Editorial Comment on: Impact of Percutaneous Suprapubic Tube Drainage on Patient Discomfort after Radical Prostatectomy

Postoperative patient comfort in suprapubic drainage versus transurethral catheterization following robot-assisted radical prostatectomy: a prospective randomized clinical trial

PURPOSE

To evaluate the impact of the type of urinary diversion (suprapubic vs. transurethral catheterization) on patients' postoperative pain after radical prostatectomy, development of bacteriuria and long-term functional results.

METHODS

A randomized, prospective clinical trial was performed including 160 patients who underwent robot-assisted radical prostatectomy after randomization into two groups: intraoperatively, a transurethral catheter (control group) or an additional suprapubic tube (with removal of the transurethral catheter in the morning of postoperative day 1; intervention group) was placed. Primary study endpoint was postoperative pain objectified by the numeric rating scale questionnaire. Secondary endpoints were bacteriuria after catheter removal and functional outcomes after up to 2 years of follow-up.

RESULTS

There were no significant differences in demographic and perioperative data. Starting on postoperative day 2, patients in the suprapubic diversion group had significantly less pain on every time point preceding the removal of the catheter compared to the control cohort with a median overall numeric rating score on postoperative day 1-4 of 2.4 points in the transurethral versus 1.3 in the intervention group (p = 0.012). No statistical difference was found in postoperative bacteriuria and complications as well as in functional results, quality of life and incontinence rates after a median follow-up of 22 months.

CONCLUSIONS

Suprapubic drainage in robot-assisted radical prostatectomy shows significantly decreased pain levels during the catheterization period compared to the transurethral diversion without compromising long-term functional results. Intraoperative placement of a suprapubic tube should be discussed as a standard procedure for further improvement of patients' postoperative comfort.

Radical prostatectomy after previous transurethral resection of the prostate: robot-assisted laparoscopic versus open radical prostatectomy in a matched-pair analysis

PURPOSE

To determine whether previous transurethral resection of the prostate (TURP) compromises the surgical outcome and pathologic findings in patient who underwent either radical robot-assisted laparoscopic prostatectomy (RALP) or open retropubic radical prostatectomy (RRP) after TURP, because TURP is reported to complicate radical prostatectomy and there are conflicting data.

PATIENTS AND METHODS

From July 2008 to July 2010, 357 patients underwent RALP. Of these, 19 (5.3%) patients had undergone previous TURP. Operative and perioperative data of patients were compared with those of matched controls selected from a database of 616 post-RRP patients. Matching criteria were age, clinical stage, the level of preoperative prostate-specific-antigen, the biopsy Gleason score, the American Society of Anesthesiologists classification score, and prostate volume assessed during transrectal ultrasonography. All RRP and RALP procedures were performed by experienced surgeons.

RESULTS

Mean time to prostatectomy was 67.4 months in the RALP group and 53.1 months in the RRP group. Mean operative time was 217 ± 51.9 minutes for RALP and 174 ± 57.7 minutes for RRP (P<0.05). The overall positive surgical margin rate was 15.8% in both groups (pT(2) tumors: 10.5% for RALP and 5.3% for RRP; P=1.0). Mean estimated blood loss was 333 ± 144 mL in RALP patients and 1103 ± 636 mL in RRP patients (P<0.001). The difference between preoperative and postoperative hemoglobin levels was 3.22 ± 0.98 g/dL for RALP and 5.85 ± 1.95 g/dL for RRP (P=0.0002). The RALP and RRP groups also differed in terms of hospital stay (8.58 ± 1.17 vs 11.74 ± 5.22 days; P=0.0037), duration of catheterization (7.95 ± 5.69 vs 11.78 ± 6.97 days; P=0.0016), postoperative complications according to the Clavien classification system (6 vs 15 patients; P=0.0027), and transfusion rate (0% vs 10.5%; P<0.001).

CONCLUSION

RALP offers advantages over open radical prostatectomy after previous surgery. Although both techniques are associated with adequate surgical outcomes, RALP appeared to be preferable in our population of patients with previous prostate surgery.

Long-term follow-up of patients undergoing percutaneous suprapubic tube drainage after robot-assisted radical prostatectomy (RARP)

Study Type - Therapy (case series). Level of Evidence 4 What's known on the subject? and What does the study add? • Initial reports of percutaneous suprapubic tube (PST) drainage following RARP demonstrated feasibility and short-term safety, while decreasing patient discomfort and utilization of anti-cholinergic medication. • This study demonstrates the long-term safety and efficacy of bladder drainage by PST; splinting the urethrovesical anastomosis is simply not essential if mucosal apposition is ensured.

OBJECTIVES

• To evaluate the long-term safety and functional outcomes of patients undergoing percutaneous suprapubic tube (PST) drainage after robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

• Between January 2008 and October 2009, 339 patients undergoing RARP by one surgeon experienced in RA surgery (M.M.) had postoperative bladder drainage with PST and a minimum of 1-year follow-up for urinary function. • Functional outcomes were obtained via patient-administered questionnaire. • Complications were captured by exhaustive review of multiple datasets, including our prospective prostate cancer database, claims data, as well as electronic medical and institutional morbidity and mortality records.

RESULTS

• Urinary function assessed by patient-administered questionnaire was analysed at a mean (sd) follow-up of 11.5 (1.7) months; after RARP with PST placement, 293 patients (86.4%) had total urinary control and only nine (2.7%) required >1 pad/day. • In all, 86 patients (25.4%) never wore a pad; the median time to 0-1 pad/day was 2 weeks (interquartile range [IQR] 0,6); median time to total control was 6 weeks (IQR 1,22). • The mean (sd) follow-up for complications was 23.7 (6.1) months. In all, 15 patients (4.4%) had a procedure-specific complication, of which 13 were minor (Clavien Class I/II 3.8%); one patient had a bladder neck contracture. • In all, 16 patients (4.7%) required Foley placement after RARP for gross haematuria (two patients), urinary retention (three), tube malfunction (four) or need for prolonged Foley catheterization (seven).

CONCLUSIONS

• PST placement after RARP is safe and efficacious on long-term follow-up. • Splinting of the urethrovesical anastomosis is not a critical step of RP if a watertight anastomosis and excellent mucosal apposition are achieved.