Robotic approach to vesicourethral anastomotic stenosis and resection of remaining prostate after radical prostatectomy

ABSTRACT Objective: To show a total transabdominal robotic approach to an extensive recalcitrant vesicourethral anastomotic stenosis (VUAS) after open radical prostatectomy (ORP) with end-to-end anastomosis. While there is very little literature on the matter and even fewer videos showing the actual surgical view with a step-by-step explanation in complex cases, VUAS robotic transabdominal surgery provides better view and reach, with potentially better continence results, without the need for pubectomy. Methods: A 72-year-old male was submitted to a failed ORP for Gleason 3+4 localized cancer 2 years before, where the wrong plane of dissection left behind prostate remnants and the seminal vesicles, which evolved with a complex stenosis and recurrent episodes of acute urinary retention (AUR) that started two weeks after the first catheter removal. Five endoscopic procedures in total were unsuccessful and AUR reoccurred. A vesico-urethral cystography (VUC) and multiparametric prostate and urethral MRI found the seminal vesicles with prostate remnants, two centimeters urethral stenosis from bladder neck to bulbar urethra and periurethral fibrosis with no evidence of residual tumor. PSA was 1.2 and prostate biopsy showed no tumor on prostate remnant. A transabdominal robotic approach was chosen. Results: Prostate residue, bladder neck and periurethral fibrosis were excised, with healthy mucosa found on both ends. End-to-end anastomosis was successful. Drain and catheter were removed on the 1st and 14th post-operative day, respectively, with good urinary stream. A VUC at 30 days showed a patent bladder neck. Incontinence was 3 pads/day after catheter removal and decreased to 1 pad/day after 180 days. Conclusions: VUAS may reach 15% (1, 2) and endourologic therapies are first-line choices, however, recalcitrant cases require reconstruction (3-6). The most common approach is perineal, with high incontinence rates, reaching >90% (7, 8). The retropubic alternative has better but also discouraging numbers of up to 58% incontinence rates (9). Though with 100% social continence results, the 2021 European guidelines still could not recommend the robotic procedure as standard of care due to evidence limited to anecdotal reports (10-12).

Robotic approach to vesicourethral anastomotic stenosis and resection of remaining prostate after radical prostatectomy.

OBJECTIVE: To show a total transabdominal robotic approach to an extensive recalcitrant vesicourethral anastomotic stenosis (VUAS) after open radical prostatectomy (ORP) with end-to-end anastomosis. While there is very little literature on the matter and even fewer videos showing the actual surgical view with a step-by-step explanation in complex cases, VUAS robotic transabdominal surgery provides better view and reach, with potentially better continence results, without the need for pubectomy. METHODS: A 72-year-old male was submitted to a failed ORP for Gleason 3+4 localized cancer 2 years before, where the wrong plane of dissection left behind prostate remnants and the seminal vesicles, which evolved with a complex stenosis and recurrent episodes of acute urinary retention (AUR) that started two weeks after the first catheter removal. Five endoscopic procedures in total were unsuccessful and AUR reoccurred. A vesico-urethral cystography (VUC) and multiparametric prostate and urethral MRI found the seminal vesicles with prostate remnants, two centimeters urethral stenosis from bladder neck to bulbar urethra and periurethral fibrosis with no evidence of residual tumor. PSA was 1.2 and prostate biopsy showed no tumor on prostate remnant. A transabdominal robotic approach was chosen. RESULTS: Prostate residue, bladder neck and periurethral fibrosis were excised, with healthy mucosa found on both ends. End-to-end anastomosis was successful. Drain and catheter were removed on the 1st and 14th post-operative day, respectively, with good urinary stream. A VUC at 30 days showed a patent bladder neck. Incontinence was 3 pads/day after catheter removal and decreased to 1 pad/day after 180 days. CONCLUSION: VUAS may reach 15% (1, 2) and endourologic therapies are first-line choices, however, recalcitrant cases require reconstruction (3-6). The most common approach is perineal, with high incontinence rates, reaching >90% (7, 8). The retropubic alternative has better but also discouraging numbers of up to 58% incontinence rates (9). Though with 100% social continence results, the 2021 European guidelines still could not recommend the robotic procedure as standard of care due to evidence limited to anecdotal reports (10-12).

Tradução para o português An International Continence Society (ICS) report on the terminology for adult neurogenic lower urinary tract dysfunction (ANLUTD).

INTRODUÇÃO: A terminologia para disfunção neurogênica do trato urinário inferior em adultos (DNTUIA) deve ser definida e organizada com base clínica em um relatório de consenso. MÉTODOS: Este relatório foi criado por um Grupo de Trabalho sob o endosso e diretrizes do Standardization Steering Committee (SSC) da International Continence Society (ICS), auxiliado em intervalos por julgadores externos. Todas as definições relevantes para DNTUIA foram atualizadas com base em pesquisas nos últimos 14 anos. Um extenso processo de 18 rodadas de revisão interna e externa foi realizado para examinar exaustivamente cada definição, com tomada de decisão pela opinião coletiva (consenso). RESULTADOS: O Relatório de Terminologia para a DNTUIA, englobando 97 definições (42 novas e oito modificadas), foi desenvolvido. Este relatório é clinicamente baseado nos diagnósticos definidos mais comuns. Clareza e facilidade de uso têm sido os principais objetivos para torná-lo interpretável por profissionais e pessoas em treinamento em todos os diferentes grupos envolvidos não só na disfunção do trato urinário inferior, mas também em muitas outras especialidades médicas. CONCLUSÃO: Baseado no consenso, o Relatório de Terminologia para a DNTUIA foi produzido para auxiliar na pesquisa e na prática clínica.

Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis

ABSTRACT Purpose: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. Materials and Methods: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. Results: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). Conclusions: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis.

PURPOSE: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. MATERIALS AND METHODS: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. RESULTS: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). CONCLUSIONS: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Tradução para o português An International Continence Society (ICS) report on the terminology for adult neurogenic lower urinary tract dysfunction (ANLUTD)

RESUMO Introdução A terminologia para disfunção neurogênica do trato urinário inferior em adultos (DNTUIA) deve ser definida e organizada com base clínica em um relatório de consenso. Métodos Este relatório foi criado por um Grupo de Trabalho sob o endosso e diretrizes do Standardization Steering Committee (SSC) da International Continence Society (ICS), auxiliado em intervalos por julgadores externos. Todas as definições relevantes para DNTUIA foram atualizadas com base em pesquisas nos últimos 14 anos. Um extenso processo de 18 rodadas de revisão interna e externa foi realizado para examinar exaustivamente cada definição, com tomada de decisão pela opinião coletiva (consenso). Resultados O Relatório de Terminologia para a DNTUIA, englobando 97 definições (42 novas e oito modificadas), foi desenvolvido. Este relatório é clinicamente baseado nos diagnósticos definidos mais comuns. Clareza e facilidade de uso têm sido os principais objetivos para torná-lo interpretável por profissionais e pessoas em treinamento em todos os diferentes grupos envolvidos não só na disfunção do trato urinário inferior, mas também em muitas outras especialidades médicas. Conclusão Baseado no consenso, o Relatório de Terminologia para a DNTUIA foi produzido para auxiliar na pesquisa e na prática clínica.

Overactive bladder - pharmacological treatment.

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Overactive bladder - pharmacological treatment

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Long-term results of the implantation of the AMS 800 artificial sphincter for post-prostatectomy incontinence: a single-center experience

ABSTRACT Objectives Report the long-term outcomes of the AMS 800 artificial sphincer (AS) for the treatment post-prostatectomy incontinence (PPI) in a single center in Brazil. Materials and Methods Clinical data from patients who underwent the procedure were retrieved from the medical records of individuals with more than 1 year of follow-up from May 2001 to January 2016. Continence status (number of pads that was used), complications (erosion or extrusion, urethral atrophy, and infection), malfunctions, and need for secondary implantation were evaluated. The relationship between complications and prior or subsequent radiation therapy (RT) was also examined. Results From May 2001 to January 2016, 121 consecutive patients underwent AS implantation for PPI at an oncological referral center in Brazil. At the last visit, the AS remained implanted in 106 patients (87.6%), who reported adequate continence status (maximum of 1 pad/day). Eight-two subjects (67.8%) claimed not to be using pads on a regular basis at the final visit (completely dry). Revision occurred in 24 patients (19.8%). Radiation therapy (RT) for prostate cancer following radical prostatectomy was used in 47 patients before or after AS placement. Twelve patients with a history of RT had urethral erosion compared with 3 men without RT (p=0.004). Conclusion Considering our outcomes, we conclude that AS implantation yields satisfactory results for the treatment of PPI and should remain the standard procedure for these patients. Radiation therapy is a risk factor for complication.

Long-term results of the implantation of the AMS 800 artificial sphincter for post-prostatectomy incontinence: a single-center experience.

OBJECTIVES: Report the long-term outcomes of the AMS 800 artificial sphincer (AS) for the treatment post-prostatectomy incontinence (PPI) in a single center in Brazil. MATERIALS AND METHODS: Clinical data from patients who underwent the procedure were retrieved from the medical records of individuals with more than 1 year of follow-up from May 2001 to January 2016. Continence status (number of pads that was used), complications (erosion or extrusion, urethral atrophy, and infection), malfunctions, and need for secondary implantation were evaluated. The relationship between complications and prior or subsequent radiation therapy (RT) was also examined. RESULTS: From May 2001 to January 2016, 121 consecutive patients underwent AS implantation for PPI at an oncological referral center in Brazil. At the last visit, the AS remained implanted in 106 patients (87.6%), who reported adequate continence status (maximum of 1 pad/day). Eight-two subjects (67.8%) claimed not to be using pads on a regular basis at the final visit (completely dry). Revision occurred in 24 patients (19.8%).Radiation therapy (RT) for prostate cancer following radical prostatectomy was used in 47 patients before or after AS placement. Twelve patients with a history of RT had urethral erosion compared with 3 men without RT (p=0.004). CONCLUSION: Considering our outcomes, we conclude that AS implantation yields satisfactory results for the treatment of PPI and should remain the standard procedure for these patients. Radiation therapy is a risk factor for complication.

Initial experience with sacral neuromodulation for the treatment of lower urinary tract dysfunction in Brazil.

OBJECTIVES: We report on the short-term outcomes of sacral neuromodulation (SNM) for treatment of idiopathic lower urinary tract dysfunction in Brazil (procedures performed before 2014). MATERIALS AND METHODS: Clinical data and surgical outcomes of patients who underwent SNM staged procedures were retrospective evaluated. Urological assessment included a focused medical history and physical examination, measurement of postvoid residual volumes, urodynamics, and bladder diaries. A successful test phase has been defined by improvement of at least 50% of the symptoms, based on bladder diaries. RESULTS: From January 2011 to December 2013, eighteen consecutive patients underwent test phase for SNM due to refractory overactive bladder (15 patients), non-obstructive chronic urinary retention (2 patients), and bladder pain syndrome/interstitial cystitis (1 patient). All patients underwent staged procedures at four outpatient surgical centers. Mean age was 48.3±21.2 (range 10-84 years). There were 16 women and 2 men. Median follow-up was 3 months. Fifteen patients (83.3%) had a successful test phase and underwent implantation of the pulse generator (IPG). Median duration of the test phase was 7 days (range 5-24 days). Mean age was 45.6±18.19 years in responders versus 61.66±34.44 years in non-responders (p=0.242). Mean operative time (test phase) was 99±33.12 min in responders versus 95±35 min for non-responders (p=0.852). No severe complications were reported. CONCLUSION: SNM is a minimally invasive treatment option for patients with refractory idiopathic lower urinary tract dysfunction. Our initial experience with staged technique showed that tined-lead electrodes yielded a high rate of responders and favorable clinical results in the short-term follow-up.

Overactive bladder - 18 years - Part I.

Overactive bladder syndrome is one of the lower urinary tract dysfunctions with the highest number of scientific publications over the past two decades. This shows the growing interest in better understanding this syndrome, which gathers symptoms of urinary urgency and increased daytime and nighttime voiding frequency, with or without urinary incontinence and results in a negative impact on the quality of life of approximately one out of six individuals - including both genders and almost all age groups. The possibility of establishing the diagnosis just from clinical data made patients' access to specialized care easier. Physiotherapy resources have been incorporated into the urological daily practice. A number of more selective antimuscarinic drugs with consequent lower adverse event rates were released. Recently, a new class of oral drugs, beta-adrenergic agonists has become part of the armamentarium for Overactive Bladder. Botulinum toxin injections in the bladder and sacral neuromodulation are routine modalities of treatment for refractory cases. During the 1st Latin-American Consultation on Overactive Bladder, a comprehensive review of the literature related to the evolution of the concept, epidemiology, diagnosis, and management was conducted. This text corresponds to the first part of the review Overactive Bladder 18-years.

Overactive bladder - 18 years - Part II.

Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics - pillars of the overactive bladder pharmacotherapy - started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning - as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder - 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Overactive bladder - 18 years - Part II

ABSTRACT Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics – pillars of the overactive bladder pharmacotherapy – started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning – as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder – 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Initial experience with sacral neuromodulation for the treatment of lower urinary tract dysfunction in Brazil

ABSTRACT Objectives: We report on the short-term outcomes of sacral neuromodulation (SNM) for treatment of idiopathic lower urinary tract dysfunction in Brazil (procedures performed before 2014). Materials and Methods: Clinical data and surgical outcomes of patients who underwent SNM staged procedures were retrospective evaluated. Urological assessment included a focused medical history and physical examination, measurement of postvoid residual volumes, urodynamics, and bladder diaries. A successful test phase has been defined by improvement of at least 50% of the symptoms, based on bladder diaries. Results: From January 2011 to December 2013, eighteen consecutive patients underwent test phase for SNM due to refractory overactive bladder (15 patients), non-obstructive chronic urinary retention (2 patients), and bladder pain syndrome/interstitial cystitis (1 patient). All patients underwent staged procedures at four outpatient surgical centers. Mean age was 48.3±21.2 (range 10-84 years). There were 16 women and 2 men. Median follow-up was 3 months. Fifteen patients (83.3%) had a successful test phase and underwent implantation of the pulse generator (IPG). Median duration of the test phase was 7 days (range 5–24 days). Mean age was 45.6±18.19 years in responders versus 61.66±34.44 years in non-responders (p=0.242). Mean operative time (test phase) was 99±33.12 min in responders versus 95±35 min for non-responders (p=0.852). No severe complications were reported. Conclusion: SNM is a minimally invasive treatment option for patients with refractory idiopathic lower urinary tract dysfunction. Our initial experience with staged technique showed that tined-lead electrodes yielded a high rate of responders and favorable clinical results in the short-term follow-up.

Overactive bladder - 18 years - Part I

ABSTRACT Abstract: Overactive bladder syndrome is one of the lower urinary tract dysfunctions with the highest number of scientific publications over the past two decades. This shows the growing interest in better understanding this syndrome, which gathers symptoms of urinary urgency and increased daytime and nighttime voiding frequency, with or without urinary incontinence and results in a negative impact on the quality of life of approximately one out of six individuals – including both genders and almost all age groups. The possibility of establishing the diagnosis just from clinical data made patients' access to specialized care easier. Physiotherapy resources have been incorporated into the urological daily practice. A number of more selective antimuscarinic drugs with consequent lower adverse event rates were released. Recently, a new class of oral drugs, beta-adrenergic agonists has become part of the armamentarium for Overactive Bladder. Botulinum toxin injections in the bladder and sacral neuromodulation are routine modalities of treatment for refractory cases. During the 1st Latin-American Consultation on Overactive Bladder, a comprehensive review of the literature related to the evolution of the concept, epidemiology, diagnosis, and management was conducted. This text corresponds to the first part of the review Overactive Bladder 18-years.

Results of preoperative electrical stimulation of pelvic floor muscles in the continence status following radical retropubic prostatectomy.

PURPOSE: To evaluate preoperative rectal electrical stimulation in the recovery of urinary continence in patients who undergo radical retropubic prostatectomy. MATERIALS AND METHODS: Patients were divided into 3 randomized groups: control, pelvic exercises, and electrical stimulation. A 1 hour pad-test, the ICIQ-SF, and the SF-36 were performed 1, 3, and 6 months after the surgical procedure. RESULTS: Of the 58 patients who were initially included in the study, 9 were excluded due to radiotherapy after surgical intervention, an indwelling urethral catheter for more than 30 days, high surgical risk, loss of follow-up, or incomplete participation in the study routines and spontaneous interruption. Forty-nine patients concluded the study (15 in the control group, 17 in the exercise group, and 17 in the electrical stimulation group). We did not observe any significant difference in the pad test (p > 0.05), the 8 domains of the SF-36, or ICIQ-SF score compared with control groups (control, exercise, and electrical stimulation). CONCLUSION: Preoperative rectal electrical stimulation has no impact on continence status in patients who undergo radical retropubic prostatectomy. There is no difference in the three above mentioned groups with regard to urinary leakage and quality of life.

Results of preoperative electrical stimulation of pelvic floor muscles in the continence status following radical retropubic prostatectomy

Purpose To evaluate preoperative rectal electrical stimulation in the recovery of urinary continence in patients who undergo radical retropubic prostatectomy. Materials and Methods Patients were divided into 3 randomized groups: control, pelvic exercises, and electrical stimulation. A 1 hour pad-test, the ICIQ-SF, and the SF-36 were performed 1, 3, and 6 months after the surgical procedure. Results Of the 58 patients who were initially included in the study, 9 were excluded due to radiotherapy after surgical intervention, an indwelling urethral catheter for more than 30 days, high surgical risk, loss of follow-up, or incomplete participation in the study routines and spontaneous interruption. Forty-nine patients concluded the study (15 in the control group, 17 in the exercise group, and 17 in the electrical stimulation group). We did not observe any significant difference in the pad test (p > 0.05), the 8 domains of the SF-36, or ICIQ-SF score compared with control groups (control, exercise, and electrical stimulation). Conclusion Preoperative rectal electrical stimulation has no impact on continence status in patients who undergo radical retropubic prostatectomy. There is no difference in the three above mentioned groups with regard to urinary leakage and quality of life. .