2001 to 2016. Patients were divided into two groups: AUS filled with NS or contrast. Patient demographics and device characteristics were compared. Device survival was defined as time to the need for reoperation. We compared device survival between AUS filled with NS versus contrast using a Kaplan-Meier curve adjusted for age, cuff size, and pressure regulating balloon (PRB) size.

RESULTS

A total of 39,363 patients were included. 34,674 (88.1%) devices were filled with NS. The reoperation rate overall was 24.5%, with no difference between groups. The mean time to reoperation overall was 3 years (±3.0). After adjustment for age, cuff size, and PRB size, Kaplan-Meier analysis demonstrated a similar time to reoperation between the two groups.

CONCLUSION

The use of contrast in the AUS does not appear to change rates of the device malfunction, fluid loss, or need for reoperation. Since filling the device with contrast does not appear inferior to saline in terms of longevity, we feel this should be considered a safe tool for the implanting surgeon.

Climacturia: a comprehensive review assessing pathophysiology, prevalence, impact, and treatment options regarding the "leak of pleasure"

Aim of this review is to summarize and evaluate the current literature on the pathophysiology, prevalence, sociosexual impact, and potential treatment options of climacturia. Climacturia, defined as orgasm-associated urinary incontinence and characterized by great prevalence variability, ranging between 15.7 and 93% was, so far, a relatively neglected post-radical prostatectomy functional side-effect. Recent studies have shown that it can significantly impact the quality of life of couples after prostate cancer treatment. A knowledge gap characterizes the pathophysiologic pathways while treatment is based on empirically chosen treatment options (condom use, presexual intercourse urination) or on therapeutic modalities proposed by low-quality studies (pelvic floor muscle training, penile applied devices). Evidence regarding efficacy of surgical techniques (artificial urinary sphincter, male sling, or dual implantation of penile prosthesis with a sling) for climacturia treatment are limited but with an increasing trend of relevant published data in the last 5 years. The mini-jupette sling plus inflatable penile prosthesis placement is a promising surgical technique that has been studied in a multi-institutional cohort with encouraging results regarding climacturia, erectile dysfunction, and mild-incontinence control. However, future studies with longer follow-up and larger sample sizes are certainly needed to confirm the long-term safety and benefits of this intervention.

Daily urine loss immediately after urethral catheter removal may be an effective predictor of long-term urinary incontinence following robot-assisted laparoscopic radical prostatectomy

PURPOSE

Some patients who undergo robot-assisted laparoscopic radical prostatectomy (RARP) continue to experience long-term urinary incontinence (UI). This study aimed to evaluate easily obtainable factors that can predict long-term UI following RARP.

MATERIALS AND METHODS

A total of 315 patients who underwent RARP for localised prostatic cancer were analysed. We separated the patients into two groups, namely, the Continence group and the Incontinence group, according to the presence or absence of UI at 12 months after surgery, and we compared the patients' characteristics and operative data to identify clinical signs associated with long-term UI. Additionally, correlations between these factors and postoperative urethral function were evaluated. Urinary continence was defined as both the use of 0 pads/per day and <2 g of urine lost using the 24-hours pad weight test.

RESULTS

Of 315 patients, 250 (79.4%) achieved urinary continence and 65 (20.6%) had long-term UI. Age, storage-related lower urinary tract symptoms before surgery, nerve-sparing surgery and the 24-hours urine loss immediately after urethral catheter removal significantly affected long-term UI after RARP. Multivariate logistic regression analyses revealed that the 24-hours urine loss after catheter removal was a significant predictor of long-term UI. Receiver operating characteristic curve analysis identified a urine loss of 330 g/d as the optimal cut-off value, which yielded 92% sensitivity and 84% specificity, and it showed significant correlations with postoperative urethral function and the time to recover urinary continence.

CONCLUSION

The 24-hours urine loss immediately after urethral catheter removal may be the most reliable and useful predictor of long-term UI following RARP.

The impact of transition from conventional robot-assisted radical prostatectomy to retzius sparing robot-assisted radical prostatectomy: A retrospective multivariate analysis

Introduction:

To assess the outcomes of Retzius sparing robotic-assisted radical prostatectomy (RS-RARP) in comparison with the conventional RARP.

Materials and Methods:

A retrospective analysis of 320 cases of RARP, performed from 2014 April to 2019 April, was performed. The predictor variables included age, body mass index, clinical stage, prostate-specific antigen, Gleason score category in biopsy, D'Amico risk category, presence of the median lobe, prior transurethral resection of the prostate, and the ability to perform the RS-RARP. The outcome variables included console time, blood loss, blood transfusion, nerve sparing, bladder neck sparing, positive surgical margins (PSM), number and the site of PSMs, extracapsular invasion, seminal vesicle involvement, complications, continence, erectile function, biochemical recurrence, and adjuvant treatment. Regression analysis was performed using the linear regression for the continuous variables and binary logistic regression for the categorical variables with two levels.

Results:

Three hundred and twenty patients underwent radical prostatectomy from 2014 April to 2019 April. We started the RS-RARP program in December 2016. Twenty-three patients who did not meet the inclusion criteria were excluded and a total of 297 patients were studied. Multivariate analysis demonstrated that RS-RARP was a strong positive independent predictor for continence recovery at 3 months, 6 months, and 12 months. RS-RARP was an independent predictor of reduced console time and increased probability of bladder neck sparing. RS-RARP was also independently associated with increased PSM in the posterolateral, anterolateral, and the apical regions.

Conclusion:

RS-RARP has better continence rates up to 12 months compared with the conventional approach, but is associated with increased PSM at certain locations.

Evaluation of Risk Factors for Adverse Functional Outcomes after Radical Prostatectomy in Patients with Previous Transurethral Surgery of the Prostate

INTRODUCTION

A history of transurethral surgery of the prostate is generally considered as a risk factor of adverse functional outcomes after radical prostatectomy (RP). We tested whether the risk of postoperative urinary incontinence (UIC) and erectile dysfunction (ED) after RP could be further substantiated in such patients.

MATERIALS AND METHODS

We tested the effect of the following variables on UIC and ED rates 1 year after RP: residual prostate volume after transurethral desobstruction, the time from transurethral desobstruction to RP, the type of transurethral desobstruction (TURP vs. laser enucleation), age, and nerve-sparing surgery (yes vs. no). UIC was defined as usage of any pad except a safety pad. ED was defined as no sexual intercourse possible.

RESULTS

Overall, 216 patients treated with RP between 2010 and 2019 in a tertiary care center were evaluated. All patients had previously undergone transurethral desobstruction. Regarding UIC analyses, only time from transurethral desobstruction to RP significantly influenced UIC rates (p = 0.003). Regarding ED rates, none of the tested variables reached statistical significance.

CONCLUSION

The risk of UIC and ED after RP is substantial in men who had previously undergone transurethral desobstruction. The time from transurethral desobstruction to RP significantly impacts on the postoperative UIC rates. This observation should be further explored in future studies.

Artificial Urinary Sphincter Complications: Risk Factors, Workup, and Clinical Approach

PURPOSE OF REVIEW

To review risk factors for AUS complications and present a systematic approach to their diagnosis and management.

RECENT FINDINGS

Established risk factors for AUS complications include catheterization, channel TURP, pelvic radiation, urethroplasty, anticoagulation, cardiovascular disease, diabetes mellitus, frailty index, hypertension, low albumin, and low testosterone. We present our algorithm for diagnosis and management of AUS complications. Despite being the gold standard of treatment for men with SUI, major and minor complications can occur at any point after AUS insertion. Careful consideration of the urologic, medical, and operative risk factors for each patient can help prevent complications. A systematic approach to early and late complications facilitates their identification and effective management. The evaluating urologist must have a thorough understanding of potential AUS complications in order to restore quality of life in men with bothersome SUI.

Surgeon Automated Performance Metrics as Predictors of Early Urinary Continence Recovery After Robotic Radical Prostatectomy-A Prospective Bi-institutional Study

Background

During robotic surgeries, kinematic metrics objectively quantify surgeon performance.

Objective

To determine whether clinical factors confound the ability of surgeon performance metrics to anticipate urinary continence recovery after robot-assisted radical prostatectomies (RARPs).

Design, setting, and participants

Clinical data (patient characteristics, continence recovery, and treatment factors) and surgeon data from RARPs performed between July 2016 and November 2018 were prospectively collected. Surgeon data included 40 automated performance metrics (APMs) derived from robot systems (instrument kinematics and events) and summarized over each standardized RARP step. The data were collected from two high-volume robotic centers in the USA and Germany. Surgeons from both institutions performed RARPs. The inclusion criteria were consecutive RARPs having both clinical and surgeon data.

Intervention

RARP with curative intent to treat prostate cancer.

Outcome measurements and statistical analysis

The outcome was 3- and 6-mo urinary continence recovery status. Continence was defined as the use of zero or one safety pad per day. Random forest (SAS HPFOREST) was utilized.

Results and limitations

A total of 193 RARPs performed by 20 surgeons were included. Of the patients, 56.7% (102/180) and 73.3% (129/176) achieved urinary continence by 3 and 6 mo after RARP, respectively. The model anticipated continence recovery (area under the curve = 0.74, 95% confidence interval [CI] 0.66–0.81 for 3-mo, and area under the curve = 0.67, 95% CI 0.58–0.76 for 6 mo). Clinical factors, including pT stage, confounded APMs during prediction of continence recovery at 3 mo after RARP (Δβ median –13.3%, interquartile range [–28.2% to –6.5%]). After adjusting for clinical factors, 11/20 (55%) top-ranking APMs remained significant and independent predictors (ie, velocity and wrist articulation during the vesicourethral anastomosis). Limitations included heterogeneity of surgeon/patient data between institutions, although it was accounted for during multivariate analysis.

Conclusions

Clinical factors confound surgeon performance metrics during the prediction of urinary continence recovery after RARP. Nonetheless, many surgeon factors are still independent predictors of early continence recovery.

Patient summary

Both patient factors and surgeon kinematic metrics, recorded during robotic prostatectomies, impact early urinary continence recovery after robot-assisted radical prostatectomy.

Laparoscopic surgery experience does not influence oncological and functional results of robotic-assisted laparoscopic prostatectomy

INTRODUCTION

Surgery is one of the treatment alternatives for prostate cancer, and robotic-assisted laparoscopic prostatectomy (RALP) has become the new trend in the past decade. There is no consensus yet for surgeons who will perform RALP whether they need to be trained or experienced in laparoscopy. In this study, it was aimed to investigate the effectiveness of the surgeon's laparoscopy experience in the perioperative and postoperative results of RALP patients.

MATERIAL AND METHOD

Patients who underwent RALP were retrospectively screened. The first 20 cases done by surgeons in both groups and 40 cases in total were included in the study. Surgeons with laparoscopy training were designated as group 1, and surgeons without laparoscopy training were designated as group 2. Patient's age, preoperative prostate-specific antigen (PSA) value, prostate biopsy pathology, radical prostatectomy pathology, surgical margin positivity, extracapsular extension, and seminal vesicle invasion status, blood transfusion rate, operation time, length of hospital stay, and 1-year follow-up potency and urinary incontinence rates were compared.

RESULTS

There was no difference between the two groups in terms of age, preoperative PSA, preoperative biopsy results, blood transfusion rates, operation times, and the length of hospital stay of the patients. When the postoperative oncological and functional results of the patients were examined, there was no difference between the two groups in the prostatectomy pathology (p = 0.895), extracapsular extension (pT3a) (p = 0.519), positive surgical margin (pSM) (p = 0.723), and seminal vesicle invasion (pT3b) (p = 0.756). Potency and urinary incontinence rates were similar in both groups at the end of one year follow-up (p = 0.327, 0.500 respectively).

CONCLUSIONS

Based on our study, it is clearly seen that regardless of the surgeon's experience of laparoscopy, it can be safely preferred when looking at the oncological and functional results of RALP.

MiRNAs and radical prostatectomy: Current data, bioinformatic analysis and utility as predictors of tumour relapse

BACKGROUND

Studies of microRNAs (miRNAs) and genes have particular interest for cancer biology and medicine due to the discovery of new therapeutic targets and markers. These studies are extensively influenced by anticancer therapy, as miRNAs interfere with the therapy's efficacy in prostate cancer (PCa).

OBJECTIVES

In this article, we summarise the available data on the influence of radical prostatectomy (RP) and biochemical recurrence on miRNA expression.

MATERIALS AND METHODS

Molecular targets of these miRNAs, as well as the reciprocal relations between different miRNAs and their targets, were studied using the DIANA, STRING and TransmiR databases. Special attention was dedicated to the mechanisms of PCa development, miRNA, and associated genes as tumour development mediators.

RESULTS AND DISCUSSION

Combined analysis of the databases and available literature indicates that expression of four miRNAs that are associated with prostate cancer relapse and alter their expression after RP, combined with genes that closely interact with selected miRNAs, has high potential for the prediction of PCa relapse after RP. PCa tissues and biofluids, both immediately after RP for diagnostics/prognostics and in long-term (relapse) monitoring, may be used as sources of these miRNAs.

CONCLUSION

An overview of the usefulness of published data and bioinformatics resources looking for diagnostic markers and molecular targets is presented in this article. The selected miRNA and gene panels have good potential as prognostic and PCa relapse markers after RP and likely could also serve as markers for therapeutic efficiency on a broader scale.

Urinary continence recovery and oncological outcomes after surgery for prostate cancer analysed by risk category: results from the LAParoscopic prostatectomy robot and open trial

PURPOSE

To evaluate urinary continence (UC) recovery and oncological outcomes in different risk-groups after robot-assisted radical prostatectomy (RALP) and open retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

We analysed 2650 men with prostate cancer from seven open (n = 805) and seven robotic (n = 1845) Swedish centres between 2008 and 2011 in a prospective non-randomised trial, LAPPRO. UC recovery was defined as change of pads less than once in 24 h. Information was collected through validated questionnaires. Rate of positive surgical margins (PSM) and biochemical recurrence (BCR), defined as prostate-specific antigen (PSA) > 0.25 mg/ml, were recorded. We stratified patients into two risk groups (low-intermediate and high risk) based on the D'Amico risk classification system.

RESULT

Among men with high-risk prostate cancer, we found significantly higher rates of UC recovery up to 24 months after RRP compared to RALP (66.1% vs 60.5%) RR 0.85 (CI 95% 0.73-0.99) while PSM was more frequent after RRP compared to RALP (46.8% vs 23.5%) RR 1.56 (CI 95% 1.10-2.21). In the same group no significant difference was seen in BCR. Overall, however, BCR was significantly more common after RRP compared to RALP at 24 months (9.8% vs 6.6%) RR 1.43 (Cl 95% 1.08-1.89). The limitations of this study are its non-randomized design and the relatively short time of follow-up.

CONCLUSIONS

Our study indicates that men with high-risk tumour operated with open surgery had better urinary continence recovery but with a higher risk of PSM than after robotic-assisted laparoscopic surgery. No significant difference was seen in biochemical recurrence.  TRIAL REGISTRATION: ISRCTN06393679.

Prevalence of Postprostatectomy Incontinence Requiring Anti-incontinence Surgery After Radical Prostatectomy for Prostate Cancer: A Retrospective Population-Based Analysis

Purpose

The aim of this study was to examine the prevalence of surgery for post-prostatectomy incontinence (PI) following minimally invasive surgery compared to conventional open surgery for prostate cancer.

Methods

This retrospective cohort study used the Florida State Ambulatory Surgery and State Inpatient Databases, 2008 to 2010, RP patients were identified using ICD-9/10 procedure codes and among this cohort PI was identified also using ICD-9/10 codes. Surgical approaches included Minimally invasive (robotic or laparoscopic) vs. open (retropubic or perineal) RP. The primary outcome was the overall prevalence of surgery for PI. The secondary outcome was the association of PI requiring anti-incontinence surgery with the surgical approach for RP.

Results

Among the 13535 patients initially included in the study (mean age, 63.3 years), 6932 (51.2%) underwent open RP and 6603 (49.8%) underwent minimally invasive RP. The overall prevalence of surgical procedures for PI during the observation period among the all patients who had received RP was 3.3%. The rate of PI surgery for patients receiving minimally invasive surgery was higher than that for patients receiving open surgery (4.8% vs. 3.0%; risk difference, 1.8%; 95% CI, 0.3% to 3.4%). The adjusted prevalence of PI surgery for patients who had undergone laparoscopic RP was higher than that for those with retropubic RP (8.6% vs. 3.7%).

Conclusions

Among patients undergoing RP for prostate cancer, the prevalence of PI surgery is not negligible. Patients undergoing minimally invasive RP had higher adjusted rates for PI surgery compared to open approaches, which was attributed to high rate of PI surgery following laparoscopic approach and low rate of PI surgery following perineal approach. More studies are needed to establish strategies to reduce the rate of PI surgery after RP.

Standing cough test stratification of moderate male stress urinary incontinence

PURPOSE

Patient-reported history of pads per day (PPD) is widely recognized as a fundamental element of decision-making for anti-incontinence procedures. We hypothesize that SUI severity is often underestimated among men with moderate SUI. We sought to compare patient history of incontinence severity versus objective in-office physical examination findings.

MATERIALS AND METHODS

We retrospectively reviewed our single-surgeon male SUI surgical database from 2007-2019. We excluded patients with incomplete preoperative or postoperative data and those who reported either mild or severe SUI, thus having more straightforward surgical counseling. For men reported to have moderate SUI, we determined the frequency of upgrading SUI severity by recording the results of an in-office standing cough test (SCT) using the Male Stress Incontinence Grading Scale (MSIGS). The correlation of MSIGS with sling success rate was calculated. Failure was defined as >1 PPD usage or need for additional incontinence procedure.

RESULTS

Among 233 patients with reported moderate SUI (2-3 PPD), 89 (38%) had MSIGS 3-4 on SCT, indicating severe SUI. Among patients with 2-3 PPD preoperatively, sling success rates were significantly higher for patients with MSIGS 0-2 (76/116, 64%) compared to MSIGS 3-4 (6/18, 33%) (p <0.01).

CONCLUSIONS

Many men with self-reported history of moderate SUI actually present severe SUI observed on SCT. The SCT is a useful tool to stratify moderate SUI patients to more accurately predict sling success.

The effects of bladder neck sparing with an additional anterior urethral fixation on postoperative continence after robot-assisted radical prostatectomy

OBJECTIVE:

Urinary incontinence remains one of the main problems affecting the quality of life after radical prostatectomy. Along with the improved understanding of the precise anatomy of the prostate, urethra and their surrounding structures, minimally invasive surgical techniques have been refined and described, aiming to improve functional outcomes without oncological compromise. This study aimed to investigate the impacts of anterior urethral fixation (AUF) and bladder neck sparing (BNS) on the early continence success after Robot-assisted Radical Prostatectomy (RALP).

METHODS:

This retrospective study included 120 patients who underwent RALP between January 2018 and June 2019. Patients were allocated to one of two groups; group 1 (n=60) underwent RALP with BNS, group 2 (n=60) underwent RALP with both AUF and BNS. The patient continence status was measured at baseline on day 7 and in the 1^st, 3^rd, and 6^th months postoperatively.

RESULTS:

Concerning Incontinence Impact Questionnaire-7 form, statistically significant better results in group 2 were recorded in all visits, but the last (month 6) (p=0.023). Following catheter removal, postmicturition symptoms, including incomplete emptying and post-micturition dribble rate, were significantly higher in group 1 after catheter removal and in the 1^st month (13.3% vs. 0 p=0.006). This difference was not recorded at the next visits (months 3 and 6).

CONCLUSION:

Our findings showed that the combination of AUF and BNS significantly increases early continence rates and decreases post-mictional symptoms after RALP without hampering oncologic outcomes.

Robot-Assisted Radical Prostatectomy in Low-Volume Regions: Should It Be Abandoned or Adopted? A Multi-Institutional Outcome Study

Purpose: To present multinational experience in robot-assisted radical prostatectomy (RARP) by fellowship-trained expertise in low-volume regions in Gulf Cooperation Council (GCC) countries and to compare the current results with global outcomes reported in recent meta-analyses. Methods: A retrospective review of prospectively collected data was performed for patients undergoing RARP for localized prostate cancer (PCa). Three fellowship-trained surgeons at four academic and referral centers in Saudi Arabia and Kuwait performed all procedures between February 2014 and December 2019. Data on demographics, perioperative characteristics, pathology, and adverse events were collected. Results: A total of 207 patients were included with a median (IQR) follow-up duration of 28 (15-38) months. The median prostate volume and prostate-specific antigen were 42 (32-53) g and 9.1 (5.8-14.1) ng/mL, respectively. While 65.2% of patients had a Gleason score ≥7, 20% had grade group 4 disease, and 7.8% had ≥cT3 disease. The mean ± SD operative time was 203 ± 52 minutes, and the mean estimated blood loss was 158 ± 107 mL. Only 4 (1.9%) patients received perioperative blood transfusions. Positive surgical margins were observed in 21.7% of patients, all of whom had ≥pT3 disease. There were 23 complications in 18 (8.7%) patients, including Clavien-Dindo grade III complications in 2.4%. At the 12-month follow-up, 35.8% of patients were potent, 94.6% were continent, and 9.2% had biochemical recurrence. Conclusions: The safety and efficacy of RARP by fellowship-trained expertise in GCC countries were well established. The outcomes seem promising and comparable to international centers and should improve with increasing case volume and fellowship-trained expertise.

MRI predicts prostatic urethral involvement in men undergoing radical prostatectomy: implications for cryo-ablation of localized prostate cancer

PURPOSE

To determine whether multi-parametric magnetic resonance imaging (mpMRI) can reliably predict proximity of prostate cancer to the prostatic urethra in a contemporary series of men undergoing radical prostatectomy (RP) at two academic centers.

METHODS

Clinical characteristics of consecutive men undergoing pre-operative mpMRI prior to RP and whole-mount axial serial step-sectioned pathology examination at two academic centers between Jun 2016 and Oct 2018 were analyzed retrospectively. Every tumor was characterized by its pathologic minimum distance to the prostatic urethral lumen (pMDUL). Only the cancer closest to the urethra represented the prostatic urethral index lesion. The radiologic minimum distance of the index lesion to the prostatic urethral lumen was measured and noted as ≤ 5 mm versus  > 5 mm. The sensitivity, specificity, positive and negative predicting values (PPV and NPV) and area under the receivers operating characteristics curve (AUC) were calculated for performance of mpMRI for predicting pMDUL ≤ 5 mm.

RESULTS

Of the 163 surgical specimens examined, 112 (69%) exhibited a pMDUL ≤ 5 mm. These men had significantly higher grade group (GG) and advanced pathological and clinical stage. The rates of high PI-RADS score and presence of gross extracapsular extension were also significantly greater for the group with pMDUL ≤ 5 mm. The AUC, sensitivity, specificity, PPV, and NPV were 0.641, 51.8, 76.5, 82.9, and 42.4%, respectively, for mpMRI to predict pMDUL < 5 mm.

CONCLUSIONS

Nearly 70% of men undergoing RP present with tumor within 5 mm of the prostatic urethra. These tumors present higher risk characteristics, and mpMRI exhibited moderate performance and high PPV in their pre-operative detection. Physicians performing partial gland ablation should take these results into consideration during treatment selection and planning.

What is the impact of post-radical prostatectomy urinary incontinence on everyday quality of life? Linking Pad usage and International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) for a COMBined definition (PICOMB definition)

AIMS

To identify the definition for urinary continence (UC) after radical prostatectomy (RP) which reflects best patients' perception of quality of life (QoL).

METHODS

Continence was prospectively assessed in 634 patients, 12 months after RP using the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) and the number of pads employed in a 24-hour period (pad usage). We used the one-way ANOVA technique with posthoc pairwise comparisons according to Scheffé's method (homogeneous subsets) for assessing the degree of QoL deficit related to urinary incontinence (UI).

RESULTS

The continence prevalence is 64.4%, 74.1%, 88.3%, and 35.8% using "0 pads," "1 safety pad," "1 pad," and "ICIQ score 0" definitions, respectively. Pad usage is moderately strongly associated with ICIQ 1, 2, and 3 (ρ = 0.744, 0.677, and 0.711, respectively; p < 0.001). Concordance between classical UC definitions is acceptable between "0 pads-ICIQ score 0" (K = 0.466), but poor for "1 safety pad" and "1 pad" (K = 0.326 and 0.137, respectively). Patients with "0 pad usage" have better QoL related to urine leakage than patients with "1 safety pad" or "1 pad" (1.41 vs. 2.44 and 3.11, respectively; p < 0.05). There were no significant differences found regarding QoL between patients with ICIQ score 0 and ICIQ score 2 (1.01 vs. 1.63; p = 0.63).

CONCLUSIONS

Pad usage and the ICIQ-SF's answers provide useful information. We propose a combined definition (0 pads and ICIQ score ≤2) as it is the definition with the least impact on daily QoL.

New Evolution of Robotic Radical Prostatectomy: A Single Center Experience with PERUSIA Technique

Radical prostatectomy (RP) is the standard surgical treatment of organ-confined prostate cancer in patients with a life expectancy of at least 10 years. In a recent prospective study, we described the PERUSIA (Posterior, Extraperitoneal, Robotic, Under Santorini, Intrafascial, Anterograde) technique, which is an extraperitoneal full nerve sparing robotic RP, showing its feasibility and safety. The aim of this retrospective study was to evaluate the peri-operative, oncologic, and functional outcomes of the PERUSIA technique. We retrospectively analyzed the data of 454 robotic-assisted radical prostatectomies (RARP) performed using the PERUSIA technique from January 2012 to October 2019. We evaluated perioperative outcomes (operative time, estimated blood loss, catheterization time, complication rate, length of stay), oncological (positive surgical margins and biochemical recurrence), and functional outcomes in terms of urinary continence and sexual potency. The overall complication rate was 16%, positive surgical margins were 8.1%, and biochemical recurrence occurred in 8.6% at median follow-up of 47 months. Urinary continence was achieved in 69% of cases the day after the removal of the catheter, in 92% at 3 months, and in 97% at 12 months after surgery. The average rate of sexual potency was 72% and 82% respectively 3 and 12 months after surgery. Our findings show that the PERUSIA technique is a safe extraperitoneal approach to perform a full nerve sparing technique providing exciting functional outcomes.

Laparoscopic single port radical prostatectomy in the 2020: Why not? Our experience

OBJECTIVES

To analyze the feasibility, safety and advantages of Laparo-Endoscopic Single-site Surgery radical prostatectomy (LESS-RP) based on our personal experience.

PATIENTS AND METHODS

Details of 520 patients were retrospectively analyzed, from 2009 to 2019. Extraperitoneal approach, with only two accesses (2.5 cm and 5 mm respectively) was used to perform radical prostatectomy. Perioperative characteristics and postoperative oncologic and functional outcomes are reported.

RESULTS

The mean age was 66.6 ± 5.6 years. Mean PSA level was 9 ± 3.5 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 116 (22.4%), 275 (52.8%), and 129 (24.8%) respectively. Mean operative time was 156 ± 43 min. Mean estimated blood loss was 214 ± 93 ml. Positive surgical margins (PSMs) were detected in 110 (21.2%) patients. PSM rates in pT2 and pT3 stages were 20.1% and 22.9%, respectively. The overall complication rate was 9.2%, based on the modified Clavien classification. The 12 months continence and potency rates were 90.9% and 49.1%, respectively. The biochemical recurrence rate was 6.8%, at the median follow-up time of 26.7 months (IQR 12-32).

CONCLUSIONS

Our analyses show that LESS-RP is a safe procedure, if performed by surgeons with adequate experience and skills. Unlike the classic laparoscopic prostatectomy, this technique allows better aesthetic and psychological results, reduced postoperative pain, and a faster return to normal daily activity with the same functional and oncological results.

Robot-assisted Radical Prostatectomy Using the Novel Urethral Fixation Technique Versus Standard Vesicourethral Anastomosis

BACKGROUND

Urinary continence recovery after radical prostatectomy is a major issue even in the robotic era. Surgical techniques aimed at improving earlier return to continence are continuously sought.

OBJECTIVE

To describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative complications.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, single-center, single-surgeon cohort of 70 consecutive patients undergoing RARP between January and December 2019 was analyzed. A study group of 35 patients operated on with the urethral fixation technique was compared with a control group of 35 patients receiving standard vesicourethral anastomosis.

SURGICAL PROCEDURE

Urethral fixation versus standard vesicourethral anastomosis during RARP was evaluated. In the study group, the urethral stump was fixed to the dorsal median raphe posteriorly and to the medial portion of the levator ani muscle posterolaterally. The same posterior musculofascial reconstruction incorporating the vesicourethral anastomosis was performed in both groups.

MEASUREMENTS

Urinary continence recovery, perioperative complications, operating room time, and estimated blood loss were recorded and compared between the two groups.

RESULTS AND LIMITATIONS

The two groups were comparable with regard to all demographic, clinical, and pathological variables. Recovery of urinary continence at 3 mo after catheter removal was reported by 34 (97.1%) patients in the study and 28 (80%) patients in the control group (p =  0.02). Patients in the study group reported significantly higher rates of urinary continence even at 1 wk and 1 mo after catheter removal compared with the control group (68.6% vs 45.7%, p =  0.04, and 80% vs 54.3%, p =  0.04, respectively). No differences were observed in operating room time (p =  0.7) or estimated blood loss (p =  0.65). Ninety-day postoperative complications were observed in one (2.9%) patient in the study and in four (11.4%) in the control group (p =  0.3). The main limitation is the nonrandomized comparison of relatively small cohorts.

CONCLUSIONS

In our study, we observed a significant improvement in early urinary continence recovery, with no increase in operating room time or perioperative complications, using the novel urethral fixation technique compared with the standard vesicourethral anastomosis during RARP.

PATIENT SUMMARY

We describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy. Compared with the standard technique, utilization of our technique was found to be associated with an improved early recovery of urinary continence, with no increase in operating room time or perioperative complications.

Correlation of urinary loss rate after catheter removal and long-term urinary continence after robot-assisted laparoscopic radical prostatectomy

Objectives

To assess the correlation of urine loss rate after catheter removal with long‐term continence after robot‐assisted radical prostatectomy.

Methods

We enrolled 163 patients on whom robot‐assisted radical prostatectomy was carried out and whose urine loss rate we were able to evaluate after catheter removal. Urinary incontinence was evaluated from immediately after removal of the catheter to the date of discharge, and at 1, 3, 6 and 12 months after surgery. Urine loss rate was defined as the urine loss volume divided by the total urine volume.

Results

The continence rates of patients with ≤1% urine loss rate on the day of catheter removal were 100% at 6 and 12 months after surgery. A multivariate analysis proved that ≤10% urine loss rate on the day of catheter removal was a significant predictor of continence at 3 months after surgery. Furthermore, the continence rate at 12 months of patients who did not achieve ≤10% urine loss rate on the day of catheter removal was 79.5%. Among them, the continence rate at 12 months of patients who achieved ≥15% urine loss rate improvement from the day of catheter removal to the next day was 95.2%; the factor differed significantly between the continence and incontinence groups at 12 months after surgery.

Conclusions

The urine loss rate on the day of catheter removal is significantly related to the acquisition of urinary continence. Furthermore, our findings suggest that long‐term urinary continence can be expected, even in the event of poor urine loss rate on the day of catheter removal, if it improves on the next day.