The importance of maximal restoration of peri-prostatic support

Transcription

1 Providing the best evidence for each surgical option in organ confined prostate cancer The importance of maximal restoration of peri-prostatic support A. Mottrie ORSI-Academy Melle Belgium OLV Hospital Aalst Belgium

2 Early Continence How to achieve the ideal outcome? Accurate patient selection (age, comorbidity, oncological risk group) Good knowledge of anatomy Surgical steps for ideal outcome Preservation of puboprostatic ligaments & muscle fibers Preservation of membranous urethra Anterior fixation Restoration of posterior aspect of rhabdosphincter (Rocco s stitch) Bladder neck preservation Preservation of neurovascular bundles and continence nerves

3 Division of puboprostatic ligaments Pubourethral component

4 Knowledge of Anatomy: Puboprostatic ligaments Steiner MS The puboprostatic ligament and the male urethral suspensory mechanism: an anatomic study. Urology 1994; 44 (4):

5 Anatomical landmarks: Urethral Sphincter Membranous urethra (sphincteric urethra) In its course from the apex of the prostate to the perineal membrane, the membranous urethra spans on everage 2 to 2.5 cm (range 1.2 to 5 cm)

6 Apical dissection : tips & tricks Borin, et al 2007 Urethral stump length, PSM and continence after RALP first 200 cases: transection of the urethra at the prostatourethral junction: PSM 17,6% (74% apical) continence at 6 mo: 89% second 200 cases: transection 3-6 mm distal to the prostatourethral junction: PSM 7.5% (apical 5.5%) continence at 6 mo: 91%

7 Collar technique

8 Posterior Reconstruction

9 Anatomical landmarks: urethral sphincter CG:Cowpers gland LA: levator ani * : striated part X: external smooth muscular part : internal smooth muscular part Stolzenburg et al Eur Urol 2007; 51:

10 3. VESICO-URETHRAL ANASTOMOSIS AALST TECHNIQUE Aims: 1. Haemostasis 2. Mechanical support and anastomosis stability 3. Maximal strength at the level of the posterior plate, holding power of the anastomosis 30 cm V-lock suture: posterior reconstruction with 4 stitches on Denovillers and 3 on urethral stump (all layer but mucosa) ad posterior mucosa mucosa layer (right to left) 23 cm V-lock suture: additional posterior mucosa-mucosa layer (left to right) Lateral and anterior plate according to Van-Velthoven technique

11 Posterior Reconstruction & Anastomosis

12 Apical Dissection & posterior reconstruction CLINICAL OUTCOMES MATERIAL AND METHODS Comparative study of 189 consecutive patients treated with RARP between January and December 2015 by a single experienced surgeon January-May 2015: 81 patients control group June-December 2015: 108 patients collar technique Primary outcome: rate of apical PSM Secondary outcome: urinary continence (0-1 safety pad/day) at catheter removal, at 1,3,6 and 12 months

13 Apical Dissection & posterior reconstruction CLINICAL OUTCOMES Overall Control group Collar technique P value No. patients 189 (100) 81 (42.9) 108 (57.1) - Age at surgery (years) Median (IQR) 65 (59-69) 65 (57-69) 65 (59-39) 0.9 Baseline total PSA level (ng/ml) Median (IQR) 8.2 ( ) 8.3 (6-12.5) 8.1 (5.6-11) 0.9 Gleason grade group Clinical stage T1 T2 T3 D'Amico Risk Group, n (%) Low Intermediate High mpmri results (%) Negative Organ confined lesion ECE SVI 88 (46.6) 53 (28) 23 (12.2) 12 (6.3) 13 (6.9) 74 (39.2) 84 (44.4) 31 (16.4) 62 (32.8) 79 (41.8) 48 (25.4) 37 (19.6) 109 (57.7) 36 (19) 7 (3.7) 44 (54.3) 19 (23.5) 7 (8.6) 4 (4.9) 7 (8.6) 32 (39.5) 35 (43.2) 14 (17.3) 30 (37) 31 (38.3) 20 (24.7) 17 (21) 48 (59.3) 14 (17.3) 2 (2.5) 44 (40.7) 34 (31.5) 16 (14.8) 8 (7.4) 6 (5.6) 42 (38.9) 49 (45.4) 17 (15.7) 32 (29.6) 48 (44.4) 28 (25.9) 20 (18.5) 61 (56.5) 22 (20.4) 5 (4.6)

14 Apical Dissection & posterior reconstruction CLINICAL OUTCOMES Overall Control group Collar technique P value Low risk 3 (4.8) 2 (6.7) 1 (3.1) 0.5 Intermediate risk 5 (6.3) 3 (9.7) 2 (4.2) 0.3 High risk 8 (16.7) 4 (20) 4 (14.3) 0.6 MpMRI negative 1 (2.7) 0 (0) 1 (5) 0.4 MpMRI organ confined lesion 5 (4.6) 3 (6.3) 2 (3.3) 0.5 MpMRI with ECE-SVI 10 (23.3) 6 (37.5) 4 (14.8) 0.09 MpMRI apical index lesion 4 (10.8) 4 (40) 0 (0) Pathologic stage T2 5 (4.1) 5 (8.9) 0 (0) 0.01 Pathologic stage T3a 7 (14.9) 3 (17.6) 4 (13.3) 0.7 Pathologic stage T3b-T4 4 (19) 1 (12.5) 3 (23.1) 0.5

15 2. Apical Dissection & posterior reconstruction FUNCTIONAL OUTCOMES No pad at 12 months: 93.8% vs. 99.1%

16 VESICO-URETHRAL ANASTOMOSIS Gratkze et al, Eur Urol. 2016

17 VESICO-URETHRAL ANASTOMOSIS CONCLUSIONS Collar technique & posterior reconstruction: improving oncology (lowers PSM at apex) promising continence rates early catheter removal possible July 15, Orsi Academy Proefhoevestraat Melle Belgium