What is the long-term relevance of clinically detected postoperative anastomotic urine leakage after robotic-assisted laparoscopic prostatectomy?

Clinical significance and risk factors of urethrovesical anastomotic urinary leakage following robot-assisted radical prostatectomy: a multi-institutional study

Background

There has been a limited number of reports on the significance and risk factors of urethrovesical anastomotic urinary leakage (AUL) following robot-assisted radical prostatectomy (RARP). We aimed to analyze the clinical significance of AUL and evaluated its risk factors.

Methods

We conducted a multi-institutional study to review patients with prostate cancer undergoing RARP in three centers (The University of Tokyo Hospital, Mitsui Memorial Hospital, and Chiba Tokushukai Hospital). “Positive AUL” was defined as urinary extravasation at the anastomosis detected by post-operative cystogram and was further categorized into minor or major AUL. Univariate and multivariate analyses were performed to identify predictors of AUL. Postoperative continence rates and time to achieve continence were also analyzed.

Results

A total of 942 patients underwent RARP for prostate cancer in 3 centers. Of these patients, a cystogram after the RARP procedure was not performed in 26 patients leaving 916 patients for the final analysis. AUL was observed in 56 patients (6.1%); 34 patients (3.7%) with minor AUL and 22 patients (2.4%) with major AUL. Patients with major AUL exhibited a significantly longer time to achieve continence than those without major AUL. Multivariate analysis demonstrated that longer console time (≥ 184 min) was significantly associated with overall AUL, and higher body mass index (≥ 25 g/kg²) was a significant predictor of both major and overall AUL.

Conclusions

The presence of major AUL was associated with the achievement of urinary continence, suggesting clinical relevance of its diagnosis by postoperative cystogram. A selective cystogram has been proposed for high-risk cases. Furthermore, identification of the risk factors of AUL will lead to optimal application.

Bladder Neck Contracture Following Radical Retropubic versus Robotic-Assisted Laparoscopic Prostatectomy

INTRODUCTION

Radical retropubic prostatectomy (RRP) and robotic-assisted laparoscopic prostatectomy (RALP) are co-standard surgical therapies for localized prostatic adenocarcinoma. These surgical modalities offer similar outcomes; however, lower rate of bladder neck contracture (BNC) is amongst the touted benefits of RALP. The differences between approaches are largely elucidated through multiple-surgeon comparisons, which can be biased by differential experience and practice patterns. We aimed to eliminate inter-surgeon bias through this single-surgeon comparison of BNC rates following RRP and RALP.

MATERIALS AND METHODS

We retrospectively reviewed all RRPs and RALPs performed by one surgeon over 4 years. We compared clinical characteristics, intraoperative and postoperative outcomes.

RESULTS

RRP patients had more advanced cancer and a higher biochemical recurrence rate. No significant differences were noted between groups in rates of anastomotic leakage, BNC, or 12-month postoperative pad-free continence.

CONCLUSION

RRP offers similar outcomes to RALP with regard to postoperative urinary extravasation, urinary continence, and BNC.

The Single-Knot Running Vesicourethral Anastomosis after Minimally Invasive Prostatectomy: Review of the Technique and Its Modifications, Tips, and Pitfalls

The vesicourethral anastomosis represents a step of major difficulty at the end of minimally invasive radical prostatectomy. Over 10 years ago, we have devised the single-knot running vesicourethral anastomosis, which has been widely adopted in urologic departments worldwide. Aim of the current paper is to review the technique, its adaptability in complex situations, its complications, and possible modifications, including the use of barbed sutures.

Effect of Bladder Neck Preservation and Posterior Urethral Reconstruction during Robot-Assisted Laparoscopic Radical Prostatectomy for Urinary Continence

PURPOSE

To report our results on urinary continence after bladder neck preservation (BNP) and posterior urethral reconstruction (PUR) during robot-assisted laparoscopic radical prostatectomy (RALP).

MATERIALS AND METHODS

Data from 107 patients who underwent RALP were compared on the basis of whether the patients underwent BNP and PUR, BNP only, or the standard technique (ST). In group A (n=31 patients), ST was performed by using Ven velthoven continuous suturing for urethrovesical anastomosis. In group B (n=28 patients), ST with only PUR was performed. In group C (n=48 patients), both the BNP and PUR techniques were used. "Recovery of continence" was defined as the use of 1 pad (50 ml) or less within 24 hours.

RESULTS

The three groups were comparable in terms of patient demographics. The mean operative time and the mean blood loss decreased significantly from group A to group C (p=0.021 for mean operative time and p=0.004 for the mean blood loss). Mean catheterization time was 8.9, 7.8, and 7.1 days in each group (p=0.047). Early return of urinary continence at 3 months was observed in group B (89.2%) and group C (90.6%) compared with group A (71%). However, continence at 6 months was comparable in the 3 groups (87.5% in group A, 92.8% in group B, and 92.3% in group C). Rates of positive surgical margins decreased from 30.2% in group A to 20% in group B and 12% in group C.

CONCLUSIONS

BNP and PUR during RALP showed a favorable impact on the early postoperative recovery of continence while not affecting positive surgical margins.