Are urologic surgeons performing robot-assisted radical prostatectomy at the University of Alberta meeting surgical quality performance benchmarks? The PROCURE-02 quality assurance study.

INTRODUCTION: Robot-assisted radical prostatectomy (RARP) is a standard of care primary treatment for men with clinically localized prostate cancer (CLPC). The 2010 Canadian Urological Association (CUA) consensus guideline examining surgical quality performance for radical prostatectomy suggested benchmarks for surgical performance. To date, no study has examined whether Canadian surgeons are achieving these benchmarks. We determined the proportion of University of Alberta (UA) urologic surgeons achieving the CUA surgical quality performance outcome (SQPO) benchmarks. METHODS: A retrospective quality assurance analysis of prospectively collected data from the PROstate Cancer Urosurgery Repository of Edmonton (PROCURE) was performed. Men who underwent RARP for CLPC between September 2007 and May 2018 by one of seven surgeons were analyzed. SQPO were an unadjusted pT2-R1 resection rate <25%, blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. Descriptive statistics were used to determine the proportion of surgeons achieving the benchmarks. RESULTS: Data were evaluable for 2821 men. Seven of seven (100%) surgeons achieved a blood transfusion rate <10%, rectal injury rate <1%, and 90-day mortality rate <1%. However, only six of seven surgeons achieved an unadjusted pT2-R1 resection rate <25%; one surgeon had an unadjusted pT2-R1 resection rate of 27.9%. Limitations include the lack of centralized pathology review for surgical margin status by a dedicated genitourinary pathologist. CONCLUSIONS: UA surgeons are achieving the CUA SQPO benchmarks for blood transfusion, rectal injury, and perioperative mortality. However, not all UA urologists are achieving a pT2-R1 resection rate <25%. Surgical quality performance initiatives designed to improve cancer control may be warranted.

Canadian Experience with the Adjustable Transobturator Male System for Post-Prostatectomy Incontinence: A Multicenter Study.

PURPOSE: We assessed the efficacy and safety profile of the ATOMS® (Adjustable Transobturator Male System) for post-prostatectomy incontinence in a multicenter North American setting. MATERIALS AND METHODS: We reviewed outcomes from 8 centers in men who underwent treatment of post-prostatectomy incontinence with an ATOMS. Primary study outcomes were pad changes and continence, defined as requiring 1.0 or 0 pad postoperatively in patients who required 2.0 or more pads preoperatively and 0 pad in those who required more than 1.0 or 2.0 pads preoperatively. Secondary outcomes included improvement, 90-day complications and patient satisfaction. RESULTS: A total of 160 patients were enrolled in study with a median followup of 9.0 months. Preoperative median pad use was 4 per day (IQR 3-5). Of the patients 36.3% reported severe preoperative incontinence, 31.3% received prior radiotherapy and 16.3% underwent previous incontinence surgery. Median postoperative pad use after adjustments was 0.5 per day (IQR 0-1, p <0.001). The overall continence rate was 80.0% with improvement in 87.8% of cases. Of the patients 70.1% underwent a mean ± SD of 2.4 ± 2.7 adjustments (IQR 0-16). The patient satisfaction rate was 86.3%, 22.3% experienced 90-day complications of any grade and 7 (4.4%) experienced Clavien III complications primarily related to the injection port. Patients with a history of radiotherapy were less likely to be continent (62.5% vs 87.9%, p=0.002), improved (77.1% vs 92.6%, p=0.02) or satisfied (69.8% vs 93.2%, p=0.001). Similarly patients with previous incontinence surgery had lower rates of continence, improvement and satisfaction (57.7%, 73.1% and 69.6%, respectively). CONCLUSIONS: In the short term the ATOMS is a safe and efficacious device to treat post-prostatectomy incontinence. Patients with concurrent radiotherapy and previous incontinence surgery respond to treatment but are less likely to be continent, improved or satisfied.

Chordee and Penile Shortening Rather Than Voiding Function Are Associated With Patient Dissatisfaction After Urethroplasty.

OBJECTIVE: To identify factors that predict patient satisfaction after urethroplasty by prospectively examining patient-reported quality of life scores using 3 validated instruments. METHODS: A 3-part prospective survey consisting of the International Prostate Symptom Score (IPSS), the International Index of Erectile Function (IIEF) score, and a urethroplasty quality of life survey was completed by patients who underwent urethroplasty preoperatively and at 6 months postoperatively. The quality of life score included questions on genitourinary pain, urinary tract infection (UTI), postvoid dribbling, chordee, shortening, overall satisfaction, and overall health. Data were analyzed using descriptive statistics, paired t test, univariate and multivariate logistic regression analyses, and Wilcoxon signed-rank analysis. RESULTS: Patients were enrolled in the study from February 2011 to December 2014, and a total of 94 patients who underwent a total of 102 urethroplasties completed the study. Patients reported statistically significant improvements in IPSS (P < .001). Ordinal linear regression analysis revealed no association between age, IPSS, or IIEF score and patient satisfaction. Wilcoxon signed-rank analysis revealed significant improvements in pain scores (P = .02), UTI (P < .001), perceived overall health (P = .01), and satisfaction (P < .001). Univariate logistic regression identified a length >4 cm and the absence of UTI, pain, shortening, and chordee as predictors of patient satisfaction. Multivariate analysis of quality of life domain scores identified absence of shortening and absence of chordee as independent predictors of patient satisfaction following urethroplasty (P < .01). CONCLUSION: Patient voiding function and quality of life improve significantly following urethroplasty, but improvement in voiding function is not associated with patient satisfaction. Chordee status and perceived penile shortening impact patient satisfaction, and should be included in patient-reported outcome measures.

The effect of urethral transection on erectile function after anterior urethroplasty.

PURPOSE: To prospectively assess the effect of urethral transection on erectile function after anterior urethroplasty. METHODS: From February 2012 to December 2014, 104 patients were enrolled in a prospective study assessing erectile function (EF) after anterior urethroplasty. Participants completed the International Index of Erectile Function (IIEF) questionnaire preoperatively and 6 months postoperatively. Outcome measures were the incidence of erectile dysfunction (ED) defined by ≥5-point change in EF and mean change in the EF domain. Factors examined were urethral transection, stricture location, patient age and other demographics. Fisher's exact test, Student's t test and linear regression were used to evaluate associations when appropriate. RESULTS: Seventeen patients were excluded because of poor EF, leaving 87 patients for analysis. Twenty-two patients (25.3 %) had urethral transection during urethroplasty, while 65 underwent non-transecting techniques (74.7 %). For the entire cohort, IIEF scores remain unchanged (20.16 versus 20.14; p = 0.98). Eighteen patients (20.7 %) developed ED, while 15 (17.2 %) experienced an improvement in EF. Urethral transection was not associated with ED (p = 0.22) or mean change in EF (-0.8 versus +0.2; p = 0.71). Stricture location was not associated with ED, but patient age ≥50 was associated with a decrease in mean postoperative EF (-2.84 versus +1.85; p = 0.04). On linear regression analysis patient age remained independently associated with adverse change in EF (p = 0.05). CONCLUSIONS: Urethroplasty can result in a decline in erectile function in some patients but overall is associated with minimal change in erectile function. Urethral transection is not associated with adverse change in erectile dysfunction after urethroplasty however, advanced patient age is.