V12-11: The use of scaffolding tissue biografts to bolster the vesicourethral anastomosis during salvage robot-assisted radical prostatectomy reduces leak rates and catheter times.
In One of the key contributing factors to morbidity associated with salvage robot-assisted radical prostatectomy (sRARP) is a significant vesicourethral anastomosis (VUA) disruption causing a large prolonged urinary leak, perineal pain and delayed catheter removal. The reason for this leak is often not due to a poorly sutured anastomosis but rather to post-operative tissue breakdown secondary to inadequately vascularized tissue caused by the ablative nature of primary therapy. In this study, we used a tissue biomaterial graft called Matristem® from ACell® that was sewn into the base of the VUA in order to provide better integrity and to act as a scaffold for improved healing and prevention of anastomotic disruption.
From March to July in 2015, 8 patients underwent sRARP with Matristem scaffold placement at the time of VUA after primary therapy failure (Group 1). Primary radiation therapy was used in 6 patients (75%) (IMRT- 3 cases and brachytherapy- 3), cryoablation- in 1 patient (12.5%), and high intensity focused ultrasound (HIFU)- in 1 patient (12.5%). Group 1 patients were then propensity matched to patients in the GRI database undergoing sRARP with no graft placement (Group 2) and with patients undergoing primary RARP with no graft placement (Group 3). The endpoints to define the VUA healing were a prevalence of anastomotic disruption confirmed by presence of extensive leak of contrast media beyond anastomotic site on cystography and catheterization time.
Clinically significant anastomotic disruption was observed in one patient out of 8 (12.5%) with median catheterization time of 11.2 days (range: 10-32) in Group 1 and in 3 patients out of 8 (37.5%) in Group 2 with 17.4 days (range: 10-57), respectively (Table 1). The rate of other perioperative complications according to Clavien definition of ≥ 2 was same in Group 1 and Group 2 [1 case (12.5%) (p>0.3)], while Group 3 had no perioperative complications. Group 3 had significantly less catheterization time [median- 6.3 days (range: 5-7), p=0.05], when compared to either Group 1 or Group 2. Overall, sRALP without graft placement was associated within anastomotic disruption, while primary RALP alone did not have this complication. However, this VUA disruption as an evidence of a significant leak was noticed only in cases that underwent primary radiation therapy.
ConcluThe occurrence of anastomotic disruptions after sRARP are drastically reduced by the use of a tissue scaffold incorporated into the VUA. Incorporation of a Matristem graft into the base of anastomosis decreased the rate of disruption, enhanced healing and reduced catheterization time in patients undergoing sRALP.