Niyati Harneja

Effect of a Risk-stratified Grade of Nerve-sparing Technique on Early Return of Continence After Robot-assisted Laparoscopic Radical Prostatectomy

BACKGROUND The impact of nerve sparing (NS) on urinary continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP) has yet to be defined. OBJECTIVE To evaluate the effect of a risk-stratified grade of NS technique on early return of urinary continence. DESIGN, SETTING, AND PARTICIPANTS Data were collected from 1546 patients who underwent RALP by a single surgeon at a tertiary care center from December 2008 to October 2011. Patients were categorized preoperatively by a risk-stratified approach into risk grades 1-4, with risk grade 1 patients more likely to receive NS grade 1 or complete hammock preservation. This categorization was also conducted for risk grades 2-4, with grade 4 patients receiving a non-NS procedure. INTERVENTION Risk-stratified grading of NS RALP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Univariate and multivariate analysis identified predictors of early return of urinary continence, defined as no pad use at ≤ 12 wk postoperatively. RESULTS AND LIMITATIONS Early return of continence was achieved by 791 of 1417 men (55.8%); of those, 199 of 277 (71.8%) were in NS grade 1, 440 of 805 (54.7%) were in NS grade 2, 132 of 289 (45.7%) were in NS grade 3, and 20 of 46 (43.5%) were in NS grade 4 (p<0.001). On multivariate analysis, better NS grade was a significant independent predictor of early return of urinary continence when NS grade 1 was the reference variable compared with NS grade 2 (p<0.001; odds ratio [OR]: 0.46), NS grade 3 (p<0.001; OR: 0.35), and NS grade 4 (p=0.001; OR: 0.29). Lower preoperative International Prostate Symptom Score (p=0.001; OR: 0.97) and higher preoperative Sexual Health Inventory for Men score (p=0.002; OR: 1.03) were indicative of early return of urinary continence. Positive surgical margin rates were 7.2% (20 of 277) of grade 1 cases, 7.6% (61 of 805) of grade 2 cases, 7.6% (22 of 289) of grade 3 cases, and 17.4% (8 of 46) of grade 4 cases (p=0.111). Extraprostatic extension occurred in 6.1% (17 of 277) of NS grade 1 cases, 17.5% (141 of 805) of NS grade 2 cases, 42.5% (123 of 289) of NS grade 3 cases, and 63% (29 of 46) of NS grade 4 cases (p<0.001). Some limitations of the study are that the study was not randomized, grading of NS was subjective, and possible selection bias existed. CONCLUSIONS Our study reports a correlation between risk-stratified grade of NS technique and early return of urinary continence as patients with a lower grade (higher degree) of NS achieved an early return of urinary continence without compromising oncologic safety.

Improving time to continence after robot-assisted laparoscopic prostatectomy: augmentation of the total anatomic reconstruction technique by adding dynamic detrusor cuff trigonoplasty and suprapubic tube placement.

After robot-assisted laparoscopic prostatectomy, total anatomic reconstruction (TR) with the additions of a circumapical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter was performed in 49 patients from June to July 2012. Continence at 6 weeks after catheter removal was assessed for an initial group of 23 patients, and also at 2 weeks in an additional 26 patients who most recently had undergone surgery. Follow-up appointments and telephone interviews were used to assess pad use and continence. Of the initial 23 patients receiving the modified TR, 60.9% had 0 pad use at 6 weeks. By 2 weeks, 65.4% of the most recent 26 patients operated on achieved continence with 0-1 pad use. Preservation and reconstruction of the pelvic floor and supporting bladder structures leads to an earlier return of continence. These key steps need to be validated and confirmed in larger and randomized trials.

Corrigendum re: “Effect of a Risk-stratified Grade of Nerve-sparing Technique on Early Return of Continence After Robot-assisted Laparoscopic Radical Prostatectomy” [Eur Urol 2013;63:438–44]

In the introduction, the Nationwide Inpatient Sample found that 61.3% (not 60%) of radical prostatectomies from October 2008 to December 2009 were robotic assisted. In the third paragraph of the discussion section, the sample size should be 1417 (not 1546), as detailed in Table 1. In Table 1, the positive surgical margin rate should be 7.83% (not 7.9%). Our conclusions are not affected and remain unchanged.

V1272 ENHANCEMENT OF TOTAL ANATOMIC RECONSTRUCTION BY ADDING DYNAMIC DETRUSOR CUFF TRIGONOPLASTY AND SUPRA PUBIC TUBE PLACEMENT

INTRODUCTION AND OBJECTIVES: With the basic principle of restoring a patient’s anatomy to its original state postoperatively, we attempted to identify technical aspects of total anatomical reconstruction that led to early return of urinary continence after robot-assisted laparoscopic prostatectomy (RALP). METHODS: An analysis was performed in 107 consecutive men who underwent RALP as well as total anatomic reconstruction (TR) with the additions of a circum-apical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter by a single surgeon at a tertiary care center between June 2012 and September 2012. Patient demographics and post-operative urinary control was recorded at interval follow-up visits. Additionally, telephone interviews and follow-up questionnaires were used to assess pad usage and continence. RESULTS: Of the 107 patients operated between June 2012 and September 2012, 14 patients were lost to follow-up. Therefore, data is reported on 93 patients. We defined early continence as patients using zero pads at 6 weeks or less. 39.8% of men who underwent the modified TR achieved early continence. 65.5% of the patients operated achieved continence with the use of 0-1 pad at 6 weeks. CONCLUSIONS: Reconstructing the pelvic anatomy and supporting bladder structures leads to an earlier return to continence. Larger randomized trials will need to confirm these key steps.

The Use of Magnetic Resonance Imaging in the Management of Prostate Cancer

In the current era, the use of magnetic resonance imaging (MRI) has become routine for the evaluation and management of prostate cancer (PCa), with most patients undergoing a 1.5-T MRI. There is a direct relationship between magnet strength and spatial resolution of the image: the higher the magnet, the higher the spatial resolution. In a 3-T MRI, a phased array pelvic coil is used instead of an endorectal coil, which could decrease patient refusal to undergo MR imaging due to avoidance of the discomfort associated with an endorectal coil. Multiparametric MRI (mpMRI) has become the gold standard in PCa scanning and is more reliable than T2-weighted (T2W) MRI alone [1]. The T2-weighted MRI sequence has a lower specificity due to a high frequency of low signal intensity foci, which causes false positives. In standard practice, multiparametric imaging modalities are based on the combination of T2-weighted (T2W-MRI), dynamic contrast enhancement (DCE-MRI), and diffusion-weighted imaging (DW-MRI) to improve detection, location, and characterization of PCa. Due to its time-consuming nature, another technique known as MR spectroscopy (MRSI) is likely to be restricted for scientific purposes.