- Email: [email protected]
The Devil Is in the Details: Still True
EURURO-6352; No. of Pages 2 EUROPEAN UROLOGY XXX (2015) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
The Devil Is in the Details: Still True Fiona C. Burkhard * Department of Urology, University Hospital Bern, Inselspital, Bern, Switzerland
Robotic surgery has conquered the field of urology at a speed unmet in any other discipline. This may be due to the exceptional marketing, the willingness of urologists to accept and adopt new techniques, and the potential for improvement in patient care. The latter, however, remains to be proven. A new technique should not only adhere to the existing, established, and optimized technique, with which experience has been gained over years, but also improve outcomes and/or reduce costs. With robotic cystectomy and urinary diversion, equality in terms of extirpative and oncologic results may have been achieved at certain selected centers of excellence but, by far, not as a routine procedure. Intracorporeal construction of an orthotopic bladder substitute is in its fledgling stage and requires extremely high technical skills. Saying this, it also has to demonstrate an improvement in comparison to open surgery [1]. One of the main goals of orthotopic bladder substitution is to optimize patients’ quality of life by maintaining an intact body image and quasinormal voiding function (eg, daytime and nighttime continence, complete emptying, bladder control). Functional outcome depends on how cystectomy is performed, with a special emphasis on nerve sparing to maintain urethral function. The orthotopic bladder substitute itself has to have certain characteristics such as low pressure and high compliance. This is best achieved when the reservoir is spherical, based on Laplace’s law (pressure = tension / radius), so that the maximum capacity and the lowest possible pressure for the given surface of bowel is obtained. The value of urodynamics in intestinal reservoirs is limited. As long as the same technique is used (cross-folded ileal segment of similar length), a difference in volume or pressure spikes is not to be expected. Based on the
above-mentioned Laplace’s law, urodynamic results depend on the capacity of the reservoir. A small or low-capacity reservoir has higher pressure spikes and end filling pressure, whereas a reservoir with higher capacity will have lower spikes and end filling pressures. In 1964, Ekman et al elegantly showed that pressure spikes that can cause urinary incontinence are lower and appear at much higher filling volume in spherical reservoirs compared with neotubular (two opposing segments) or tubular configurations [2]. Bladder capacity, in contrast, is the result of postoperative patient education, that is, teaching the patient how to slowly increase bladder capacity to an optimal volume of 400–500 ml. Overdistension with volumes of up to 1000 ml, as in the series by Satkunasivam et al [3] in this month’s issue of European Urology, give wonderful urodynamic results with low pressure and high capacity but should be avoided because it leads to a floppy bag with incomplete emptying. Patients in this series had a postvoid residual of >250 ml after urodynamics, which has not been observed by others with the same type of bladder substitute [4]. In comparison to the open surgery group, almost double the number of men in the robotic group required catheterization, a factor that has an negative impact on quality of life and an increased risk for infectious complications. Impaired emptying is often the result of outlet obstruction, for example, due to kinking of the outlet or mucosal prolapse, and should be recognized quickly and treated appropriately. Assessment of health-related quality of life in bladder substitutes are fraught with potential pitfalls. The Bladder Cancer Index (BCI) was designed to assess quality of life with bladder cancer in general [5]. The questions concerning urinary domains are not necessarily appropriate for bladder substitutes. This is obviated by the fact that, despite
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2015.06.041. * Department of Urology, University Hospital Bern, Inselspital, Anna Seiler Haus, Bern 3014, Switzerland. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2015.07.057 0302-2838/# 2015 Published by Elsevier B.V. on behalf of European Association of Urology.
Please cite this article in press as: Burkhard FC. The Devil Is in the Details: Still True. Eur Urol (2015), http://dx.doi.org/10.1016/ j.eururo.2015.07.057
EURURO-6352; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2015) XXX–XXX
the patients being wetter and needing bigger pads, there was no significant difference in BCI scores, although a trend in favor of open surgery was observed [3]; however, based on the small number of patients, statistical relevance may be somewhat limited. As functional outcome is also dependent on surgical technique, especially nerve sparing, it would have been interesting to assess erectile function in these patients. For the moment, robotic orthotopic bladder substitution at most is equal to open surgery. In this context, the robotic group had a certain disadvantage [3]. The trend toward better continence in the open surgery group could be explained by the significantly longer follow-up, with the patients in the robotic group having less time to recover from neuropraxia and to increase their bladder capacity. In summary, the authors showed that a spheroidal reservoir with low pressure and high compliance can be constructed robotically, which in itself is an achievement demanding excellent technical skills [3]. Functional outcome in this limited number of patients and in comparison to a retrospective series of open orthotopic neobladder seems slightly inferior, although not statistically significant because of the small numbers. We await with interest
further studies to determine whether robotic cystectomy and intracorporeal construction of an orthotopic bladder substitute are true advancements. Conflicts of interest: The author has nothing to disclose.
References [1] Bochner BH, Dalbagni G, Sjoberg DD, et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol 2015;67:1042–50. [2] Ekman H, Jacobsson B, Kock NG. The functional behaviour of different types of intestinal urinary bladder substitutes. Congr Int Soc Urol London 1964;2:213–7. [3] Satkunasivam R, Santomauro M, Chopra S, et al. Robotic intracorporeal orthotopic neobladder: urodynamic outcomes, urinary function, and health-related quality of life. Eur Urol. In press. http://dx. doi.org/10.1016/j.eururo.2015.06.041 [4] Burkhard FC, Kessler TM, Springer J, Studer UE. Early and late urodynamic assessment of ileal orthotopic bladder substitutes combined with an afferent tubular segment. J Urol 2006;175:2155–60, discussion 2160-1. [5] Gilbert SM, Wood DP, Dunn RL, et al. Measuring health-related quality of life outcomes in bladder cancer patients using the Bladder Cancer Index (BCI). Cancer 2007;109:1756–62.
Please cite this article in press as: Burkhard FC. The Devil Is in the Details: Still True. Eur Urol (2015), http://dx.doi.org/10.1016/ j.eururo.2015.07.057
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
The Devil Is in the Details: Still True Fiona C. Burkhard * Department of Urology, University Hospital Bern, Inselspital, Bern, Switzerland
Robotic surgery has conquered the field of urology at a speed unmet in any other discipline. This may be due to the exceptional marketing, the willingness of urologists to accept and adopt new techniques, and the potential for improvement in patient care. The latter, however, remains to be proven. A new technique should not only adhere to the existing, established, and optimized technique, with which experience has been gained over years, but also improve outcomes and/or reduce costs. With robotic cystectomy and urinary diversion, equality in terms of extirpative and oncologic results may have been achieved at certain selected centers of excellence but, by far, not as a routine procedure. Intracorporeal construction of an orthotopic bladder substitute is in its fledgling stage and requires extremely high technical skills. Saying this, it also has to demonstrate an improvement in comparison to open surgery [1]. One of the main goals of orthotopic bladder substitution is to optimize patients’ quality of life by maintaining an intact body image and quasinormal voiding function (eg, daytime and nighttime continence, complete emptying, bladder control). Functional outcome depends on how cystectomy is performed, with a special emphasis on nerve sparing to maintain urethral function. The orthotopic bladder substitute itself has to have certain characteristics such as low pressure and high compliance. This is best achieved when the reservoir is spherical, based on Laplace’s law (pressure = tension / radius), so that the maximum capacity and the lowest possible pressure for the given surface of bowel is obtained. The value of urodynamics in intestinal reservoirs is limited. As long as the same technique is used (cross-folded ileal segment of similar length), a difference in volume or pressure spikes is not to be expected. Based on the
above-mentioned Laplace’s law, urodynamic results depend on the capacity of the reservoir. A small or low-capacity reservoir has higher pressure spikes and end filling pressure, whereas a reservoir with higher capacity will have lower spikes and end filling pressures. In 1964, Ekman et al elegantly showed that pressure spikes that can cause urinary incontinence are lower and appear at much higher filling volume in spherical reservoirs compared with neotubular (two opposing segments) or tubular configurations [2]. Bladder capacity, in contrast, is the result of postoperative patient education, that is, teaching the patient how to slowly increase bladder capacity to an optimal volume of 400–500 ml. Overdistension with volumes of up to 1000 ml, as in the series by Satkunasivam et al [3] in this month’s issue of European Urology, give wonderful urodynamic results with low pressure and high capacity but should be avoided because it leads to a floppy bag with incomplete emptying. Patients in this series had a postvoid residual of >250 ml after urodynamics, which has not been observed by others with the same type of bladder substitute [4]. In comparison to the open surgery group, almost double the number of men in the robotic group required catheterization, a factor that has an negative impact on quality of life and an increased risk for infectious complications. Impaired emptying is often the result of outlet obstruction, for example, due to kinking of the outlet or mucosal prolapse, and should be recognized quickly and treated appropriately. Assessment of health-related quality of life in bladder substitutes are fraught with potential pitfalls. The Bladder Cancer Index (BCI) was designed to assess quality of life with bladder cancer in general [5]. The questions concerning urinary domains are not necessarily appropriate for bladder substitutes. This is obviated by the fact that, despite
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2015.06.041. * Department of Urology, University Hospital Bern, Inselspital, Anna Seiler Haus, Bern 3014, Switzerland. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2015.07.057 0302-2838/# 2015 Published by Elsevier B.V. on behalf of European Association of Urology.
Please cite this article in press as: Burkhard FC. The Devil Is in the Details: Still True. Eur Urol (2015), http://dx.doi.org/10.1016/ j.eururo.2015.07.057
EURURO-6352; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2015) XXX–XXX
the patients being wetter and needing bigger pads, there was no significant difference in BCI scores, although a trend in favor of open surgery was observed [3]; however, based on the small number of patients, statistical relevance may be somewhat limited. As functional outcome is also dependent on surgical technique, especially nerve sparing, it would have been interesting to assess erectile function in these patients. For the moment, robotic orthotopic bladder substitution at most is equal to open surgery. In this context, the robotic group had a certain disadvantage [3]. The trend toward better continence in the open surgery group could be explained by the significantly longer follow-up, with the patients in the robotic group having less time to recover from neuropraxia and to increase their bladder capacity. In summary, the authors showed that a spheroidal reservoir with low pressure and high compliance can be constructed robotically, which in itself is an achievement demanding excellent technical skills [3]. Functional outcome in this limited number of patients and in comparison to a retrospective series of open orthotopic neobladder seems slightly inferior, although not statistically significant because of the small numbers. We await with interest
further studies to determine whether robotic cystectomy and intracorporeal construction of an orthotopic bladder substitute are true advancements. Conflicts of interest: The author has nothing to disclose.
References [1] Bochner BH, Dalbagni G, Sjoberg DD, et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol 2015;67:1042–50. [2] Ekman H, Jacobsson B, Kock NG. The functional behaviour of different types of intestinal urinary bladder substitutes. Congr Int Soc Urol London 1964;2:213–7. [3] Satkunasivam R, Santomauro M, Chopra S, et al. Robotic intracorporeal orthotopic neobladder: urodynamic outcomes, urinary function, and health-related quality of life. Eur Urol. In press. http://dx. doi.org/10.1016/j.eururo.2015.06.041 [4] Burkhard FC, Kessler TM, Springer J, Studer UE. Early and late urodynamic assessment of ileal orthotopic bladder substitutes combined with an afferent tubular segment. J Urol 2006;175:2155–60, discussion 2160-1. [5] Gilbert SM, Wood DP, Dunn RL, et al. Measuring health-related quality of life outcomes in bladder cancer patients using the Bladder Cancer Index (BCI). Cancer 2007;109:1756–62.
Please cite this article in press as: Burkhard FC. The Devil Is in the Details: Still True. Eur Urol (2015), http://dx.doi.org/10.1016/ j.eururo.2015.07.057