DETRUSOR HYPOCONTRACTILITY AFTER OPEN RETROGRADE, ANTEGRADE AND ROBOT-ASSISTED RADICAL PROSTATECTOMY: FUNCTIONAL AND URODYNAMIC PRELIMINARY DATA

Gerardo Pizzirusso 1, Federico Lanzi 1, Federica Scipioni1, Nicola Tosi 1, Filippo Cecconi 1, Filippo Gentile1, Aude Canale 1, Giovanni De Rubertis1, Gabriele Barbanti1
  • 1 AOU Senese - U.O.C. di Urologia (Siena)

Objective

The aim of the present study is to evaluate a particular set of patients who develops a post micturition residual after radical prostatectomy for clinically localized prostate cancer. Prospective collection of clinical, pathological and functional data started in order to confirm the etiopathological hypothesis of a significative surgical stress of nervous fibers of hypogastric plexus that may occur during traction and isolation of seminal vesicles. Moreover, this study had to answer the empirical observation of a different distribution of post micturition residual development through different approaches to the intervention : open retrograde, open antegrade and robot assisted antegrade radical prostatectomy.

Methods and results

We prospectively evaluated 59 consecutive patients undergone open retrograde (ORP), 64 open antegrade (OAP) and 52 robot-assisted radical prostatectomy (RRP) for clinically localized prostate cancer. Groups resulted homogeneous in terms of clinical and pathological staging, preoperative PSA and bioptic and pathological Gleason Score. Functional follow-up included the administration of ICIQ-SF questionnaire at months 1,3,6 and 12 and uroflowmetry at the 6th month postoperative. In case of non pathological flow and post micturition residual (PMR)≥30cc in patients without preoperative PMR we performed urodynamic evaluation according to International Continence Society (ICS) recommendations.
Data resulted complete for 53 patients undergone open retrograde (ORP), 61 to open antegrade (OAP) and 52 to robotic-assisted radical prostatectomy (RRP). Mean follow-up was (range) 23.7(13-49) months. Overall, 88.5% of ORP, 89.2 of OAP and 90.5% of RRP Group patients fulfilled our continence criteria (≤1pad and ICIQ-SF≤2) at a minimum follow-up of 12months. In ORP Group 11/24(45.8%) patients without preoperative PMR developed a postoperative PMR≥30cc, 12/27(44.4%) of OAP and 8/32(25%) of RRP. These patients were further investigated through urodynamic study. In ORP Group we identified a true newly-onset PMR significantly linked to a detrusor hypocontractility in 8/11(72.7%) patients: mean Qmax, PDet and PMR of patients with true PMR were (range) 11.8(5.9-14.5)mL/s, 31.7(18.1-45.1)cmH2O and 42(32-56)cc Vs 13.2(8.2-16.2)mL/s, 33.7(20.6-47.2)mmH2O and PMR<30cc in the remaining 3 cases. In OAP Group mean Qmax, PDet and PMR of the 6/12(50%) patients with true PMR were (range) 13.6(6.8-19.4)mL/s, 32.4(19.6-45.3)cmH2O and 36.4(32-48)cc Vs 14.5(8.1-15.3)mL/s, 37.8(21.2-48.9)mmH2O and PMR<30cc in the remaining 6 cases. In RRP Group mean Qmax, PDet and PMR of the 2/8(25%) patients with true PMR were (range) 14.2(9.1-19.3)mL/s, 36.2(25.5-46.9)cmH2O and 35.4(32-38.4)cc Vs 15.1(10.7-19.5)mL/s, 40.4(30.2-50.6)mmH2O and PMR<30cc in the remaining 6 cases. It was found a significant correlation of surgical procedure to the onset of detrusor hypocontractility wich resulted greater in ORP Group Vs OAP one (p=0.0036), in OAP Group Vs RRP one (p=0.006) and in ORP Group Vs RRP Group (p<0.0001). The exiguity of RRP patients with true PMR didn’t allow the comparison of various nerve-sparing techniques

Discussion

A newly onset post micturition residual in patients undergone radical prostatectomy may be due to a detrusor hypocontractility; its various prevalence among the surgical techniques may be referred to different nervous fibers of hypogastric plexus stress during isolation of seminal vesicles: thus, bladder mobilization and traction results greater during open retrograde than open antegrade and robot-assisted prostatectomy in which bladder manipulation is usually limited to the neck region. The extension of pre and postoperative urodynamic evaluation to patients with and without preoperative PMR and to nerve-sparing procedures could better define the efficacy of PMR as a signal of detrusor hypocontractility

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