V11-12: The Detrusor Apron Sparing Hood (DASH) Technique for Robot-Assisted Radical Prostatectomy
One of the major health related quality of life issues following radical prostatectomy (RP) is urinary incontinence. The detrusor apron (DA), although well described, is often sacrificed during RP despite its role in continence being unclear. Herein, we present our modified technique for continence preservation, which we call the Detrusor Apron Sparing Hood (DASH) technique.
We developed our technique using the idea, development, exploration, assessment, long-term follow-up (IDEAL) guidelines as a framework for development, specifically utilizing the idea, development and exploration aspects to help guide our process. For the idea phase, we conducted a literature review to investigate the anatomic and functional roles of the DA regarding continence. We also stained two patient specimens obtained from our traditional RP technique to examine the DA; the specimens were first stained using the Trichrome Masson method, and then we added an S-100 stain to explore the presence of nerves anteriorly. The development phase consisted of modifying our surgical steps such that the DA would be maximally preserved. We also determined how to incorporate the DA into our total anatomical reconstruction technique. We then performed our modified technique on 10 patients to assess the technique&[prime]s safety and technical/procedural success. The exploration phase consisted of performing the DASH technique in 100 patients and subsequently collecting follow-up data concerning their time to continence recovery.
One key modification in the DASH technique includes omission of the endopelvic fascia bilaterally. As the lateral prostatic fascia dissection moves distally, the DA is identified and incised off the anterior aspect of the prostate typically at the base or mid segment of the prostate. The only modification of our anastomosis is that we suture the DA back onto the anterior aspect of the bladder at the end. As of October 2018, we have successfully performed the DASH in 158 patients. Of them, 113 have completed the first follow-up visit (average 5 weeks). The continence rate, defined as no need for pads or condom devices was 73%.
The DASH technique is a safe and feasible method of performing RP. More follow-up is necessary to assess long-term outcomes.