Novel “hood technique” improves post-RARP urinary continence

Use of the novel “hood technique” for robotic-assisted prostatectomy (RARP) led to an early return of continence in patients with localized prostate cancer, according to findings from a study published in European Urology.^1,2

Among patients receiving the “hood technique,” the continence rate exceeded 80% at 4 weeks following catheter removal, and by 48 weeks post-catheter, the continence rate rose to 95%. The technique also had a low rate of positive surgical margins.

Ash Tewari, MBBS, MCh

"A common side effect that patients worry about following a radical prostatectomy is urinary incontinence. But this study shows that using a novel surgical technique, the RARP ‘hood technique,’ we can reduce postoperative urinary incontinence and facilitate early return of continence in patients with localized prostate cancer. In the study, patients also reported better preservation of anatomical structures around the urethra and were able to achieve early return of urinary continence without a negative impact on complications and cancer outcomes,” Ash Tewari, MBBS, MCh, senior author of the study, chair of the Department of Urology at the Mount Sinai Health System, and professor, Urology, Oncological Sciences, Icahn School of Medicine at Mount Sinai, stated in a press release.¹

The “hood technique,” according to the study authors, “preserves the contents of the space of Retzius using an anterior approach. With [this] novel technique, preserved tissue after prostate removal has the appearance of a “hood” comprising the detrusor apron, arcus tendineus, puboprostatic ligament, anterior vessels, and some fibers of the detrusor muscle. This hood surrounds and safeguards the membranous urethra, external sphincter, and supportive structures.”²

The study included 300 patients with localized prostate cancer who received the RARP “hood technique” at the Mount Sinai Health System between April 2018 and March 2019. Patients with anterior tumor location were not allowed to participate in the study. All patients except 1 participated in the 12-month post-procedure follow-up.

At baseline, the median patient age was 64 years, (interquartile range [IQR], 58-68), the median BMI was 27 kg/m2, and the median prostate volume was 51 ml. The median PSA was 5.7 ng/mL and the median PSA density was 0.12 ng/mL2. Over half (51%) of patients were clinical stage T1, 35% were T2, and 14% were T3. Overall, 15.6% of patients had a Gleason score of 3+3; 40.4% were 3+4; 25% were 4+3; 13% were 4+4; and 6% were >4+4. Per CAPRA scoring, 66% of patients had intermediate-risk disease, while 11.6% and 22.4% had low- and high-risk disease, respectively.

The median total surgery time was 169 minutes. ­Overall, 6% of patients had positive surgical margins, while 94% had negative surgical margins.

Patients had their catheter removed on day 7 following surgery. The study defined continence as the patient being completely pad free. At week 1 following catheter removal, 21% of patients were continent. The continence rate rose to 36% by week 2, 83% by week 4, and 88% by week 6. The continence rates by weeks 12, 24, and 48 were 91%, 94%, and, 95%, respectively.

Of the 299 patients in the safety analysis, 270 (90.3%) has no surgical complications following RARP. Among the 29 (9.7%) patients with surgical complications after RARP, 17 had grade 2 urinary tract infection, 7 had grade 3a acute urinary retentions, 4 had grade 3a meatal stenosis, and 1 had grade 3b incisional hernia.

Study limitations noted by the authors included the lack of randomization and a control arm, as well as the single-site conduction of the research potentially limiting the generalizability of the findings.

References

1. Mount Sinai Study Shows Novel Surgical Technique For Prostate Cancer Improves Urinary Continence. Mount Sinai Health System. Posted October 16, 2020. https://bit.ly/2H5IXw5. Accessed October 16, 2020.

2. Wagaskar VG, Mittal A, Stanislaw 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]. Eur Urol doi.org/10.1016/j.eururo.2020.09.044