EURURO Vol. 71 No. 5

828 844

incontinence, one of them severe enough to require
an ATOMS implant (AMI, Vienna, Austria). Another
two patients in the control group had incontinence due
to detrusor hyperactivity, and a further patient had mixed
incontinence. Detrusor overactivity was observed in four
patients, three in the control group and one in the ARVUS
group. Erection was evaluated in patients with initial IIEF-5
score 19. At 6 and 12 mo, 40.0% and 73.33% of patients in
the control group and 38.8% and 72.22% of patients in the
ARVUS group could achieve erection . Univariate
analysis showed that the type of the operation was the only
predictive factor of continence at 8 wk (OR 8.486, 95% CI
2.774–25.954; p < 0.001).
4. Discussion
PPI is a common complication that significantly impairs
quality of life . Some men suffering from PPI are even
willing to undergo another surgery such as placement of a
sling, adjustable balloons, urethral bulking agents, or an
artificial urinary sphincter . Robotic surgery with its
technical advantages has the potential to enhance and
improve RP, especially in terms of continence . At our
institution, we perform approximately 240 RARPs every
year. Patients are then monitored for oncologic and
functional outcomes and we try to help patients with PPI
in cooperation with a physiotherapist.
In designing our ARVUS approach, we were inspired by
the work of Dal Moro et al. , who introduced a new
reconstruction technique for posterior urethral support in
non-NS RARP. There are clear benefits of NS techniques for
erectile function recovery , but their positive role in
improving continence is not unanimously accepted
Nevertheless, extending the approach of Dal Moro
et al, we developed a technique for obviating neurovascular
bundle damage in patients undergoing NS RARP. Inclusion
of patients treated with NS RARP better reflects everyday
clinical practice. From our own observations and the
literature , the fibres of the levator ani muscle and
levator ani fascia, together with the prostatic fascia, are in
close contact with the rhabdosphincter and prostate. In
performing RARP, these structures are carefully separated.
In our view, we should try to restore these functional-
anatomical relations. We hypothesise that there are several
possible effects of ARVUS that we believe were not fully
explained by Dal Moro et al. . (1) We create a dorsal
dynamic suspensory support for the urethra similar to sling
operations. (2) We reconstruct the dorsal musculofascial
plate, which serves as a fixation point for the rhabdos-
pincter fibres. This constitutes the most widely used
principle described by Rocco and colleagues. (3) Posterior
reconstruction avoids tension on the anastomosis and (4)
prevents bladder prolapse (the free space previously
occupied by the prostate is filled). (5) This procedure can
also reduce the probability of urethrovesical anastomosis
leakage, which is important for proper anastomosis healing,
and (6) can improve haemostasis (7) In the final step,
the arcus tendineus is reattached to the bladder neck, which
allows anterior stabilisation of the vesicourethral complex
, restoring the anatomy closer to the presurgical state
and rebuilding an effective pressure transmission system to
prevent PPI . In our opinion, the better functional results
observed in our study are due not only due to the possible
physiological role of our reconstruction approach but also to
a well-performed resection phase consisting of sparing
techniques (preservation of urethral length, bladder neck,
puboprostatic ligaments, and nerves).
Cognisant of the ambiguity of continence definitions in
the literature we decided to use both a validated
questionnaire (ICIQ-SF) and 0 pads/d to define continence.
In our view, the methods used do not undermine the
validity of this study, since it was a randomised trial. Pad
tests were not used given our experience with noncompli-
ance.
The ARVUS group showed improved early continence
rates compared to the control group immediately after
catheter removal and at 2, 4, and 8 wk after catheter
removal, even though the immediate continence difference
between the groups (24 h) was not statistically significant.
The 6- and 12-mo results showed better continence rates in
the ARVUS group. Concerning erectile function, there was
no difference between the two groups. More than 70% of the
patients who had good preoperative erectile function had
restored function at 12 mo.
Our results are in accordance with other studies showing
the benefits of functional reconstruction on early recovery
(30 d after surgery) of urinary continence, although
reconstruction techniques and continence definitions vary.
In a nonrandomised single-arm study, Porpiglia et al.
recorded promising continence rates of 71.8%, 77.8%, 89.3%,
94.4%, and 98.0% at 24 h and 1, 4, 12, and 24wk, respectively,
after catheter removal. In a randomised clinical trial, Jeong
et al. observed a shorter time to social continence for
their one-step posterior reconstruction (18 d) compared to
no reconstruction (30 d). In two other randomised clinical
trials, Hurtes et al. and Koliakos et al. found better
early continence rates after combined posterior and anterior
reconstructions compared to standard single-layer anasto-
mosis. In the largest prospective study to date (803 patients),
Coelho et al. observed a shorter interval to urinary
continence recovery and, similar to our findings, no
significant difference in long-term continence rates. Two
other randomised clinical trials provided contradictory
results. Although Menon et al. showed high continence
rates for anterior and posterior reconstruction, these authors
also found similar results in their control group (single-layer
Table 3 – Patients achieving erectio
Time point Patients achieving erection, n (%)
Control group (n = 34) ARVUS group (n = 32)
Before surgery 15 18
6 mo 6 (40.0) 7 (38.8)
12 mo 11 (73.33) 13 (72.22)
ARVUS = advanced reconstruction of vesicourethral support.
a Erection was defined as an International Index of Erectile Function-5
score 19.
E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 8 2 2 – 8 3 0 828