Are early continence recovery and oncological outcomes biased by different devices in prostatic apex dissection during laparoscopic radical prostatectomy?
Treatment of prostate cancer has evolved considerably in the last decade. All the efforts of surgery were addressed to obtain optimal oncologic outcomes, with low rate of complications and minimal negative impact on erectile function or continence to assure good quality of life in treated patient. New surgical devices, such as dissector and hemostatic scalpels, allow a precise surgical field definition with a finest dissection of the anatomic structures, with subsequent reduced operative times, better oncological and functional outcomes. Although monopolar scissors (MS) are still widely used, radiofrequency (RF) and ultrasound (US) scalpels have been introduced in LRP because they offer a good support for dissection and hemostasis, minimizing operative time and blood loss. Despite the widespread use of these scalpels in laparoscopy, there are few studies comparing these devices in terms of oncological and functional outcomes after radical prostatectomy. The aim of the present study is to compare the use of MS, RF and US scalpels in relation to the recovery of urinary continence and positive margins in patients undergoing extraperitoneal LRP (ELRP).
Methods and results
A total of 150 men were prospectively enrolled during the period between September 2009 and April 2013. All of the patients had a diagnosis of prostatic adenocarcinoma, as determined by transperineal ultrasound-guided biopsy after preliminary clinical evaluation involving digital rectal examination (DRE) and assessment of serum prostate-specific antigen (PSA) levels (total PSA, free-PSA, and ratio). Clinical stage of the disease was determined in all patients by abdominopelvic magnetic resonance and whole-body bone scintigraphy. All patients who met the following preoperative criteria, according to European Association of Urology (EAU) guidelines, underwent bilateral nerve sparing (NS) ELRP: PSA ≤10 ng/mL; life expectancy >10 years ; no extracapsular disease, negative DRE, no more than 2 positive cores per lobe, primary Gleason pattern = 3.
Postoperative (90 and 180 days after ELRP) evaluation of continence was performed for all patients with the International Consultation on Incontinence self-administered Questionnaire –Urinary Incontinence Short Form (ICIQ-UI Short Form), a condition-specific, quality of life questionnaire developed by the International Continence Society (ICS) for patients with urinary incontinence.
Using a stratified randomization to control for baseline covariates, the patients were randomly assigned to group A (RF; n = 50), group B (US; n = 50) or group C (MS; n = 50).
Age, prostate-specific antigen, clinical stage, body mass index (BMI), and baseline urinary function were similar in all groups. Perioperative data did not differ significantly between the 3 groups. Focusing on intraoperative data there were not differences regarding operative times and blood loss.
Surgical complications were evaluated basing on Clavien classification, the rates were 8% (grade 1), 10% (grade 2) and 2% (grade 3) for group A; 8% (grade 1), 12% (grade 2) and 4% (grade 3), group B; 10% (grade 1), 14% (grade 2) and 2% (grade 3) group C. Bladder neck strictures rate was 4 % (2 patients) in group A; 6% (3 patients) in group B; 4% (2 patients) group C. All patients were treated with transurethral incision of bladder neck within 3 months postoperatively. Similar to overall surgical margin positivity, there were no significant differences between groups in term of apical margin positivity.
Mean days of catheterization were group A 6,69; group B 8,86 and group C 8,25 (Figure 1). Moreover, no differences regarding functional outcomes evaluated by ICIQ scores at 1 month, at 3 months and 6 months were observed.
The reported rates in literature of urinary incontinence after radical prostatectomy range from 2.5% to 87.0%, and differ considerably according to its definition, follow-up duration, and surgical technique. The purpose of this study was to analyze the effects of the use of different devices during the same surgical procedure on continence recovery after surgery and oncological positive margins after LRP. Results of the present study showed that the use of RF, US and cold scissors were similar with respect to operative time, blood loss, postoperative hospital stay, while a shorter catheterization time in RF group of patients has been found. In addition, in our case series, the recovery of continence was reported by 71.7% of patients 3 months postoperatively, reaching 94.7% at 6 months follow-up. There are not nowadays in literature studies focusing the outcomes of different devices during the apex dissection and urethral stump preparation on early recovery of continence. Our study represents the first evaluation of continence recovery in LRP with respect to different devices used for prostatic apex dissection.
Most surgeons choose one device or the other basing their decision on practical aspects, such as its ergonomic feature and its hemostatic efficacy. Larger prospective randomized studies with a longer follow-up are necessary to assess other scalpel devices and to encourage surgeons to select a particular device based on an objective demonstration of its superiority.
Oncological, functional and operative outcomes are similar between these different devices during LRP. This is the first study in literature focused on continence recovery with respect to different devices used in LRP. In our study, none scalpel has demonstrated its superiority in continence recovery, confirming literature data on their efficacy and safety.
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