The relationship between continence and perineal body tone before and after radical prostatectomy: a pilot study.

INTRODUCTION: Recent preliminary studies showed that tonic-trophic characteristics of the pelvic muscles are related to postoperative male urinary incontinence. The aim of the current study was to test whether perineal body tone (PBT), evaluated using the Beco perineometer (Perineocaliper), is related to urinary continence recovery after robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: The study population consisted of 48 patients who underwent RALP between January and July 2009. Surgical interventions were performed by a single surgeon and patients were evaluated by a single physiotherapist. All patients were taught pelvic floor muscle exercises (PFME). PBT was evaluated in each patient preoperatively, as well 30 days and 3 months after surgery. In addition, patients were evaluated with a 24-hr pad-test and the International Consultation on Incontinence-questionnaire (ICI-Q). RESULTS: Mean age at surgery was 65.5 years (range 46-63). Twenty-four patients underwent a bilateral nerve-sparing procedure (50%). One-month after surgery, 25 (52.1%) patients were continent while 23 (47.9%) patients were still incontinent. A statistically significant difference in preoperative perineometric measures was observed between continent and incontinent patients (mean 1.36 cm vs. 0.80 cm; P < 0.001). This difference was even more pronounced when comparing postoperative perineometric measures (mean 1.24 cm vs. 0.43 cm; P < 0.001). Evaluation of patients 3 months after surgery showed an increase in perineometric measures (mean increase 0.76 cm). The increase was significantly higher in patients who became continent after 3 months relative to patients who were still incontinent despite PFME (mean perineometric measures 1.45 cm vs. 1.00 cm; P = 0.021). CONCLUSIONS: Our results demonstrate that urinary continence recovery is related to PBT recovery. Further studies are needed to confirm whether perineometric measures may be used as a predictive tool for the risk-stratification of postoperative UI.

Vardenafil can improve continence recovery after bilateral nerve sparing prostatectomy: results of a randomized, double blind, placebo-controlled pilot study.

INTRODUCTION: Phosphodiesterase type 5 inhibitors (PDE5-I) have acquired an established role in the treatment of post-prostatectomy erectile dysfunction (ED). Several trials in men with ED and lower urinary tract symptoms associated with benign prostatic hyperplasia suggest that PDE5-I could improve both erectile function and urinary symptoms. AIM: To assess the role of vardenafil in continence recovery after bilateral nerve sparing radical prostatectomy (BNS-RP). METHODS: Thirty-nine patients with prostate cancer were recruited. After BNS-RP, patients were double-blinded assigned to three arms: a) vardenafil on demand; b) vardenafil nightly; and c) placebo. MAIN OUTCOMES MEASURES: Urinary function (UF) and urinary bother (UB) of University of California-Los Angeles Prostate Cancer Index questionnaire were assessed preoperatively and at 1, 3, 6, 9, 10, and 12 months. Twelve-month outcomes were compared to 1 month with a t-test. The differences in UF and UB (at 3, 6, 9, 10, and 12 months) between the three treatment arms were calculated by an analysis of variance. With ALLFIT we estimated half-maximal recovery times (ER50) and maximal recovery (R(max)) in three groups. RESULTS: The improvement of UF and UB between 1 and 12 months was significant in all arms except for placebo (UF: P = 0.125; UB: P = 0.089). Nightly resulted in greater UF at 3, 6, and 9 months and greater UB at 6 months compared with placebo (P = 0.042, P = 0.044 and P = 0.039); after nightly administration, patients presented higher UB than after on-demand use, 3 and 6 months postoperatively (P = 0.036 and P = 0.017). ALLFIT demonstrated a similar ER50 in all groups (2.6 months for both UF and UB) and indicated that nightly administration induced significant improvements in R(max) compared with placebo (both <0.0001). CONCLUSIONS: Vardenafil can improve continence recovery after BNS-RP compared with placebo. The daily use of vardenafil seems to provide better continence rate, although it does not seem to influence the timing needed to achieve full continence.

Current role of robotic assisted partial nephrectomy.

The modern urologists are nowadays greatly involved in the surgical management of small renal masses, where nephron sparing surgery showed adequate oncological results, with a saving of a great amount of healthy renal tissue. Among the various minimally invasive surgical options, laparoscopic partial nephrectomy duplicates the open technique considered the standard of referral. Robotic assisted partial nephrectomy, aims to add to laparoscopy all the well known advantages offered by the Da Vinci system, such as the 3-Dvision and 7 degree of freedom of surgical instruments. We reviewed the current English literature on robotic partial nephrectomy published in 2008-2009 with at least 20 cases, adding our experience of 26 cases. Although the retroperitoneoscopic approach showed to be feasible in selected cases, all the procedures reported were performed with a transperitoneal approach. Among the 106 robotic assisted partial nephrectomy procedures selected, the mean tumor diameter was 2.8 cm; the mean operative time was 148.7 min with a mean warm ischemia time of 23.8 min and the positive surgical margins rate was 1.8%, reflecting the learning curve of the procedure. Overall complications rate was 15%, although the majority were minor and conservatively treated. Although robotic partial nephrectomy is still in its infancy, it showed adequate overall results when compared to laparoscopic partial nephrectomy with similar results but with a reduced learning curve. Actually robotic partial nephrectomy should be considered a viable option for nephron sparing surgery both in experienced laparoscopy centers for larger lesions in robotic naive centers where it may become the standard option for the treatment of small renal masses.

Robotic assisted radical prostatectomy in morbidly obese patients: how to create a cost-effective adequate optical trocar.

Obesity is a major health issue in modern society, and with the progressive widespread employment of robotic assisted radical prostatectomy (RALP), the urologist-robotic surgeon is increasingly involved in the treatment of obese patients. However, the vast majority of urological departments are not equipped with a complete set of bariatric instruments. One of the potential difficulties of robotic surgery on the morbidly obese patient is the relatively short length of the optical trocar sheath, as the optical robotic arm requires some very valuable centimeters of the sheath to hang onto. This condition may make it impossible to properly reach the peritoneal cavity with the optical trocar during the RALP procedure. We present a series of four morbidly obese patients (BMI ranging from 42.1 to 46.2) with localized prostate cancer treated with RALP. We have developed an effective and "easy-to-implement" solution to the problem of properly elongating the sheath of the optical trocar which involves the use of the plastic cylindrical transparent protective tube of a disposable 26-Ch Amplatz sheath. The Amplatz sheath, with an internal diameter of 13 mm and length of 25 cm, perfectly fits outside of the 13-mm trocar usually employed for the optical trocar. Additionally, the cylindrical tube perfectly fits and hangs onto the robotic optical arm system. Mean operative time was 202.5 min (range 185-220 min). Mean blood loss was 284 mL (range 185-380 mL). Catheterization time and hospital stay were 5 and 6 days, respectively, in all patients. All procedures were safely completed, and no minor or major complications were reported. The optical trocar lengthening technique allowed us to properly perform RALP procedures even in severely morbidly obese patients in an urological setting not equipped for bariatric minimally invasive surgery.

Robot-assisted uretero-ureterostomy for iatrogenic lumbar and iliac ureteral stricture: technical details and preliminary clinical results.

BACKGROUND: Although the incidence of iatrogenic ureteral strictures is low, the treatment remains challenging. OBJECTIVE: To report our technique of robot-assisted uretero-ureterostomy (RAUU) for adults with iatrogenic lumbar and iliac stricture. DESIGN, SETTING, AND PARTICIPANTS: A descriptive study was performed by our department. Since April 2009, five patients underwent RAUU: Two patients had developed a lumbar or iliac ureteral stricture following a ureterorenoscopy, one had ureteral catheter positioning, one had colon surgery, and one had resection of retroperitoneal cystic lymphangioma. Preoperative evaluation includes history, computed tomography (CT) scan, and mercaptoacetyltriglycine-3 (MAG3) diuretic renal scan. SURGICAL PROCEDURE: A flank position was used for all patients with lumbar stenosis. A supine position with the bed turned 30° was required for iliac stricture. The optical port, two 8-mm robotic ports, and one 5-mm assistant port were used. A precise definition of the site and extension of the stricture was done using the flexible ureterorenoscope. After the stricture resection, the anastomosis was performed with two running sutures on a ureteral double-J stent. MEASUREMENTS: Success was defined as no postoperative symptoms and evidence of no obstruction at the CT/urography and at the MAG3 scan at 6-mo follow-up. RESULTS AND LIMITATIONS: RAUU was technically feasible in all five patients. Average operating time was 135min, and median hospital stay was 3 d. No significant complications occurred. Absence of stricture recurrence and no reduction of kidney function were confirmed by CT/urography and MAG3 scans. At a mean follow-up of 8 mo, all patients were asymptomatic. The main limitations were the short follow-up and the small sample size. CONCLUSIONS: RAUU is feasible and safe for repairing iatrogenic lumbar and iliac ureteral strictures. The flexible ureterorenoscopy is useful to localise the obstruction and to correctly define its site and extension to spare as much ureter as possible.

Retroperitoneal and transperitoneal robot-assisted pyeloplasty in adults: techniques and results.

BACKGROUND: The surgical management of ureteropelvic junction obstruction (UPJO) has dramatically evolved over the past 20 yr due to the development of new technology. OBJECTIVE: Our aim was to report the feasibility and efficacy of robot-assisted pyeloplasty (RAP) performed by either the retroperitoneal or the transperitoneal approach. DESIGN, SETTING, AND PARTICIPANTS: A stage 2 investigative study was conducted including development (stage 2a) and exploration (stage 2b) of transperitoneal and retroperitoneal RAP performed in 55 patients at an urban tertiary university department of urology. SURGICAL PROCEDURE: Retroperitoneal RAP was performed with the patient in full flank position using a 12-mm Hasson-style optical port at the tip of the 12th rib, plus two operative 8-mm robotic trocars and an assistant 5-mm port. The stenotic ureteropelvic junction was excised, the ureter was spatulated, and a dismembered pyeloplasty was performed in all cases. Transperitoneal RAP was performed with the patients in the 60° flank position. The optical port is in the umbilical area, plus two 8-mm operative robotic ports and one 5-mm assistant port. The pyeloplasty technique is similar to the retroperitoneoscopic approach. In both groups, the stent can be positioned in an anterograde or retrograde fashion. MEASUREMENTS: Success consisted of no evidence of obstruction on computed tomography urography or mercaptoacetyltriglycine-3 diuretic renal scan, no postoperative symptoms, and no further treatment. RESULTS AND LIMITATIONS: Thirty-six patients underwent retroperitoneoscopic RAP and 19 transperitoneal RAP for UPJO. All the procedures were completed with robotic assistance. The overall objective success (measured by diuretic renal scan and/or imaging techniques) was 96% with two cases of recurrence (both in the retroperitoneal group). The main limitation was the short follow-up, although all patients reached at least a 6-mo follow-up. CONCLUSIONS: RAP performed either retroperitoneally or transperitoneally was revealed as a feasible and reproducible surgical option for the treatment of UPJO, offering a subjective optimal plasty reconfiguration at short follow-up.

Simplifying patient positioning and port placement during robotic-assisted laparoscopic prostatectomy.

Proper patient positioning and port placement is of critical importance in robotic-assisted laparoscopic radical prostatectomy (RALP). Not having the patient in the correct Trendelenburg position or not being able to move the surgical instruments freely in the abdominal cavity can be frustrating, especially for naïve robotic surgeons (ie, those at the beginning of the learning curve for this procedure), and can lead to further difficulties in performing the intervention. We describe the use of a nautical inclinometer and a plastic, double-equilateral triangle with an 8-cm-long border to reach the correct Trendelenburg position easily and to place trocars correctly during RALP.

Dorsal onlay graft urethroplasty using penile skin or buccal mucosa for repair of bulbar urethral stricture: results of a prospective single center study.

OBJECTIVE: To compare the outcomes of dorsal onlay graft urethroplasty using penile skin (PS) or buccal mucosa (BM) free grafts in the repair of adult bulbourethral strictures. METHODS: From January 1998 to March 2003, 30 patients with bulbar urethral strictures underwent urethral reconstruction with PS (17) or with BM free graft (13). Follow-up was done at 6, 12 and 18 months postoperatively, and every year subsequently. Success was defined as normalization of IPSS and a stable Q(max) value >20 ml/s. Any further instrumentation for stricture recurrence was considered a failure. RESULTS: Mean follow-up was 51 months (20-74). The overall success rate was 80% (85% in the BM and 76% in the PS group). Improvement of uroflowmetry, IPSS and QoL did not show a significant difference between the two groups. A significant improvement of the orgasmic function domain of the IIEF was found in patients treated with a PS graft. Post-operative complications were lip hypoesthesia (30%), retraction of the ventral skin of the penis (7%), post-voiding dribbling (8% with BM graft, and 7%, with PS graft). Six patients, 2 with BM (15%) and 4 with PS graft patch (24%) required further treatment due to stricture recurrence. CONCLUSION: Results of PS or BM graft are comparable at 18 month follow-up, although orgasmic function is significantly improved in patients receiving a PS graft. Nevertheless, with extended follow-up, the use of PS seems to be associated with a higher failure rate.