Re: Is It Just Enough to Keep Long Membranous Urethra for Providing Early Continence After Robot-Assisted Laparoscopic Radical Prostatectomy? (From: Haga N, Ogawa S, Yabe M, et al. J Endourol 2015;29:683-690)

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.

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.