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Hood technique can facilitate swift return to urinary continence after radical prostatectomy

European Urology
Reuters Health - 26/10/2020 - The "hood" technique for robot-assisted prostatectomy enabled a return to continence within four months, without compromising surgical margins, in a single-center, single-surgeon study.

"The clinical findings show that early urinary continence is possible and the novel hood technique helped to speed up this process," Dr. Ashutosh (Ash) Tewari of the Icahn School of Medicine at Mount Sinai in New York City told Reuters Health by email. "Ninety-five percent of patients were able to achieve urinary continence within days to a week rather than waiting weeks using the more standard techniques."

"Hundreds of thousands of patients have undergone one or another transperitoneal anterior radical prostatectomy technique, so most surgeons are already familiar with this approach," he said. "The hood technique was a minimalistic change in an already existing and familiar approach for many surgeons."

Following prostate removal, the new technique preserves tissues that together have the appearance of a hood - namely, "the detrusor apron, arcus tendineus, puboprostatic ligament, anterior vessels, and some fibers of the detrusor muscle," Dr. Tewari explained. The strategy "spared musculofascial structures anterior to the urethral sphincter complex, with early return of continence after surgery without compromising positive surgical margin rates."

As reported in European Urology, the researchers studied outcomes of 300 patients (median age, 64) treated by Dr. Tewari using the robotic-assisted prostatectomy (RARP) hood technique between 2018-2019. Fifty-one percent had stage T1 cancer; 35%, T2; and 14%, T3.

Catheter removal was performed on postoperative day seven. The continence rate - defined as completely pad free - at one, two, four, six, 12, 24, and 48 weeks after catheter removal were 21%, 36%, 83%, 88%, 91%, 94%, and 95%, respectively.

Fourteen patients (5%) were not continent at the end of 12-months follow-up: nine were using an occasional one pad per day (PPD); three were using two PPDs; and one was using four PPDs.

The overall positive surgical margin rate was 6%.

Thirty patients (9.7%) experienced complications after RARP: 17 (5.7%) had Clavien-Dindo grade I complications; 11 (3.6%), grade II; and one (0.4%), grade III.

Despite the technique's success, "guidelines should not be changed as comparative trials are still needed," Dr. Tewari said. "This is not the only technical refinement happening in this field. There are and will be many other approaches and techniques that will impact the guidelines We need to tailor the surgery towards the patient, rather than applying one surgery to every patient."

Dr. Ali Zhumkhawala, a urologic oncology surgeon at City of Hope in Duarte, California commented in an email to Reuters Health, "Many studies have shown the importance of preservation or reconstruction of anterior support in post-operative continence. The 'hood' technique appears to be a feasible modification on more traditional techniques with low complication rates and low positive margin rates."

That said, like Dr. Tewari, he noted that while the technique is "very promising," comparative studies are needed. "In addition," he said, "surgeons with less experience may not see the continence rates and low positive margin rates presented by Dr. Tewari's group."

By Marilynn Larkin

SOURCE: https://bit.ly/3dXpkCg European Urology, online October 14, 2020.

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