Evaluating post radical prostatectomy mechanisms of early continence

Retzius-sparing vs. posterior urethral suspension: similar early-phase post-robotic radical prostatectomy continence outcomes

Stress urinary incontinence (SUI) is a risk of robotic-assisted radical prostatectomy (RP) which can be a frustrating problem for both surgeons and patients. We aim to compare short-term continence outcomes between patients undergoing Retzius Sparing RP (RS-RP) and those undergoing standard RP with the inclusion of a PUS suture technique and suprapubic tube (PUS-RP). A retrospective review of 105 consecutive patients who underwent RP was performed, comparing patients who underwent RS-RP and PUS-RP. Our main outcome was pad usage as a surrogate for SUI. Patients were evaluated 4 weeks following RP and again at approximately 3 months. Continence was defined as no pad usage or up to one safety pad per day. Risk factors associated with not being continent were identified using univariate and multivariate analyses. In our cohort, 52 patients underwent RS-RP and 53 patients underwent PUS-RP. The two groups had similar patient demographics. Although not statistically significant, there was a higher rate of a positive surgical margin in the RS-RP compared to PUS-RP (25% vs 15%, p = 0.204). At one month follow-up for PUS-RP and RS-RP, there was no significant difference in the frequency of continent men (69.2% vs. 76.9%, p = 0.302). At 3-month follow-up for the two groups of patients, again, there was no significant difference in the frequency of continence for PUS-RP and RS-RP (86.2% vs 88%, p = 0.824). Patients who underwent RS-RP had similar rates of continence to those patients undergoing PUS-RP in the short-term post-operative period.

Predictors of Early Continence After Single-port Transvesical Robot-assisted Radical Prostatectomy

OBJECTIVE

To identify the factors associated with a short time of return to continence.

METHODS

We analyzed the first 110 SP TV RARP consecutive cases performed by one surgeon from 2020 to 2022. Continence was defined as zero to one safety pad. Two statistical analyses were done. First, patients were divided: group A (n = 62) included individuals who achieved continence within the initial week postcatheter removal; group B (n = 48) rest of the patients. Descriptive statistics were compared, followed by logistic regression for independent variables. Second, time to continence was analyzed as a continuous variable employing linear regression. The primary outcomes were the independent variables significantly associated with a short time to continence.

RESULTS

All cases were completed successfully, without additional ports or conversions. Median urinary catheter duration and time to continence were 3 and 3.5days, respectively. Patients achieving continence within 1week significantly presented with fewer preoperative urinary tract symptoms, lower prostate-specific antigen levels, and had smaller specimen weights postoperatively. Multivariable logistic regression established low specimen weight as the sole significant factor (P = .04). Furthermore, linear regression demonstrated that alterations in independent variables accounted for 12.7% of the variance in time to continence (P = .62).

CONCLUSION

The regionalization of surgery to the bladder employing a retropubic space-sparing extraperitoneal approach during SP TV RARP contributes to a fast return to continence. According to our model, the factors that significantly predict a shorter time to continence include lower preoperative International Prostate Symptom Score, prostate-specific antigen, and postoperative specimen weight.

Comparative study of each surgical step in radical prostatectomy under 3D and 2D laparoscopy

Objective

Comparing the specific advantages and surgical outcomes of each step in radical prostatectomy under 3D vs. 2D laparoscopy.

Methods

From October 2019 to January 2023, our urology department treated 63 cases of prostate cancer, using an odd-even arrangement method to divide into two groups. This is a non-randomized prospective study, with 33 odd-numbered cases in the 3D group and 30 even-numbered cases in the 2D group. The surgery was divided into four steps: (1) establishing an extraperitoneal pneumoperitoneum (2) pelvic lymph node dissection (3)excising the prostate (4)bladder-urethral anastomosis, comparing the two groups in terms of surgical time, blood loss, and relevant postoperative indicators for each step.

Results

All 63 surgeries were successfully completed without any conversions. Comparing 3D and 2D laparoscopy groups, there were statistically significant differences in total surgery time (123.5 ± 15.3 min vs. 145.6 ± 17.2 min, P < 0.05), total blood loss (198.3 ± 18.4 ml vs. 243.1 ± 20.1 ml, P < 0.05), prostate excision time (55.1 ± 8.4 min vs. 67.2 ± 9.3 min, P < 0.05) and blood loss (101.6 ± 12.2 ml vs. 123.8 ± 14.1 ml, P < 0.05), bladder-urethral anastomosis time (30.5 ± 4.3 min vs. 37.6 ± 5.1 min, P < 0.05) and blood loss (62.7 ± 9.7 ml vs. 82.5 ± 8.2 ml, P < 0.05). There were no statistical differences in the time and blood loss during the establishment of extraperitoneal pneumoperitoneum and the cleaning of pelvic lymph nodes (P > 0.05). In terms of urinary incontinence rates, the 3D laparoscopy group was lower than the 2D group, and in terms of preserving erectile function, the 3D group was higher than the 2D group, with significant statistical differences (P < 0.05). There were no statistically significant differences between the two groups in terms of postoperative drainage days, hospitalization days, hospitalization costs, time of catheter removaland positive margin rates (P > 0.05).

Conclusion

Compared to traditional 2D laparoscopy, 3D laparoscopy can shorten the operation time and reduce bleeding in the steps of prostate excision and bladder-urethral anastomosis, but there was no significant difference in peri-operative outcomes.

Combination of deep learning and ensemble machine learning using intraoperative video images strongly predicts recovery of urinary continence after robot-assisted radical prostatectomy

BACKGROUND

We recently reported the importance of deep learning (DL) of pelvic magnetic resonance imaging in predicting the degree of urinary incontinence (UI) following robot-assisted radical prostatectomy (RARP). However, our results were limited because the prediction accuracy was approximately 70%.

AIM

To develop a more precise prediction model that can inform patients about UI recovery post-RARP surgery using a DL model based on intraoperative video images.

METHODS AND RESULTS

The study cohort comprised of 101 patients with localized prostate cancer undergoing RARP. Three snapshots from intraoperative video recordings showing the pelvic cavity (prior to bladder neck incision, immediately following prostate removal, and after vesicourethral anastomosis) were evaluated, including pre- and intraoperative parameters. We evaluated the DL model plus simple or ensemble machine learning (ML), and the area under the receiver operating characteristic curve (AUC) was analyzed through sensitivity and specificity. Of 101, 64 and 37 patients demonstrated "early continence (using 0 or 1 safety pad at 3 months post-RARP)" and "late continence (others)," respectively, at 3 months postoperatively. The combination of DL and simple ML using intraoperative video snapshots with clinicopathological parameters had a notably high performance (AUC, 0.683-0.749) to predict early recovery from UI after surgery. Furthermore, combining DL with ensemble artificial neural network using intraoperative video snapshots had the highest performance (AUC, 0.882; sensitivity, 92.2%; specificity, 78.4%; overall accuracy, 85.3%) to predict early recovery from post-RARP incontinence, with similar results by internal validation. The addition of clinicopathological parameters showed no additive effects for each analysis using DL, EL and simple ML.

CONCLUSION

Our findings suggest that the DL algorithm with intraoperative video imaging is a reliable method for informing patients about the severity of their recovery from UI after RARP, although it is not clear if our methods are reproducible for predicting long-term UI and pad-free continence.

Efficacy of the transvesical approach for robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision for the treatment of localized prostate cancer

Objective

This study explores the feasibility and safety of the transvesical approach of robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision.

Methods

From June 2017 to May 2021, 41 patients aged from 51 to 69 years underwent the transvesical approach of robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision (L-RALP). The prostate volume was 22.0-57.8 ml (mean: 36.3 ± 11.1 ml), with a preoperative PSA value of 3.7-12.3 ng/ml (mean: 7.3 ± 1.2 ng/mL). All preoperative Gleason scores were less than or equal to 7 points, and the preoperative TNM stage ranged from T2a to T2b. All patients were diagnosed with prostate cancer by preoperative prostate biopsy or postoperative pathological specimens after prostatectomy. The operation, blood loss, hospitalization, erectile function and postoperative urinary continence were recorded. Patients were defined as continent if they answered "zero pad" per day, and they were invited to fill out The International Consultation on Incontinence Questionnaire (ICI-Q-SF) after the catheter removal at 4 and 24 weeks.

Results

All the operations were completed by robotic-assisted radical prostatectomy without transition to open surgery. The surgery time was 105-131 min (mean: 111.3 ± 14.9 min), with an estimated blood loss of 50-220 ml (mean: 95.5 ± 27.3 ml). The postoperative hospital stay was 3-8 days (mean: 5.2 ± 1.7 days), and the postoperative catheter was removed after 5-7 days (mean: 6.3 ± 1.1 days). After 24 weeks of follow-up, 35 cases (85.4%, 35/41) obtained immediate urinary continence after the catheter removal in 24h. All patients had regained continence 24 weeks postoperatively (100%, 41/41).

Conclusion

The transvesical approach of robotic-assisted radical prostatectomy via a bladder neck and prostate combined longitudinal incision is a safe and effective surgical technique, beneficial for early continence recovery and erectile function, and it is also suitable for prostate cancer patients after prostate enucleation.

Sustainable functional urethral reconstruction improves early urinary continence after robot-assisted radical prostatectomy: a randomised controlled trial

OBJECTIVE

To evaluate the impact of sustainable functional urethral reconstruction (SFUR) on early recovery of urinary continence (UC) after robot-assisted radical prostatectomy.

PATIENTS AND METHODS

Overall, 96 patients with primary prostate cancer were randomised into the SFUR or standard group (n = 48 each). The primary outcome was the 1-month UC recovery. Secondary outcomes included short-term (≤3 months) UC recovery, urinary function, micturition-related bother, perioperative complications, and oncological outcomes. Kaplan-Meier curves and Cox proportional hazard models were used to assess the 3-month UC recovery. Generalised estimating equations were used to compare postoperative urinary function and micturition-related bother.

RESULTS

The 1-month UC recovery rates, median 24-h pad weights, and median operative time in the SFUR and standard groups were 73% and 49% (P = 0.017), 0 and 47 g (P = 0.001), and 125 and 103 min (P = 0.025), respectively. The UC recovery rates in the SFUR vs standard groups were 53% vs 23% at 1 week (P = 0.003), 53% vs 32% at 2 weeks (P = 0.038), and 93% vs 77% at 3 months (P = 0.025). The median time to UC recovery in the SFUR and standard groups was 5 and 34 days, respectively (log-rank P = 0.006); multivariable Cox regression supported this result (hazard ratio 1.73, 95% confidence interval 1.08-2.79, P = 0.024). Similar results were observed when UC was defined as 0 pads/day. Urinary function (P = 0.2) and micturition-related bother (P = 0.8) were similar at all follow-up intervals. The perioperative complication rates, positive surgical margin rates, and 1-year biochemical recurrence-free survival were comparable between both groups (all P > 0.05).

CONCLUSION

SFUR resulted in earlier UC recovery without compromising postoperative urinary function. Long-term validation and multicentre studies are required to confirm the results of this novel technique.