Preservation of Lateral Prostatic Fascia is Associated with Urine Continence after Robotic-Assisted Prostatectomy

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1 european urology 55 (2009) available at journal homepage: Prostate Cancer Preservation of Lateral Prostatic Fascia is Associated with Urine Continence after Robotic-Assisted Prostatectomy Henk G. van der Poel *, Willem de Blok, Neil Joshi, Eric van Muilekom Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands Article info Article history: Accepted January 13, 2009 Published online ahead of print on January 21, 2009 Keywords: Prostate cancer Prostatectomy Urine incontinence Quality of life Abstract Background: Among several clinical factors, nerve or prostatic fascia preservation is associated with an improved continence outcome in several studies. Objective: We study the clinical aspects associated with urine continence after prostatectomy, paying special attention to the extent and location of fascia preservation. Design, setting, and participants: European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core 30 (QLQ-C30) and Prostate Cancer Module (PR25) questionnaires were used to evaluate quality-of-life (QoL) parameters prior to and at 6 and 12 mo after surgery for 151 men treated with robotassisted laparoscopic prostatectomy (RALP) for localised prostate cancer. Fascia preservation was scored at 12 locations around the circumference of the prostate. Any involuntary urine loss showed a strong correlation with several domains of the EORTC QLQ-C30 and was therefore chosen as the definition of urine incontinence. Intervention: Robot-assisted laparoscopic prostatectomy (RALP). Measurements: Any urine incontinence. Results and limitations: Of the preoperative and intraoperative characteristics, a low fascia preservation (FP) score and a higher score for preoperative voiding complaints (EORTC QLQ-P25 domain 1) were associated with an increased risk of urine incontinence and pad use at 6 and 12 mo postoperatively. In the multivariate binary logistic regression analysis, the extent of fascia preservation at the lateral aspects of the prostate as assessed by the FP score was the best predictor of urine continence at 6 and 12 mo postoperatively. The odds ratio for urine incontinence in men with preservation of the lateral prostatic fascia was (95% CI, ) and (95% CI, ) for preservation at the right and left aspects, respectively. This is a retrospective analysis not containing pad-test data. Conclusions: Fascia preservation at the lateral aspect of the prostate was the best predictor of urine continence after RALP. These data suggest that preservation of fascial support lateral rather than dorsolateral to the urethra and prostate may protect neurovascular structures important to improving postprostatectomy urine continence. # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. Tel ; Fax: address: h.vd.poel@nki.nl (H.G. van der Poel) /$ see back matter # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 55 (2009) Introduction Urine incontinence is one of the most feared complications of prostatectomy. Although definitions of postoperative urine incontinence vary among studies, everybody who performs prostatectomy knows that patients generally experience increased urine loss in a variety of conditions. The cause and risk factors of this reduced ability of the pelvic musculature to support urine continence is only partly understood. Preoperative urethral length assessed by magnetic resonance imaging (MRI) predicted earlier continence recovery [1,2]. Urodynamic and urethral pressure evaluation showed that the postprostatectomy urethral maximum closing pressure correlated with urine continence and was markedly reduced in incontinent men [3,4]. These findings suggest that both anatomic and functional changes are associated with postprostatectomy continence. Of clinical factors that have been associated with postprostatectomy urine incontinence, reduced nerve or fascia preservation was identified as one of the independent predictors in a variety of prostatectomy approaches, including open retropubic, perineal, and laparoscopic techniques [5 9]. Since it is unclear which anatomical structures relevant to urine continence are protected by an attempted nerve-sparing prostatectomy, we will refer to fascia preservation when an attempt of potency preservation is made by preserving structures surrounding the prostate. The extent of fascia preservation has changed over time. Initially, Walsh and Donker defined the tissue at the dorsolateral site of the prostate as the major area important for nerve preservation [10]. In this approach, unilateral fascia preservation dorsolaterally to the prostate improved urine continence compared to no fascia preservation but was inferior to bilateral preservation [5,11]. Fasciapreserving prostatectomy was shown to improve both the time interval to regain continence as well as long-term urine continence rates [5]. Withthe advent of laparoscopic and robot-assisted prostatectomy techniques, the so-called veil of Aphrodite principle of nerve preservation was introduced by Mani Menon [12]. Recently, we showed that a simple intraoperative scoring system for the extent of fascia preservation was strongly correlated with questionnaire-assessed postoperative erectile function [13]. Thus, retrospective analyses show that more extensive fascia preservation during prostatectomy increases the chance of postoperative urine continence. It remains unclear how fascia preservation improves postoperative continence. Urethral sphincter innervation is closely related to the prostate apex [14 16] and is often found to be adversely affected in men with postprostatectomy incontinence [11]. Urine continence varies widely among studies and showed no convincing improvement with novel surgical approaches such as laparoscopy or robot assistance. To improve on postprostatectomy continence, it therefore remains pivotal to study which prostate fascia areas are associated with urethral innervation and support for improved continence. To further the understanding of the role of fascia preservation in postprostatectomy urine continence, we will focus on the functional consequences of the extent and location of fascia preservation [13] in comparison to other clinical factors for their predictive value of any involuntary urine loss and quality of life (QoL). 2. Materials and methods Robot-assisted laparoscopic prostatectomy (RALP) was performed in 151 men for localised prostate cancer. All men were diagnosed with prostate cancer by transrectal ultrasound (TRUS) guided biopsies at least 6 wk prior to surgery. Men with earlier transurethral resection of the prostate were excluded. A transperitoneal robot-assisted prostatectomy was performed using the da Vinci S surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA) by a single surgeon (HvdP). Prostate volume had no bearing on the use of fascia preservation. No cauterisation was used for dissection of the distal parts of the prostatic fascia and prostate apex. After ligation of the Santorini plexus with a figure-of-8 vicryl 3-0 stitch at the level of the prostatic apex, the plexus was transected with cold scissors and the prostate apex and proximal urethra were dissected from the pelvic floor. The urethra was coldly transected at the level of the apex. After prostate removal, the extent of achieved fascia preservation was scored perioperatively by the surgeon (Fig. 1) as described earlier (Fig. 2) [13]. The fascia preservation (FP) score was the sum of the number of locations the prostatic fascia was preserved (Fig. 1). At 12 circumferential segments of the prostate, the continuity of fascia preservation from base to apex was scored. When fascia was preserved, it was scored as 1 (vs 0). A maximum score of 12 indicated bilateral maximal FP. Lateral preservation was defined as FP at positions R2, R3 or L2, L3. Ventral preservation was defined as FP at positions R1, R2 or L1, L2. In addition, fascia preservation was scored by side as 0 (no FP, n = 15), 1 (unilateral FP, n = 63), or 2 (bilateral FP, n = 73). FP was performed on those sides where fewer than two biopsies contained cancer with a Gleason sum score of, at most, 6. In the majority of cases, this meant that lateral preservation of the prostatic fascia was only possible when the dorsolateral aspects were preserved. In 0.7% and 2.1% of

3 894 european urology 55 (2009) Fig. 1 Intraoperative view of the urethral dissection and the extent of lateral fascia preservation: (A) Both left and right lateral fascia preserved, (B) no lateral fascia preservation, or (C) unilateral, left fascia preservation. cases, lateral fascia at position 3 could be preserved in men where dorsolateral preservation (position 5) was not possible on the right and left side of the prostate, respectively. FP scores for men with positive and negative surgical margins were not significantly different (5.3 vs 5.1). All men filled out the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core 30 Fig. 2 Fascia preservation (FP) score scheme. The example shows preservation of L5 and L6 only, with a total FP score of 2.

4 european urology 55 (2009) (QLQ-C30) and Prostate Cancer Module (PR25) questionnaires prior to surgery and at 6 and 12 mo postoperatively. Men were followed every 3 mo for the first 2 yr after surgery, and diaper use was recorded at these visits as 0 (no diaper use), 1 (one diaper used per 24 h), or 2 (more than one diaper used per 24 h). Return to baseline for QoL domains was defined as a domain score equal to or higher than the preoperative score or as a symptom score equal to or lower than the preoperative score for EORTC QLC-C30 and PR25 domains. For statistical analysis, Fisher exact test and the binary logistic regression analysis function of SPSS v.15.1 was used. The significance level was set at 5%. 3. Results 3.1. Urine incontinence and quality of life Follow-up data at 6 and 12 mo were available for all men. For men not reporting any urine incontinence at 6 mo, >80% returned to baseline score for all the QoL domains. Men with urine incontinence at 6 mo were significantly less likely to return to baseline score for physical and role functioning, fatigue, financial difficulties, and global health status (Table 1). At 12 mo, the EORTC QLQ-C30 score for Table 1 Association of patient demographics and quality of life (QoL) domains in the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and urine incontinence 6 mo postoperatively y Continent men Incontinent men p-value (n = 81) (n = 70) Mean (SD) Age (yr) 59.9 (5.7) 60.1 (5.7) Preoperative PSA (ng/ml) 9.2 (5.0) 10.5 (7.5) Prostate size (cm 3 ) 44.3 (23.0) 41.8 (18.5) BMI (kg/m 2 ) 26.3 (2.9) 26.2 (3.0) OR time (min) 135 (42) 128 (60) Blood loss (cm 3 ) 288 (301) 226 (245) FP score 6.4 (3.3) 4.4 (3.3) Mean Gleason sum score 6.5 (1.3) 6.8 (1.8) No. Nerve sparing No 6 12 Unilateral Bilateral pt T0 1 T T T4 2 5 % Positive surgical margin rate EORTC QLQ-C30 domains % returning to baseline 1. Physical functioning * 93% 71% Role functioning * 91% 75% Dyspnoea 91% 83% Pain 90% 93% Fatigue * 83% 60% Insomnia 91% 88% Appetite loss 100% 97% Nausea and vomiting 98% 93% Constipation 98% 90% Diarrhoea 95% 94% Cognitive functioning 81% 75% Emotional functioning 91% 86% Social functioning 98% 91% Financial difficulties * 97% 84% Global health status * 83% 60% PSA = prostate-specific antigen; BMI = body mass index; OR = operating room; FP = fascia preservation. * p < y For each domain, patients returning to baseline were compared with men not returning to their preoperative QoL domain level for the presence of urine continence. Statistical analysis was done by t test for means and by Fisher exact test.

5 896 european urology 55 (2009) fatigue was the only domain less likely to return to baseline in men complaining of any involuntary urine loss. Any involuntary urine loss showed a strong correlation with several domains of the EORTC QLQ-C30. Interestingly, the use of diapers at 6 mo was not significantly associated with return to baseline for any of the EORTC QLQ-C30 domains. Any urine loss rather than diaper use was therefore chosen as the end point and definition of incontinence Urine incontinence prediction Urine incontinence (any involuntary loss of urine) was reported by 9% of men prior to prostatectomy and 46% and 30% of men at 6 and 12 mo postoperatively, respectively. Severe impact on QoL due to urine loss was not reported prior to prostatectomy, but 7% and 3% of men reported severe impact on QoL due to urine loss at 6 and 12 mo postoperatively, respectively. Of the clinical characteristics studied, the FP score predicted continence at 6 mo. Fascia preservation at the lateral aspects of the prostate was accompanied by the highest incidence of fully continent men (Fig. 3). Further improvement in urine continence after 12 mo could also be predicted by the level of preoperative voiding complaints as assessed by the EORTC QLQ-PR25 domain 1 score. Men with involuntary urine loss after 12 mo had a significantly higher score for preoperative voiding complaints assessed by the EORTC QLQ-PR25 domain 1 score (Fig. 4). Of 14 men complaining of any involuntary urine loss preoperatively, 7 (50%) were dry after 6 mo. No relation was found between the presence of urine loss and age, body mass index, preoperative prostate-specific antigen (PSA), prostate volume, or blood loss during surgery (Table 2) Diaper use Prior to surgery, two (1%) men used diapers for urine incontinence. At 6 and 12 mo postoperatively, 39% and 18% of men, respectively, reported wearing diapers for (occasional) urine incontinence. Diaper use correlated with urine incontinence; however, at 6 and 12 mo, 19% and 28% of men reporting diaper use had no urine loss. The bother score for diaper use as assessed by EORTC QLQ-PR25 question 8 decreased in men at 12 mo when compared to 6 mo postoperatively: Severe bother for the use of diapers was 12% after 6 mo compared to 4% after 12 mo for all men using diapers. At 6 and 12 mo, respectively, 7% and 2% used more than one diaper a day. Fig. 3 Percentage of men with full urine continence at 6 mo for the different fascia preservation (FP) locations for the left and right side of the prostate.

6 european urology 55 (2009) Fig. 4 European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire, Prostate Cancer Module (QLQ-PR25) domain 1 score for lower urinary tract symptoms (LUTS) prior to surgery for continent and incontinent men after 12 mo ( p = 0.001, analysis of variance [ANOVA]). 4. Discussion The extent of fascia preservation was the strongest predictor of postprostatectomy urine continence. Preservation of the lateral aspects of the prostatic fascia largely contributed to the postoperative urine continence. Preservation of the lateral aspects of the prostatic fascia reduced the risk of postoperative urine incontinence at 6 mo by >60%, whereas preservation of the dorsolateral fascia of the prostate was not significantly associated with postoperative urine continence. These findings suggest that not only erectile function but also continence may benefit from more extensive fascia preservation. Exactly how preservation of the lateral aspects of the prostatic fascia contributes to continence remains speculative. A possible explanation may be found in the fact that lateral bundles provide innervation to the urethra. The literature lends clear support to this hypothesis. The innervation of the external urethral sphincter is provided through the pudendal nerve and pelvic hypogastric plexus. Controversy remains on the function of both innervation routes, and the hypothesis that mixed innervation of the proximal urethra is essential for proper external urethral function has been presented [15]. The role of this mixed innervation is supported by recent animal studies. Narayan et al showed small nerve branches from the pudendal nerve reaching the external urethral sphincter just distal to the prostate apex [14]. The pudendal nerve was shown to be important Table 2 Characteristics associated with urine incontinence at 6 and 12 mo in univariate and multivariate binary logistic regression analysis y Univariate Multivariate HR (CI) p HR (CI) p 6mo Age (yr) ( ) BMI (kg/m 2 ) ( ) Prostate size (cm 3 ) ( ) Preoperative PSA (ng/ml) ( ) OR time (min) ( ) Blood loss (cm 3 ) ( ) Nerve sparing * ( ) FP score ( ) ( ) Voiding complaints ( ) mo Age (yr) ( ) BMI (kg/m 2 ) ( ) Prostate size (cm 3 ) ( ) Preoperative PSA (ng/ml) ( ) OR time (min) ( ) Blood loss (cm 3 ) ( ) Nerve sparing * ( ) FP score ( ) ( ) Voiding complaints ( ) ( ) BMI = body mass index; PSA = prostate-specific antigen; OR = operating room; FP = fascia preservation. y To prevent co-linearity, given the strong correlation between nerve sparing and FP score, the former parameter was not included in the multivariate analysis. * Nerve sparing was scored as 0 (none), 1 (unilateral), and 2 (bilateral).

7 898 european urology 55 (2009) for urethral sensory feedback and, via this mechanism, for the activity of the external urethral sphincter during voiding [17]. Impaired membranous urethral sensitivity seemed to be associated with urine incontinence, particularly in patients with occasional urine leakage [18]. Pudendal-related perineal reflexes were found to be unaffected by prostatectomy, whereas autonomic afferent denervation of the membranous urethra mucosa was found in the majority of men (77%), and denervation was more common in men with postoperative urine incontinence (92%) [18]. Besides the pudendal nerve branches, the pelvic nerve branches were found to innervate the inner smooth-muscle layer of the external urethral sphincter [19]. Stimulation of these nerves resulted in a slow increase in urethral pressure that could be sustained over longer periods. Impressive anatomic dissection of the nerve supply of the proximal urethra by Karam et al in the fetus clearly showed that despite the fact that unmyelinated fibers enter the urethral sphincter at the dorsolateral aspects on both sites, the majority of myelinated fibers innervating the deeper layers of the smooth-muscle sphincter originating from the pelvic nerves enter the urethra from the anterolateral aspects [20]. Lateral dissection of the urethra at the level of external striated sphincter may seriously damage both pudendal and pelvic nerve branches to the urethra and thereby impair both maximal urethral closure pressure as well as membranous urethral sensitivity, both affecting postoperative continence. The dissection of a long stump of urethral tissue should therefore be avoided, particularly at the lateral aspects. In light of the innervation of the proximal urethra, it is also interesting to consider the use of so-called median fibrous raphe and urethral suspensions to improve postoperative continence. Although retrospective analyses suggested improvement in early continence [21 23], a recent randomised study could not confirm the benefit [24]. A possible explanation for this lack of efficacy may be found in the fact that the area of the median fibrous raphe is rich in nerve branches to the proximal urethra that may easily be damaged by suspending stitches placed in this area [25]. Local damage to the external urethral sphincter is another explanation for postoperative urine incontinence. In the current series, care is taken not to damage the external urethral sphincter by applying only cold dissection of the prostatic apex. The fact that the majority of men do recover from initial involuntary urine loss within 6 mo suggests that urine incontinence may not be caused by extensive damage to the external urethral sphincter itself but rather to supporting structures and nerves. Other factors found to predict an increased risk of postprostatectomy incontinence were age at surgery [26] and treatment for urethral strictures [27]. Others showed that, despite an initial earlier recovery to continence in younger men, after 12 mo, age was no longer predictive of continence recovery after laparoscopic prostatectomy [28]. Lepor and Kaci [29] were unable to identify factors predicting early continence recovery in a group of 500 men. In our analysis, age was not a predictor of any involuntary urine loss after prostatectomy at either 6 or 12 mo postoperatively. A possible explanation may be the fact that patients selected for surgery were relatively fit. The oldest man in the series was 75 yr, underwent unilateral fascia preservation, and was subsequently free of involuntary urine loss at 6 mo. Lower urinary tract symptoms (LUTS) prior to prostatectomy predicted an increased risk of postoperative urine incontinence according to some investigators [30] but not others [31]. Here, we found a higher incidence of postoperative urine incontinence at 12 mo in men with more preoperative voiding problems as assessed by the EORTC QLQ- PR25 domain 1 score. Within domain 1 (voiding complaints), the strongest predictor of urine incontinence at 12 mo was the presence of preoperative voiding urgency. Urine incontinence per our definition significantly affected QoL in several domains, including global health status, whereas diaper use did not. This again emphasises the importance of multifactorial analysis of urine continence, as was well demonstrated by Menon et al [24]. We chose any involuntary urine loss as our end point, as is justified by our finding that any urine loss rather than diaper use affected many aspects of QoL. The current analysis has several limitations. First, despite the fact that questionnaire data were sampled prospectively, selection of patients for fascia preservation was based on patient factors, and preoperative erectile function may have influenced the extent of preservation. Unfortunately, we envision difficulties in randomisation in a prospective analysis considering the load of evidence for a benefit of more extensive fascia preservation for both erections and continence. Therefore, a retrospective analysis, as presented, may be helpful to identify risk factors for urine incontinence without putting patients at risk. Second, we have no pad-test data. Ideally, the amount of urine leakage could have been better substantiated by such information. The fact that many QoL domains were strongly affected by any urine loss led us to select this as the

8 european urology 55 (2009) definition of incontinence. Third, early questionnaire-based incontinence data prior to 6 mo after the procedure were not available. Since novel suspension procedures may provide improvement of early continence according to some, these methods may have additional benefit in patients at risk; that is, after non fascia preservative surgery. Finally, from these data, it is unclear what the role of fascia preservation is on positive surgical margin rate. It remains essential to score location of margin positivity in correlation to fascia preservation. Unfortunately, data on exact margin location were not available. 5. Conclusions Any urine incontinence, rather than diaper use, predicted a lower rate of return to preoperative level for physical and role functioning, fatigue, financial difficulties, and global health status. Lateral preservation of prostatic fascia improved postprostatectomy urine continence at 6 and 12 mo. Preserving the lateral aspects of the prostatic fascia further improves upon the beneficial effects of dorsolateral fascia preservation on postoperative continence. Anterolateral fascia preservation up to the area of the puboprostatic ligaments showed no further benefit for continence. Author contributions: Henk G. van der Poel 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: van der Poel, de Blok. Acquisition of data: van der Poel, de Blok. Analysis and interpretation of data: van der Poel, de Blok. Drafting of the manuscript: van der Poel, Joshi. Critical revision of the manuscript for important intellectual content: van der Poel, de Blok, Joshi. Statistical analysis: van der Poel, de Blok. Obtaining funding: none. Administrative, technical, or material support: van der Poel, de Blok, van Muilekom. Supervision: van der Poel. 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. References [1] Coakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 2002;168: [2] Nguyen L, Jhaveri J, Tewari A. Surgical technique to overcome anatomical shortcoming: balancing post-prostatectomy continence outcomes of urethral sphincter lengths on preoperative magnetic resonance imaging. 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Neurourol Urodyn 2006;25:2 7. [31] Link RE, Su LM, Sullivan W, Bhayani SB, Pavlovich CP. Health related quality of life before and after laparoscopic radical prostatectomy. J Urol 2005;173: Editorial Comment on: Preservation of Lateral Prostatic Fascia is Associated with Urine Continence after Robotic-Assisted Prostatectomy W. Stuart Reynolds, Scott E. Eggener Section of Urology, Department of Surgery, The University of Chicago Medical Center, 5841 South Maryland Avenue, MC 6038, Chicago, IL 60637, United States seggener@surgery.bsd.uchicago.edu Despite decades of technical innovation, postprostatectomy incontinence (PPI) continues to be a common and troubling occurrence. The exact pathophysiology and predictors of PPI have not been optimally elucidated but clearly involve patient-specific anatomic and neurologic factors that are affected and altered by intraoperative technical decisions. In the present article [1], the authors correlate the degree of lateral periprostatic fascial preservation (FP) the FP score during robotic-assisted prostatectomy with the likelihood of urinary continence following surgery. While attempts to quantify FP may be justifiable and intuitively appealing, there are several concerns regarding this scoring system. First, as with any technical modification, data must provide clear assurance that positive surgical margin and biochemical recurrence rates are not altered. The study is currently underpowered and lacks appropriate follow-up to address such concerns. Second, the reproducibility and validity of the scoring system needs to be confirmed by other investigators. Third, the distinction between FP and nerve sparing remains unclear, and the FP score appears to be a surgeon-determined surrogate for the extent of nerve sparing. Numerous technical modifications have been championed over the years to improve erectile function [2] and urinary continence [3]; however, diligence is required to rigorously study and properly assess these modifications prior to widespread adoption. Without randomization, any technical alteration may simply be a result of surgeon experience rather than the modification itself. In the specific case of posterior urethral reconstruction, for example, initial retrospective studies were promising [4], but the results of a randomized controlled study did not concur [5]. Finally, the ability to predict quality-of-life outcomes is less important if those outcomes cannot be

10 european urology 55 (2009) either effectively prevented or preemptively treated. As such, additional study is needed of the pathophysiology of PPI, and further research is warranted to develop novel treatments, such as stem cell manipulation, that may correct the cascade of abnormalities initiated by the surgery itself. References [1] Van der Poel HG, de Blok W, Joshi N, van Muilekom E. Preservation of lateral prostatic fascia is associated with urine continence after robotic-assisted prostatectomy. Eur Urol 2009;55: [2] Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Euro Urol 2007;51: [3] Tewari A, Jhaveri J, Rao S, et al. Total reconstruction of the vesico-urethral junction. BJU Int 2008;101: [4] 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: [5] Menon M, Muhletaler F, Campos M, Peabody JO. 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: DOI: /j.eururo DOI of original article: /j.eururo Editorial Comment on: Preservation of Lateral Prostatic Fascia is Associated with Urine Continence after Robotic-Assisted Prostatectomy Oliver W. Hakenberg Department of Urology, Rostock University, Ernst-Heydemann-Strasse 6, D Rostock, Germany oliver.hakenberg@med.uni-rostock.de This paper reports an association between postoperative continence function and the extent of prostatic fascia preservation in robot-assisted radical prostatectomy [1]. It is a one-surgeon series in which, in addition to conventional nerve sparing, more prostatic fascia were preserved. The extent of prostatic fascia preservation was visually judged intraoperatively by the surgeon and was graded [1]. This concept is novel and is based on the veil of Aphrodite concept proposed by Menon et al [2]. The presented study, however, has limitations. The concept of quantifying fascia preservation is not easy to understand, and unfortunately, the authors refer for further explanation to another publication that is not yet available online [3]. The subjective nature of the fascia quantification is severely limiting. Additionally, the study does not show that fascia preservation improves continence in addition to conventional nerve sparing, but this is the crucial question. There are other limitations: Neither a continence questionnaire nor a pad test were used; the patient number is limited; age was not a factor influencing continence (which it does in numerous other studies); there was a high rate of positive margins; and the aspect of a learning curve is not considered [4]. The reported continence results are somewhat less excellent (but maybe more realistic) than those of other series of robotic radical prostatectomy [5]. It also looks as if anterior fascia preservation revives the concept of sparing the puboprostatic ligaments. Finally, since the whole idea was to improve postoperative erectile status, it would have been good to show data on that. The authors have chosen to split these crucial data into two separate manuscripts, which is not helpful for the interested reader. Thus, we feel that this paper discusses a new idea, but the data presented do not convince us. References [1] Van der Poel HG, de Blok W, Joshi N, van Muilekom E. Preservation of lateral prostatic fascia is associated with urine continence after robotic-assisted prostatectomy. Eur Urol 2009;55: [2] Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51: [3] Van der Poel HG, de Blok W. Role of the extent of fascia preservation and erectile function after robot-assisted laparoscopic prostatectomy. Urology. In press. [4] Artibani W, Fracalanza S, Cavalleri S, et al. Learning curve and preliminary experience with da Vinci-assisted laparoscopic radical prostatectomy. Urol Int 2008;80: [5] Mottrie A, Van Migem P, De Naeyer G, Schatteman P, Carpentier P, Fonteyne E. Robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of 184 cases. Eur Urol 2007;52: DOI: /j.eururo DOI of original article: /j.eururo