Posterior reconstruction of the rhabdosphincter improves early recovery of urinary continence after robot-assisted radical prostatectomy

INTRODUCTION AND OBJECTIVES Meta-analyses have recently demonstrated that posterior reconstruction of the rhabdosphincter (PRR) offers an advantage in terms of early continence recovery in the first 30-45 days after radical prostatectomy. At the same time, large variability in results of PRR use was documented. The aim of our study was to prospectively evaluate the efficacy of PRR (Rocco stich) in prostate cancer patients undergoing robot-assisted radical prostatectomy (RARP) in terms of early recovery of urinary continence. METHODS From January 2012 to June 2014 398 consecutive patients with biopsy proven prostate cancer (PCa) were randomized to PRR (n=201) vs No PRR (n=197) groups. The inclusion criteria were age 40-75 years, clinically localized PCa (cT1c to cT2cN0M0), informed consent signed, RARP pre-planned, no urinary incontinence pre-surgery. Patients after TURP or neoadjuvant hormones, as well as salvage cases were not included. Barbed sutures were used for both PRR and anastomosis. Urinary continence was defined as the No pad usage (assessed by Question 5 of the Expanded Prostate Cancer Index Composite (EPIC) Urinary assessment). RESULTS The mean patients age was 61.2+-6.2 years, BMI 27.3+-2.8, total PSA 8.1 (1.8-23) ng/ml, and prostate volume 36.5 (18-135) cc. According to D Amico risk classification 32% (n=127), 27% (n=107) and 41% (n=164) of men were from low, intermediate and high-risk groups respectively. Biopsy Gleason score of 6 (3+3), 7 (3+4), 7 (4+3) and 8 was detected in 49% (n=195), 24% (n=95), 16% (n=64) and 11% (n=44) of patients. Basic patients characteristics did not differ between PRR vs no PRR group. After the exclusion of men with EBRT indicated (n=45) and non-compliant patients (n=38) 315 participants had full data collected. After 1, 2, 3, 6 and 12 months the percentage of men reporting 0 pad use in PRR vs No PRR group was 57.9% vs 39.1% (p<0.01), 69.2% vs 60.9% (p=0.01), 78.6% vs 71.8% (p=0.02), 90.6% vs 89.7% (NS) and 95% vs 94.2% (NS). There was no difference in overall complications rate, potency recovery (IIEF-5 scores at 6 and 12 months) or biochemical recurrence rates (PSA>0.2 ng/ml at 6 and 12 months) between groups. The anastomotic time was slightly longer in PRR vs no PRR group (14 vs 9 min, p<0.01). Limitations of the study are: 1) single center trial, 2) follow-up performed by physicians and not third party. CONCLUSIONS Restoration of the posterior aspect of the rhabdosphincter improves the urinary continence recovery comparing to No reconstruction of the rhabdosphincter group at 1, 2 and 3 months after RARP. After 6 to 12 months follow-up, the difference between groups became statistically insignificant, although the advantage of earlier continence recovery is of great importance for many men. Larger international prospective randomized study evaluating the same topic (with more parameters planned for assessment) is ongoing.