Selective versus standard ligature of the deep venous complex during laparoscopic radical prostatectomy: effects on continence, blood loss, and margin status

Dorsal venous complex ligation-free and parietal endopelvic fascia preserving in laparoscopic radical prostatectomy: A prospective study of single centre

Objectives

This study aims to describe a novel dorsal venous complex (DVC) ligation-free and parietal endopelvic fascia preserving technique for laparoscopic radical prostatectomy and to evaluate its post-operative outcomes.

Methods

From April 2020 to May 2021, a total of 125 patients with localized prostate cancer received laparoscopic radical prostatectomy by a single surgeon. In the procedure, a novel technique of DVC ligation-free and parietal endopelvic fascia preserving was used. Preoperative characteristics of patients and perioperative results were recorded. In this study, continence was defined as zero to one pad per day. Oncological outcomes were evaluated based on positive surgical margin.

Results

Five patients required a blood transfusion. Mean post-operative hospital stay was 3.9 days (2-5), and the catheter could be removed on post-operative day 7 to 9. Final pathologic evaluations were 87 stage pT2, 22 stage pT3a, and 7 pT3b, 9 stage pT4, respectively. The positive surgical margin rate was 10.4% in total. Ninety-three patients (74.4%) returned to urinary continence 2 months post-operatively, and 11 patients (11/125) developed biochemical recurrence 6 months post-operatively.

Conclusions

The DVC ligation-free and parietal endopelvic fascia preserving technique provides early recovery from incontinence without adversely affecting the oncological outcome.

Continence-Sparing Techniques in Radical Prostatectomy: A Systematic Review of Randomized Controlled Trials

Background: Numerous continence-sparing radical prostatectomy techniques have been developed to enhance postoperative early continence (EC) recovery; however, evidence regarding the best approach remains controversial. The objectives are to provide a critical appraisal of various prostatectomy techniques, based on the evidence of quality-assessed randomized control trials (RCTs); to summarize the immediate continence and the EC reported; and to propose a new standardization for continence outcomes reporting. Methods: Data acquired from five medical registries were reported to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Evidence from published, English, full-text RCTs reporting postoperative urinary continence outcomes within 6 months from surgery was included. The heterogeneity of surgical techniques and continence definitions did not allow a meta-analysis. All RCTs were critically appraised, and quality assessed. Results: In total, 39 RCTs were included: 19 of 39 studies were low-quality RCTs, presenting small cohort, monocentric, or single-surgeon data. The best RCT-supported evidence is in favor of robot-assisted radical prostatectomy (RARP) compared with laparoscopic radical prostatectomy (LRP) and of the Retzius-sparing (RS) technique over the traditional prostatectomy. Other techniques such as bladder neck and puboprostatic ligament (PPL) preservation, posterior reconstruction with or without combination of anterior suspension technique, and nerve-sparing (NS) approach seem to enhance EC. Oppositely, the endopelvic fascia preservation, bladder neck mucosa eversion/plication/slings, and the selective ligature of dorsal venous complex (DVC) were not significantly associated with EC improvements. RCTs are lacking on pubovesical complex-sparing, seminal vesicle preservation, anterior reconstruction of the puboprostatic collar, musculofascial reconstruction, and DVC suspension to the periosteum of the pubic bone techniques. Conclusions: RARP and RS have high-quality evidence supporting their ability to enhance postoperative EC recovery. NS, bladder neck, and PPL preservation may contribute to better EC recovery, although the evidence level is low. Further multicenter RCTs are needed to establish the optimal combination of standard surgical techniques. A new continence outcome-reporting standardization was proposed.

The progress of dorsal vascular complex control strategy in radical prostatectomy

Radical prostatectomy has undergone a development from open to laparoscopic surgery to a surgical robotic approach. With improved surgical equipment and the continuous development of surgical techniques, various surgical strategies for controlling the dorsal vascular complex (DVC) during RP have been investigated, which affect intraoperative blood loss, postoperative tumour control and postoperative urinary and sexual function. The present narrative review summarizes the latest anatomical information about the prostatic apex and DVC and then describes the three types of DVC control. More detailed anatomy of the DVC is required and the optimal DVC control under different situations needs further research.

Impact of Early Dorsal Venous Complex Ligation on Urinary Continence Recovery after Robot-assisted Radical Prostatectomy: Results from a Phase 3 Randomized Controlled Trial

BACKGROUND

Whether early ligation of the dorsal venous complex (DVC) might improve recovery of urinary continence (UC) after robot-assisted radical prostatectomy (RARP) has never been investigated in a prospective randomized study.

OBJECTIVE

To assess whether early DVC ligation might affect UC recovery after RARP.

INTERVENTION

DVC ligation (early vs standard).

DESIGN, SETTING, AND PARTICIPANTS

A total of 312 patients with prostate cancer underwent primary RARP at a tertiary care institution.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was UC recovery at 1 and 4 mo after RARP. UC was defined as 0 pads/1 safety pad per day. All patients completed the International Prostate Symptom Score (IPSS) and International Consultation of Incontinence Questionnaire (ICIQ)-Short Form questionnaires. Secondary outcomes were early (≤4 mo) erectile function recovery, the positive surgical margin (PSM) rate, 30-d Clavien-Dindo complications, and biochemical recurrence rates. Quality of life was assessed using the EQ-5D-5L questionnaire. The association between treatment arm and UC recovery was also tested using multivariable regression models.

RESULTS AND LIMITATIONS

After surgery, 23 patients withdrew their consent and 29 were lost to follow-up, leaving 261 patients available for per-protocol analyses. Of these, 32 patients (24%) in the experimental group and 37 (29%) in the control group used no pad/one safety pad at 1 mo after RARP, whereas 96 (72%) in the control group versus 83 (65%) in the control group were continent at 4-mo follow-up (both p = 0.3). Median ICIQ and IPSS scores did not differ between the groups at both time points. The results were confirmed on multivariable regression analyses. PSMs were observed for 32 patients (25%) in the experimental group versus 30 (22%) in the control group (p = 0.6). The incidence of postoperative complications (17% experimental vs 13% control) and the 1-yr biochemical recurrence-free survival did not differ between the groups.

CONCLUSIONS

In this randomized clinical trial, we did not find evidence that early ligation of the DVC during RARP was associated with better UC recovery after surgery in comparison to the standard technique. Given its safety in terms of surgical margins and complications, this technique may be considered as an option for surgical dissection according to the physician's preference.

PATIENT SUMMARY

Our trial showed that for patients undergoing robot-assisted surgical removal of the prostate, the timing of a specific step to control bleeding from a network of veins draining the prostate did not affect recovery of urinary continence after surgery. The results indicate that earlier control of these veins may be considered as an option according to the surgeon's preference.

Management with Santorini’s Plexus Should Be Personalized during Prostatectomy

The aim of this study is to compare the results of laparoscopic prostatectomy in terms of management with Dorsal Venosus Complex (DVC)/Santorini’s plexus as it is still an open question in the field of urology. For this purpose, 457 patients after prostatectomy derived from two high volume centers were compared. In one center, patients underwent DVC ligation in all cases, whereas in the second center, this step was omitted. Subsequently, the histological and functional results were compared. Results showed that DVC management has an impact on blood loss and the duration of the surgery. In addition, omitting DVC ligation is demonstrated to reduce positive margin rate within the apex if the cancer was localized in this region. The continence and erectile function were similar in the 12-month follow up.

Beforehand transection and suturing (BTS) of the dorsal vascular complex: a novel technique in laparoscopic radical prostatectomy

Background

Beforehand transection and suturing (BTS) of the dorsal vascular complex (DVC), a novel technique in non-neurovascular bundle sparing (NVB-sparing) extraperitoneal laparoscopic radical prostatectomy (eLRP), had been proposed; this study aimed to evaluate this technique in clinical laparoscopic procedures.

Methods

Using this new technique, the DVC was transected and sutured after dissection of the pelvic fascia and before dissection of the prostate, especially before ligation of the bilateral prostatic pedicles. This study retrospectively analyzed the data of 90 non NVB-sparing eLRP patients [traditional technique (n=60) and BTS technique (n=30)].

Results

The surgical time in the BTS technique group was 121.73±24.53 min, which was significantly shorter (P=0.0015) than the traditional technique group (144.12±39.68 min). The calculated blood loss in the traditional technique group was 388.45±232.78 mL, and 264.16±130.70 mL in the BTS technique group (P=0.0016). The estimated blood loss in the traditional technique group was 350.34±311.80 mL, which was significantly greater than the BTS technique group (250.33±145.31 mL, P=0.0422). The transfusion rate in the traditional technique group was significantly greater than the BTS technique group (15.00% vs. 0.00%; P=0.0266). The biochemical recurrence rate in traditional technique group was 48.33%, which was higher than in the BTS group (30.00%) (P=0.0465). There was no significant difference between the 2 groups with respect to the pre-operative hemoglobin (Hb) concentration, pre-operative hematocrit (HCT), post-operative Hb concentration, post-operative HCT, ΔHCT, pre-operative blood volume, rectal perforation, open conversion, apical capsule residue, false suture, post-operative bleeding, urinary leakage, re-operation, surgical site infection, post-operative stay, and emission time of urinary incontinence.

Conclusions

In managing the relationship between the DVC and prostate in patients undergoing non NVB-sparing eLRP, the BTS technique was shown to be more effective and safer than the traditional technique.

Beforehand transection and suturing (BTS) of the dorsal vascular complex: a novel technique in laparoscopic radical prostatectomy

BACKGROUND

Beforehand transection and suturing (BTS) of the dorsal vascular complex (DVC), a novel technique in non-neurovascular bundle sparing (NVB-sparing) extraperitoneal laparoscopic radical prostatectomy (eLRP), had been proposed; this study aimed to evaluate this technique in clinical laparoscopic procedures.

METHODS

Using this new technique, the DVC was transected and sutured after dissection of the pelvic fascia and before dissection of the prostate, especially before ligation of the bilateral prostatic pedicles. This study retrospectively analyzed the data of 90 non NVB-sparing eLRP patients [traditional technique (n=60) and BTS technique (n=30)].

RESULTS

The surgical time in the BTS technique group was 121.73±24.53 min, which was significantly shorter (P=0.0015) than the traditional technique group (144.12±39.68 min). The calculated blood loss in the traditional technique group was 388.45±232.78 mL, and 264.16±130.70 mL in the BTS technique group (P=0.0016). The estimated blood loss in the traditional technique group was 350.34±311.80 mL, which was significantly greater than the BTS technique group (250.33±145.31 mL, P=0.0422). The transfusion rate in the traditional technique group was significantly greater than the BTS technique group (15.00% vs. 0.00%; P=0.0266). The biochemical recurrence rate in traditional technique group was 48.33%, which was higher than in the BTS group (30.00%) (P=0.0465). There was no significant difference between the 2 groups with respect to the pre-operative hemoglobin (Hb) concentration, pre-operative hematocrit (HCT), post-operative Hb concentration, post-operative HCT, ΔHCT, pre-operative blood volume, rectal perforation, open conversion, apical capsule residue, false suture, post-operative bleeding, urinary leakage, re-operation, surgical site infection, post-operative stay, and emission time of urinary incontinence.

CONCLUSIONS

In managing the relationship between the DVC and prostate in patients undergoing non NVB-sparing eLRP, the BTS technique was shown to be more effective and safer than the traditional technique.

How to Prevent and Manage Post-Prostatectomy Incontinence: A Review

PURPOSE

To provide an overview of the currently available evidence relating to the prevention and management strategies of urinary incontinence (UI) after radical prostatectomy (RP).

MATERIALS AND METHODS

A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning post-RP UI. The search strategy included these words: urinary continence; urinary continence recovery; urinary incontinence; radical prostatectomy; and prostate cancer.

RESULTS

Post-RP UI still represents a challenging issue for both urologic patients and clinicians. A complete preoperative assessment of the risk factors associated with post-RP UI aids both in counseling those patients with a higher estimated likelihood of postoperative UI and in identifying those who would probably benefit from preventive strategies in the preoperative and in the intraoperative settings. Over the last decades different surgical strategies based on either the "preservation" or the "reconstruction" of the anatomical elements responsible for urinary continence (UC) led to an overall improvement of postoperative functional outcomes. Finally, several therapeutic strategies should be evaluated for the postoperative UI management. Artificial urinary sphincter implantation represents the gold standard for treatment, notwithstanding its wide adoption is limited due to high costs and significant risk of surgical revision. In this context, male sling positioning seems the most promising strategy, in particular in mild and moderate post-RP UI.

CONCLUSIONS

To enhance the likelihood of obtaining an optimal UC recovery after RP, it is here strongly suggested to intervene throughout the overall clinical management process thus including the pre-, intra- and postoperative settings.

Randomised comparison of techniques for control of the dorsal venous complex during robot-assisted laparoscopic radical prostatectomy

OBJECTIVE

To prospectively compare the effects of endoscopic stapling, division and suture ligation, and suture ligation with suspension of the dorsal venous complex (DVC) on continence during robot-assisted laparoscopic radical prostatectomy (RARP).

PATIENTS AND METHODS

In all, 300 consecutive patients undergoing RARP by a single surgeon were randomised to three groups: endoscopic stapling, cut and suture ligation, and suture ligation with suspension. The only difference between the groups was the technique to control the DVC. Pad-free continence (PFC) and overall continence (0 pads/day with or without security pad) were assessed with patient reported pad usage records and validated questionnaires (Expanded Prostate Cancer Index) at 3, 12, and 15 months. Secondary endpoints were erectile function (EF) recovery (defined as erections sufficient for sexual activity) and the rate of apical surgical margins. Univariate and multivariate analyses were conducted to determine predictors for recovery of both urinary continence and EF.

RESULTS

The three groups were comparable in terms of age, body mass index, prostate size, American Urological Association symptom score, Sexual Health Inventory for Men, and clinical stage. There were no differences found in terms of operative times, estimated blood loss, pathological stage, and positive apical margin. There was no difference between the three groups with regard to overall continence or PFC at 3 months. However, overall continence at 15 months for ligation and suspension was 99% and was superior to stapler (88%) (P = 0.002) and cut and suture ligation (88%) (P = 0.002). Additionally, PFC at 15 months was superior for ligation and suspension (87%) as compared to stapler (73%) and cut and suture ligation (75%) (P = 0.045). The technique of DVC control did not impact EF. Men with nerve sparing had better continence compared to no nerve sparing at 3 months (62% vs 42%, P = 0.045), but not at 15 months. The median time to continence was 2 months for patients receiving nerve sparing compared to 4.5 months for non-nerve sparing (P = 0.02).

CONCLUSION

Suture suspension of the DVC during RARP contributes to higher overall continence rates compared to stapling and cut and suture. Nerve sparing contributes to earlier return of continence than non-nerve sparing.

Feasibility and continence outcomes of extended prostatic urethral preservation during robot-assisted radical prostatectomy

BACKGROUND

The prostatic urethra is conventionally resected during robot-assisted radical prostatectomy (RARP). We describe the technical feasibility and urinary continence outcomes of extended prostatic urethral preservation (EPUP) during RARP.

METHODS

A single surgeon at a National Comprehensive Cancer Network institute performed 48 consecutive RARP operations using EPUP from March 2014 to March 2016, during which time 177 conventional non-EPUP RARP operations were performed by other surgeons. Prior to this period, the EPUP surgeon had performed 17 non-EPUP RARP operations over 15 months. Total intracorporeal urethral length (IUL) preserved during EPUP was measured intraoperatively. Associations of EPUP and IUL with continence recovery rates and/or times were tested in Fisher's exact and log rank univariate analyses and Cox logistic regression multivariable analyses.

RESULTS

Median IUL preserved during EPUP was 4.0 cm (range 2.5-6.0 cm), and urethral dissections typically spanned the prostatic apex to mid-gland or base. Seven-week continence rates were significantly higher with versus without EPUP. EPUP patient rates of using 0 or 0-1 pads per day immediately after catheter removal were 19% and 35%, respectively. These rates increased significantly (53% and 76%, respectively), as did the IUL preserved (median 5.0 cm), among more recent EPUP patients (n = 17), which suggested a learning curve. In multivariable analyses including all patients, an EPUP approach was an independent predictor of faster continence recovery. In multivariable analyses of the EPUP subset, a longer IUL preserved was independently associated with faster continence recovery. No EPUP patient had a urethral fossa positive margin, and apical positive margins were similarly infrequent among EPUP and non-EPUP patients.

CONCLUSIONS

EPUP is technically feasible during RARP and associated with faster continence recovery. Future investigation into the generalizability of these findings and the oncologic safety of EPUP is warranted.

Delayed versus standard ligature of the dorsal venous complex during laparoscopic radical prostatectomy: A systematic review and meta-analysis of comparative studies

PURPOSE

To evaluate current views on comparing delayed ligature of the dorsal venous complex (D-DVC) with standard ligature of the dorsal venous complex (S-DVC) for safety, urinary control and oncological outcomes during laparoscopic radical prostatectomy.

METHODS

A comprehensive searching of PubMed, Web of science, Embase and the Cochrane Library was made and then we performed a meta-analysis, including all randomized controlled trials (RCTs) and retrospective studies, to evaluate the two different techniques.

RESULTS

Two RCTs and six retrospective studies containing 1822 cases (222 cases from RCTs and 1600 cases from retrospective studies) were identified. Although D-DVC was related to more blood loss (WMD: 7.30 mL; 95% CI, 2.43 to 12.16; p = 0.003), the blood transfusion rate between the two groups showed no significant difference (OR = 1.93; 95% CI, 0.55 to 6.73; p = 0.31), and patients in the D-DVC group could benefit from a shorter operative time (WMD: -30.83 min; 95% CI, -53.32 to -8.35; p = 0.007). Positive apical margin events were significantly less in the D-DVC group (OR = 0.39; 95% CI, 0.22 to 0.71; p = 0.002). As for urinary control, there were no differences in continence rates after 3 months (OR = 1.64; 95% CI, 0.98 to 2.73; p = 0.06) and 12 months (OR = 1.00; 95% CI, 0.63 to 1.57; p = 0.99) of follow-up. However, there was a significantly higher continence rate after 6 months of follow-up in the D-DVC group (OR = 1.46; 95% CI, 1.02 to 2.11; p = 0.04).

CONCLUSIONS

Standard and delayed approaches to DVC are equally safe and result in similar urinary control. The delayed approach could decrease the positive apical margin rate. However, further large-scale prospective studies are needed to investigate and compare the prognosis and long-term functional outcomes between the two approaches.

Standard vs delayed ligature of the dorsal vascular complex during robot-assisted radical prostatectomy: results from a randomized controlled trial

PURPOSE

Prospective randomized trial to compare standard vs delayed approach to dorsal vascular complex (s-DVC vs d-DVC) in robot-assisted radical prostatectomy (RARP).

METHODS

Patients scheduled for RARP were randomized into a 1:1 ratio to receive either s-DVC or d-DVC by two experienced surgeons. In s-DVC arm an eight-shaped single stitch was given at the beginning of the procedure and the DVC was subsequently cut at time of apical dissection; in d-DVC arm the plexus was transected at the end of prostatectomy, prior to apex dissection and then sutured. Primary endpoint was difference in estimated blood loss (EBL) and a sample size of 226 cases was calculated; ad interim analysis was planned after 2/3 of recruitment.

RESULTS

Endpoint was reached at ad interim analysis after 162 cases (81 s-DVC, 81 d-DVC) and recruitment was, therefore, interrupted. Baseline and tumor characteristics were overlapping. EBL was significantly higher in d-DVC arm (mean EBL 107 vs 65 ml, p = 0.003), but without differences in post-operative hemoglobin, transfusions and complications. Overall PSM rate was higher in d-DVC arm (21.0 vs 14.8%, p = 0.323), with statistical significance relatively to organ-confined disease (15.5 vs 3.6%, p = 0.031). Apical involvement was instead significantly higher in s-DVC arm (prevalence in PSM patients 66.7 vs 23.5%, p = 0.020). Post-operative PSA, continence and potency rates were similar between groups.

CONCLUSIONS

Standard and delayed approaches to DVC are safe and lead to similar functional outcomes. A delayed approach exposes to a higher risk of PSM in organ-confined disease but with a lower risk of apical involvement.

Should aspirin be suspended prior to robot-assisted radical prostatectomy? A systematic review and meta-analysis

Background:

Low-dose aspirin use has been correlated with an increased risk of bleeding and overall complications in surgical and invasive diagnostic procedures. In this review, our aim was to analyze the current literature on whether robot-assisted radical prostatectomy (RARP) is feasible and safe in patients taking low-dose aspirin perioperatively.

Methods:

A systematic review was performed identifying a total of 767 studies, published between January 2000 and September 2017, with five of these studies meeting the inclusion criteria for the meta-analysis, totalizing 1481 patients underwent RARP. Patients were divided into two groups: taking aspirin (group A) and those not taking aspirin (group B) perioperatively.

Results:

There were no significant differences between groups in the overall [group A 10.7% versus group B 15.7%, risk ratio (RR) 0.83; p = 0.45; I² = 0%] or major complication rates (group A 1% versus group B 3%, RR 0.98; p = 0.98; I² = 0%), rate of cardiovascular events (group A 1.4% and group B 0.5%, RR 2.06; p = 0.24; I² = 9%), blood loss (group A 278 ml versus group B 307 ml, SMD −0.12; p = 0.91; I² = 96%), or hospital length of stay [group A 4 days (3–5) and group B 4 days (3–4), SMD −0.09; p = 0.52; I² = 0%]. There was a slightly higher blood-transfusion rate in group A (2.6%) versus group B (1.6%) (RR, 5.05; p = 0.04; I² = 0%).

Conclusion:

Continued aspirin use in the perioperative period does not correlate with an increase in surgical morbidity, blood loss, or hospital length of stay. There was a slightly higher blood-transfusion rate in patients taking low-dose aspirin (group A) perioperatively.

Retzius-sparing versus standard robot-assisted radical prostatectomy: a prospective randomized comparison on immediate continence rates

BACKGROUND

Post-prostatectomy urinary incontinence is an adverse event leading to significant distress. Our aim was to evaluate immediate urinary continence (UC) recovery in a single-surgeon prospective randomized comparative study between the traditional robot-assisted laparoscopic radical prostatectomy (TR-RALP) and the Retzius-sparing RALP (RS-RALP), for the treatment of the clinically localized prostate cancer (PCa).

METHODS

102 consecutive PCa patients were prospectively randomized to TR-RALP (57) or RS-RALP (45). Postoperative continence was defined as patient-reported absence of leakage or use of 0 pads/day. The immediate continence rate and 95% confidence interval (CI 95%) were calculated for each treatment. Univariable and multivariate logistic regressions were used to assess predictors of immediate continence following RALP. Continence rates from 1 to 6 months were calculated by Kaplan-Meier curves; log-rank test was used for the curve comparison. Two analyses were performed, considering a per-protocol (PP) population regarding all randomized patients that received nerve-sparing RALP and an Intention-To-Treat (ITT) population regarding all randomized patients that received RALP.

RESULTS

In the PP analysis, the rates of immediate continence were 12/40 (30%) (CI 95% 17-47%) for the TR-RALP and 20/39 (51.3%) (CI 95% 35-68%) for the RS-RALP (p = 0.05). In the ITT analysis, the corresponding rates were 12/57 (21%) (CI 95% 11-34%) for the TR-RALP and 23/45 (51%) (CI 95% 36-66%) for the RS-RALP (p = 0.001). Median time to continence was 21 days for the TR-RALP and 1 day for RS-RALP, respectively (p = 0.02). The relative Kaplan-Meier curves regarding continence resulted statistically different when compared with the log rank test (p = 0.02). In the multivariate analysis, lower age and the Retzius-sparing approach were significantly associated to earlier continence recovery.

CONCLUSIONS

The Retzius-sparing approach significantly reduces time to continence following RALP. Further studies are required to confirm the reproducibility of our results and investigate the role of the RS-RALP as an additional "protective" factor for postoperative continence in the elderly population.

Laparoscopic radical prostatectomy in 2018: 20 years of worldwide experiences, experimentations, researches and refinements

INTRODUCTION

After the first feasibility report in 1997, a growing interest has risen in the urologic community for laparoscopic radical prostatectomy (LRP) and several authors have contributed to the evolution of the technique. We attempt a review of the available evidences and provide a broad framework of different technical refinements considering their impact on pentafecta.

EVIDENCE ACQUISITION

The PubMed/Medline database was searched. Duplicates and "Expert opinion" papers were removed. Studies were included according to the aim of the present paper to present a selected review on LRP and report our personal experience.

EVIDENCE SYNTHESIS

In 1999 Guillonneau et al. codified their transperitoneal-posterior-antegrade technique for LRP. Since then, several modifications of the transperitoneal approach were published and the extraperitoneal route was also proposed. Sparing the bladder neck and reconstructing the posterior muscolofascial plate were proven to improve continence rate. Nerve-sparing LRP were performed in order to maximize postoperative recovery of the sexual function. Novel techniques to ligate the Santorini plexus and sew the urethrovesical anastomosis provided improvement in operative time, intraoperative blood loss and reduced the incidence of postoperative urinary-leakages. In the recent years, the single-site approach as pushed the limits of LRP and three-dimensional (3D) systems for endoscopic surgery were developed.

CONCLUSIONS

Thanks to several technical improvements, LRP provides brilliant oncologic and functional outcomes and it is now considered the treatment of choice in many institutions worldwide. Although it is a technically demanding procedure, the recent introduction of 3D systems will reduce the steepness of its learning curve.

The efficacy and feasibility of total reconstruction versus nontotal reconstruction of the pelvic floor on short-term and long-term urinary continence rates after radical prostatectomy: a meta-analysis

Background

Recently, total pelvic floor reconstruction (TR) has been the treatment of choice for improving urinary incontinence (UI) after radical prostatectomy (RP). However, the superiority of TR with respect to urinary continence recovery following RP remains controversial. This study identified the effect of TR versus nonTR of the pelvic floor on short-term and long-term continence rates after RP.

Methods

A literature search was performed in November 2017 using the PubMed, Embase, and Web of Science databases. Only comparative research or clinical studies reporting urinary continence outcomes was included in the meta-analysis, and the quality of evidence was evaluated using the 2011 Level of Evidence for therapy research.

Results

We analyzed ten studies reporting urinary continence rates after RP at one or more postoperative time points (1, 2, 4, 12, 24, and 52 weeks). TR was associated with significantly better urinary continence outcomes at 1 week (OR 2.76, 95% CI 1.58–4.84, P < 0.001), 2 weeks (OR 2.57, 95% CI 1.74–3.80, P < 0.001), 4 weeks (OR 2.61, 95% CI 1.56–4.38, P < 0.001), 12 weeks (OR 4.33, 95% CI 2.01–9.33, P < 0.001), 24 weeks (OR 3.83, 95% CI 1.54–9.55, P = 0.004), 52 weeks (OR 4.10, 95% CI 1.80–9.38, P < 0.001) after RP. There was no difference in the rate of complications between the two arms (OR 0.54, 95% CI 0.19–1.54, P = 0.25).

Conclusions

Compared with nonTR, TR is significantly and positively associated with a return to continence but not with complication rate in men following RP, suggesting that TR may be useful for decreasing the urinary incontinence rate after surgery.

How robotic surgery is changing our understanding of anatomy

The most recent revolution in our understanding and knowledge of the human body is the introduction of new technologies allowing direct magnified vision of internal organs, as in laparoscopy and robotics. The possibility of viewing an anatomical detail, until now not directly visible during open surgical operations and only partially during dissections of cadavers, has created a ‘new surgical anatomy’. Consequent refinements of operative techniques, combined with better views of the surgical field, have given rise to continual and significant decreases in complication rates and improved functional and oncological outcomes. The possibility of exploring new ways of approaching organs to be treated now allows us to reinforce our anatomical knowledge and plan novel surgical approaches. The present review aims to clarify some of these issues.

The application of a blunt-tip needle to suture the dorsal venous complex in robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

Complete haemostasis of the dorsal venous complex (DVC) is of great importance in robot-assisted radical prostatectomy. In this study, we investigated the efficacy of blunt-tip needles in the surgery.

METHODS

Cases of robot-assisted laparoscopic radical prostatectomy were reviewed. If a blunt-tip needle had been used to suture the DVC, the patient was recruited to the blunt-tip group. If a regular needle was used, the patient was recruited to the control group. Patient characteristics and perioperative outcomes were recorded.

RESULTS

One hundred and nine cases were reviewed. A blunt-tip needle was used to suture the DVC in 67 cases, and a regular needle in 42 cases. All characteristics of the two groups are comparable (p > 0.05). In 66 cases in the blunt-tip group, no sutures or coagulations were needed when suturing the DVC, Five cases of DVC-related bleeding were observed in the control group, which is higher than in the blunt-tip group (p = 0.031). At the same time, no catheter was sutured in the blunt-tip group. All patients were followed for at least six months. The continence rate in the blunt-tip group is 89.6%, significantly higher than in the control group (73.8%, p = 0.031).

CONCLUSIONS

Using a blunt-tip needle to suture the DVC may reduce DVC-related bleeding and provide a better surgical field. It may be helpful in improving postoperative continence. However, its effect on positive margin at the apex still needs further investigation.

"Total reconstruction" of the urethrovesical anastomosis contributes to early urinary continence in laparoscopic radical prostatectomy

Purpose:

To demonstrate the effect of total reconstruction technique on postoperative urinary continence after laparoscopic radical prostatectomy (LRP).

Material and Methods:

LRP was performed using a standard urethrovesical anastomosis in 79 consecutive patients (Group-A) from June 2011 to October 2012, and a total reconstruction procedure in 82 consecutive patients (Group-B) from June 2012 to June 2013. The primary outcome measurement was urinary continence assessed at 1, 2, 4, 12, 24 and 52 weeks after catheter removal. Other data recorded were patient age, body mass index, International Prostate Symptoms Score, prostate volume, preoperative PSA, Gleason score, neurovascular bundle preservation, operation time, estimated blood loss, complications and pathology results.

Results:

In Group-A, the continence rates at 1, 2, 4, 12, 24 and 52 weeks were 7.59%, 20.25%, 37.97%, 58.22%, 81.01% and 89.87% respectively. In Group-B, the continence rates were 13.41%, 32.92%, 65.85%, 81.71%, 90.24% and 95.12% respectively. Group––B had significantly higher continence rates at 4 and 12 weeks after surgery (P<0.001 and P=0.001). There were no significant differences between the groups with respect to patient's age, body mass index, prostate-specific antigen level, prostate volume, IPSS, estimated blood loss, number of nerve-sparing procedures and postoperative complications.

Conclusions:

Total reconstruction technique in the procedure of urethrovesical anastomosis during LRP improved early recovery of continence.

Full Neurovascular Sparing Extraperitoneal Robotic Radical Prostatectomy: Our Experience with PERUSIA Technique

INTRODUCTION

Primary aim of this study was to investigate the feasibility and the safety of PERUSIA (posterior, extraperitoneal, robotic, under santorini, intrafascial, anterograde) radical prostatectomy (RP). Secondary aim was to evaluate oncologic and functional results. The main intent of PERUSIA is to reduce injury of the Neuro-Vascular Bundles (NVB) and to preserve periurethral anterior structures. This is the first reported prospective cohort study about our technique.

MATERIALS AND METHODS

We collected prospective data of a cohort of 210 patients who had undergone PERUSIA RP between January 2013 and May 2015. Key points of this technique included the following: posterior approach to intrafascial plane, which was developed from the median to lateral side, anterograde preservation of the Veil of Aphrodite, and development of an anterior avascular plane to preserve the santorini plexus. We included only sexually potent patients with low-risk disease. Perioperative, oncologic, and functional outcomes were collected. Postoperative full continence was defined as no pad use. Patients were defined potent when International Index of Erectile Function (IIEF-5) score was >17. Median follow-up was 22 months.

RESULTS

Median operative time and median estimated blood loss were 120 minutes and 150 mL, respectively. 25 patients (11.9%) experienced a total of 36 complications overall with an overall complication rate of 17.1%. We reported 3 (8.3%) grade IIIb complications and no major ones. Overall positive surgical margin rate was 20% with biochemical recurrence occurring in 3.8% of patients at a median follow-up of 22 months. Immediate urinary continence rate (1 day after catheter removal) was 66.6%. At 3 and 12 months, the continence rate was 90.4% and 96.1%, respectively, while sexual potency rate was 70.4% and 80.9%.

CONCLUSION

PERUSIA RP has proved to be safe and effective for low-risk prostate cancer with exciting functional outcomes in terms of early recovery of urinary continence and sexual potency.

Recovery of urinary continence after radical prostatectomy

INTRODUCTION

In the era of minimally-invasive surgery, urinary incontinence (UI) after radical prostatectomy (RP) still represents a troublesome issue for a considerable rate of patients. Factors associated with the risk of post-RP UI, need to be carefully assessed throughout the overall clinical management process thus including the pre-operative, intra-operative and post-operative setting.

AREAS COVERED

This review analyses current published evidences regarding clinical and surgical aspects associated with urinary continence (UC) recovery after RP. A careful evaluation of patient's clinical characteristics should be carried out before surgery in order to properly counsel the patients regarding the risk of UI. In the last two decades, the advent of robotic surgery has led to an overall improvement of functional outcomes after RP, thanks to the development of different surgical strategies based on either the 'preservation' or the 'reconstruction' of the anatomical elements responsible for urinary continence. Finally, several therapeutic strategies including either a conservative approach, or pharmacological and surgical treatments, should be carefully considered for the post-operative management of UI. Expert commentary: A comprehensive pre-operative patient's clinical assessment, along with a proper and well-conducted surgical procedure and an effective post-operative care management are essential element to achieve a high probability of UC recovery.

Laparoscopic anterior pelvic exenteration for locoregionally advanced rectal cancer directly invading the urinary bladder: A case report of low anterior resection with en bloc cystectomy for sphincter preservation

Laparoscopic multi-visceral resection in patients with T4 colorectal cancer remains controversial. A 73-year-old man was admitted to the hospital for rectosigmoid cancer directly invading the urinary bladder trigone without distant metastasis. We successfully performed complete resection by laparoscopic anterior pelvic exenteration while preserving the anus. After laparoscopic mobilization of the rectum, urinary bladder, and prostate, the urethra and urethral catheter were dissected to reveal the lower rectum. By pulling the urethral catheter toward the head, the prostate was excised retrogradely from the lower rectum anterior wall. The lower rectum was resected and anastomosed by the double stapling technique with a safe distal margin from the tumor. Pathological findings of the resected specimen indicated no residual tumor in the surgical margin. There was no evidence of recurrence 34 months after surgery. En bloc, R0, laparoscopic anterior pelvic exenteration for T4 rectal cancer is feasible. However, further studies with long-term follow-up are required to resolve oncological outcomes.

Minimum 5-year follow-up of 1138 consecutive laparoscopic radical prostatectomies

OBJECTIVES

To investigate the long-term outcomes of laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS

In all, 1138 patients underwent LRP during a 163-month period from 2000 to 2008, of which 51.5%, 30.3% and 18.2% were categorised into D'Amico risk groups of low-, intermediate- and high-risk, respectively. All intermediate- and high-risk patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning, and had a pelvic lymph node dissection (PLND), which was extended after April 2008. The median (range) patient age was 62 (40-78) years; body mass index was 26 (19-44) kg/m(2) ; prostate-specific antigen level was 7.0 (1-50) ng/mL and Gleason score was 6 (6-10). Neurovascular bundle was preservation carried out in 55.3% (bilateral 45.5%; unilateral 9.8%) of patients.

RESULTS

The median (range) gland weight was 52 (14-214) g. The median (range) operating time was 177 (78-600) min and PLND was performed in 299 patients (26.3%), of which 54 (18.0%) were extended. The median (range) blood loss was 200 (10-1300) mL, postoperative hospital stay was 3 (2-14) nights and catheterisation time was 14 (1-35) days. The complication rate was 5.2%. The median (range) LN count was 12 (4-26), LN positivity was 0.8% and the median (range) LN involvement was 2 (1-2). There was margin positivity in 13.9% of patients and up-grading in 29.3% and down-grading in 5.3%. While 11.4% of patients had up-staging from T1/2 to T3 and 37.1% had down-staging from T3 to T2. One case (0.09%) was converted to open surgery and six patients were transfused (0.5%). At a mean (range) follow-up of 88.6 (60-120) months, 85.4% of patients were free of biochemical recurrence, 93.8% were continent and 76.6% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation.

CONCLUSIONS

The long-term results obtainable from LRP match or exceed those previously published in large contemporary open and robot-assisted surgical series.

Impact of barbed suture in controlling the dorsal vein complex during laparoscopic radical prostatectomy

OBJECTIVE

To compare applications of unidirectional knotless barbed suture and traditional two single polyglactin sutures for dorsal vein complex (DVC) control during laparoscopic radical prostatectomy (LRP).

MATERIAL AND METHODS

This was a non-randomized, prospective matched-pair pilot study. Thirty-one LRP cases with barbed suture (V-Loc®) were match-paired with 31 LRP cases in which traditional two single polyglactin stitches according to patient's prostate volume and body mass index (BMI) were used. Time needed for DVC ligation, DVC control and operation time were recorded. Peri- and postoperative parameters were noted. Statistical analyses were performed.

RESULTS

Mean age was 65.4±6.3 years. Mean follow-up was 20.2±3.3 months. Mean BMI and prostate volume were similar in both groups. Mean preoperative clinical stage, Gleason score, and PSA were comparable between both groups. Mean DVC ligature time and mean DVC controlling time in group 1 were statistically shorter than in group 2 (p=0.04, p<0.001). Continence rates were significantly higher in group 1 than in group 2 in early follow-up (p=0.005).

Total pelvic floor reconstruction during non-nerve-sparing laparoscopic radical prostatectomy: impact on early recovery of urinary continence

OBJECTIVES

To develop a modified technique of "total pelvic floor reconstruction" during non-nerve-sparing laparoscopic radical prostatectomy, and to determine its effect on postoperative urinary outcomes.

METHODS

A total of 128 patients who underwent non-nerve-sparing laparoscopic radical prostatectomy were evaluated, including 81 with total pelvic floor reconstruction and 47 with non-total pelvic floor reconstruction. Nerve-sparing cases were excluded. Urinary outcomes were assessed with self-administrated questionnaires (Expanded Prostate Cancer Index Composite) at 1, 3, 6 and 12 months after laparoscopic radical prostatectomy. The total pelvic floor reconstruction technique included two concepts involving posterior and anterior reconstructions. In posterior reconstruction, Denonvilliers' fascia was approximated to the bladder neck and the median dorsal raphe by slipknot. The anterior surface of the bladder-neck was approximated to the anterior detrusor apron and the puboprostatic ligament collar for anterior reconstruction.

RESULTS

There were no significant differences between the two groups in the patients' characteristics, and in perioperative and oncological outcomes. In the total pelvic floor reconstruction group, the continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy were 45.7%, 71.4%, and 84.6%, respectively. In the non-total pelvic floor reconstruction group, the continence rates were 26.1%, 46.8% and 60.9%, respectively. The total pelvic floor reconstruction technique resulted in significantly higher continence rates at 3, 6 and 12 months after laparoscopic radical prostatectomy, respectively (all P < 0.05). The mean interval to achieve continence was significantly shorter in the total pelvic floor reconstruction group (mean 7.7 months) than in the non-total pelvic floor reconstruction group (mean 9.8 months; P = 0.0003).

CONCLUSION

The total pelvic floor reconstruction technique allows preservation of the blood supply to the urethra and physical reinforcement of the pelvic floor. Therefore, this technique is likely to improve urinary continence outcomes after laparoscopic radical prostatectomy.

Health-related quality of life in the first year after laparoscopic radical prostatectomy compared with open radical prostatectomy

OBJECTIVE

To assess health-related quality of life in the first year after laparoscopic radical prostatectomy compared with that after open radical prostatectomy.

METHODS

The subjects were 105 consecutive patients with localized prostate cancer treated with laparoscopic radical prostatectomy between January 2011 and June 2012. Health-related quality of life was evaluated using the International Prostate Symptom Score, Medical Outcome Study 8-Items Short Form Health Survey (SF-8) and Expanded Prostate Cancer Index Composite at baseline and 1, 3, 6 and 12 months after surgery. Comparisons were made with data for 107 consecutive patients treated with open radical prostatectomy between October 2005 and July 2007.

RESULTS

The International Prostate Symptom Score change was similar in each group. The laparoscopic radical prostatectomy group had a better baseline Medical Outcome Study 8-Items Short Form Health Survey mental component summary score and a better Medical Outcome Study 8-Items Short Form Health Survey physical component summary score at 1 month after surgery. In Expanded Prostate Cancer Index Composite, obstructive/irritative symptoms did not differ between the groups, but urinary incontinence was worse until 12 months after surgery and particularly severe after 1 month in the laparoscopic radical prostatectomy group. The rate of severe urinary incontinence was much higher in the laparoscopic radical prostatectomy group in the early period. Urinary bother was worse in the laparoscopic radical prostatectomy group at 1 and 3 months, but did not differ between the groups thereafter. Urinary function and bother were good after nerve sparing procedures and did not differ between the groups. Bowel and sexual function and bother were similar in the two groups.

CONCLUSION

Urinary function in the first year after laparoscopic radical prostatectomy is worse than that after open radical prostatectomy.

Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy

Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted in the last few years despite having a prolonged learning curve. This article describes the RALP learning curve, reviews in detail the challenging steps of the operation, describes the authors' RALP technique, and concludes with tips to overcome the learning curve.