Alternative Surgical Technique Induces Early Return of Continence in Localized Prostate Cancer

Ashutosh Tewari, MD

A novel surgical technique called the “hood technique” for robotic-assisted radical prostatectomy was shown to achieve early return of urinary continence without a negative impact on complications and cancer outcomes among men with localized prostate cancer, according to study findings published in European Urology.¹ 

The findings indicate that the hood technique allows for early return of continence after surgery without compromising positive surgical margin rates by sparing musculofascial structures anterior to the urethral sphincter complex.

“A common [adverse] effect that patients worry about following a radical prostatectomy is urinary incontinence,” said Ashutosh Tewari, MD, senior author of the trial.² “This study shows that [by] using a novel surgical technique, the robotic-assisted radical prostatectomy ‘hood technique,’ we can reduce postoperative urinary incontinence and facilitate early return of continence in patients with localized prostate cancer.”

The robotic-assisted radical prostatectomy hood technique is performed with the goal of preserving the detrusor apron, puboprostatic ligament complex, arcus tendinous, endopelvic fascia, and pouch of Douglas. Moreover, the technique preserves tissue after robotic-assisted radical prostatectomy by creating a “hood” to safeguard the membranous urethra, external sphincter, and supportive structures.² 

Currently, radical prostatectomy is the standard of care for patients with localized prostate cancer. However, despite improvements in surgical technique, patients may develop urinary incontinence as a result of surgery.² 

Identifying novel techniques to reduce the risk of urinary incontinence is key to improving patients’ quality of life, which can be significantly impacted as a result of radical prostatectomy.¹ 

The institutional review board–approved study enrolled 300 patients with localized prostate cancer who underwent robotic-assisted radical prostatectomy with the hood technique. Patients were accrued between April 2018 and March 2019 to Mount Sinai Health System, where the study was conducted. 

Patients with anterior tumor location based on biopsy or multiparametric MRI were excluded from the study.

Among all patients, the median age was 64 years. All but 1 patient participated in the 12-month follow-up following robotic-assisted radical prostatectomy with the hood technique.

Pre- and intraoperative variables, as well as postoperative functional and oncological outcomes and complications were collected as clinical data. Additionally, descriptive statistical analysis was performed.

At 1, 2, 4, 6, 12, 24, and 48 weeks after catheter removal, the continence rates among patients were 21%, 36%, 83%, 88%, 91%, 94%, and 95%, respectively. The positive surgical margin rate was 6%. 

A minority of patients (9.7%; n = 30) experienced complications after robotic-assisted radical prostatectomy, including Clavien-Dindo grade I (5.7%; n = 17), grade II (3.6%; n = 11), and grade III (0.4%; n = 1) complications. 

The hood technique might offer an alternative approach to the traditional robotic-assisted radical prostatectomy anterior approach.2 Moreover, the novel technique may confer early continence, low positive surgical margin rate, and the ability to visualize anatomical landmarks.² 

Regarding limitations, the study was conducted within a single institution, so therefore, the results may not be applicable to the general patient population. Additionally, the study was nonrandomized and lacked a comparative arm.

References

1. Wagaskar VG, Mittal A, Sobotka S, et al. Hood technique for robotic radical prostatectomy–preserving periurethral anatomical structures in the space of retzius and sparing the pouch of Douglas, enabling early return of continence without compromising surgical margin rates. Published online October 14, 2020. Accessed October 21, 2020. Eur Urol. doi:10.1016/j.eururo.2020.09.044
2. Mount Sinai study shows novel surgical technique for prostate cancer improves urinary continence. News release. Newswise. October 16, 2020. Accessed October 21, 2020. https://bit.ly/3m2pyuK