Elsevier

Urology

Volume 79, Issue 2, February 2012, Pages 449-457
Urology

Reconstructive Urology
Risk Factors and Quality of Life for Post-prostatectomy Vesicourethral Anastomotic Stenoses

https://doi.org/10.1016/j.urology.2011.07.1383Get rights and content

Objective

To evaluate the difference in vesicourethral anastomotic stenosis (VUAS) rates after open radical retropubic prostatectomy (RRP) vs robot-assisted radical prostatectomy (RARP), and to analyze associated factors and effect on quality of life.

Methods

From 2001 to 2009, a total of 1038 patients underwent RARP and 707 patients underwent open RRP. Perioperative factors and Expanded Prostate Cancer Index Composite (EPIC) quality of life scores were compared between patients who did and did not develop a VUAS. Independent significant predictors of VUAS development were identified using multivariable modeling.

Results

The incidence of VUAS in open RRP cases was higher (53/707, 7.5%) than for RARP (22/1038, 2.1%) (P < .0001). Intervention consisted of dilation in 34 of 75 cases (45.3%), internal urethrotomy in 8 of 75 (10.7%), and multiple procedures in 30 of 75 (40%). Open technique (P < .0001, odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.8-5.2), prostate-specific antigen (PSA) recurrence (P = .02, OR = 2.2, 95% CI = 1.2-4.1), postoperative hematuria (P = .02, OR = 3.7, 95% CI = 1.2-11.3), urinary leak (P = .002, OR = 6.0, 95% CI = 1.9-19.2), and urinary retention (P = .004, OR = 3.5, 95% CI = 1.5-8.7) were significant independent predictors of VUAS development. EPIC incontinence scores were similar between VUAS and non-VUAS patients, whereas irritative voiding scores were worse initially with VUAS but became similar by 12 months.

Conclusion

There is a higher rate of VUAS after open RRP vs RARP. Most cases of VUAS require endoscopic intervention. Predictors include open surgery, PSA recurrence, and postoperative hematuria, urinary leak, and retention. There is no diminution of quality of life scores at 12 months.

Section snippets

Patient Selection, Operative Technique, and Postoperative Surveillance

Through our Institutional Review Board (IRB)–approved prostate cancer database, we identified 1038 patients undergoing RARP and 707 patients undergoing open RRP for clinically localized prostate cancer, from September 2001 to December 2009. This period represented a common time frame during which both open and robotic radical prostatectomies were performed at our institution. In addition, we excluded patients who received preoperative radiation therapy and censored patients for the development

Results

Demographic characteristics of both patients undergoing open RRP and RARP are detailed in Table 1. There were several statistically significant differences. Patients undergoing RARP tended to be slightly older (mean 60.4 vs 59.7 years, P = .04), have more medical comorbidities, including diabetes mellitus (9.6 vs 6.5%, P = .02), hypertension (25.9 vs 5.5%, P < .0001), and congestive heart failure (8 vs 4.1%, P = .02). They had fewer high-grade (8+) biopsy Gleason scores (5.2 vs 10.5%, P =

Comment

VUAS incidence is significantly lower after robot-assisted vs open prostatectomy techniques (7.5 vs 2.1% P < .0001). Independent predictors of VUAS include open surgery, PSA recurrence, and postoperative hematuria, urinary leak and urinary retention. PSA recurrence as an independent predictor may indicate unrecognized advanced tumor stage with micrometastatic disease, rendering surgery more difficult. Robot assistance is thought to provide enhanced pelvic visualization9 and improved

Conclusions

Overall, the incidence of VUAS is significantly decreased in robot-assisted vs open radical prostatectomies. This may be attributed to a variety of factors, including downward stage migration of prostate cancer over time and the advantages of robotics (improved visualization, a running anastomosis). Surgical expertise is paramount, with precise dissection and creation of a water-tight anastomosis. Here, we attempt to identify significant independent predictors of VUAS development: open

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