|Year : 2020 | Volume
| Issue : 6 | Page : 267-272
Surgical and functional outcomes of robotic-assisted radical prostatectomy in patients with previous transurethral resection of the prostate
Sih-Han Chen1, Chun-Hsien Wu2, Richard Chen-Yu Wu3, Wade Wei-Ting Kuo4, Yen-Hsi Lee5, Ryh-Chyr Li6, Yung-Yao Lin3, Victor Chia-Hsiang Lin6
1 Department of Urology, E-Da Hospital, Kaohsiung, Taiwan
2 Department of Urology, E-Da Hospital; Department of Chemical Engineering, Institute of Biotechnology and Chemical Engineering; Department of Nursing; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
3 Department of Urology, E-Da Hospital; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
4 Department of Urology, E-Da Hospital; Department of Chemical Engineering, Institute of Biotechnology and Chemical Engineering, I-Shou University; School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
5 Department of Chemical Engineering, Institute of Biotechnology and Chemical Engineering; School of Medicine, College of Medicine, I-Shou University; Department of Urology, E-Da Cancer Hospital, Kaohsiung, Taiwan
6 Department of Urology, E-Da Hospital; School of Medicine, College of Medicine; School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
|Date of Submission||04-Jun-2020|
|Date of Decision||11-Sep-2020|
|Date of Acceptance||25-Sep-2020|
|Date of Web Publication||26-Dec-2020|
Victor Chia-Hsiang Lin
No. 1, Yida Road, Jiaosu Li, Yanchao District, Kaohsiung City
No. 1, Yida Road, Jiaosu Li, Yanchao District, Kaohsiung City
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of this study was to assess the surgical and functional outcomes of robotic-assisted radical prostatectomy (RARP) in patients with previous transurethral resection of the prostate (TURP). Materials and Methods: The present article studies 99 patients who underwent RARP, including 13 patients with previous TURP at a single institution, in the period from April 2016 to February 2019. Propensity score matching 1:1 was performed to identify 13 patients with no previous TURP. The matched variables were age and preoperative prostate-specific antigen level. Surgical and functional outcomes were compared between the two groups. Descriptive statistics were evaluated using the Chi-square test. t-test was performed for continuous variables. Results: Regarding preoperative characteristics, no previous TURP group had a higher clinical stage (P = 0.026). The nerve-sparing procedure was similar between the two groups. Concerning intraoperative outcomes for the group with previous TURP history, the operating room time was increased by 25 min (P = 0.140), and the estimated blood loss was increased by 50 ml (P = 0.192). As for the postoperative pathological characteristics, there was no significant difference in the positive surgical margin rate between the two groups. The continence rate in the 3rd month for the group with previous TURP history was 69.2% versus 92.3% for the group with no previous TURP history, and after the 1st year, the rates were 100% versus. 92.3%. There was no significant difference in the potence recovery rate between the two groups after 1-year follow-up. Conclusion: RARP is safe and feasible in patients with localized prostate cancer with previous TURP history. Functional outcomes after 1-year follow-up were comparable for patients with previous TURP.
Keywords: Functional outcomes, prostate cancer, robotic-assisted radical prostatectomy, transurethral resection of the prostate
|How to cite this article:|
Chen SH, Wu CH, Wu RC, Kuo WW, Lee YH, Li RC, Lin YY, Lin VC. Surgical and functional outcomes of robotic-assisted radical prostatectomy in patients with previous transurethral resection of the prostate. Urol Sci 2020;31:267-72
|How to cite this URL:|
Chen SH, Wu CH, Wu RC, Kuo WW, Lee YH, Li RC, Lin YY, Lin VC. Surgical and functional outcomes of robotic-assisted radical prostatectomy in patients with previous transurethral resection of the prostate. Urol Sci [serial online] 2020 [cited 2021 Jan 21];31:267-72. Available from: https://www.e-urol-sci.com/text.asp?2020/31/6/267/305097
| Introduction|| |
Prostate cancer is the seventh leading cause of death from cancer for males in Taiwan and the second leading cause of cancer death for males in the United States. Compared to watchful waiting for localized prostate cancer, radical prostatectomy could reduce local tumor progression and distant metastasis and increase cancer-specific survival and overall survival., Since the introduction of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) in 2000, robotic-assisted radical prostatectomy (RARP) had rapidly grown in popularity because the robotic system helps surgeons perform delicate dissection and precise vesicourethral anastomosis reconstruction. The incidental finding of prostate cancer after transurethral resection of the prostate (TURP) was 1.4%. However, patients who underwent RARP with previous TURP history would have greater operative difficulties and may compromise the continence outcome.,,,, One large retrospective study revealed that no prolonged operative time and increased estimated blood loss were reported in surgeries performed on patients who underwent RARP with previous TURP history; yet, worse functional outcome was observed. Historical studies are full of controversial results. Therefore, this study aims at assessing the impact on functional and surgical outcomes in patients who underwent RARP after TURP in our medical institution.
| Subjects and Methods|| |
One hundred consecutive patients with clinically localized prostate adenocarcinoma, who underwent RARP and pelvic lymph node dissection at our institution from April 2016 to February 2019, were retrospectively enrolled according to the regulation of the Institutional Review Board in our hospital (IRB EMRP 102-093). Patients, who had metastatic disease presentation or received any kind of neoadjuvant therapy (n = 1) before RARP, were excluded from our study. Clinicopathological characteristics were prospectively collected from our database, of which 13 patients had undergone TURP. A 1:1 propensity score matching cohort was retrieved. The matched variables were age and pre-RARP prostate-specific antigen (PSA) levels.
One high-volume surgeon performed all RARP using the da Vinci Xi Surgical System via either extraperitoneal or intraperitoneal approach, and all patients underwent pelvic lymph node dissection, either the standard or extended fashion accordingly. Cystoscopy had been performed for patients with previous TURP history before RARP in order to assess whether ureteral catheterization was indicated. Neurovascular bundle preservation was attempted according to preoperative pathologic finding and also the preoperative erection function of the patients. All the patients would receive posterior reconstruction of the rhabdosphincter and anterior suspension during RARP. In addition, all patients had bladder neck reconstruction with mucosal eversion during operation. After the vesicourethral anastomosis was performed, 50–100 ml of diluted water instilled into the Foley catheter is used to check if there was any urine leakage.
Cystography was performed for patients who had fragile bladder and urethral tissue or difficult vesicourethral anastomosis according to the surgeon's opinion. 150–200 ml of diluted contrast instilled into a Foley catheter is used at low pressure. Any contrast leak at the anastomosis site would be noted under fluoroscopy in the lateral oblique position.
The primary outcomes were the recovery of urinary continence and erectile function. The functional outcome regarding continence was assessed preoperatively and at 3, 6, 9, and 12 months after RARP. Urinary continence was defined as the use of zero or no more than one protective safety pad per 24 h. Pelvic floor muscle exercise would be instructed postoperatively to all the patients. Furthermore, erection hardness score questionnaires were used preoperatively and prospectively 12 months after RARP to assess the patient's erectile function. Potence was defined as erectile hard enough for vaginal penetration with or without phosphodiesterase type 5 inhibitors. In addition, patients who had preoperative potence and did not have androgen deprivation therapy (ADT) would be selected for subgroup potence analysis.
Surgical outcomes consisted of three parts. Intraoperative characteristics were the first part. The parameters compared between the two groups included estimated blood loss, transfusion, skin-to-skin operative room time, catheterization time, and postoperative hospital stay. In addition, the postoperative pathologic characteristics included pathological Gleason score, pathological tumor stage, prostate volume, positive surgical margin (PSM), positive lymph nodes, seminal vesicle invasion, and lymphovascular invasion. The last part was the postoperative complications. Early complications were defined as complications that happened within 1 month postoperatively. Late complications were defined as complications that happened after 1 month postoperatively. All the complications were stratified by the Clavien classification. Hemorrhage meant that the blood loss during the operation was >500 ml.
To minimize potential selection biases, propensity score matching regarding age and PSA was used in the group with TURP history to the group with no previous TURP history in a 1:1 fashion. Descriptive statistics of categorical variables were evaluated using the Chi-square test. t-test and Mann–Whitney U-test were performed for continuous variables. Kaplan–Meier curve was performed to assess the rate of early continence recovery. All analyses were performed using IBM SPSS software (version 24; IBM Corp., Armonk, NY, USA). A two-sided P < 0.05 was considered statistically significant.
| Results|| |
Patients' characteristics after 1:1 propensity score matching are shown in [Table 1]. Preoperative characteristics were matched according to PSA and age adequately. In the group with no previous TURP history, patients had a higher clinical stage which reached statistical significance (P = 0.026). The comorbidity rate between the two groups was similar. The preoperative potence rates for the group with previous TURP history and the group with no previous TURP history were 69.2% and 43.8%, i.e., there was no significant difference between the two groups. The group with previous TURP history had a 100% preoperative continence rate, and the group with no previous TURP history also had a 100% preoperative continence rate. Ten patients (76.9%) in the group with previous TURP history performed extraperitoneal RARP, and seven patients (43.8%) in the group with no previous TURP history performed the extraperitoneal RARP (P = 0.411). In addition, nerve-sparing procedures were similar for both groups (P = 0.368). Two patients in the group with previous TURP history needed ureteral catheterization before RARP. In the current study, the mean duration from TURP to RARP was 23 months. Seven patients who were detected adenocarcinoma on TURP chips (53.8%) underwent RARP within 3 months after TURP. Six patients, who had benign prostatic hyperplasia on TURP chips, developed prostate adenocarcinoma on subsequent follow-up.
After propensity score matching, intraoperative findings are demonstrated in [Table 2]. The operative room time was increased by 25 min in the group with previous TURP history (P = 0.140), and the estimated blood loss was increased by 50 ml in the group with previous TURP (P = 0.192). Two cases (15.4%) in the group with previous TURP history required blood transfusion compared to zero cases who needed to have a blood transfusion in the group with no previous TURP history. The length of catheterization time was increased by 1 day in the group with previous TURP history (P = 0.055). The hospital stay time was similar between the two groups. Two patients in the group with TURP history performed the cystography after RARP, and two patients in the group with no TURP history performed the cystography after RARP. Postoperative pathologic characteristics are presented in [Table 2]. The PSM rate was not significantly increased in the previous TURP group (P = 0.691). [Table 3] lists the postoperative complications. The overall early and late complications did not have a significant difference between the two groups. Two patients (15.4%) in the group with previous TURP history developed deep vein thrombosis which was the most common early complication. One patient (7.7%) in the group with no previous TURP history had urethral stricture which was completely recovered after repeated urethral sounding. Postoperative functional outcomes are listed in [Table 4]. The continence rate at 3 months for the group with previous TURP history and the group with no previous TURP history was 69.2% versus 92.3%, respectively (P = 0.161). The continence rate between the group with previous TURP history and the group with no previous TURP history at 12 months was similar (100% vs. 92.3%). Only one patient in the group with no previous TURP history had urinary incontinence during follow-up. In [Figure 1], the early recovery of urinary incontinence did not have a significant difference between the two groups. Besides, post-RARP potence rates in 12 months were similar between the two groups (15.4% vs. 15.4%). There were 6 and 4 patients with and without previous TURP respectively after omitting the patient received ADT. In this subgroup analysis, 33.3% and 50% patients recovered to be potent with or without PDE5 inhibitor after 12 months follow up.
| Discussion|| |
Patients in the group with no previous TURP history had a higher continence rate at 3 months. However, the continence rate at 12 months was similar between the two groups instead. The potence recovery rate did not have a significant difference between the two groups after 12-month follow-up.
A number of studies reported that patients who underwent RARP, whether with or without TURP history, did not have a significant difference in the functional outcomes.,, However, Pompe et al. reported that worse functional outcome was observed in patients who underwent previous TURP in a large prostatectomy cohort. After propensity matching, the authors concluded that continence rates after 3 and 12 months were worse for the group with TURP history (67.5%/74.1% and 81%/88.4%), and the erectile function for the group with TURP history and the group with no TURP history were 29.8% and 40.1%, respectively, after 1-year follow-up. Gupta et al. tried to explain patients with a history of TURP who had worse urinary outcomes: (1) surrounding fibrosis would affect surgeon to preserve adequate residual urethral length and perform well urethrovesical anastomosis, (2) widen bladder neck after TURP would increase the need for bladder neck reconstruction, and (3) TURP itself might disable the internal sphincter mechanism and place the external sphincter at risk which increases incontinence risk.
In the current study, all of the patients in the group with TURP history were totally continent and 92.3% of the patients in the group with no previous TURP history were continent after 1-year follow-up. Only one patient in the group with no previous TURP history, who was of 83 years old with type II diabetes mellitus, had urinary incontinence. The continence rates for patients with previous TURP history were not less than those of the patients with no previous TURP history. All the patients in the present study underwent posterior support of the rhabdosphincter and anterior suspension, which might be the reason for satisfied continence rates for both groups. Atiemo et al. concluded that postoperative continence was depended on the rhabdosphincter. Reconstruction of remnant Denonvilliers' fascia and posterior bladder neck to the posterior rhabdosphincter were performed in all RARP patients, which might be useful for the earlier postoperative return of urinary continence. Hurtes et al. concluded that anterior suspension associated with posterior reconstruction during RARP would improve the early recovery of continence rate.
Klein suggested performing the bladder neck reconstruction during radical prostatectomy for better urinary control since 1992. Several technical methods including circular flap, bladder neck plication, invagination, and intussusception were commonly used for decades to improve the continence early recovery after the operation. Nevertheless, these were mainly underpowered studies and such findings were not confirmed by further prospective studies. Besides, the bladder neck preservation was developed to preserve the internal sphincter and better urinary outcomes. Kim et al. concluded that the bladder neck preservation technique could improve early recovery of urinary continence. In the current study, bladder neck reconstruction was performed for all patients. The bladder neck reconstruction may have a positive effect on continence recovery rates.
There were many factors that could influence erectile function after radical prostatectomy. Gupta et al. hypothesized that periprostatic adhesions would make neurovascular bundle identification more difficult and increase the risk of impotence. In addition, Mazzola and Mulhall concluded that the side effects of ADT on sexual function were significant. However, radiation therapy would not increase erectile dysfunction after radical prostatectomy. In the present study, the overall potence rate was similar between the two groups. After taking preoperative erectile function, and patients who underwent ADT and radiation therapy after RARP into consideration, two of six patients (33.3%) in the group with TURP history and two of four patients (50.0%) in the group with no TURP history recovered to potence after 12-month follow-up.
One hypothesis reported by several authors was that patients with previous TURP history who underwent RARP would have scarring and fibrosis at their bladder neck which might be the worse outcomes for operative time, length of stay, and overall complication rate.,, Besides, different methods would have different degrees of the bladder neck and periprostatic changes. Suardi et al. found that there was significant difficulty in the dissection of the neuromuscular bundles in patients with previous TURP history. However, recent data showed that the operative room time and estimated blood loss were increased in the group with TURP history though it did not reach statistical significance. The catheterization time was longer in the group with previous TURP history. The Foley catheter would be removed after 1 week approximately. The difficulty of vesicourethral anastomosis, body weight index, and volume of pelvic drainage fluid would be considered in order to determine whether or not the urethral catheter should be removed. In addition, the hospital stay time, early complications, and late complications were similar between the two groups. Two patients experienced deep venous thrombosis in the group with previous TURP history. The risk of deep venous thrombosis was increased for these two patients due to their overweight body mass index. Only one patient (7.6%) had late complications, which was the urethral stricture in the group with no previous TURP history. No late complications were observed in the group with previous TURP history. In the current study, the nerve-sparing procedure rate was higher in the group with previous TURP history, which had similar results compared to earlier studies.,, Hampton et al. reported 1768 patients who underwent RARP, of which 51 had undergone prior TURP. Positive margin rates were observed 35.3% in the group with previous TURP history compared to 17.6% in the group with no previous TURP history. In contrast, Tugcu et al. exhibited that the positive margin was similar between patients who underwent RARP with or without a history of TURP. Whether the PSM rate were affected by previous TURP still remained debatable.,, In the present study, the PSM rate was not increased in the group with previous TURP history. Although the group with no previous TURP history had a higher clinical stage, it did not have a significant effect on the PSM rate. The current study hypothesized that the clinical stage might be too subjective, which may have a bias. The postoperative pathologic stage was similar between these two groups.
There were several limitations to the current study. It was a retrospective study, and the cohort was small with short follow-up time. The interval between TURP to RARP was 23 months, with a wide range from 2 to 113 months. The clinical stage was different between the two groups. Echo checks were not performed regularly in order to assess the lymphocele, which might be asymptomatic. Thus, the complications rate might be underestimated.
| Conclusion|| |
RARP is safe and feasible in patients with localized prostate cancer, with previous TURP history. By posterior support of the rhabdosphincter and anterior suspension, patients could have a satisfied continent rate. Besides, the recovery of functional outcomes resembles those of the patients who had no previous TURP.
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Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4]