Incidence of bladder neck contracture after robot‐assisted laparoscopic and open radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To evaluate the incidence and risk factors for bladder neck contracture (BNC) in men treated with robot‐assisted laparoscopic radical prostatectomy (RALP) and open radical prostatectomy (ORP), as BNC is a well‐described complication of ORP and may be partially attributable to technique.

PATIENTS AND METHODS

The University of California San Francisco Urologic Oncology Database was queried for patients undergoing RALP or ORP from 2002 to 2008. Patient demographics, prostate cancer‐specific information, surgical data, and follow‐up were collected. For each surgical approach, multivariate Cox proportional hazards regression was performed to evaluate associations of demographics and clinical characteristics with BNC. Time to BNC after RP was evaluated using life table and Kaplan–Meier methods.

RESULTS

From 2002 to 2008, 988 patients underwent RP as primary treatment and had at least 12 months of follow‐up. Of these men, 695 underwent ORP and 293 underwent RALP. The mean (sd ) age was 59.3 (6.80) years and 91% of men were Caucasian. D’Amico risk groups at diagnosis were low (38%), intermediate (38%), and high (24%). The BNC incidence was 2.2% (22 cases) overall, 1.4% (four) for RALP, and 2.6% (18) for ORP (P= 0.12). Patients with BNC were diagnosed a median (range) of 4.7 (1–15) months after surgery. At 18 months after surgery, the BNC‐free rate was 97% for ORP and 99% for RALP (log‐rank P= 0.13). The most common presenting complaint was slow stream, followed by urinary retention. In Cox proportional hazards regression analysis, earlier year of surgery, older age at diagnosis and higher PSA level at diagnosis were significantly associated with BNC among ORP patients. In the RALP group, none of the covariates were associated with BNC.

CONCLUSIONS

The overall incidence of BNC was low in both RALP and ORP groups. Technical factors such as enhanced magnification and a running bladder anastomosis may explain the lower BNC incidence in the RALP group.     

Sexual function recovery after robot‐assisted radical prostatectomy: Outcomes from an Italian referral centre and predicting nomogram

Aims of this study were to assess sexual recovery after robotic‐assisted radical prostatectomy (RARP) and to build a nomogram predicting 1‐year sexual function. From May 2015 to July 2016, all patients eligible for RARP at our institution were invited to enter the study. The Expanded Prostate cancer Index Composite (EPIC) questionnaire was administered pre‐operatively, then at 45 days, and at 3, 6, 9, and 12 months post‐operatively. According to sexual function scores, patients were divided into four classes. Multivariate analysis was used to investigate the influence of patient‐ and disease‐related features on sexual recovery. A total of 643 patients were included. Age was associated with baseline potency (p < .0001). Bioptic Gleason score (GS; p = .0002), American Society of Anesthesiologists (ASA) score ( = .002ASA Physical Status Classification System ) and Charlson Comorbidity Index (CCI; p = .02) were negatively associated with potency. Baseline sexual function was associated with potency recovery. A nomogram resulted from fitting a proportional odds logistic model for ordinal outcomes, with 1‐year sexual function as a dependent variable and baseline sexual potency, age, body mass index (BMI), clinical stage, biopsy GS, initial prostate‐specific antigen (iPSA), ASA score, and CCI as predictors. After further validation, this nomogram could be a useful tool for the pre‐operative counselling.     

Age at surgery, educational level and long-term urinary incontinence after radical prostatectomy

Study Type – Harm (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Several factors, including age, body mass index (BMI), prostate size and previous transurethral resection of the prostate, have been suggested to play a part in determining the risk of urinary incontinence after radical prostatectomy. Results relating to the importance of each factor have been conflicting, so we need more data to be able to identify the relevant factors. In this consecutive series, with information from 1179 patients who had undergone radical prostatectomy, age at the time of surgery, educational level, respiratory disease and salvage radiation therapy predicted the occurrence of long‐term urinary incontinence. Increasing age predicted the risk in an exponential manner, and the data indicate a correlation across all educational levels. There was no certain association between previous transurethral resection of the prostate, increased BMI or prostate size and urinary incontinence.

OBJECTIVE

? To identify predictors for long‐term urinary leakage after radical prostatectomy.

PATIENTS AND METHODS

? A consecutive series of 1411 patients who underwent radical prostatectomy (open surgery or robot‐assisted laparoscopic surgery) at Karolinska University Hospital between 2002 and 2006 were invited to complete a study‐specific questionnaire. ? Urinary leakage was defined as use of two or more pads per day.

RESULTS

? Questionnaires were received from 1288 (91%) patients with a median follow‐up of 2.2 years. Age at surgery predicts in an exponential manner long‐term urinary incontinence at follow‐up with an estimated relative increase of 6% per year. ? Among the oldest patients, 19% had urinary incontinence compared with 6% in the youngest age group, translating to a prevalence ratio of 2.4 (95% confidence interval [CI], 1.5–8.1). ? Low educational level, as compared with high, yielded an increased age‐adjusted prevalence ratio of 2.5 (95% CI, 1.7–3.9). ? Patients who had undergone salvage radiation therapy had an increased prevalence of urinary incontinence (2.5; 95% CI, 1.6–3.8), as did those with respiratory disease (2.4; 95% CI, 1.3–4.4). ? Body mass index, prostate weight, presence of diabetes or previous transurethral resection did not appear to influence the prevalence of urinary incontinence.

CONCLUSIONS

? In this series, a patient’s age at radical prostatectomy influenced, in an exponential manner, his risk of long‐term urinary incontinence. ? Other predictors are low educational level, salvage radiation therapy and respiratory disease. ? Intervention studies are needed to understand if these data are relevant to the prevalence of urinary leakage if a radical prostatectomy is postponed in an active monitoring programme.     

Suture versus staple ligation of the dorsal venous complex during robot‐assisted laparoscopic radical prostatectomy

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVES

To present our operative and postoperative functional outcomes of sutured compared with endovascular staple ligation of the dorsal venous complex (DVC) during robot‐assisted laparoscopic radical prostatectomy (RALP). Ligation of the DVC during RALP with an endovascular stapler has purported advantages of decreased apical positive surgical margin (PSM) rate, blood loss, and operative time when compared with suture ligation.

PATIENTS AND METHODS

In all, 162 patients who underwent RALP between October 2005 and April 2008 by one surgeon (R.B.N.) were assessed. We retrospectively analysed two different treatment groups: group 1 underwent DVC ligation with a single suture, while group 2 underwent endovascular staple ligation.

RESULTS

Of the 162 patients evaluated, 67 had suture ligation (group 1) and 95 had staple ligation (group 2) of the DVC. Baseline patient characteristics (age, body mass index, biopsy Gleason score, clinical stage) and tumour characteristics (specimen weight, tumour volume, pathological Gleason score and stage) did not differ between the groups. Estimated blood loss (494 mL vs 288 mL), time to dissect out, ligate and transect the DVC (30 min vs 24 min), apical PSM rate (13.4% vs 2.1%) differed significantly between groups 1 and 2 respectively, favouring staple ligation of the DVC. At 6 months follow‐up, there was no difference between the groups for PSA recurrence (3.7% vs 0%), complete continence (63.4% vs 55.7%) and Sexual Health Inventory for Men score (8.4 vs 8.6).

CONCLUSIONS

In the present study, staple ligation of the DVC during RALP resulted in improved apical PSM rates, faster operative times and less blood loss.     

Quantitative assessment of fascia preservation improves the prediction of membranous urethral length and inner levator distance on continence outcome after robot‐assisted radical prostatectomy

Aims

To determine whether preoperative prostate/pelvic anatomical structures and intraoperative fascia preservation (FP) predict continence recovery after robot‐assisted radical prostatectomy (RARP).

Methods

Between January 2012 and March 2016, 439 prostate cancer (PCa) patients with normal preoperative continence were retrospectively included. FP score was defined as the extent of FP from base to apex of the prostate, quantitatively assessed by the surgeon. Anatomical prostate structures were measured on endorectal preoperative Magnetic Resonance Imaging. The International Consultation on Incontinence Questionnaire‐Short Form (ICIQ‐SF) was used to assess urinary incontinence (UI). Cox analysis was used to determine predictive factors for early continence recovery. Finally a binary logistic regression analysis was performed to develop a risk calculator.

Results

At a median follow up of 12.1 months 50.8% of men reported UI. In the Cox multivariate analysis longer membranous urethral length (MUL; P < 0.0001; OR 1.309; CI 1.211, 1.415) and shorter inner levator distance (ILD; P < 0.0001; OR 0.904; CI 0.85, 0.961) were predictors of earlier continence recovery. In the multivariate binary logistic regression analysis longer MUL (P < 0.0001; OR 1.565, CI 1.362, 1.798), shorter ILD (P < 0.0001; OR 0.819, CI 0.742, 0.904) and higher FP score (P = 0.024; OR 1.089, CI 1.011, 1.172) were independent predictors of continence outcome. The risk calculator predicted continence recovery between 1.3% and 99%.

Conclusions

Preoperative longer MUL and shorter ILD, but also intraoperative FP independently improve continence recovery after RARP. The risk calculator could be used to identify patients at high risk of UI.     

A prospective,non‐randomized trial comparing robot‐assisted laparoscopic and retropubic radical prostatectomy in one European institution

OBJECTIVE

To compare the functional results of two contemporary series of patients with clinically localized prostate cancer treated by robot‐assisted laparoscopic prostatectomy (RALP) or retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

This was a non‐randomized prospective comparative study of all patients undergoing RALP or RRP for clinically localized prostate cancer at our institution from February 2006 to April 2007.

RESULTS

We enrolled 105 patients in the RRP and 103 in the RALP group; the two groups were comparable for all clinical and pathological variables, except median age. For RRP and RALP the respective median operative duration was 135 and 185 min (P < 0.001), the intraoperative blood loss 500 and 300 mL (P < 0.001) and postoperative transfusion rates 14% and 1.9% (P < 0.01). There were complications in 9.7% and 10.4% of the patients (P = 0.854) after RRP and RALP, respectively; the positive surgical margin rates in pT2 cancers were 12.2% and 11.7% (P = 0.70). For urinary continence, 41% of patients having RRP and 68.9% of those having RALP were continent at catheter removal (P < 0.001). The 12‐month continence rates were 88% after RRP and 97% after RALP (P = 0.01), with the mean time to continence being 75 and 25 days (P < 0.001), respectively. At the 12‐month follow‐up, 20 of 41 patients having bilateral nerve‐sparing RRP (49%) and 52 of 64 having bilateral nerve‐sparing RALP (81%) (P < 0.001) had recovery of erectile function.

CONCLUSIONS

RALP offers better results than RRP in terms of urinary continence and erectile function recovery, with similar positive surgical margin rates.     

Late‐onset incontinence in a cohort of radical prostatectomy patients

A cohort of 235 subjects, who underwent radical prostatectomy from 1994 to 2002, completely continent at the 2‐year follow up and with the last follow‐up visit in 2009, was examined to assess incidence and risk factors of late‐onset incontinence. Median follow up was 100 months, range 84–176. At the last follow‐up visit, 209 (89%) maintained continence, and 26 (11%) became incontinent. Specifically 14 out of 26 (6%) used one pad and 12 (5%) used two or more pads daily. Incidence of age ≥65 years at radical prostatectomy was greater in the subgroup who developed late incontinence, 109/209 (52%) vs 19/26 (73%). Incidence of adjuvant or salvage radiotherapy, of hormonal manipulation and of extraprostatic disease was similar in the two subgroups. Univariate and multivariate analysis did not disclose any difference. Late‐onset incontinence is to be expected in about 10% of subjects who became completely continent after radical prostatectomy. The cause is likely to be related to ageing. Patients should be informed about the long‐term risk of becoming incontinent.