Kelly Monahan

Rectal Injury During Robot-Assisted Radical Prostatectomy: Incidence and Management

PURPOSE Rectal injury during robot-assisted radical prostatectomy is a rare but significant complication. Since the Clavien grading classification of complications does not include intraoperative injury without further sequelae, rectal injury may be underreported in the literature. We present what is to our knowledge the largest retrospective review to date of rectal injury and subsequent management. MATERIALS AND METHODS We reviewed the records of 6,650 patients who underwent robot-assisted radical prostatectomy at a total of 6 institutions. Patient characteristics, perioperative parameters, pathological findings and rectal injury management were tabulated and analyzed for intraoperative predictors of outcome and subsequent management. RESULTS A total of 11 rectal injury cases were identified of the 6,650 robot-assisted radical prostatectomies for a combined 0.17% incidence of rectal injury. Of rectal injuries 72.7% were identified intraoperatively and most did well with primary closure. Delayed recognition injury presented as rectourethral fistula without septic complications and required delayed fistula repair after primary diversion. We found no conclusive association of rectal injury with any patient parameter, intraoperative differences, pathological finding or surgeon experience. Posterior prostate plane dissection, including seminal vesicle dissection, is the crucial stage when rectal injury can occur and be identified. CONCLUSIONS Our review of the records at 6 centers revealed a combined 0.17% incidence of rectal injury. This compares favorably to the incidence in modern open and laparoscopic radical prostatectomy series. No preoperative, intraoperative or pathological differences correlated with injury. Cases in which rectal injury was identified intraoperatively required fewer surgical repeat interventions but ultimately each group had acceptable long-term urinary and bowel function results.

Bladder neck plication stitch: a novel technique during robot-assisted radical prostatectomy to improve recovery of urinary continence.

BACKGROUND AND PURPOSE Efforts to improve postprostatectomy incontinence have led to many modifications in surgical technique. We present our experience with a novel technique to improve continence outcomes in patients who are undergoing robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS A consecutive series of 159 patients after initiation of a bladder neck plication stitch was compared with the most recent group before the change. After completion of the vesicourethral anastomosis, a single suture was used to plicate the distal bladder neck. A structured questionnaire was used for follow-up. Continence criteria used were 1 pad per day for social continence and 0 pad per day for total continence. RESULTS A total of 334 patients were included in the study: 159 in the plication stitch group vs 175 in the control group. Average age was 59.1 vs 59.6 years, average body mass index was 27.9 vs 28.3 kg/m(2), and average prostate volume was 58.1 vs 60.9 cc, respectively. The mean time to reach social continence was 3.63±3.01 vs 5.33±4.89 weeks (P=0.004), and total continence was 5.10±3.80 vs 8.49±6.32 weeks (P=0.002), respectively. Chance of total continence improved with the bladder plication stitch: Odds ratio of 1.95±0.72 (P<0.001) at 1 month, 1.25±0.56 (P=0.113) at 3 months, and 2.07±0.66 (P=0.005) at 12 months. There were no bladder neck contractures or other urinary complications noted in either group. CONCLUSIONS The bladder plication stitch is a simple and effective technical modification for shortening the period of recovery of urinary continence in RARP patients. Randomized controlled trials are under way to further evaluate this technique.

MP23-17 IMPROVED OUTCOMES DURING ROBOTIC PROSTATECTOMY UTILIZING AIRSEAL TECHNOLOGY

AirSeal is a newer technology utilizing an integrated access system during minimally invasive surgery. Its goal is to provide stable pneumoperitoneum and continuous smoke evacuation. A few small volume studies have compared AirSeal to the standard multicomponent insufflation system and have shown an improvement in stable pneumoperitoneum and ease of manipulating objects through the AirSeal port. In this study, we compare the standard system to the AirSeal system to evaluate potential benefits in a larger cohort. METHODS

MP42-18 PATIENTS ELIGIBLE FOR ACTIVE SURVEILLANCE WHO CHOSE TO UNDERGO PROSTATECTOMY: THE DIFFERENCE BETWEEN PROSTATE CANCER FEATURES ON BIOPSY AND FINAL PATHOLOGIC REPORT

cancer significant association with finding upstaging/upgrading at RP specimens in this subset of patients. Positive Surgical Margin (PSM) was noted in 66(16%) patients, and the PSM rate was significantly higher in patients who were upstaged in the RP specimens. The mean follow-up of the study population was 28 months and the predicted Biochemical Recurrence Free survival at 5 years was 92% and 88% in the patients who were not and were upstaged/upgraded at RP specimens respectively CONCLUSIONS: Percentage of positive cores appears to predict pathological upstaging/upgrading at radical prostatectomy in patients subjected to Active Surveillance

Erratum to: Surgeon perception is not a good predictor of peri-operative outcomes in robot-assisted radical prostatectomy (J Robotic Surg, 10.1007/s11701-011-0293-4)

Surgeons have always used their cognitive intuition for the execution of skilled tasks and real-time perception of intra-operative outcomes. We attempted to measure the overall accuracy of intra-operative surgeon perception on the functional outcome of early continence after robot-assisted radical prostatectomy (RARP). A single experienced surgeon (D.I.L.) used a scoring sheet to prospectively capture his subjective opinion of how well a particular portion of the RARP procedure was completed. Surgeon perception of factors affecting post-operative continence such as quality of bladder neck preservation, nerve sparing, urethral length, anastomosis, striated sphincter thickness, quality of Rocco repair and bladder neck plication suture (total 7 variables) were graded as ‘‘poor’’, ‘‘average’’ or ‘‘good’’. Urinary continence was graded as either total continence [0 pads per day (PPD) or social continence (security pad or one PPD)]. A total of 273 (39 patients 9 7 variables) responses were recorded: 58.6% were rated as ‘‘good’’, 32.2% as ‘‘average’’ and 8.4% as ‘‘poor’’. A log-rank test for all perception variables showed no significant differences in subsequent achievement of continence (either 0 or 1 PPD) (P [ 0.05) at both the 1and 3-month time points. In the case of some perception variables, patients with ‘‘bad’’ scores gained continence a median of 3 weeks sooner than patients with ‘‘good’’ scores. Surgeon perception of intra-operative performance during RARP is a poor predictive indicator of subsequent functional outcome in terms of urinary continence. Intersurgeon variability of perception may vary and needs further investigation.