EURURO Vol. 71 No. 5

Introduction

Radical prostatectomy (RP) for localised prostate cancer has

excellent oncologic results and a low rate of complications

[1,2]

. However, functional outcomes in terms of continence,

and erection still lag behind,markedly reducing the quality of

everyday life for patients, especially those who are younger

and more active

[3]

. The proportion of continent patients at

12 mo after surgery ranges from 69% to 96%

[4] .

Noteworthy

is the relatively long duration to achieve continence. The

disparities in the literature result from various definitions of

continence and measurement methods (questionnaires,

number of pads, pad test). A number of factors have been

identified for postprostatectomy incontinence (PPI), includ-

ing patient characteristics (body mass index, age, prostate

volume, and comorbidities), surgeon experience, and surgical

precision

[5]

. No effect of pelvic floor muscle exercise before

surgery on PPI has been conclusively demonstrated

[6]

The advent of minimally invasive methods has facilitated

new surgical techniques, ways of resection, and especially

the reconstruction phase after RP, aimed at improving

functional results without impairing early oncologic out-

comes

[7] .

This allows us to adjust the anatomical and

functional relationships in the pelvis after removal of the

prostate to ameliorate PPI and reduce the time to achieve

complete continence. A number of papers and several

reviews with very promising results in this direction have

been published. The time to complete continence has been

gradually reduced to 3-6 months, resulting in clear benefits

for patients

[5] .

Hence, it is now possible to refine the

surgical technique in order to reduce the incidence of PPI,

rather than resolve the PPI when it occurs

[8]

There are a number of operating procedures and

techniques for improving continence after RARP: preserva-

tion of the bladder neck, nerve-sparing (NS) techniques,

preserving maximum length of the urethra, preserving the

puboprostatic ligament and endopelvic fascia, posterior

rhabdosphincter reconstruction, anterior reconstruction,

and suture of the arcus tendineus to the bladder neck

[9,10] .

This study was motivated by a new technique for

performing the reconstructive phase of RARP, involving

suture of the pelvic floor muscles to create a dynamic

semicircular support for the urethra

[11] .

This technique has

been adopted in operations without the use of NS techniques

with excellent results for continence. This inspired us to use

the principle to devise our own method for advanced

reconstruction of vesicourethral support (ARVUS) obviating

damage to the neurovascular bundles, creating support for

the anastomosis, fixing the arcus tendineus to the bladder

with the medial levator ani, and correcting the functional-

anatomical relations after RP. Here we present the first

results for this method in comparison to the standard

posterior reconstruction method of Rocco that we have

routinely used at our institution since 2009

[12]

Patients and methods

2.1.

Study population and design

This was a prospective, randomised study involving 66 consecutive

patients presenting to our Department of Urology for RARP from June to

September 2014. The inclusion criterion was localised prostate cancer

(cT1–2N0M0). Exclusion criteria were: patients not suitable for RARP or

any neoadjuvant hormonal treatment, prior radiation therapy, no

transurethral resection of the prostate, and previous history of urethral

stricture and urinary incontinence. Patients were randomised to two

groups using the online software QuickCalcs (GraphPad Software, San

Diego, CA, USA) with blinding for group allocation. The study coordinator

informed the surgeon of the randomisation outcome before surgery. The

other members of the team involved in the study did not know the

randomisation results. The ethics committee of the University Hospital

had strong objections to blinded procedures in patients, but eventually

approved the blinding protocol. This was done at the outset of the study.

The patients gave their written informed consent. One surgeon (V.S.)

with experience of more than 800 RARPs performed the surgeries. This

innovative technique had already been performed in 15 patients who

were not included in this study.

Conclusions:

The ARVUS technique yielded better urinary continence results than standard

posterior reconstruction, with no negative impact on erectile function, complication rate, or

oncologic outcome. External validation is warranted before clear recommendations can be

made.

Patient summary:

We showed that postprostatectomy incontinence can be assuaged using

a new technique for vesicourethral anastomosis reconstruction during robot-assisted

radical prostatectomy (RARP). This could significantly improve the quality of life of patients

after RARP. More studies are needed to support our results.

[(Fig._1)TD$FIG]

Fig. 1 – Anatomic structures involved in the reconstruction phase.

NVB = neurovascular bundle.

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