The Powerful Impact of Double-Layered Posterior Rhabdosphincter Reconstruction on Early Recovery of Urinary Continence After Robot-Assisted Radical Prostatectomy

Comparison of Retzius-Sparing Robot-Assisted Radical Prostatectomy vs. Conventional Robot-Assisted Radical Prostatectomy: An Up-to-Date Meta-Analysis

Background: The Retzius space-sparing robot-assisted radical prostatectomy (RS-RARP) has shown better results in urinary continence, but its efficacy and safety compared to conventional robot-assisted radical prostatectomy (c-RARP) remain controversial.

Material and Methods: A research was conducted in Medline via PubMed, Cochrane Library, EMBASE, and Web of Science up to January 4, 2021, to identify studies comparing RS-RARP to c-RARP. We used RevMan 5.3 and STATA 14.0 for meta-analysis.

Results: A total of 14 studies involving 3,129 participants were included. Meta-analysis showed no significant difference in positive surgical margins (PSMs), but the RS-RARP group had significantly higher PSM rates in the anterior site [odds ratio (OR) = 2.25, 95% CI: 1.22–4.16, P = 0.01]. Postoperative continence in RS-RARP group at 1 month (OR = 5.72, 95% CI: 3.56–9.19, P < 0.01), 3 months (OR = 6.44, 95% CI: 4.50–9.22, P < 0.01), 6 months (OR = 8.68, 95% CI: 4.01–18.82, P < 0.01), and 12 months (OR = 2.37, 95% CI: 1.20–4.70, P = 0.01) was significantly better than that in the c-RARP group. In addition, the RS-RARP group had a shorter console time (mean difference = −16.28, 95% CI: −27.04 to −5.53, P = 0.003) and a lower incidence of hernia (OR = 0.35, 95% CI: 0.19–0.67, P = 0.001). However, there were no significant differences in estimated blood loss, pelvic lymph node dissection rate, postoperative complications, 1-year-biochemical recurrence rate, and postoperative sexual function.

Conclusions: Compared with c-RARP, RS-RARP showed better recovery of continence, shorter console time, and lower incidence of hernia. Although there was no significant difference in overall PSM, we suggest that the surgeon should be more careful if the lesion is in the anterior prostate.

Patient- and Tumour-related Prognostic Factors for Urinary Incontinence After Radical Prostatectomy for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

While urinary incontinence (UI) commonly occurs after radical prostatectomy (RP), it is unclear what factors increase the risk of UI development.

OBJECTIVE

To perform a systematic review of patient- and tumour-related prognostic factors for post-RP UI. The primary outcome was UI within 3 mo after RP. Secondary outcomes included UI at 3-12 mo and ≥12 mo after RP.

EVIDENCE ACQUISITION

Databases including Medline, EMBASE, and CENTRAL were searched between January 1990 and May 2020. All studies reporting patient- and tumour-related prognostic factors in univariable or multivariable analyses were included. Surgical factors were excluded. Risk of bias (RoB) and confounding assessments were performed using the Quality In Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were performed for all prognostic factor, where possible.

EVIDENCE SYNTHESIS

A total of 119 studies (5 randomised controlled trials, 24 prospective, 88 retrospective, and 2 case-control studies) with 131 379 patients were included. RoB was high for study participation and confounding; moderate to high for statistical analysis, study attrition, and prognostic factor measurement; and low for outcome measurements. Significant prognostic factors for postoperative UI within 3 mo after RP were age (odds ratio [OR] per yearly increase 1.04, 95% confidence interval [CI] 1.03-1.05), membranous urethral length (MUL; OR per 1-mm increase 0.81, 95% CI 0.74-0.88), prostate volume (PV; OR per 1-ml increase 1.005, 95% CI 1.000-1.011), and Charlson comorbidity index (CCI; OR 1.28, 95% CI 1.09-1.50).

CONCLUSIONS

Increasing age, shorter MUL, greater PV, and higher CCI are independent prognostic factors for UI within 3 mo after RP, with all except CCI remaining prognostic at 3-12 mo.

PATIENT SUMMARY

We reviewed the literature to identify patient and disease factors associated with urinary incontinence after surgery for prostate cancer. We found increasing age, larger prostate volume, shorter length of a section of the urethra (membranous urethra), and lower fitness were associated with worse urinary incontinence for the first 3 mo after surgery, with all except lower fitness remaining predictive at 3-12 mo.

No clinical significance of the time interval between biopsy and robotic-assisted radical prostatectomy for patients with clinically localized prostate cancer on biochemical recurrence: a propensity score matching analysis

Purpose

To investigate the impact of the time interval (TI) between prostate biopsy and robot-assisted radical prostatectomy (RARP) on the risk of biochemical recurrence (BCR).

Methods

We retrospectively reviewed the medical records of 793 consecutive patients who were treated with RARP at our institution. Patients were divided into three groups, according to TI, to compare BCR-free survival (BCRFS) rates: Group 1 (n = 196), TI < 3 months; Group 2 (n = 513), 3 ≤ TI < 6 months; Group 3 (n = 84), TI ≥ 6 months. Eighty-three patients with TI ≥ 6 months were matched with an equal number of patients with TI < 6 months based on propensity scores by using four preoperative factors: prostate-specific antigen (PSA), primary (pGS) and secondary (sGS) Gleason score and positive prostate biopsy.

Results

The 5-year BCRFS rates for TI Groups 1, 2, and 3 were 76%, 80.7% and 82.6% (P = 0.99), respectively. The multivariate analysis revealed that PSA, pGS, sGS and a positive prostate biopsy were independent preoperative risk factors for BCR. The propensity adjusted 5-year BCRFS for patients with TI ≥ 6 months was 84.0%. This was not worse than that of patients with TI < 6 months (71.0%, P = 0.18).

Conclusions

In our cohorts, a delay in the time from biopsy to RARP did not significantly affect recurrence. Therefore, hasty treatment decisions are unnecessary for at least 6 months after diagnosis of early prostate cancer.

The Impact of Lateral Bladder Neck Preservation on Urinary Continence Recovery After Robot-Assisted Radical Prostatectomy

OBJECTIVE

Urinary incontinence is one of the most bothersome adversities after robot-assisted radical prostatectomy (RARP). The aim of this study was to investigate the urinary continence recovery and the effect of various surgical techniques.

MATERIALS AND METHODS

We previously reported that posterior rhabdosphincter reconstruction and nerve-sparing were independent predictors of urinary continence recovery 1 month after catheter removal in 199 patients who underwent RARP. Retrospectively, we further reviewed those 199 patients for urinary continence recovery at 3 months or later after RARP. The relationships of urinary continence with perioperative findings, including surgical procedures, were evaluated at 3 to 12 months after RARP. The Fisher exact test and Mann-Whitney rank sum test were used for evaluating variables between the groups. Multivariate logistic regression analysis was performed to investigate the association between urinary continence and perioperative factors.

RESULTS

On univariate analyses, surgeon experience, lateral bladder neck preservation (BNP), anterior reconstruction, and posterior reconstruction were significantly associated with urinary continence recovery 3 months after RARP, but only lateral BNP was independently associated with urinary continence recovery in a multivariate analysis. Similarly, on univariate analyses, surgeon experience, lateral BNP, and posterior reconstruction were significantly associated with continence recovery at 6 months or later after surgery. However, multivariate analyses showed that only lateral BNP was significantly associated with urinary continence recovery 6 months or later after surgery.

CONCLUSION

Although the lateral BNP technique did not affect immediate urinary continence recovery, this procedure was significantly associated with continence recovery 3 months or later after RARP.

Pelvic Floor Reconstruction After Radical Prostatectomy: A Systematic Review and Meta-analysis of Different Surgical Techniques

Radical prostatectomy (RP) is the gold standard for the treatment of localized PCa. A meta-analysis was conducted to evaluate the effect of different techniques of pelvic floor reconstruction on urinary continence. A comprehensive search was made for trials that evaluated the efficacy of pelvic floor reconstruction. Relevant databases included PubMed, Embase, Cochrane, Ovid, Web of Science databases and relevant trials from the references. Random-effects model was used to estimate risk ratios (RRs) statistics. Pooled results of patients treated with posterior reconstruction (PR) demonstrated complete urinary continence improved at 1-4, 28-42, 90, 180 and 360 days following catheter removal. Anterior suspension (AS) was associated with improvement only at 28-42 days. The anterior reconstruction (AR) + PR was associated with urinary continence at 1-4, 90 and 180 days. AS + PR was not associated with any benefit. And PR improved social urinary continence at 7-14 and 28-42 days. No benefit was associated with AS. AR + PR had better outcomes at 90 and 180 days. AS + PR was significant improved at 28-42 and 90 days. Patients who underwent RP and PR had the least urinary incontinence. No significant benefit was observed after AS. AR + PR and AS + PR had little benefit in the post-operative period.

Impact of barbed suture in controlling the dorsal vein complex during laparoscopic radical prostatectomy

OBJECTIVE

To compare applications of unidirectional knotless barbed suture and traditional two single polyglactin sutures for dorsal vein complex (DVC) control during laparoscopic radical prostatectomy (LRP).

MATERIAL AND METHODS

This was a non-randomized, prospective matched-pair pilot study. Thirty-one LRP cases with barbed suture (V-Loc®) were match-paired with 31 LRP cases in which traditional two single polyglactin stitches according to patient's prostate volume and body mass index (BMI) were used. Time needed for DVC ligation, DVC control and operation time were recorded. Peri- and postoperative parameters were noted. Statistical analyses were performed.

RESULTS

Mean age was 65.4±6.3 years. Mean follow-up was 20.2±3.3 months. Mean BMI and prostate volume were similar in both groups. Mean preoperative clinical stage, Gleason score, and PSA were comparable between both groups. Mean DVC ligature time and mean DVC controlling time in group 1 were statistically shorter than in group 2 (p=0.04, p<0.001). Continence rates were significantly higher in group 1 than in group 2 in early follow-up (p=0.005).

Current techniques to improve outcomes for early return of urinary continence following robot-assisted radical prostatectomy

Although open retropubic radical prostatectomy has been the most commonly used surgical technique for patients with localized prostate cancer for decades, robot-assisted radical prostatectomy (RARP) has recently become an alternative option and widely used in Japan as well as around the world. RARP has been shown to have higher postoperative continent rates than retropubic and laparoscopic radical prostatectomy; however, urinary incontinence has remained one of the most significant causes for concern among patients who seek surgical treatment for prostate cancer, even after the introduction of RARP. The literature has shown that certain technical modifications to improve urinary continence are advocated as potential aids to reduce the risk of urinary incontinence after RARP. These modifications might be divided into 3 categories to realize the improvement of early return of urinary continence after RARP: 1) preservation, 2) reconstruction, and 3) reinforcement of the anatomic structures in the pelvis, which will make a new supporting system after radical prostatectomy. In this review, we discuss the intraoperative techniques to improve outcomes for early return of urinary continence following RARP, and provide a critical summary of current knowledge on its outcome in the literature.