V4-05: Robotic Assisted Radical Prostatectomy Bladder Neck reconstruction with anterior and posterior intussusception
VideoIntroductions and Objectives
Urinary continence represents a competitive TRIFECTA goal of Robot Assisted Laparocopic Radical Prostatectomy (RALP). Continence outcomes relate to methodological instruments, source of data (patient v. physcian), definitions, preoperative risk factors and pivotal intraoperative factors driven by execution of surgical technique. In terms of technique, several factors have been evaluated, such as: Preserving the urethral complex (vascular control, urethral length, neurovascular bundles and puboprostatic ligaments) and keeping pudendal nerve branches intact. Improving the management of the bladder neck (preservation, tubularization, reconstruction). Reconstruction of Rhabdophincter of the bladder neck was introduced by Walsh & Marschke (J Urol-2002) as the use of buttressing sutures, aimed to prevent the bladder neck from pulling apart as the bladder fills. These investigators found patient-reported early continence outcomes of: 3-month continence rates of 84%. 7% rate of bladder neck contracture.
We participated in a phase IIIb randomized clinical trial (RCT) employing personal digital device (PDA) that asked continence related questions to patients screened and randomized on a daily basis. Patients were screened the day of catheter removal and provided with the PDA. Those reporting 2 or more pad per day usage were eligible for randomization to study drug vs. control for 12 weeks. This video clip shows our vesico-urethral anastomosis surgical technique with posterior and anterior intussusception of the bladder neck. A wide bladder neck is managed with posterior tennis racquet reconstruction. Otherwise a “parachute” approach is used.
96 patients were screened between October 2011 and August 2013. 46 patients did not met criteria for randomization. 40 of these failed because they met continence outcome (0-1 PPD). 4 of the whom 6 failed for other reasons (UTI, other) met continence outcome within 3 months of RALP. 50 patients were randomize. 38 patient met study continence outcome (0-1 PPD). All together 82/96 (85%) within 3 months of RALP
Intussusception of the bladder neck is feasible, reproducible and time efficient. The 3 month continence outcomes from patients involved in a RCT was superior by 21% from those observed in of prior RCT that evaluated the reconstruction of the rhabdosphinter (Sutherland et al. J Urol 2011)