S P CIENTIFIC APER Posterior Reconstruction and Outcomes of Laparoscopic Radical Prostatectomy in a High-Risk Setting U. Anceschi, MD, M. Gaffi, MD, C. Molinari, MD, and C. Anceschi, MD ABSTRACT continence at 1 and 3 mo. The increased adjuvant radio- therapyrateandqualityoflifeaftersurgeryobservedwith Background and Objectives: To detail the technique ourtechniquesuggestthatinthehigh-risksettinganearly and evaluate the impact of a personal modified posterior functionalrecoverymaysubstantiallyinfluencetheonco- reconstruction technique (PDR) on the outcomes of ex- logic outcome of eLRP. trafascial laparoscopic radical prostatectomy (eLRP) in a consecutive series of 52 patients affected by high-risk KeyWords:High-riskprostatecancer,Laparoscopicrad- prostate cancer (HRPCa). ical prostatectomy, Posterior reconstruction, Early conti- nence. Methods: From October 2007 to March 2012, 52 patients underwent PDR during eLRP for HRPCa. Fifty-four pa- tientswhounderwenteLRPforHRPCawithnoPDRwere considered as historical controls. Mean operative time (MOT), mean catheterization time (MCT), % continence INTRODUCTION and quality of life (QoL) at a scheduled follow-up, % anastomotic leakage, % adjuvant therapy were compared Althoughnouniformdefinitionforhigh-riskprostatecan- between the groups. Percentage of continence and QoL cer (HRPCa) exists, it is generally agreed that clinical were prospectively assessed by self-administered vali- suspicion of extraprostatic extension (cT3), high biopsy dated questionnaires (ICI-Q-SF; SF-36) at 1, 3, 6, and12 Gleason sum, (8–10) and high pretreatment PSA levels months. ((cid:1)20.0ng/mL) represent adverse disease characteristics.1 Results: PDR was associated wither higher continence ratesat1and3mo(P(cid:1).028,P(cid:1).006),alowerincidence ThebestmanagementofHRPCaremainsdebatable.Inthe of cystographic leakage (P (cid:1) .002), and an increased last decade, for patients with HRPCa, urologists tradition- adjuvant radiotherapy rate (P (cid:1) .008). At 1- and 3-mo ally recommended radiotherapy or androgen deprivation interval, in the PDR group, we found a higher number of therapy over radical prostatectomy (RP), because rates of patientsreportingbettergeneralhealth,(P(cid:1).01,P(cid:1).03) incontinence with surgery were high and cure rates were reduced role limitations due to physical health, (P (cid:1) .02, discouraging.2 With the development of a mini-invasive P (cid:1) .001), and emotional problems (P (cid:1) .001, P (cid:1) .02). approach to RP and advancements in laparoscopic tech- niques, both morbidity and functional outcomes have Conclusions: PDR is associated with a lower degree of improved substantially.3,4 anastomoticleakage,anditsignificantlyenhancesurinary According to several series, extrafascial laparoscopic rad- PoliclinicoTorVergata,DepartmentofUrology,Rome,Italy(Dr.U.Anceschi);S. ical prostatectomy (eLRP) in the high-risk setting appears Camillo-ForlaniniHospital,DepartmentofUrology,Rome,Italy(Drs.Gaffi,Moli- to be a reasonable option in select cases,5,6 but early nari,C.Acceschi). recoveryofurinarycontinenceremainsachallenge.7Pos- Drs.AnceschiU,GaffiM,MolinariC,AnceschiChavenoconflictsofinterestto terior Denonvilliers’ reconstruction (PDR) has recently disclose. emerged as a topic of current research interest in the AcknowledgmentstoMrs.MichelaCanganiandMr.AlessandroBoveforproviding attempt to improve the recovery of urinary continence illustrationsofourwork;toMrs.FrancescaErcoliforherstrongandcontinuous support. after RP.8 Addresscorrespondence:toUmbertoAnceschi,MD,DepartmentofUrology,Viale deiColliPortuensi579-CAP00151Rome(Italy).PoliclinicoTorVergata,Viale We present a modified PDR performed in a series of 52 Oxford 81 00133- Rome – Italy. Telephone: (cid:2)39–0665744402; Mobile: (cid:2)39– eLRPsforHRPCa.Thisreportdetailsthesurgicalsteps,the 3395836431,E-mail:[email protected] feasibility, and the effectiveness of our technique in pro- DOI:10.4293/108680813X13794522666365 motingearlycontinenceandenhancingQoLinmenwith ©2013byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby theSocietyofLaparoendoscopicSurgeons,Inc. high-risk disease. JSLS(2013)17:535–542 535 PosteriorReconstructionandOutcomesofLaparoscopicRadicalProstatectomyinaHigh-RiskSetting,AnceshiUetal. MATERIALS AND METHODS Usually,inthehigh-risksetting,wedonotsparetheBNas a rule, and we dissect the prostate outside the lateral Between October 2007 and March 2012, 52 patients with prostaticfascia(extrafascialRP),becausethepreservation HRPCaunderwenteLRPwithPDR(groupA).Asahistor- ofthesestructuresmayincreasethelikelihoodofpositive ical control, 54 preceding patients with a suitable fol- margins.12 One of the key steps of our technique is blunt low-upwhohadeLRPforHRPCawithnoPDR(groupB) dissectionoftheposteriorplanebetweentheprostateand were identified. Medical charts of all patients were re- therectalsurface,sparingtheposteriorDenonvilliers’fas- viewed from a prospectively maintained, institutional re- cia(PDF).Adeeperdissectionattheperirectalfattytissue view board-approved database. All patients provided should be avoided whenever possible, because if PDF is written informed consent prior to surgery. Each patient not adequately preserved, reconstruction may very diffi- underwent preoperative tumor staging with chest/abdo- cult (Figure 2).8 men/pelvis contrast computed tomography scan (CT) or magnetic resonance imaging (MRI) and a comprehensive After puboprostatic ligaments are divided and the dorsal preoperative assessment. Characteristics of patients en- vein complex controlled with 12 mm-Ligasure Atlas, the rolled in the study are shown in Table 1 and Figure 1, anteriorurethraisdividedandtheurethrallumenopened. respectively. Patients affected by HRPCa who met one or Finally, the specimen is entrapped in the endobag. moreofthefollowingcriteriawereincluded:cT3disease, PDRisdonebyplacingarunningMonosyn2–0sutureon high biopsy Gleason sum (cid:1) 8; PSA levels (cid:1) 20ng/mL.9 aUR-6needle,approximatingthecephaladDenonvilliers’ Any involuntary urine loss or pad use was chosen as the fascia (posteriorly to the bladder) to the cut edge of the definitionofincontinence.Patientswithpriorneoadjuvant distal paraurethral Denonvilliers’ remnant. The initial su- therapy and impaired urinary continence before surgery ture is placed at the posterior bladder neck 1cm to 2cm wereexcludedfromtheanalysis.Alltheprocedureswere from its luminal edge (Figure 3). The next suture is performedbyasinglesurgeon(CA)withextensiveexpe- placed through the tissue posterior to the transected ure- rience in eLRP for high-risk cases ((cid:3)150 procedures). thra (Figure 4). PDR is provided by a running suture performed in an anticlockwise fashion. On tying this su- Surgical Procedure ture,reconstructedPDRprovidesposteriorsupporttothe vesicourethralanastomosis(VUA),whilethebladderneck Conventional laparoscopic radical prostatectomy has been descends close to the urethral stump (Figure 5). A stan- described elsewhere extensively.10 Briefly, a 5-port trans- dard completion of the vesicourethral anastomosis with peritoneal approach is used. An extended lymph node interrupted stitches followed in both groups.13 A drain dissection is performed prior to RP, removing all lym- was left in the Retzius space before desufflation. phatictissuebetweentheexternaliliacveinandhypogas- tric vein above and below the obturator nerve, including Cystogram was performed in all patients prior to catheter the hypogastric and obturator lymph nodes.11 The pros- removal.Ifnosignificantleakwasdetected,atrialtovoid tate anterior surface is exposed after defattering and the wasconducted(Figure6).Incaseofurinaryleakage,the bladder neck (BN) is identified. catheterwasleftinplaceandthecystogramrepeatedafter a few days. Continence rates and patients’ health- related QoL were Table1. assessedwithself-administratedvalidatedICQ-SF14,15and Patients’BaselineCharacteristics SF-3616 questionnaires, respectively, at a scheduled fol- Characteristics PDRn(cid:1)52 NoPDRn(cid:1)54 P low-up (1, 3, 6, 12 mo after surgery). Sexual function Value evaluation was excluded for all extrafascial prostatecto- mies.Nocontinencerehabilitationprogramwasprovided Age 67.2(52–74) 64.5(48–75) .155 postoperativelyinbothgroups.Incaseofpositivesurgical BMI 26(23–28) 26.1(24–28) .523 margins (PSMs) after eLRP, either immediate adjuvant ra- PreoperativePSA 24.2(5–46) 21.4(4.3–68) .615 diotherapy or clinical monitoring followed by salvage MeanProstatesize(g) 56.2(27–65) 51.4(31–80) .118 radiotherapy when PSA exceeded 0.5 ng/mL were of- cT3 11 14 — fered, according to patient’s preference. During follow- GleasonScore(cid:1)8 26 22 . up, any patient who was not referred to the radiotherapy unit of our hospital was excluded from the analysis. Pa- PSA(cid:1)20ng/mL 18 19 . tientswithanypelviclymphnodeinvolvement,regardless 536 JSLS(2013)17:535–542 Figure1.Summaryofthestudy. Figure2.Intraoperativeviewafterspecimenretrieval. Figure 3. PDR reconstruction. Suture started at the posterior bladderneck. of the status of the surgical margins, underwent adjuvant used for continence score and comparison of mean val- hormonal treatment. ues,respectively.Continencestatusat1and3moandthe Statistical analysis was performed using SPSS v.13 (SPSS probability of adjuvant radiotherapy after surgery were Inc,Chicago,IL,USA).FisherztestandStudentttestwere assessedwiththeKaplan-Meiermethodandcomparedin JSLS(2013)17:535–542 537 PosteriorReconstructionandOutcomesofLaparoscopicRadicalProstatectomyinaHigh-RiskSetting,AnceshiUetal. Figure6.CystograminapatientwithPDRshowingnourinary leakage(sixthpostoperativeday). Figure 4. Anticlockwise running suture placed through the tis- sueposteriortothetransectedurethra. Table2. PerioperativeParameters both groups with the log-rank test. A P value of (cid:4) 0.05 Results PDRN(cid:1)52 NoPDR P was considered statistically significant. N(cid:1)54 Value Meanoperativetime 218(122–412) 230(90–270) .142 RESULTS Meanhospitalstay 6.8 7.2 .440 Acomparisonofpreoperativecharacteristicsbetweenthe Urinaryleakage 6 13 .002 2groupsispresentedinTable1.Therewerenosignificant (Cystogram) differences in body mass index, clinical or pathologic Urinaryretention 2 4 .519 Meanlymphnode 20(12–28) 22(9–26) .654 number Meancatheterization 7 11 .118 time tumor stage and grade, preoperative PSA, prostate size, and number of lymph nodes removed. Perioperative data are shown in Table 2. Mean operative time, mean catheterization time, mean hospital stay, and acuteurinaryretentionrateswerenotstatisticallydifferent between the groups. PDR technique resulted in lower anastomoticleakagerate(P(cid:1).002).The2groupshadno significant differences in their pathologic stages, in the frequency of PSMs, and in the Gleason score of the sur- gical specimen (Table 3). In the PDR group, the overall PSMratewas32%,andthePSMratesinpatientswithpT2 and pT3 tumors were 25% and 30%, respectively. In the control group (no PDR), the overall PSM rate was 33%, Figure 5. PDR completed. Final aspect before vesicourethral and the PSM rates in patients with pT2 and pT3 tumors anastomosis. were 26% and 29%, respectively. The proportion of pa- 538 JSLS(2013)17:535–542 tients undergoing adjuvant radiotherapy was significantly significantly greater continence rates at 1-mo and 3-mo higher in the PDR group (P (cid:1) .008; log-rank test, P (cid:1) (P(cid:1).0028;P(cid:1).006;log-ranktest,P(cid:1).0002;Figure7), .0056; Figure 8) while the salvage radiotherapy rate was although the rates at 6 mo and 12 mo were not signifi- higher in the no PDR group (Table 3). cantly affected (Table 4). Median follow-up for urinary continence was 12 mo for Finally,theproportionofpatientsreturningtotheirbase- the entire population. (Table 4). Significant differences line scores in all of the SF-36 domains was significantly wererecordedinthestudygroupatboth1-moand3-mo different between groups (Table 5). At 1- and 3-mo in- intervals, respectively. tervals, we found in the PDR group a higher number of patients reporting better general health, (1 mo: 92% P (cid:1) In the no-PDR group, the continence rates at 1, 3, 6, and .001; 3 mo: 81% P (cid:1) .03) reduced role limitations due to 12 mo after catheter removal were 37%, 54%, 70%, and physicalhealth(1mo:62%P(cid:1).02;3mo:84%P(cid:1).001) 72%,respectively.InthePDRgroup,thecontinencerates and emotional problems, respectively. (1 mo: 86%; P (cid:1) at1,3,6,and12moaftercatheterremovalwere69%,86%, .001; 3 mo: 77%; P (cid:1) .02). 67%, and 73%, respectively. PDR technique resulted in DISCUSSION Table3. In recent years, with the magnified stereoscopic view PathologicResults provided by laparoscopic surgery and the evolution of Results PDRn(cid:1)52 NoPDRn(cid:1)54 PValue surgical technique, morbidity related to RP has been sig- nificantly reduced. As a consequence, indications for RP pT2 12 18 .243 havebeenextendedeventopatientswithhigh-riskpros- pT3 34 29 .870 tatecancerwhotraditionallywereofferedradiotherapyor pT4 6 7 .569 hormonal therapy.2 PSMratepT2 25% 26% .714 Severalstudieshaveshownexcellentresultsinimproving PSMratepT3 30% 29% .629 the continence rate after RP by a posterior reinforcing OverallPSMrate 32% 33% .429 suture prior to VUA.17 According to Nguyen et al.18 the Adjuvantradiotherapy 16(30.7%) 6(11.1%) .008 rationale behind PDR is that a reapproximation of the rate distal and proximal Denonvilliers’ fascia remnants re- Salvageradiotherapy 5(9.6%) 8(14.8%) .521 creates posterior support. This theoretically improves the rate dynamic function and anatomical length of the urethral Figure7.Kaplan-Meieranalysisshowingtheprobabilityofurinarycontinenceafterlaparoscopicradicalprostatectomyinthehigh-risk setting,withandwithoutPDR. JSLS(2013)17:535–542 539 PosteriorReconstructionandOutcomesofLaparoscopicRadicalProstatectomyinaHigh-RiskSetting,AnceshiUetal. Figure 8. Kaplan-Meier analysis showing the probability of adjuvant radiotherapy after laparoscopic radical prostatectomy in the high-risksetting,withandwithoutPDR. confined PCa has shown a better continence rate com- Table4. ContinenceRates pared to conventional LRP,11 our negative trend may be relatedtothewholenumberofeLRPconsidered.Further- ContinenceRate PDRn(cid:1)52 NoPDRn(cid:1)54 PValue more, a large number of patients in the study group CatheterRemoval 19% 22% .657 underwentadjuvantradiotherapy,whichadverselyaffects (1week) early and late urinary continence (Figure 8).22 30days 69% 37% .028 While it is debatable whether adjuvant radiotherapy im- 90days 86% 54% .006 proves biochemical-free survival and reduces the risk of 180days 67% 70% .258 local recurrence, the profound impact of radiation side- 12months 73% 72% .820 effectsonpatient’shealth-relatedQoLremainsclear.2We believe that an early experience of urinary incontinence aftereLRPmayinfluencepatient’sadhesiontomultimodal therapy.Thus,inthehigh-risksetting,afastercontinence stump, increasing continence rates. Since the initial de- recovery after surgery may increase patient’s compliance scription by Rocco et al.9 and the introduction of robotic to an eventual postprostatectomy irradiation as demon- radical prostatectomy (RALP),19 several reconstruction strated by the higher rate of adjuvant radiotherapy in the techniques with multiple variations have been described study group. This provides, indirectly, a further rationale with conflicting outcomes.8,20 for PDR, especially in high-risk disease. To our knowledge, no major series have investigated Our study has several limitations. We analyzed a small selectivelytheimpactofPDRonthefunctionaloutcomes series of patients, using a historical control group for the ofeLRPforHRPCa.Thecontinenceratesinourseriesat1, comparison.Then,weconsideredonlypatientswithhigh- 3,6,and12mowere69%,86%,67%,73%,respectively.At risk disease, which precludes a direct comparison with 1-and3-mointervals,theseresultsseemtobecomparable otherseriescharacterizedbyless-selectiveinclusioncrite- to results of other larger laparoscopic and robotic se- ria. ries,7,21 but a significant decrease in urinary continence rateat6and12mowasobservedinourgroups,showing We are aware that long-term follow-up and prospective no benefit of PDR at a longer follow-up (Table 4). randomized trials with larger series are necessary before VariationsinthetechniquesdescribedforPDRmayjustify adopting a new technique in routine surgical practice. the disparity of our results with the data reported in the AlthoughtheimpactofPDRonlong-termcontinencewas literature.Additionally,becauseintrafascialLRPfororgan- lessaccentuatedinourseries,thistechniqueisreproduc- 540 JSLS(2013)17:535–542 Table5. QoLResultsAccordingtoSF-36Domains SF-36 Physical RoleLimititations BodilyPain GeneralHealth Vitality SocialFunctioning RoleLimitations MentalHealth Functioning (Physical) (Emotional) Group PDR No P PDR No P PDR No P PDR No P PDR No P PDR No P PDR No P PDR No P PDR PDR PDR PDR PDR PDR PDR PDR 1 76% 73% .30 62% 40% .02 88% 88% .90 92% 64% .01 70% 68% .78 70% 65% .84 86% 44% .001 100% 98% .85 months 3 75% 75% .61 84% 46% .00 91% 92% .86 81% 53% .03 75% 70% .88 69% 62% .76 77% 41% .02 98% 98% .92 months 6 69% 66% .89 72% 71% .85 92% 96% .84 66% 50% .76 72% 75% .81 64% 61% .60 76% 55% .61 98% 100% .88 months 12 60% 68% .83 72% 78% .90 94% 96% .81 66% 50% .52 72% 75% .66 69% 75% .41 75% 64% .68 99% 100% .95 months iblewithnoincreaseinmeanoperativetime.Theapprox- 5. 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