EUROPEAN UROLOGY 59 (2011) 72 80

Transcription

1 EUROPEAN UROLOGY 59 (2011) available at journal homepage: Surgery in Motion Influence of Modified Posterior Reconstruction of the Rhabdosphincter on Early Recovery of Continence and Anastomotic Leakage Rates after Robot-Assisted Radical Prostatectomy Rafael F. Coelho a,b,c, Sanket Chauhan a,c, Marcelo A. Orvieto a,c, Ananthakrishnan Sivaraman a,c, Kenneth J. Palmer a,c, Geoff Coughlin a,c, Vipul R. Patel a,c, * a Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA b Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Divisão de Urologia, São Paulo, Brazil c University of Central Florida School of Medicine, Orlando, Florida, USA Article info Article history: Accepted August 12, 2010 Published online ahead of print on August 20, 2010 Keywords: Prostate cancer Prostatectomy Robotics Urinary continence Outcome Please visit and to view the accompanying video. Abstract Background: Posterior reconstruction (PR) of the rhabdosphincter has been previously described during retropubic radical prostatectomy, and shorter times to return of urinary continence were reported using this technical modification. This technique has also been applied during robot-assisted radical prostatectomy (RARP); however, contradictory results have been reported. Objective: We describe here a modified technique for PR of the rhabdosphincter during RARP and report its impact on early recovery of urinary continence and on cystographic leakage rates. Design, setting, and participants: We analyzed 803 consecutive patients who underwent RARP by a single surgeon over a 12-mo period: 330 without performing PR and 473 with PR. Surgical procedure: The reconstruction was performed using two 6-in 3-0 Poliglecaprone sutures tied together. The free edge of the remaining Denonvillier s fascia was identified after prostatectomy and approximated to the posterior aspect of the rhabdosphincter and the posterior median raphe using one arm of the continuous suture. The second layer of the reconstruction was then performed with the other arm of the suture, approximating the posterior lip of the bladder neck and vesicoprostatic muscle to the posterior urethral edge. Measurements: Continence rates were assessed with a self-administrated, validated questionnaire (Expanded Prostate Cancer Index Composite) at 1, 4, 12, and 24 wk after catheter removal. Continence was defined as the use of no absorbent pads. Cystogram was performed in all patients on postoperative day 4 or 5 before catheter removal. Results and limitations: There was no significant difference between the groups with respect to patient age, body mass index, prostate-specific antigen levels, prostate weight, American Urological Association symptom score, estimated blood loss, operative time, number of nerve-sparing procedures, and days with catheter. In the PR group, the continence rates at 1, 4, 12, and 24 wk postoperatively were 22.7%, 42.7%, 91.8%, and 96.3%, respectively; inthenon-pr group, thecontinencerateswere 28.7%, 51.6%, 91.1%, and97%, respectively. Themodified PRtechniqueresulted insignificantly higher continenceratesat 1and4 wkafter catheter removal ( p = and 0.016, respectively), although the continence rates at 12 and 24 wk were not significantly affected ( p = and p = 0.741, respectively). The median interval to recovery of continence was also statistically significantly shorter in the PR group (median: 4 wk; 95% confidence interval [CI]: ) when compared to the non-pr group (median: 6 wk; 95% CI: ; log-rank test, p = 0.037). Finally, the incidence of cystographic leaks was lower in the PR group (0.4% vs 2.1%; p = 0.036). Although the patients baseline characteristics were similar between the groups, the patients were not preoperatively randomized and unknown confounding factors may have influenced the results. Conclusions: Our modified PR combines the benefits of early recovery of continence reported with the original PR technique with a reinforced watertight closure of the posterior anastomotic wall. Shorter interval to recovery of continence and lower incidence of cystographic leaks were demonstrated with our PR technique when compared to RARP with no reconstruction. # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. 410 Celebration Place, Ste 200, Celebration, FL 34747, USA. Tel address: Vipul.patel.md@flhosp.org (V.R. Patel) /$ see back matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 EUROPEAN UROLOGY 59 (2011) Introduction Excellent continence outcomes have been consistently reported after robot-assisted radical prostatectomy (RARP): the 1-yr continence rate reaches >90% in most of the large, single-center, prospective studies [1,2]. However, the early recovery of urinary continence remains a challenge. Reports on early continence differ widely, likely secondary to the lack of a standardized surgical technique, varied surgical experience, and discrepancies in the definition and assessment of urinary continence. Consequently, several technical modifications have been recently described in an attempt to improve early return of continence after radical prostatectomy (RP), including bladder neck preservation [3], incorporation of the striate urethral sphincter to the anastomosis [4], puboprostatic ligament sparing [5], tubularization of the bladder neck [6], and posterior reconstruction (PR) of the rhabdosphincter [7,8]. Among these techniques, PR is currently the most widely adopted by the highest-volume RARP centers. The PR technique, as described by Rocco and colleagues [7,8], consists of a two-step reconstruction with apposition of rhabdosphincter to the remaining Denonvillier s fascia (first step) followed by fixation of the Denonvillier s fascia median raphe complex to the posterior bladder neck (second step). The purpose of the reconstruction is to avoid caudal retraction of the sphincteric complex, preserving the urethra in its anatomic and functional position in the pelvic floor. Shorter time to recovery of urinary continence was reported by Rocco et al [7,8] in an open RP series when compared to a historical control group. The technique was subsequently reported by the same authors during laparoscopic RP, and similar improvement on early recovery of urinary continence was shown [9]. The PR technique recently has been applied during RARP with several technical modifications and inconsistent results [10 18]. The only randomized trial evaluating continence outcomes after reconstruction of the periprostatic tissues during RARP showed no improvement in early continence rates. Notwithstanding, the authors have noticed a secondary benefit of this technique in decreasing the anastomotic leak rates [12]. Nevertheless, the technique described in this study was different from the twostep reconstruction originally reported by Rocco et al [7 9]. We describe here a modified technique for PR of the rhabdosphincter during RARP and report its impact on early recovery of urinary continence and on cystographic leakage rates. 2. Materials and methods We analyzed 803 consecutive patients who underwent RARP over a 12-mo period: 330 without performing PR and 473 with PR. The data were prospectively collected in a customized database and retrospectively analyzed. All the procedures were performed by a single surgeon (VRP). Our ethics committee approved the prospective collection of the data and all patients provided written informed consent. The characteristics of patients included in the study are shown in Table 1. Continence rates were assessed with the self-administrated validated Expanded Prostate Cancer Index Composite (EPIC) questionnaire [19] at 1, 4, 12, and 24 wk after catheter removal. The questionnaire was administered either at the follow-up office visit or via . The definition of continence was based on patients responses to the questionnaire item selected to reflect the range of incontinence severity (ie, How many pads or adult diapers per day did you usually use to control leakage during the last 4 weeks? ). Continence was defined as the use of no pads. The number of weeks after catheter removal until continence was recovered was also assessed and recorded Surgical technique All cases were carried out using a transperitoneal six-port technique, as described by the authors previously [20]. An anterior approach was adopted by dissecting the Retzius space and ligating the dorsal venous complex. A periurethral suspension stitch was then placed [21] in all patients. This step was followed by bladder neck dissection and athermal mobilization of the seminal vesicles. A nerve-sparing (NS) procedure was performed, as a rule, in patients with ct1 ct2a prostate cancer, biopsy Gleason score 7, and preoperative Sexual Health Inventory for Men (SHIM) score >21. In selected patients with Gleason score 8 and small tumor volume, a NS procedure was also performed. The NS was modified and performed athermally with an early retrograde release of the neurovascular bundle [22]. In the PR group, a modified PR technique was carried out prior to vesicourethral anastomosis. The reconstruction was performed using two 3-0 Poliglecaprone sutures (on RB-1 needles) tied together, with each individual length being 12 cm. Ten knots were placed when tying the sutures to provide a bolster. The free edge of the remaining Denonvillier s fascia was identified after the prostatectomy and approximated to the posterior aspect of the rhabdosphincter and the posterior median raphe using one arm of the continuous suture. As a rule, four passes are taken from the right to the left and the suture is tied Table 1 Patients baseline characteristics Patients characteristics Without reconstruction Posterior reconstruction p value Patients, n Age, yr, median (IQR) 61 (57 67) 61 (55 66) BMI, kg/m 2, median (IQR) 28 (25 30) 28 (26 31) PSA level, ng/ml, median (IQR) 5 ( ) 4.9 ( ) AUA-SS, median (IQR) 6 (3 12) 7(3 12) Biopsy Gleason score, No. (%) (55.6) 279 (58.9) (36.3) 157 (33.2) 8 27 (8.1) 37 (7.9) IQR = interquartile range; BMI = body mass index; PSA = prostate-specific antigen; AUA-SS = American Urological Association symptom score.

3 74 [(Fig._1)TD$FIG] EUROPEAN UROLOGY 59 (2011) [(Fig._2)TD$FIG] Fig. 2 (A) Second layer of posterior reconstruction. (B) The posterior lip of the bladder neck and vesicoprostatic muscle are sutured to the posterior urethral edge. Fig. 1 (A) First layer of posterior reconstruction. (B) The free edge of the remaining Denonvillier s fascia is approximated to the posterior aspect of the rhabdosphincter. (Fig. 1A B). The second layer of the reconstruction was then performed with the other arm of the suture approximating the posterior lip of the bladder neck (full thickness) and the vesicoprostatic muscle, as describedbywalzetal[23], to the posterior urethral edge and to the already reconstructed median raphe (Fig. 2A B). This suture was then tied to the end of the first suture arm. One of the key steps for an appropriate reconstruction is the preservation of the Denonvillier s fascia when dissecting the posterior plane between the prostate and the rectal wall. If this dissection is performed at the perirectal fat tissue, the Denonvillier s fascia is usually not adequately spared, precluding PR. The anastomosis was performed in a similar fashion in both groups, using another two 20-cm 3-0 monocryl sutures tied together. The posterior aspect of the anastomosis was performed in a clockwise direction starting at the 5 o clock position and ending at 10 o clock. The anterior aspect of the anastomosis was then performed with the second arm of the suture in a counterclockwise direction and both sutures were tied together at the 10 o clock position. A Jackson-Pratt drain was positioned in the pelvic gutter.

4 EUROPEAN UROLOGY 59 (2011) Table 2 Perioperative parameters Perioperative parameters Without reconstruction Posterior reconstruction p value Patients, n Operative time, min, median (IQR) 75 (65 90) 75 (75 80) Estimated blood loss, ml, median (IQR) 100 ( ) 100 ( ) No. days with catheter, median (IQR) 5 (4 6) 5 (4 6) Radiologic leakage, No. (%) 7 (2.1) 2 (0.42) Urinary retention, No. (%) 3 (0.9) 3 (0.63) Overall complication rate *, No. (%) 19 (5.7) 26 (5.5) Nerve-sparing procedure, No. (%) Bilateral nerve sparing 211 (64) 318 (67.2) Unilateral nerve sparing 56 (17) 73 (15.5) Non nerve sparing 63 (19) 82 (17.3) IQR = interquartile range. * Complications within 30 d of surgery Diagnosis of anastomotic leakage Cystogram was performed in all patients on postoperative day 4 or 5. Up to 200 ml of contrast media was instilled into the bladder with gravity. Films were taken with anteroposterior and oblique views allowing identification of possible anastomotic leaks posterior to the bladder. A postdrainage film was also obtained for complete evaluation of contrast extravasation. The films were reviewed by a radiologist and by the surgeon prior to catheter removal. In the event of identifying a urinary leakage, the catheter was left in place for an additional 3 7 d and the cystogram repeated to rule out persistent leakage. Urinary retention was managed similarly with prolonged catheter drainage until the patient was able to completely empty the bladder Statistical analysis The two groups were statistically compared for patient age, body mass index (BMI), preoperative prostate-specific antigen (PSA) levels, prostate weight, American Urological Association symptom score (AUA-SS), biopsy Gleason score, pathologic stage, positive surgical margins (PSM), estimated blood loss, operative time, blood transfusion rates, number of days with catheter, number of NS procedures, and continence rates. To compare the numerical variables, student t test or the Mann-Whitney rank sum test was used. To compare categorical variables, the chi-square test or the Fisher exact test was used. To compare the interval before the return of urinary continence we used the Kaplan-Meier method and the log-rank test to analyze the differences between the curves. Continuous parametric variables were reported as the mean value plus or minus standard deviation. Continuous nonparametric variables were presented as the median values and interquartile range (IQR). The information was processed with Systat v.3.5 (Systat Software Inc, Chicago, IL, USA); statistical significance was defined as p < Results There was no significant difference between the groups with respect to patient s age, BMI, preoperative PSA levels, prostate weight, AUA-SS, and biopsy Gleason score (Table 1). In the non-pr group, 211 (64%) patients underwent a bilateral NS procedure, 56 (17%) a unilateral NS procedure, and 63 (19%) a non-ns procedure. In the PR group, 318 (67.2%) patients underwent a bilateral NS procedure, 73 (15.5%) a unilateral NS procedure, and 82 (17.3%) a non-ns procedure. There was no significant difference between the groups with respect to the number of NS procedures performed ( p = 0.626) (Table 2). The mean operative time, estimated blood loss, blood transfusion rates, mean number of days with urinary catheter, overall complication rates, and postoperative acute urinary retention rates were similar between the groups (Table 2). However, the incidence of cystographic leaks was statistically significantly lower in the PR group (0.4% vs 2.1%; p = 0.036). The two groups had no significant differences in their pathologic stage, in the frequency of PSMs, and in the Gleason score of the surgical specimen (Table 3). In the non- PR group (Group 1), the overall PSM rate was 11% (36 of 330) and the PSM rates in patients with pt2 and pt3 tumors were Table 3 Pathologic stage and positive surgical margin rates Without reconstruction Posterior reconstruction p value Pathologic stage, No. (%) pt2 262 (79.4) 393 (83) 0.19 pt3 68 (20.6) 80 (17) PSM rates, proportion (%) 36/330 (11) 54/473 (11.4) pt2 18/262 (6.8) 28/393 (7.1) pt3 18/63 (28.5) 26/78 (33.3) Gleason score of surgical specimen, No. (%) (35.4) 177 (37.5) (56.3) 274 (58) 8 27 (8.2) 21 (4.5)

5 76 EUROPEAN UROLOGY 59 (2011) [(Fig._3)TD$FIG] Table 4 Continence rates at 1, 4, 12, and 24 weeks after robotassisted radical prostatectomy with and without posterior reconstruction Without reconstruction Posterior reconstruction p value Follow-up time, proportion (%) 1 wk 75/330 (22.7) 136/472 (28.7) wk 141/330 (42.7) 244/472 (51.6) wk 303/330 (91.8) 431/472 (91.1) wk 318 /330 (96.3) 459/472 (97) % (18 of 262) and 28.5% (18 of 63), respectively. In the PR group (Group 2), the overall PSM rate was 11.4% (54 of 473) and the PSM rates in patients with pt2 and pt3 tumors were 7.1% (28 of 393) and 33% (26 of 78), respectively. We received the EPIC questionnaires from all the 473 patients evaluated in the PR group and all the 330 patients in the non-pr group at all time points analyzed. In the non- PR group, the continence rates at 1, 4, 12, and 24 wk after catheter removal were 22.7%, 42.7%, 91.8%, and 96.3%, respectively. In the PR group, the continence rates at 1, 4, 12, and 24 wk after catheter removal were 28.7%, 51.6%, 91.1%, and 97%, respectively. The PR technique resulted in significantly greater continence rates at 1 and 4 wk ( p = and p = 0.016, respectively), although the rates at 12 and 24 wk were not significantly affected (Table 4). The median interval to recovery of continence was statistically significantly shorter in the PR group (median: 4 wk; 95% confidence interval [CI]: ) compared with the non-pr group in the Kaplan-Meier curves (median: 6 wk; 95% CI: ) (log-rank test, p = 0.037) (Fig. 3). 4. Discussion Urinary incontinence following RP is still a major source of morbidity and significant concern for patients with organconfined prostate cancer who desire surgical treatment. Validated questionnaires administered postoperatively demonstrated that urinary incontinence has the greatest impact on patient s quality of life [24]. As a result, a variety of surgical techniques, such as the PR, have been described in the attempt to improve the recovery of urinary continence after RP [3 8]. The PR technique was first reported by Rocco and colleagues in 2001 [7] and this technical modification has since become a common practice during RARP. Nevertheless, multiple variations of the initial technique and conflicting continence outcomes have been reported (Table 5) [10 17]. Nguyen et al [11] compared 32 consecutive patients who underwent RARP with PR to a historical control group of 32 patients who underwent RARP without PR. Continence was assessed by telephone interview and it was defined as the use of no pad or one pad. Additionally, intraoperative transrectal ultrasonography was performed to measure the length of the membranous urethra before and after PR. The continence rates were higher in the PR group at 3 d (34% vs 3%; p = 0.007) and 6 wk after catheter removal (56% vs 17%; p = 0.006); the reconstruction technique restored the length of the transected membranous urethra by a mean of 2 mm, showing the reestablishment of the urinary sphincter in a Fig. 3 Kaplan-Meier curves showing the probability of urinary incontinence after robot-assisted radical prostatectomy, with and without posterior reconstruction of the rhabdosphincter (log-rank test, p = 0.037). more cranial position with the PR technique. Similarly, Tewari et al [10] showed better continence rates with reconstruction of the periprostatic tissues during RARP. These authors described a technique for anterior and posterior reconstruction ( total reconstruction ) during RARP and compared their outcomes with RARP performed with no reconstruction (control group) or with PR only. The total reconstruction technique described included preservation of puboprostatic ligaments and arcus tendineus, posterior reconstruction (as described by Rocco et al [7,8]), and reattachment of the arcus tendineus and puboprostatic plate to the bladder neck after completion of the anastomosis. The total reconstruction group had continence rates of 38%, 83%, 91%, and 97% at 1, 6, 12, and 24 wk after RARP, respectively. At all postoperative intervals analyzed the continence rates were significantly higher in the anterior and total reconstruction groups when compared with the control group. Likewise, our modified technique of PR resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 1 wk (28.7% vs 22.7%; p = 0.045) and 4 wk (51.6% vs 42.7%; p = ) after catheter removal when compared with the control group. An anterior reconstruction technique was also performed in our series: A periurethral suspension stitch, as previously described by the authors [21], was placed in all patients in both groups. We have recently reported improvement in the early continence rates after RARP when using the suspension stitch [22]. However, contrary to Tewari et al [10], the continence rates in our series at 12 wk (91.8% vs 91.1%; p = 0.908) and 24 wk (96.3% vs 97%; p = 0.741) postoperatively were similar between the groups, showing no benefit of our reconstruction technique on the long-term continence rates. By contrast with these results, Menon and colleagues [12] showed, in a prospective randomized trial, no improvement

6 Table 5 Reconstructive techniques during robot-assisted radical prostatectomy: comparative studies evaluating continence outcomes Study Patients, no. Study design Definition of continence Evaluation of continence Continence rates 1 wk, % 1 mo, % 3 mo, % 6 mo, % 12 mo, % Tewari et al [10] 182 TR Historical control No pad usage or small Validated * * 91.3 * * 304 AR liner for security instruments and 27 * 59 * * * * 214 control third-party telephone interview Nguyen et al [11] 32 PR Historical control 0 1 pad Self-administered 34 * (3 d) 56 * (6 wk) 30 no PR questionnaire 3 * (3 d) 17 * (6 wk) Menon et al [12] 57 PR Randomized 0 pad (0 g/d leak) Pad weight recorded 20 (15% day 1) no PR clinical trial by patients 16 (7% day 1) 47 Woo et al [13] 69 PR Historical control 0 1 pad Telephone interview Median time to achieve continence = 90 d * 63 no PR Median time to achieve continence = 150 d Krane et al [14] 42 PR Historical control No pad usage or small Interview with 85 (6 8wk) 42 no PR liner for security physician 86 (6 8wk) Kalisvaart et al [15] 50 PR + susp Historical control No pad usage Self-administered 42 * 50 no reconst questionnaire 20.6 Kim et al [16] 25 PR Historical control No pad usage EPIC questionnaire no PR and interview with physician Joshi et al [17] 53 PR Alternate assignment Any involuntary Physician-administered no PR parallel group study urine loss questionnaire Present study 472 PR Historical control No pad usage Self-administered 28.7 * 51.6 * no PR questionnaire TR = total reconstruction; AR = anterior reconstruction; PR = posterior reconstruction; EPIC = Expanded Prostate Cancer Index Composite. * Statistically significant difference. EUROPEAN UROLOGY 59 (2011)

7 78 EUROPEAN UROLOGY 59 (2011) in the continence rates with reconstruction of the periprostatic tissues. The authors randomized 116 consecutive patients undergoing RARP to urethrovesical anastomosis with (59 patients) or without periprostatic tissue reconstruction (57 patients). A scale was provided to each patient for pad weighing. Using no urinary leakage (0 g or no pads daily) as the definition of continence, 15% and 7%, 14% and 14%, 20% and 16%, and 42% and 47% of patients undergoing RARP with and without reconstruction were continent at 1, 2, 7, and 30 d after surgery, respectively. No statistically significant difference was found between the groups at all time points analyzed. Similarly, Joshi et al recently reported, in an alternate assignment, parallel-group study, no improvement in the continence rates with PR during RARP. One hundred seven consecutive patients undergoing RARP were alternately assigned to PR (n = 53) or control group (n =54). Continence was defined as any involuntary urine loss or pad use and it was assessed with physician-administered questionnaires. No significant differences in the continence rates were reported between the groups at 3 (25% vs 31%; p = 0.391) and 6 mo (49% vs 57%; p = 0.686) after RARP. Variations in the surgical experience and in the techniques described for PR during RARP can explain, at least in part, the disparity of the results reported in the literature. Multiple modifications of the technique initially described by Rocco et al [7,8] have been reported, precluding definitive conclusions regarding the impact of PR on early recovery of continence. In the randomized trial reported by Menon et al [12], for example, the authors only performed the first step of reconstruction originally described. After reconstructing the Denonvillier s fascia and the posterior wall of the striated sphincter, Rocco et al [7,8] also suture the reconstructed sphincter to the posterior bladder wall, fixing the sphincter 1 2 cm dorsocranially to the margin of the bladder neck. This second step is considered by the authors of the utmost importance because it increases the functional length of the posterior urethra, stabilizing the sphincteric complex in its anatomic position in the pelvic floor [25]. Similarly, in the recent study published by Joshi et al [17], only the first step of the reconstruction was performed, suturing the distal cut of the Denonvillier s fascia and the median fibrous raphe to the rhabdosphincter. Therefore, although no improvement in early continence was reported in these two studies, the PR technique employed was different from the original description, precluding accurate comparisons with the results reported by Rocco and colleagues [7 9]. Additionally, in the Menon et al [12] study, the sample size was calculated based on an expected difference of 30% in the continence rates between the groups. Therefore, the study was underpowered for detection of smaller improvements in the continence rates with PR, as shown in our study. Our technique of PR follows the same principles described by Rocco and colleagues, consisting in a two-layer reconstruction of the posterior musculofascial plate. In fact, we initially applied the original Rocco technique to our RARP series [26]. However, we have subsequently modified the second step of the reconstruction: Instead of simply fixing the reconstructed sphincter to the posterior bladder wall, we incorporate the full-thickness of the posterior bladder neck, the vesicoprostatic muscle, and the posterior urethral edge to the second suture line. This posterior wall is then reinforced with another continuous suture during the modified van Velthoven vesicourethal anastomosis. We believe that our technical modification combines the benefits of the Rocco technique (fixing the sphincter in more cranial position in the pelvic floor) with a reinforced watertight closure of the posterior wall of the anastomosis. Additionally, the vesicourethral anastomosis per se is noticeably facilitated by the tension-free approximation of posterior bladder neck to the urethral stump provided by our modified PR technique. As a result, we have shown lower incidence of cystographic leaks in the PR group when compared with the control group (0.4% vs 2.1%; p = 0.036). Similar results were also reported by Menon et al [12], who demonstrated lower anastomotic leak rates when performing reconstruction of the periprostatic tissues during RARP (8.7% vs 3.3%; p < 0.05). Anastomotic urinary leakage has been correlated with delayed recovery of continence after RARP [27], which can also help to explain the improvement on the early continence rates provided by our modified PR technique. We believe that preservation of the periprostatic tissues and urethral length is facilitated by the robotic approach, which can help to explain the more slight improvement in the continence rates with PR during RARP when compared with the original description in an open RP series [7,8]. Nevertheless, although the impact of our reconstruction on early continence was less accentuated, the technique is simple, reproducible, with no increase in operative time, and without any potential harm to patients. Additionally, the vesicourethral anastomosis is clearly facilitated after the PR, which resulted in a significant decrease in the anastomotic leak rates in our series. Finally, since urinary incontinence has a profound impact on patient s healthrelated quality of life [24], any improvement on early continence rates can positively affect patients well being in the postoperative period. The strengths of our study are the large number of patients analyzed in each group, single-surgeon experience, uniform surgical technique, and the use of self-administrated validated questionnaires to evaluate continence serially after RARP. However, our study has some limitations. Our results cannot not be generalized to low-volume RARP centers, since we analyzed continence rates after RARP performed by a single surgeon with large prior surgical experience. Additionally, although the patients baseline characteristics and the perioperative parameters were similar between the groups, the patients were not preoperatively randomized and unknown confounding factors may have influenced the results. Furthermore, a potential temporal bias caused by the evolution of the learning curve should be considered, since we used a historical control group for the comparison. Nevertheless, all procedures were performed by a single surgeon with prior experience of >1500 cases, reducing the effect of learning curve on the outcomes. Finally, although our reconstruction follows the same principles proposed by Rocco and colleagues (a two-step reconstruction of the

8 EUROPEAN UROLOGY 59 (2011) rhabdosphincter), we describe here a modification of the original technique, which precludes direct comparisons with previous series using different techniques. 5. Conclusions Our modified technique for PR of the rhabdosphincter resulted in a statistically significant shorter interval to recovery of continence and higher continence rates at 1 and 4 wk after catheter removal when compared with RARP performed without PR. Lower incidence of cystographic leaks was also observed in the PR group. However, prospective randomized studies using the same technique are necessary before definitive conclusions can be drawn and the results generalized to all urologic surgeons. Author contributions: Vipul R. Patel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Coelho, Patel. Acquisition of data: Coelho, Chauhan. Analysis and interpretation of data: Coelho. Drafting of the manuscript: Coelho. Critical revision of the manuscript for important intellectual content: Orvieto, Palmer, Coughlin, Sivaraman. Statistical analysis: Coelho. Obtaining funding: None. Administrative, technical, or material support: Patel. Supervision: Patel. Other (specify): None. Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/ affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None. Appendix A. Supplementary data The Surgery in Motion video accompanying this article can be found in the online version at doi: / j.eururo and via Subscribers to the printed journal will find the Surgery in Motion DVD enclosed. References [1] Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic, robotassisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol 2009;55: [2] Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel MB, Patel VR. Roboticassisted radical prostatectomy: a review of current outcomes. BJU Int 2009;104: [3] Deliveliotis C, Protogerou V, Alargof E, Varkarakis J. Radical prostatectomy: bladder neck preservation and puboprostatic ligament sparing-effects on continence and positive margins. Urology 2002; 60: [4] Walsh PC, Quinlan DM, Morton RA, Steiner MS. Radical retropubic prostatectomy. Improved anastomosis and urinary continence. Urol Clin North Am 1990;17: [5] Lowe BA. Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study. J Urol 1997;158: [6] Steiner MS, Burnett AL, Brooks JD, Brendler CB, Stutzman RE, Carter HB. Tubularized neourethra following radical retropubic prostatectomy. J Urol 1993;150: [7] Rocco F, Gadda F, Acquati P, et al. Personal research: reconstruction of the urethral striated sphincter. Arch Ital Urol Androl2001;73: [8] Rocco F, Carmignani L, Acquati P, et al. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol 2006;175: [9] Rocco B, Gregori A, Stener S, et al. Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol 2007; 51: [10] Tewari A, Jhaveri J, Rao S, et al. Total reconstruction of the vesicourethral junction. BJU Int 2008;101: [11] Nguyen MM, Kamoi K, Stein RJ, et al. Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int 2008;101: [12] Menon M, Muhletaler F, Campos M, et al. Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol 2008;180: [13] Woo JR, Shikanov S, Zorn KC, Shalhav AL, Zagaja GP. Impact of posterior rhabdosphincter reconstruction during robot-assisted radical prostatectomy: retrospective analysis of time to continence. J Endourol 2009;23: [14] Krane LS, Wambi C, Bhandari A, Stricker HJ. Posterior support for urethrovesical anastomosis in robotic radical prostatectomy: single surgeon analysis. Can J Urol 2009;16: [15] Kalisvaart JF, Osann KE, Finley DS, Ornstein DK. Posterior reconstruction and anterior suspension with single anastomotic suture in robot-assisted laparoscopic radical prostatectomy: a simple method to improve early return of continence. J Robot Surg 2009; 3: [16] Kim IY, Hwang EA, Mmeje C, Ercolani M, Lee DH. Impact of posterior urethral plate repair on continence following robot-assisted laparoscopic radical prostatectomy. Yonsei Med J 2010;51: [17] Joshi N, de Blok W, van Muilekom E, van der Poel H. Impact of posterior musculofascial reconstruction on early continence after robot-assisted laparoscopic radical prostatectomy: results of a prospective parallel group trial. Eur Urol 2010;58:84 9. [18] Stein RJ. The case for posterior musculofascial plate reconstruction in robotic prostatectomy. Urology 2009;74: [19] Wei J, Dunn R, Litwin M, Sandler H, Sanda M. Development and validation of the Expanded Prostate Cancer Index Composite (EPIC) for comprehensive assessment of health-related quality of life in men with prostate cancer. Urology 2000;56: [20] Patel VR, Tully AS, Holmes R, Lindsay J. Robotic radical prostatectomy in the community setting the learning curve and beyond: initial 200 cases. J Urol 2005;174: [21] PatelVR, CoelhoRF, Palmer KJ, RoccoB. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol 2009;56: [22] Coughlin G, Pankaj D, Palmer KJ, et al. Athermal early retrograde release of the neurovascular bundle during nerve-sparing roboticassisted laparoscopic radical prostatectomy. J Robot Surg 2009;1: 13 7.

9 80 EUROPEAN UROLOGY 59 (2011) [23] Walz J, Burnett AL, Costello AJ, et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol 2010;57: [24] Jonler M, Madsen FA, Rhodes PR, Sall M, Messing EM, Bruskewitz RC. A prospective study of quantification of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy. Urology 1996;48: [25] Rocco B, Rocco F. Re: assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol 2009;181: [26] Coughlin G, Dangle PP, Patil NN, et al. Surgery illustrated focus on details. Modified posterior reconstruction of the rhabdosphincter: application to robotic-assisted laparoscopic prostatectomy. BJU Int 2008;102: [27] Patil N, Krane L, Javed K, Williams T, Bhandari M, Menon M. Evaluating and grading cystographic leakage: correlation with clinical outcomes in patients undergoing robotic prostatectomy. BJU Int 2009; 103: