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AUA 2018

AUA 2018: Early versus Standard Catheter Removal After Complete Anatomical Reconstruction During Robot-Assisted Radical Prostatectomy: Results from RIPRECA

San Francisco, CA (UroToday.com) With the advent and wide-spread adoption of the da Vinci robotic system for performing robotic radical prostatectomy, urologists are able to precisely perform the urethrovesical anastomosis under high-definition and magnified vision. Several studies have suggested that bladder neck contracture rates are lower for patients undergoing robotic vs open radical prostatectomy [1-2], suggesting that the anastomosis technique may be superior for robotic prostatectomy. Furthermore, patient quality of life is most impacted by the post-operative indwelling Foley catheter. Based on the above observations, whether the Foley catheter can be removed early to enhance patient satisfaction without compromising post-operative care is an important clinical question. Giuliana Lista, MD, and colleagues presented results of their single institution randomized control trial (RCT) assessing early vs standard catheter removal after robotic radical prostatectomy. The objective of their trial was to evaluate urinary retention rate, discomfort and postoperative functional outcomes of early (3rd postoperative day) vs standard catheter removal (5th postoperative day).

This RCT was conducted from September 2016 to May 2017 at Humanitas Clinical and Research Hospital, Milan, Italy. Eligible patients for robotic radical prostatectomy were randomized into two groups: Group A - 3rd postoperative day catheter removal vs. Group B - 5th postoperative day catheter removal. Exclusion criteria for the trial included patients with prior urethral or prostate surgery. At the completion of the urethrovesical anastomosis, patients were included in the trial if they had a negative intraoperative anastomosis leak test, which constituted 250 cc of saline mixed with methylene blue instilled into the bladder. Outcomes included:
  • Urinary retention rate after catheter removal
  • Functional outcomes: evaluated with ICIQ-M-LUTS, IPSS, IIEF5 questionnaires at hospital discharge and at 1, 3 and 6 months after surgery
  • Postoperative discomfort: quantified with abdominal, urethral and perineal VAS score at hospital discharge and 1 month after surgery
  • Early urinary continence rate: assessed with PAD test at hospital discharge and at 1 month after surgery
For this RCT, there were 77 (50.3%) and 76 (49.7%) patients that underwent early (Group A) and standard catheter removal (Group B), respectively. There was no difference in baseline characteristics, which included age, BMI, prostate volume, PSA, clinical stage, biopsy Gleason score or median IPSS, IIEF or ICIQ scores.

Results of the outcomes are as follows:
  • Urinary retention: Group A – n=3 (3.9%) vs Group B – n=1 (1.3%) (p=0.3) 
  • Continence rate at hospital discharge: Group A – n=41 (53.3%) vs Group B – n=35 (46%) (p=0.4) 
  • Continence rate at 1 month: Group A – n=55 (72%) vs Group B – n=58 (76%) (p=0.5)
  • ICIQ-M-LUTS voiding and incontinence score at hospital discharge – no difference between groups (p=0.75 and 0.12) 
  • ICIQ-M-LUTS voiding and incontinence score at 1 month – no difference between groups (p=0.8 and 0.11) 
  • Median ICIQ MLUTS voiding symptoms and IPSS score at 3 months – no difference between groups (p=0.38 and 0.56) 
  • Median ICIQ MLUTS voiding symptoms and IPSS score at 6 months – no difference at 6 months (p=0.18 and 0.17)
  • Urethral discomfort at hospital discharge - significantly higher in Group B patients (p=0.02)
  • Uroflowmetry - median maximum flow rate at 1 month: Group A – 17 ml/s vs Group B – 18 ml/s (p=0.29) • Uroflowmetry - median voided volume at 1 month: Group A – 179 ml vs Group B – 234 ml (p=0.05)
The authors are to be congratulated for completing this RCT. However, one of the limitations of the study is that there was no sample size calculation to detect discernable differences between the early vs standard catheter removal groups. The authors concluded that early catheter removal represents a feasible and safe option in patients treated with robotic radical prostatectomy. Although not pragmatic in US hospital systems where patients typically are discharged on postoperative day 1 or 2 with their Foley catheter, Giuliana suggests that their findings may promote decreased hospital stay (the catheter is removed prior to discharge secondary to many patients traveling from large distances to their medical center) and patient discomfort.

Presented by: Giuliana Lista, MD Humanitas Clinical and Research Hospital, Milan, Italy
Co-Authors: Giovanni Lughezzani, Nicolò Buffi, Roberto Peschechera, Pasquale Cardone, Massimo Lazzeri, Paolo Casale, Luisa Pasini, Silvia Zandegiacomo, Alessio Benetti, Alberto Saita, Rozzano Giorgio Guazzoni, Rozzano Milan, Italy

References:
1. Cho HJ, Jung TY, Kim DY, et al. Prevalence and risk factors of bladder neck contracture after radical prostatectomy. Korean J Urol 2013;54(5):297-302.
2. Krambeck AE, DiMarco DS, Rangel LJ, et al. Radical prostatectomy for prostatic adenocarcinoma: A matched comparison of open retropubic and robot-assisted techniques. BJU Int 2009;103(4):448-453.

Written by:  Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA