BERKELEY, CA (UroToday.com) - The precise etiology of post-prostatectomy incontinence remains unknown and is likely multifactorial.
Various surgical techniques to minimize incontinence after radical prostatectomy have been described, including maximization of urethral length, rectourethralis reconstruction, and minimizing damage to the rhabdosphincter. Selective suture ligation of the dorsal venous complex has also been described as a means to minimize damage to the rhabdosphincter during robotic assisted laparoscopic prostatectomy (RALP).
We began to utilize this technique in June 2009 and soon thereafter noted quicker return of continence in our patients. Therefore, the purpose of our study was to further explore and confirm our observations by evaluating the outcomes of selective suture ligation after athermal division of the DVC (SSL-DVC) versus suture ligation prior to athermal division of the DVC (SL-DVC) during RALP. We compared the results of 240 men undergoing SSL-DVC to those of 303 men undergoing SL-DVC by a single surgeon at our institution. Our hypothesis was that patients undergoing SSL-DVC would have less damage to the rhabdosphincter and thus earlier return of urinary continence and improved postoperative urinary function scores measured by the Expanded Prostate Cancer Index Composite (EPIC).
Our results showed that men undergoing SSL-DVC had improved 5-month postoperative EPIC urinary function (72.9 vs. 55.4, p <0.001) and continence (defined as zero pad use, 61.4% vs. 39.6%, p <0.001). However, 12 month urinary outcomes were similar between both groups. While men undergoing SSL experienced greater blood loss (mean: 184.3 vs. 175.6ml, p = 0.033), the transfusion requirement was similar in each group (0.4% vs. 0%, p = 0.442). Despite concerns of decreased visualization during apical dissection, apical positive margins were also similar (1.3% vs. 2.7%, p = 0.361). Finally, performing DVC-SSL significantly shortened operative time by 15 minutes (mean: 131.8 min vs. 147.0 min, p <0.0001).
Therefore, we concluded that SSL of the DVC after athermal division is an easily reproducible technique that can lead to earlier return of continence in patients undergoing RALP. This is likely due to minimized damage to the rhabdosphincter, which may be injured by earlier and less selective suture ligation prior to DVC division. Performing this technique does not increase the likelihood of blood transfusion or positive apical margins.
For a complete description and video of our surgical technique in performing SSL-DVC, please refer to our article in the Surgery in Motion section in European Urology.
Written by:
Keith J. Kowalczyk MD and Jim C. Hu MD, MPH as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Division of Urology
Brigham and Women's Hospital/Harvard Medical School
Boston, MA
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