Combined bladder neck preservation and posterior musculofascial reconstruction during robotic assisted radical prostatectomy: effects on early and long term urinary continence recovery

Retrotrigonal Layer Dissection from a Posterior Approach Enables Bladder Neck Preservation in Robot-Assisted Radical Prostatectomy

BACKGROUND

We developed a novel surgical technique: dissection of the retrotrigonal layer from a posterior approach in robot-assisted radical prostatectomy (RARP). This approach enables earlier access to the posterior space during bladder neck dissection and helps preserve the bladder neck. We evaluated the safety and efficacy of this technique in terms of bladder neck preservation Methods: We retrospectively reviewed 238 consecutive patients who underwent RARP using this technique from August 2021 to September 2023. Key metrics included the success rate of accessing the posterior space prior to bladder neck opening during the dissection and the rate of bladder neck preservation. In addition, oncological and surgical safety, as well as continence recovery, were assessed.

RESULTS

The median age and prostate-specific antigen level were 72 (65-75) years and 7.35 (5.40-11.5) ng/mL, respectively. In 153 (64%) patients, the posterior space was successfully accessed before bladder neck opening, with the success rate increasing from 56% in the series' first half to 72% in the second half (p = 0.015). The bladder neck was preserved in 120 (53%) patients, and this rate increased from 39% in the first half to 63% in the second half (p = 0.0004). Positive surgical margins at the junction between the prostate and bladder were observed in 10 cases (4%). Bladder neck preservation correlated with early continence recovery (hazard ratio 1.37 [95% confidence interval 1.03-1.83], p = 0.030). The grade 3 complication associated with this technique occurred in one case (0.5%).

CONCLUSION

Retrotrigonal layer dissection from a posterior approach in RARP enhances the safety and ease of bladder neck dissection and aids in its preservation, potentially leading to improved continence recovery.

Variations in predictors for urinary continence recovery at different time periods following robot-assisted radical prostatectomy

INTRODUCTION

Urinary dysfunctions are common sequelae following prostatectomy. This study aimed to discover factors that can predict urinary continence recovery at various time periods after robot-assisted laparoscopic radical prostatectomy (RARP).

METHODS

This was a retrospective analysis of data of 419 consecutive patients. Only patients followed up for ≥1 year were enrolled. An answer of "zero pad per day" in the Expanded Prostate Cancer Index Composite urinary assessment (question 5) denoted continence. Possible predictors of urinary continence recovery were evaluated at 3, 3-6, and 6-12 months after the operation.

RESULTS

Continence rates at 3, 6, and 12 months after RARP were 12.9%, 21.2%, and 40.2%, respectively. The proportions of patients using 0-1 pad were 54.2%, 75.7%, and 83.1% at 3, 6, and 12 months after RARP, respectively. Multivariable regression analysis revealed that a membranous urethral length (MUL) ≥11 mm was significantly associated with urinary continence recovery both within 3 months (odds ratio: 0.367, P = .003) and 3-6 months (odds ratio: 0.354, P = .001) after RARP. The analysis also revealed that, in patients with urinary continence at 6 months, a large prostate volume (odds ratio: 1.973, P = .044) and a high body mass index (odds ratio: 2.874, P = .027) were negative predictors of urinary continence recovery within 6-12 months.

CONCLUSION

A longer MUL was linked to urinary continence recovery within 6 months following RARP, whereas a large prostate volume and a high body mass index were adverse predictors of urinary continence recovery beyond 6 months.

The development and assessment of a predicting nomogram for the recovery of immediate urinary continence following laparoscopic radical prostatectomy

Purpose

This study aimed to develop a nomogram to predict the recovery of immediate urinary continence in laparoscopic radical prostatectomy (LRP) patients.

Methods

A prediction model was developed based on a dataset of 154 LRP patients. Immediate urinary continence was defined as free from using pads within 7 days after the removal of the urinary catheter. The least absolute shrinkage and selection operator regression (LASSO) model was applied to screen the features. Multivariate logistic regression analysis was used to establish prediction model integrating the features selected from the LASSO regression analysis. Receiver operating curve (ROC), calibration and decision curve analysis (DCA) were used to assess the model's discrimination, calibration and clinical utility.

Results

The identified features of the prediction model included age, body mass index (BMI) and three pelvic anatomic parameters measured by MRI: membranous urethral length (MUL), intravesical prostatic protrusion length (IPPL) and puborectalis muscle width (PMW). The nomogram showed good discrimination with an are under the curve(AUC) of 0.914 (95% CI, 0.865-0.959, p < 0.001). Moreover, good calibration was showed in the model. Lastly, DCA showed that the nomogram was clinically useful.

Conclusion

The developed novel nomogram that can predict the possibility for post-prostatectomy patients to recover immediate urinary continence could be used as a counseling tool to explain urinary incontinence to patients after LRP.

Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy

Radical prostatectomy directly affects urinary continence dynamics with incontinence being a major factor in patients’ quality of life, social and psychological status. In order to help maintain continence after robot-assisted radical prostatectomy (RARP), a number of surgical techniques have been described. In the present narrative review, we summarize the surgical techniques that have been applied during RARP and their effects on incontinence rates and time to continence recovery.

Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy

Radical prostatectomy directly affects urinary continence dynamics with incontinence being a major factor in patients' quality of life, social and psychological status. In order to help maintain continence after robot-assisted radical prostatectomy (RARP), a number of surgical techniques have been described. In the present narrative review, we summarize the surgical techniques that have been applied during RARP and their effects on incontinence rates and time to continence recovery.

Characteristics of urodynamic study parameters associated with intermediate-term continence after robot-assisted radical prostatectomy in elderly patients

PURPOSE

To investigate the relationship between urodynamic study (UDS) data and recovery of urinary incontinence (UI) in elderly patients who underwent robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

Seventy-five prostate cancer (PCa) patients received UDS before and at 3 months after RARP. They were divided into two groups; a younger group (<70 years old, n = 47) and older group (≥70 years, n = 28), and each was classified according to urinary continence (UC) or UI at 3 months post-RARP. Continence was defined as being pad-free or 1-safety pad usage per day.

RESULTS

In the older group, preoperative maximum urethral closure pressure (MUCP) in the UI group was significantly lower than that in the UC group. Detrusor overactivity (DO) rate was significantly higher in the older UI group than in the older UC group at both pre- and 3 months post-RARP. Persistent DO rate pre- and post-RARP was significantly higher in the older group than in the younger group. Regardless of age, postoperative DO was an independent predictor of UI 6 months post-RARP.

CONCLUSIONS

In elderly patients, low preoperative MUCP and both pre- and postoperative DO are associated with postoperative UI.

Identifying the relationship between postoperative urinary continence and residual urethra stump measurements in robot assisted radical prostatectomy patients

OBJECTIVE

To investigate the feasibility of urethral stump length and width measurements in recorded videos of robot assisted radical prostatectomy procedures using the Kinovea software and to assess if these measurements could be used as predictors of postoperative urinary continence.

METHODS

Fifty-three patients were selected from an institutional database of 1400 cases and included in the study. All videos were analysed using the computer software 'Kinovea'. All measurements were performed using the inserted bladder catheter as a reference point.

RESULTS

The reference point (bladder catheter) was available in 33 out of 53 patients. The median surgical urethral length (SUL) was significantly higher in the continent group (1050 vs. 1294 mm, p = 0.018). The urethral width measurements did not show a difference between the groups. In order to validate the Kinovea software as an accurate tool for the measurement of the urethral stump length and width results were correlated with the magnetic resonance imaging measurements of the urethra.

CONCLUSIONS

The results of this study showed a significantly longer median SUL incontinent patients.

Impact of Preoperative Magnetic Resonance Imaging Anatomic Features on Urinary Continence Recovery after Laparoscopic Radical Prostatectomy

PURPOSE

To evaluate the impact of preoperative magnetic resonance imaging anatomic features on urinary continence recovery after laparoscopic radical prostatectomy (LRP).

METHODS

We retrospectively analyzed 150 consecutive prostate cancer patients who underwent LRP between July 2015 and June 2018 in our institution. Patients reporting freedom from using safety pad (0 pads/day) were defined as urinary continent. We evaluated the association of urinary continence recovery after LRP and the perioperative variables, including age, prostatic volume (PV), intravesical prostatic protrusion length (IPPL), membranous urethral length (MUL), and neurovascular bundle (NVB) sparing status. Kaplan-Meier and log-rank tests were used to compare urinary continence rates between groups. Univariate and multivariate Cox proportional hazards regression analyses were used to identify independent predictors for urinary continence recovery.

RESULTS

60.6% (91/150), 83.3% (125/150), and 96.0% (144/150) of the patients experienced urinary continence recovery at 3, 6, and 12 months, respectively. There was significant difference in PV, IPPL, MUL, and NVB sparing between groups stratified by urinary continence status at 3, 6, and 12 months. Kaplan-Meier curves of urinary continence rates showed significant differences between groups stratified by PV (<50 mL vs. ≥50 mL, p < 0.001), IPPL (<5 mm vs. ≥5 mm, p < 0.001), MUL (≥15 mm vs. <15 mm, p < 0.001), and NVB sparing status (yes vs. no, p = 0.003), respectively. On univariate analysis, PV, IPPL, MUL, and NVB sparing were significantly associated with urinary continence recovery (all, p < 0.05). On multivariate analysis, only IPPL (HR = 0.94, p = 0.003) and MUL (HR = 1.10, p < 0.001) were independent predictors for urinary continence recovery.

CONCLUSION

Patients with larger IPPL and shorter MUL have higher chances of delayed recovery of urinary continence after LRP. IPPL and MUL were reliable morphometric parameters for predicting urinary continence.

Anatomical, surgical and technical factors influencing continence after radical prostatectomy

Radical prostatectomy (RP) is the most frequent treatment with curative intent performed for prostate cancer to date. Different surgical approaches (perineal, transperitoneal, and extraperitoneal) and techniques (laparoscopic and robot assisted) have been described to increase the efficiency and potentially diminish the postoperative complications of this procedure. The aim of this narrative review is to investigate and define the factors that influence postprostatectomy urinary continence. We highlighted the anatomical landmarks and the modifications of surgical techniques aimed at improving the continence rates and thus, patient quality of life. After RP, the long-term continence rates range from 84% to 97%. In order to achieve good continence rates, a careful dissection along with meticulous anatomical reconstruction is required. To this end, a detailed knowledge of the periprostatic anatomy is mandatory.

Transurethral resection of the prostate with preservation of the bladder neck decreases postoperative retrograde ejaculation

Introduction

Even though transurethral resection of the prostate (TURP) is the standard surgical treatment for benign prostatic hyperplasia (BPH), there is a high rate of postoperative retrograde ejaculation.

Aim

To evaluate the effectiveness of TURP with preservation of the bladder neck in comparison with that of standard TURP.

Material and methods

This is a retrospective study. 137 men with BPH were divided into two groups: TURP with preservation of the bladder neck and standard TURP were performed respectively in group A and group B. The patients were evaluated preoperatively and at 3, 6 and 12 months after surgery by International Prostate Symptom Score (IPSS), health-related quality of life (HRQL) score, maximum urinary flow rate (Qmax), postvoid residual urine volume (PVR) and the rate of complications including retrograde ejaculation.

Results

There was no statistically significant difference between groups in terms of the operative duration, catheterization period, hemoglobin decrease, and hospital stay. At the 3-month follow-up, the rates of incontinence and retrograde ejaculation in group A were lower than those in group B. At the 6- and 12-month follow-ups, the difference in the frequency of retrograde ejaculation remained constantly stable whereas the incontinence rates were similar in both groups. The IPSS, HRQL score, Qmax, PVR and the rate of complications including hematuria, clot retention, urinary tract infection, urethral stricture, and bladder neck contracture evaluated at 3, 6 and 12 months also displayed a very similar response in the two groups.

Conclusions

Comparable with standard TURP, TURP with preservation of the bladder neck appears to provide a satisfactory clinical outcome in decreasing early postoperative incontinence and lowering the rate of retrograde ejaculation.