達文西機器手臂輔助攝護腺根除術後膀胱固定術可改善失禁的早期恢復

黃鈺翔¹、吳俊德¹、馮思中¹、虞凱傑¹、甘弘成¹、邵翊紘¹、黃亮鋼¹、林柏宏¹

¹林口長庚紀念醫院 外科部 泌尿外科

Cystopexy after robot-assisted radical prostatectomy improves early recovery of incontinence

Yu-Hsiang Huang¹, Chun-Te Wu¹, See-Tong Pang¹, Kai-Jie Yu¹, Hung-Cheng Kan¹, I-Hung Shao¹, Liang-Kang Huang¹, Po-Hung Lin¹

¹Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan

Purpose

Prostate cancer is the second most common cancer in males worldwide. Active surveillance, radical prostatectomy, and radiation plus androgen deprivation therapy are mainstay treatments for localized prostate cancer. Robotic-assisted radical prostatectomy(RaRP) is the main type of radical prostatectomy. Postoperative incontinence and erectile dysfunction after RaRP were associated with poor quality of life. The basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. Cystopexy is a relatively simple procedure that involves permanently securing the urinary bladder in a more proximal direction. By fixing the bladder within the abdominal cavity, the trigone and proximal urethra are exposed to intra-abdominal pressure that may improve the tone of the upper urethral sphincter (Figure 1). The effect of cystopexy on continence recovery was still unknown so this analysis was conducted to evaluate the benefit of cystopexy on continence recovery.

Materials & methods

Patients with primary localized or locally advanced prostate cancer receiving RaRP under transperitoneal anterior approach between January 2019 and December 2023 were enrolled in this study. Patients who received (1)Extraperitoneal approach RaRP, (2)Retzius sparing- RaRP and (3)Hood technique were excluded. 170 consecutive RaRP performed by a single surgeon during 2015 and 2019 without cystopexy and 35 cases performed by another single surgeon during 2019 and 2022 with cystopexy. Demographic data, cancer status, peri-operative parameters, as well as continence function were recorded. Bladder neck sparing, anterior fixation and Rocco’s stitch. Primary outcome was immediate(1 week), short term(1 month), intermediate(3month) and long term(6 month) continence rate, which was defined as complete dry without safe pad utility.

Results

There was no significant difference between demographic data, cancer status and peri-operative parameters. Early recovery of continence were significantly better for patients receiving cystopexy within one week (48.6% vs 31.2%, p=0.048) and one month (68.8% vs 47.6%, p=0.025). The rate of continence recovery at twelve and twenty-fourth weeks were not significantly different(Table 1). Higher rate of lymphocele (8.6%) was found in the group of patients receiving cystopexy.

Conclusions

Cystopexy after conventional transperitoneal anterior approach of robot-assisted radical prostatectomy improves early recovery of continence.

(A)                        (B)

Figure 1. (A) Cystopexy after RaRP. (B) Cystography after RaRP with Cystopexy. The blue arrows indicate suspension power from cystopexy. The red arrows indicate horizontal component force against sphincter.