A novel surgical technique for preserving the bladder neck during robot-assisted laparoscopic radical prostatectomy: preliminary results

Anterior Sphincter-sparing Suturing of the Vesicourethral Anastomosis During Robotic-assisted Laparoscopic Radical Prostatectomy

Background

Continence is an important functional outcome after robotic-assisted laparoscopic radical prostatectomy (RARP), and modifications of the surgical technique may improve outcomes.

Objective

To illustrate a novel RARP technique and to describe the observed continence outcomes.

Design setting and participants

A retrospective study of men treated with RARP between 2017 and 2021 was conducted.

Surgical procedure

During RARP, periprostatic structures are preserved, the intraprostatic urethra is partially spared, and the anterior anastomosis stitches involve the plexus structures but not the anterior urethra.

Measurements

A descriptive analysis of the pathological, functional, and short-term oncological outcomes was performed.

Results and limitations

Of 640 men, 448 (70%) with at least 1 yr of follow-up and a median age of 66 yr were included. The median operative time was 270 min and the prostatic volume 52 ml. The transurethral catheter was removed after a median of 3 d, and leakage of urine in the first 24 h after catheter removal was observed in 66/448 patients (15%). Positive surgical margins were reported in 104/448 (23%). Prostate-specific antigen persistence after prostatectomy was observed in 26/448 (6%). During a median follow-up of 2 yr (interquartile range 1-3 yr), the biochemical recurrence after prostatectomy was observed in 19/448 patients (4%). One year after prostatectomy, 406/448 patients (91%) were continent and required no pad at all, while 42/448 (9%) required at least one pad per day.

Conclusions

Not stitching the anterior urethra is a novel technical modification and may improve continence outcomes.

Patient summary

We describe a novel way to stitch the bladder neck to the urethra after removal of the prostate using a surgical robotic system. Our technique appeared safe, with promising urinary continence results.

The performance and optimum cutoff value for pelvic cavity index as a predictor of early continence after extraperitoneal single-port robotic radical prostatectomy: Role of pelvic anatomical characteristics

PURPOSE

To assess the value of pelvic cavity index (PCI), as an objective pelvimetry feature, to predict operative time, margin status and early urine continence after extraperitoneal single-port robotic radical prostatectomy (RP). We sought to define an optimal cutoff point for PCI in predicting postoperative outcomes.

METHODS

Data on 94 patients who underwent extraperitoneal single-port robotic RP and had preoperative cross-sectional imaging were enrolled. PCI was calculated as (Pelvic inlet diameter×Pelvic outlet diameter)/(Pelvic depth). The predictive value of PCI on operative time, surgical margin status and 3-month urinary continence recovery was assessed using regression models. To report the optimum cutoff value, on ROC analysis, we calculated the performance of PCI cutoff points ranging from 5.56 to 10.80 cm by every 0.01 increment.

RESULTS

No significant associations were noted between clinical characteristics (including PCI) and operative time. Similarly, other than pathological stage, no clinical variables (including PCI) were predictive of positive surgical margin. However, a higher PCI was associated with a significantly higher rates of continence 3-month after surgery (OR 2.44 (1.75 - 5.33); p= 0.01). On ROC- analysis, a PCI cutoff value=8.21 cm yielded the best accuracy (AUC= 0.733, %95 CI 0.615-0.851; p=0.001). No association was noted between variables and 6-month continence rate.

CONCLUSION

Using a single-port robotic system, operative time, positive surgical margin rate and long-term continence after prostatectomy would be independent of bony pelvis cavity. However, a higher PCI is associated with a higher rate of early continence after the surgery. PCI at a cutoff of 8.21 cm has the optimum performance to predict postoperative urine continence recovery. If validated, this information may be helpful regarding patient counseling before single-port robotic RP.

Bladder neck sparing during robot-assisted laparoscopic radical prostatectomy: Six-year experience

OBJECTIVE:

Prostate cancer is the most frequently diagnosed cancer among men in developed countries. Radical prostatectomy (RP) is the standard surgical treatment for patients with organ-confined disease and robot-assisted laparoscopic radical prostatectomy (RALP) procedures get more popular in the past 20 years. The most important factor of continence after RP is the preservation of the functional sphincter mechanisms. Tunc et al. described the novel bladder neck preserving technique in RALRP in 2015. The purpose of this study is to present our long-term results of our novel technique during RALP performed by single surgeon (LT).

METHODS:

In this study, 331 patients who went under procedure RALP between January 2012 and December 2017 analyzed retrospectively. Bladder neck sparing technique was performed for all patients used by a four-armed da Vinci robotic surgical system (Intuitive Surgical, Inc., Sunnyvale, CA). Quality of life (QoL) scores were assessed before RALP, after urethral catheter removal, and at the 1^st month after RALP used by SF-12 QoL questionnaire. Patients without urine leakage during coughing or sneezing, as well as those who stayed totally dry, were considered as continent. Those who used more than 1 protective pad per day and/or had urine leakage during coughing, sneezing, or during the night were considered incontinent.

RESULTS:

The mean operation time, docking time, and anastomosis time were 76.9±28.9, 7.2±2.2, and 18±3.1 min, respectively. Estimated blood loss was 51.6±22.9 ml. The mean hospital stay was 2.2±0.8 days. The mean duration of the catheter was 7.1±1.3 days. After catheter removal, 310 (93.6%) of patients were continent immediately. During follow-up, 318 (96%) were continent after 1 month and 329 (99.3%) were totally continent after 1 year. No patient received surgical treatment for stress incontinence.

CONCLUSION:

Since we have defined bladder neck sparing technique, we have realized that our technique is very effective with our long-term results. Our novel technique provided very early continence at the time of catheter removal after RALP within short-term follow-up in addition to favorable oncologic results.

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.

The effect of proliferative hypertrophic scars on determining treatment options for preventing recurrence of vesicourethral anastomotic stenosis after radical prostatectomy: a single-center cross-sectional study

BACKGROUND

Vesicourethral anastomotic stenosis (VUAS) following retropubic radical prostatectomy (RRP) significantly worsens quality of life.

OBJECTIVES

To investigate the relationship between proliferative hypertrophic scar formation and VUAS, and predict more appropriate surgical intervention for preventing recurrent VUAS.

DESIGN AND SETTING

Retrospective cross-sectional single-center study on data covering January 2009 to December 2019.

METHODS

Among 573 male patients who underwent RRP due to prostate cancer, 80 with VUAS were included. They were divided into two groups according to VUAS treatment method: dilatation using Amplatz renal dilators (39 patients); or endoscopic bladder neck incision/resection (41 patients). The Vancouver scar scale (VSS) was used to evaluate the characteristics of scars that occurred for any reason before development of VUAS.

RESULTS

Over a median follow-up of 72 months (range 12-105) after RRP, 17 patients (21.3%) had recurrence of VUAS. Although the treatment success rates were similar (79.5% versus 78.0%; P = 0.875), receiver operating characteristic (ROC) curve analysis indicated that dilatation using Amplatz dilators rather than endoscopic bladder neck incision/resection in patients with VSS scores 4, 5 and 6 may significantly reduce VUAS recurrence. A strong positive relationship was observed between VSS and total number of VUAS occurrences (r: 0.689; P < 0.001). VSS score (odds ratio, OR: 5.380; P < 0.001) and time until occurrence of VUAS (OR: 1.628; P = 0.008) were the most significant predictors for VUAS recurrence.

CONCLUSIONS

VSS score can be used as a prediction tool for choosing more appropriate surgical intervention, for preventing recurrent VUAS.

Subsphincteric Anastomosis During Laparoscopic Robot-Assisted Radical Prostatectomy and Its Positive Impact on Continence Recovery

Introduction: To assess the interest of a new sphincter preserving anastomosis technique for continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods: We performed a monocentric single-operator study on 187 consecutive RALP. Patients were divided into two groups: Group 1 (standard anastomosis, until December 2017) and Group 2 (subsphincteric anastomosis [SSA], since January 2018). The SSA consisted in respecting the sphincteric sleeve during the anastomosis suturing only the internal layer of the urethra with the bladder and thereby avoiding the loss of sphincteric length induced by the suture. Pre-, intra-, and postoperative data were prospectively collected and compared. Criteria of continence were as follows: no pad use and complete absence of leakage at catheter removal at 1 month and 1 year.

Results: The two groups were comparable in terms of prostate-specific antigen, gland volume, and Gleason score. In Group 2 (SSA), we observed a complete continence recovery in 75.6% at catheter removal (p = 0.0000035), in 82.9% at 1 month (p = 0.000092), and in 97.5% at 1 year (p = 0.028), independently of bladder neck preservation (p = 0.388). There was also a significant difference between the two groups concerning urinary reeducation requirement (p = 0.0006), pad use, and urinary quality of life (p = 0.0000002). No anastomosis complication was reported.

Conclusions: The SSA significantly improved the rates of immediate, early, and 1-year continence recovery after RALP. These results need further study among larger numbers of patients.