403 EARLY CONTINENCE RECOVERY AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY WITH OR WITHOUT RESTORATION OF POSTERIOR RHABDOSPHINCTER: RESULTS OF A RANDOMIZED TRIAL

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Learning curve is endless: Biochemical recurrence rates keep varying among high volume radical retropubic prostatectomy surgeons

Can FloSeal reduce the incidence of lymphoceles after lymphadenectomies in extraperitioneal radical prostatectomy (RPE)?

Gallina M.D., Suardi N., Briganti A., Passoni N.M., Bianchi M., Salonia A., Colombo R., Da Pozzo L.F., Rigatti P., Montorsi F.

Remzi M., Klingler H.C., Marberger M.

1

Medical University of Vienna, Dept. of Urology, Vienna, Austria

University Vita Salute San Raffaele Hospital, Dept. of Urology, Milan, Italy

Introduction & Objectives: Previous studies demonstrated that higher surgical volume is associated with lower rates of biochemical recurrence (BCR) after radical prostatectomy (RP) for clinically localized prostate cancer. However, these results may be artificially inflated by the fact that even surgeons with a very low surgical volume were included in such studies. We hypothesized that surgical volume may impact on BCR after surgery even among surgeons with high RP expertise. Material & Methods: The study included 1842 consecutive patients with complete clinical, pathological and follow-up data treated with RP and extended pelvic lymph node dissection (ePLND) at a single European Institution from January 2000 to January 2008 by five high volume surgeons. All surgeons performed at least 250 RPs. Patients were divided into three groups according to the pre-operative characteristics: low-risk (clinical stage T1c, biopsy Gleason sum ≤6 and PSA ≤10ng/mL; n=589), high risk (PSA≥20 ng/ml or clinical stage T3 or biopsy Gleason sum 8-10; n=437) and intermediate risk (all the remaining patients; n=816). Individual surgical volumes were tested in all the 3 risk groups. Kaplan Meier method was used to graphically explore BCR rates after surgery according to each surgeon in each group. Moreover, multivariable Cox regression models tested the association between surgical volume and BCR on the entire cohort, after adjusting for pre-operative PSA, clinical stage and biopsy Gleason sum. Results: Mean patient age was 65 yrs (median: 65.5 yrs, range: 41-85 yrs). Mean surgical volume was 430 RPs (range: 265-763). Mean number of procedures per-year was 56.8 (range: 38-85). Mean follow-up was 30.5 months (median 28.5, range 3-123). Kaplan-Meier analyses demonstrated that higher surgical volume was associated with lower rates of BCR in the whole population of patients (Log-rank p=0.006). When the univariable analyses targeted the rates of BCR in the different risk categories of patients, surgical volume was demonstrated to represent a significant predictor of BCR only in the intermediate risk group (Log-rank p=0.048). At multivariable Cox regression analyses, surgical volume represented an independent predictor of BCR (HR=0.99; p=0.006) Even after adjusting for pre-operative risk characteristics, the higher the surgical volume the lower the risk to develop BCR (HR=0.78; p=0.001). Conclusions: Our analyses demonstrate that higher surgical volume represent a powerful independent predictor of better biochemical control even when only experienced surgeons are considered. The strongest effect of surgical volume seems to be recorded in the intermediate risk patients.



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Early continence recovery after laparoscopic radical prostatectomy with or without restoration of posterior rhabdosphincter: Results of a randomized trial Salvaggio A., Granata A.M., Gregori A., Incarbone G.P., Scieri F., Romanò A.L., Pietrantuono F., Gaboardi F. Ospedale Luigi Sacco, Dept. of Urology, Milan, Italy Introduction & Objectives: Urinary incontinence is one of the major drawbacks of radical prostatectomy (RP) due to temporary or prolonged deficiency of the rhabdomyosphincter (RS). Anatomical reconstruction of the posterior aspects of RS has been advocated for a faster recovery of continence after RP. The aim of this study was to evaluate the early continence recovery after laparoscopic RP with or without restoration of posterior aspect of the RS, assessing the continence status at 3, 30, and 90 days after catheter removal. Material & Methods: After institutional approval, from March 2006 to April 2008, a two-arm randomized trial was carried out with 300 consecutive patients. Group A (153 patients) underwent standard laparoscopic RP and group B (147 patients) underwent laparoscopic RP with RS reconstruction. Continence was defined as no pads or one pad/die. The continence status was assessed 3, 30, and 90 days after catheter removal. Comparison of continence rate within each time point between groups was performed by the Pearson x2 test. Results: At 3 days after catheter removal, 31% of Group A patients versus 76% of Group B patients (p = 0.00002) were continent. A statistically significant difference was also present at 30 and 90 days (respectively 38.7% vs. 82.3%; p = 0.0004 and 68.7 vs. 90.1%; p = 0.0007). Early continence was significantly improved in the patients who underwent the anatomical reconstruction of the posterior RS. Phisiologic mechanisms that could be involved in such results are the fixation of urethra in the pelvis, the “tension free” anastomosis due to a posterior support and the reconstruction of a musculofascial plate including Denonvilliers fascia, the posterior median raphe and the dorsal wall of the RS. The musculofascial plate is a dynamic suspensory system for the prostatomembranous urethra. Conclusions: The posterior reconstruction of the RS is an easy, reproducible and effective technique for early continence recovery after laparoscopic RP.

Introduction & Objectives: Lymphoceles occur in up to 10% of the patients after lymphadenectomy in extraperitoneal RPE. Lymphoceles can cause symptoms like pain, voiding difficulties, swelling, thrombosis and infections. FloSeal Matrix consists of a bovine-derived gelatine matrix component, a human-derived thrombin component, and several mixing accessories. The effectiveness in lymphoceles comes from the crosslinked gelatine granules that allow conformation to irregular wound geometries, thereby maintaining contiguous contact with the active side of lymphorrhea. Furthermore the gelatine granules swell by up to 20% within 10 minutes after application which may offer a temponade effect. Material & Methods: A matched comparison of lymphadenectomies in extraperitioneal laparoscopic (LRPE), robot-assisted (RARPE) and open RPE (oRPE) with and without the use of Floseal was conducted. Between 01/2007 and 10/2008 142 extraperitoneal RPEs with lymphadenectomy were performed. Indications and kind of operation was only surgeon dependent. FloSeal was applied locally in the lymphadenectomy zone immediately after lymphadenectomy. Cost analysis was performed as follows: Floseal 218 Euro, Drainage 20 Euro, plain CT scan 305 Euro, one day of hospitalisation 1000 Euro, fenestration 1500 Euro. Results: Mean number of lymphnodes removed were 6.5 ± 4.5 (range 2-20). Median PSA was 6 (1.5-69) ng/ml. 32 RPEs were performed using Floseal and 110 without Floseal. In the group with and without Flowseal symptomatic lymphoceles were seen in one patient and in 16 patients, respectively. The median number of lymphnodes removed were 8 (range 5-20) in the Floseal group. The only lymphocele in the Floseal group was treated with percutaneous drainage only. In the non Floseal group, 6 symptomatic lymphoceles were treated conservatively, 4 with percutaneous drainage and 6 with fenestration after percutaneous drainage. The mean costs per patient in the Floseal versus Non Floseal group were 322 Euro (total costs 10301 Euro) versus 543 Euro (total costs: 59680 Euro), respectively, for the treatment of symptomatic lymphoceles. Conclusions: The use of Floseal after lymphadenectomy can reduce the number of symptomatic lymphoceles and is cost-effective.



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Running suture vesicourethral anastomosis in open retropubic radical prostatectomy using a suprapubic tube for urinary diversion does not lead to an elevated stricture rate: A prospective evaluation of 250 patients with a mean Follow-up of 46 months and a non randomized age & stage matched comparison to 190 patients with a transurethral Catheter for urinary diversion Hruby S., Lüftenegger W., Scholz M., Tomschi W., Höltl W. Kaiser Franz Joseph Hospital, Dept. of Urology, Vienna, Austria Introduction & Objectives: Using a running suture vesicourethral anastomosis for open radical prostatectomy provides the advantages of a watertight anastomosis, just one or two well seen and controllable knots and an uncomplicated reinsertion of a catheter when needed. Using a suprapubic catheter instead of a transurethral tube adds the advantage of stepwise beginning of the micturition and optimal control of residual urine. Additionally its more comfortable due to the lack of foreign body sensation in the urethra. In this study we prospectively evaluated the risk of an anastomotic stricture in 250 patients. Material & Methods: Since 2001 250 patients have undergone open radical prostatectomy using a running suture vesicourethral anastomosis and a suprapubic catheter for urinary diversion. The anastomosis was done using one continuous 3-zero monofil suture for each semi-circumference, which are knot together at 3 and 9 o´clock. 4 weeks post-operatively all patients were regularly reassessed (PSA, continence, potency, medical condition). Continence is defined as 0 or 1 safety pad, mild incontinence as 2-3 pads and severe incontinence as > =4 pads. Further Follow-up was done on a defined schedule by the referring physician and reported by a standardized fax. All anastomotic-strictures, regardless when they occurred, were included in this study. The influence of pathological stage, surgical margins, time to catheter removal, lymphocele, NVBstate and postoperative UTI was analyzed using JMP 6.0. The mean Follow Up was 46.2 months. To assess the method of urinary diversion we also performed a non-randomized age & stage matched comparison with 190 patients where a transurethral catheter was used for urinary diversion. Results: The mean age was 63,5+-7,2 years. Mean preoperative PSA was 7.9 ng/ml. pT stage distribution was 70.7 % pT2, 23.7% pT3 and 5.6 % pT4 in patients with a sC vs. 68.03 %, 27.13 % and 4.79 % in those with a tC (n.s.). The 4-weeks continence rate was 76,4% continent, 20,8% mild incontinent and 2,8% severe incontinent (no difference in the control group). We did not find a statistically significant factor to influence the 4-week continence rate. The time to catheter removal was 4-8 days in 63.8 %, 9-13 days in 26.3 % and >14 days in 10%. The anastomotic stricture rate was 3,2%(without TC) vs. 5.3% in those with a tc (n.s.). All strictures occurred within the first 2 years. In a multivariate analysis a postoperative UTI (p=0,022) was the only significant predictor of an anastomotic stricture. Conclusions: Using a running vesicourethral anastomosis in radical prostatectomy and a suprapubic catheter does not lead to an increased anastomotic stricture rate in this prospective study with a mean Follow up of 46.2 months. In contrast, the anastomotic stricture rate is very low combined with a high 4-week continence rate. Additionally we could not find a significant difference between using a sC or a tC for urinary diversion. Because of the aforementioned advantages the Suprapubic catheter became the standard diversion for RRPE at our department.

Eur Urol Suppl 2009;8(4):221