Endourology. Youn Chul You, Tae Hyo Kim, Gyung Tak Sung. INTRODUCTION

Transcription

1 Endourology Effect of Bldder Neck Preservtion nd Posterior Urethrl Reconstruction during Robot-Assisted Lproscopic Rdicl Prosttectomy for Urinry Continence Youn Chul You, Te Hyo Kim, Gyung Tk Sung Deprtment of Urology, Dong-A University College of Medicine, Busn, Kore Purpose: To report our results on urinry continence fter bldder neck preservtion (BNP) nd posterior urethrl reconstruction (PUR) during robot-ssisted lproscopic rdicl prosttectomy (RALP). Mterils nd Methods: Dt from 107 ptients who underwent RALP were compred on the bsis of whether the ptients underwent BNP nd PUR, BNP only, or the stndrd technique (ST). In group A (n=31 ptients), ST ws performed by using Ven velthoven continuous suturing for urethrovesicl nstomosis. In group B (n=8 ptients), ST with only PUR ws performed. In group C (n=48 ptients), both the BNP nd PUR techniques were used. Recovery of continence ws defined s the use of 1 pd (50 ml) or less within 4 hours. Results: The three groups were comprble in terms of ptient demogrphics. The men opertive time nd the men blood loss decresed significntly from group A to group C (p=0.01 for men opertive time nd p=0.004 for the men blood loss). Men ctheteriztion time ws 8.9, 7.8, nd 7.1 dys in ech group (p=0.047). Erly return of urinry continence t 3 months ws observed in group B (89.%) nd group C (90.6%) compred with group A (71%). However, continence t 6 months ws comprble in the 3 groups (87.5% in group A, 9.8% in group B, nd 9.3% in group C). Rtes of positive surgicl mrgins decresed from 30.% in group A to 0% in group B nd 1% in group C. Conclusions: BNP nd PUR during RALP showed fvorble impct on the erly postopertive recovery of continence while not ffecting positive surgicl mrgins. Key Words: Prosttectomy; Prosttic neoplsms; Urinry incontinence This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Article History: received 30 August, 011 ccepted 6 September, 011 Corresponding Author: Gyung Tk Sung Deprtment of Urology, Dong-A University College of Medicine, Dongdesin-dong 3-g, Seo-gu, Busn , Kore TEL: FAX: E-mil: sunggt@du.c.kr INTRODUCTION Robot-ssisted lproscopic rdicl prosttectomy (RALP) hs been rpidly ccepted s vible option for the minimlly invsive surgicl tretment of loclized prostte cncer. Since the introduction of the d Vinci Robotic Surgicl System (Intuitive Inc., Surgicl, CA, USA) in 001, vrious reports on RALP hve climed comprble or superior outcomes to open nd lproscopic surgery in oncologicl nd functionl spects [1]. The recovery of potency nd continence re importnt fctors for the qulity of life of ptients undergoing RALP. The recovery of continence depends on vrious fctors, nd mong these, the surgicl technique is considered most criticl. Urinry incontinence is usully temporry in most ptients. The recovery rte is stisfctory, with rtes of 85% to 97% by 1 yer fter rdicl prosttectomy, but complete recovery my require much longer time in some ptients [-6]. In this study, we compred the outcomes of bldder neck preservtion (BNP) using lterl bldder neck dissection (LBND) nd the posterior urethrl reconstruction (PUR) techniques for erly recovery of continence during RALP. The effects on the erly recovery of continence nd positive surgicl mrgins (+SMs) were Koren Journl of Urology C The Koren Urologicl Assocition, 01 9 Koren J Urol 01;53:9-33

2 30 FIG. 1. Posterior urethrl reconstruction. The posterior urethrl reconstruction (PUR) technique requires identifiction of the posterior portion of the rhbdosphincter nd the nterior leflet of Denovilliers fsci. With the use of one rm of the continuous suture, the posterior prt of the rhbdosphincter is nchored with continuous sutures of three to four bites to the remining portion of the Denovilliers fsci. evluted nd compred when the BNP technique using LBND nd the PUR technique were used. MATERIALS AND METHODS The study subjects included 107 ptients who underwent RALP owing to loclized prostte cncer within the period from Jnury 008 to August 010. The following techniques for erly recovery of continence were performed chronologiclly, nd recovery of continence ws observed during this period. In group A, stndrd RALP techniques with Ven velthoven continuous suturing for urethrovesicl nstomosis (UVA) were performed in 31 ptients. In group B, stndrd RALP techniques with PUR nd Ven velthoven continuous suturing for UVA were performed in 8 ptients. In group C, stndrd RALP techniques using LBND s the BNP technique with PUR nd Ven velthoven continuous suturing for UVA were performed in 48 ptients. The Ven velthoven technique requires continuous suturing of the urethr using monofilment 3-0 double rm sutures from 6 to 1 o clock of the urethrl lumen. The PUR technique requires identifiction of the posterior portion of the rhbdosphincter nd the nterior leflet of Denovilliers fsci. Using one rm of the continuous suture, the posterior prt of the rhbdosphincter is nchored with continuous sutures of three to four bites to the remining portion of the Denovilliers fsci. The other rm of the continuous suture is then plced to pproximte between the posterior bldder neck nd the posterior urethr nd then tied to the other rm of the continuous suture (Fig. 1). Another rm of the continuous suture is used to perform Ven velthoven continuous suturing for UVA. Lterl bldkoren J Urol 01;53:9-33 You et l FIG.. Bldder neck preservtion technique using lterl bldder neck dissection. The picture shows the left side of the lterl bldder neck dissection. The lterl bldder neck dissection technique requires precise identifiction of the detrusor muscle fibers t the criticl junction of the lterl bldder neck, prostte bse, nd the ft pd of Whitmore. Meticulous dissection is performed just medilly to the ft pd of Whitmore encountering dipose tissue nd the lterl border of the bldder neck while ppreciting the ventrolterl nd dorsl longitudinl muscles until the dissection reches the prostte bse nd the nterior surfce of the seminl vesicle. der neck dissection for the BNP technique requires precise identifiction of the detrusor muscle fibers t the criticl junction of the lterl bldder neck, prostte bse, nd the ft pd. Meticulous dissection is performed just medilly to the ft pd of Whitmore encountering dipose tissue nd the lterl border of the bldder neck, while ppreciting the ventrolterl nd dorsl longitudinl muscles, until the dissection reches the prostte bse nd the nterior surfce of the seminl vesicle. After the bilterl dissection of the lterl bldder neck, which exposes the nterior surfce of the seminl vesicle, the detrusor muscles in the posterior bldder neck re well pprecited medilly from the nterior surfce of the seminl vesicles nd the bldder neck is then pproched t the midline. The dissection is continued until distinct musculus sphincter vesice re identified nd preserved, nd then the bldder neck is divided (Figs., 3). The medicl records of the ptients were collected, nd the preopertive nd postopertive clinicl course nd recovery of continence in the three groups were compred. Digitl rectl exmintion, prostte biopsy, mgnetic resonnce imging, nd bone scn were performed before RALP in ll ptients. Periopertive prmeters such s opertive time, blood loss, ctheteriztion time, pthology dt, nd positive surgicl mrgin rte (+SMR) were reviewed from our surgicl dtbse. Urinry continence ws evluted by using the Interntionl Continence

3 31 Effect of Bldder Neck Preservtion TABLE. Intropertive nd postopertive outcomes Vrible Group A Group B Group C p-vlue Opertion time (min) EBL (ml) Ctheteriztion (dy) Postopertive diet (dy) Hospitl sty (dy) Positive surgicl mrgin Urine lek EBL, estimted blood loss. : one-wy ANOVA test. TABLE 3. Positive surgicl mrgins ccording to the loction of the prostte FIG. 3. Bldder neck trnsection. The figure shows well-preserved bldder neck t the medil spect between the prostte nd the bldder neck. Apicl (%) Bse (%) Lterl (%) TABLE 1. Preopertive ptient chrcteristics Vrible Age (yr) BMI (kg/m) PSA (ng/ml) Prostte (g) Clinicl stge T T3 T3b Vrible Group A (n=31) Group B (n=8) Group C (n=48) p-vlue Group A (n=10) Group B (n=5) (0) 1 (10) 7 (70) 1 (0) 3 (60) 1 (0) Group C (n=3) 1 (33.3) 0 (0) (66.6) p-vlue Vlues re presented s number (%). BMI, body mss index; PSA, prostte-specific ntigen. : Student s t-test. Society questionnire. Postopertive continence ws ssessed through questionnire survey dministered 1 dy fter ctheter removl, nd t intervls of 1 month, 3 months, nd 6 months fter RALP. Postopertive continence ws defined s lck of incontinence or the use of less thn one diper (50 ml) per dy for security. Postopertive cystogrms were performed in ll ptients on the 7th postopertive dy. In the cse of lekge, ctheteriztion ws mintined for n dditionl 5 to 10 dys nd the cystogrm ws repeted. The vribles before nd fter the opertion mong the ptient groups were compred by using one-wy nlysis of vrince test nd Fisher s exct test, nd p vlues of less thn 0.05 were considered sttisticlly significnt. SPSS ver. 1.0 (SPSS Inc., Chicgo, IL, USA) ws used for the sttisticl nlysis. RESULTS The men ge of the ptients in groups A, B, nd C ws 65.9, 65., nd 64.9 yers, respectively (p=0.41), nd the men preopertive prostte-specific ntigen vlues were 9.4, 10.6, nd 9. ng/ml, respectively (p=0.63). The men body mss index vlues were 4.3, 3.9, nd 4.8 kg/m, respectively, (p=0.36), nd the men prostte sizes were 33.8, 39., nd 37. g, respectively (p=0.) (Tble 1). The Gleson grde ws similr in the 3 groups: 6.89 in group A, 6.68 in group B, nd 6.61 in group C (p=0.37). Also, the Interntionl Prostte Symptom Score ws comprble in the 3 groups: 18.6 in group A, 18.8 in group B, nd 17.9 in group C (p=0.47). The tumor stges in the 3 groups were comprble (p= 0.39). The preopertive stges were s follows: 6 ptients in T, 3 in T3, nd in T3b for group A; 5 ptients in T, in T3, nd 1 in T3b for group B; nd 4 ptients in T, 5 in T3, nd 1 in T3b for group C. The men opertive times were 6.3, 19.1, nd minutes, respectively (p=0.01), nd the men blood loss ws 188, 11.3, nd ml, respectively (p=0.004). The ctheteriztion time ws 8.9, 7.8, nd 7.1 dys in ech group (p=0.047). In the postopertive cystogrm, two cses of urine lekge were reported in group A, wheres no cses were observed in groups B nd C. The postopertive +SMRs were 10 ptients in group A (31.%), 5 ptients in group B (17.9%), nd 3 ptients in group C (6.3%) (Tble ). In group A, seven ptients hd +SMs in the lterl, two in the bse, nd one in the picl re of the prostte. In group B, one ptient hd +SMs in the lterl, three in the bse, nd one in the picl re of the prostte. In group C, two ptients hd +SMs in the lterl nd one in the picl re of the prostte (Tble 3). Continence ws ssessed by recording pd usge 1 dy fter ctheter removl nd 3, 6, nd 1 months postopertively. Recovery of continence ws reported s follows: 11 Koren J Urol 01;53:9-33

4 3 You et l TABLE 4. Return of continence ccording to opertive methods Postopertive 1 month 3 months 6 months 1 months Group A Group B Group C p-vlue < Recovery of continencews defined s the use of 1 pd (50 ml) or less within 4 hours. : one-wy nlysis of vrince test. ptients by 1 month (35.5%), ptients by 3 months (71.0%), nd 7 ptients by 6 months (87.5%) in group A; 16 ptients by 1 month (57.%), 5 ptients by 3 months (89.%), nd 6 ptients by 6 months (9.8%) in group B; nd 30 ptients by 1 month (6.5%), 36 ptients by 3 months (90.6%), nd 9 ptients by 6 months (9.3%) in group C (Tble 4). Erly return of continence t 3 months of follow-up ws observed in groups B nd C compred with group A. Continence t 1 yer ws comprble in the 3 groups: 9.1% in group A, 94.5% in group B, nd 96.0% in group C. DISCUSSION Recent dvnces in video-endoscopic equipment nd the development of minimlly invsive surgicl techniques hve reduced the rtes of mortlity nd complictions from rdicl prosttectomy. In prticulr, the d Vinci Robotic Surgicl System (Intuitive Inc., Sunnyvle, CA, USA), which ws introduced in 001, offers stble nd mgnified opertive field, enbles meticulous dissection nd the preservtion of the bldder neck, nd enhnces nerve-spring nd suturing for UVA during RALP. Despite these improvements, however, temporry postopertive incontinence is blmed for lowering the qulity of life of ptients fter RALP. Therefore, to chieve erly return of continence, vrious uthors hve introduced numerous techniques with vrible outcomes [7,8]. In the current study, ptients treted with BNP using LBND nd the PUR techniques showed n dvntge with respect to erly continence. Nevertheless, no sttisticlly significnt difference ws observed t 6 nd 1 months postopertively mong the 3 groups. Since the dpttion of the running, bidirectionl monofilment nstomosis to UVA in 003, severl modifictions hve been introduced to enhnce wtertight coopttion of UVA. A technique reported by Rocco et l. [9] rose from theory bsed on the functionl ntomy nd restores the posterior spect of the rhbdosphincter with rdicl prosttectomy, from which recovery of continence is expected. Dt from open rdicl prosttectomy using Rocco s technique reported 74% recovery of continence. In ddition, in study tht followed up 100 ptients for 13.3 months, Duthie et l. [10] reported 68% recovery of continence by 1 months with the improvements in the surgicl technique. In the current study, we experienced the dditive effects of PUR when compred with the Ven velthoven continuous suturing technique. This technique llows pproximting the bldder neck closer to the urethr nd thus enbles tension-free UVA nd prevents lekge t the UVA site. Rebuck et l. [11] compred the outcomes of RALP with the Ven velthoven continuous suturing technique nd reported reduction in incontinence from 6.% to 14.3% to.3% with the progress in the surgicl technique, s shown in the cystogrm. In ddition, the recovery time ws shortened s the stff gined more experience in this technique. He lso observed decresed rte of urine lekge nd the erly recovery of continence when the highly experienced stff used the technique. In our prior experience, we moved to the continuous suturing technique for UVA from the interrupted sutures in the erly dys of lproscopic rdicl prosttectomy becuse the Ven velthoven continuous suturing technique ws shown confer better continence rte. Controversy exists in the current literture regrding BNP. The BNP technique ws first described by Curto nd Gston in 006. Using the BNP technique in 1400 cses from 001 to 010, Asimkopoulos et l. [1] reported 80% recovery of continence immeditely fter ctheter removl nd 73% recovery of continence in the remining ptients by 3 months. In South Kore, Jeong et l. [13] reported the methodology nd outcome of typicl RALP using both Rocco s nd the BNP technique. In his study, 91% recovery of continence ws observed in the ptient group tht underwent surgery using the BNP technique. In our study, Group C showed significnt benefit in erly recovery of continence. Also, more thn 90% recovery of continence ws observed in ll the groups 6 months fter RALP. However, when the outcomes were compred t 1, 3, nd 6 months fter RALP, erly recovery of continence ws confirmed in group C in which both Rocco s nd the BNP techniques were used. We ssume tht the PUR technique restores the norml ntomic position nd reinforces the bckbone in the xis of the pelvic ntomy. Regrding +SMs, some reports showed tht the +SMR ws high in the group with the BNP technique, but our study showed no differences. When performing the BNP technique by LBND, it is crucil to identify the detrusor muscle fibers t the criticl junction of the lterl bldder neck, the prostte bse, nd the ft pd lterlly. The meticulous dissection must be utilized just medilly to the ft pd of Whitmore to void indvertent bleeding from the lterl venous plexus while ppreciting the ventrolterl nd dorsl longitudinl bldder muscles medilly, until the dissection reches the prostte bse nd the nterior surfce of the seminl vesicle. Cler visuliztion nd identifiction of the surgicl lndmrks nd meticulous dissection will reduce the +SMR. When both Rocco s nd the BNP techniques were used s in group C, the erly return of continence ws observed. Koren J Urol 01;53:9-33

5 Effect of Bldder Neck Preservtion 33 In ddition, there ws no sign of lekge t the site of UVA when both techniques were used. It is possible tht recovery ws chieved erlier due to the bsence of lekge, which is thought to hve n dverse effect on the heling of the UVA nd recovery of continence. The PUR technique helps to reduce the tension between the urethr nd the bldder, leding to more stble nd wtertight UVA. There re severl limittions to our study. The study ws performed in retrospective mnner nd the ptients were not rndomly ssigned. Also, becuse opertive methods were performed chronologiclly, there my hve been some contribution of the lerning curve, becuse cses ccumulted with the BNP nd the PUR techniques. However, ptients with lrge prosttes or prominent medin lobes were not spred from performing the BNP technique nd single surgeon performed ll the procedures in this study. Even though our study did not ddress the impct of these fctors on postopertive outcomes, continence nd +SMs did not vry cross the study groups. CONCLUSIONS Posterior urethrl reconstruction reduced the risk of urine lekge nd proved to hve good outcomes on erly continence. When both bldder neck preservtion using lterl bldder neck dissection nd the posterior urethrl dissection techniques were used, much better outcome ws observed in the erly recovery of continence t the 3 month follow-up. Also, bldder neck preservtion did not influence +SMs. Further studies of these surgicl techniques re expected to chieve better qulity of life for ptients undergoing RALP. CONFLICTS OF INTEREST The uthors hve nothing to disclose. REFERENCES 1. Cho JW, Kim TH, Sung GT. Lproscopic rdicl prosttectomy versus robot-ssisted lproscopic rdicl prosttectomy: single surgeon's experience. Koren J Urol 009;50: Rssweiler J, Sentker L, Seemnn O, Htzinger M, Rumpelt HJ. Lproscopic rdicl prosttectomy with the Heilbronn technique: n nlysis of the first 180 cses. J Urol 001;166: Eden CG, Chill D, Vss JA, Adms TH, Duleh MI. Lproscopic rdicl prosttectomy: the initil UK series. BJU Int 00;90: Guillonneu B, el-fettouh H, Bumert H, Cthelineu X, Doublet JD, Fromont G, et l. Lproscopic rdicl prosttectomy: oncologicl evlution fter 1,000 cses Montsouris Institute. J Urol 003;169: Slomon L, Anstsidis AG, Ktz R, De L Tille A, Sint F, Vordos D, et l. Urinry continence nd erectile function: prospective evlution of functionl results fter rdicl lproscopic prosttectomy. Eur Urol 00;4: Peyromure M, Rvery V, Boccon-Gibod L. The mngement of stress urinry incontinence fter rdicl prosttectomy. BJU Int 00;90: Burnett AL, Mostwin JL. In situ ntomicl study of the mle urethrl sphincteric complex: relevnce to continence preservtion following mjor pelvic surgery. J Urol 1998;160: Rocco F, Crmignni L, Acquti P, Gdd F, Dell'Orto P, Rocco B, et l. Restortion of posterior spect of rhbdosphincter shortens continence time fter rdicl retropubic prosttectomy. J Urol 006;175: Rocco B, Gregori A, Stener S, Sntoro L, Bozzol A, Glli S, et l. Posterior reconstruction of the rhbdosphincter llows rpid recovery of continence fter trnsperitonel videolproscopic rdicl prosttectomy. Eur Urol 007;51: Duthie JB, Pickford JE, Gilling PJ. Robot-ssisted lproscopic prosttectomy: 010 updte. N Z Med J 010;13: Rebuck DA, Hywood S, McDermott K, Perry KT, Ndler RB. Wht is the long-term relevnce of cliniclly detected postopertive nstomotic urine lekge fter robotic-ssisted lproscopic prosttectomy. BJU Int 011;108: Asimkopoulos AD, Annino F, D'Orzio A, Pereir CF, Mugnier C, Hoepffner JL, et l. Complete periprosttic ntomy preservtion during robot-ssisted lproscopic rdicl prosttectomy (RALP): the new pubovesicl complex-spring technique. Eur Urol 010;58: Jeong W, Arki M, Prk SY, Lee YH, Kumon H, Hong SJ, Rh KH. Robot-ssisted lproscopic rdicl prosttectomy in the Asin popultion: modified port configurtion nd ultrdissection. Int J Urol 010;17: Koren J Urol 01;53:9-33