Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta‐analysis

Abstract

To evaluate the influence of posterior musculofascial plate reconstruction (PR) on early return of continence after radical prostatectomy (RP); an updated systematic review of the literature. A systematic review of the literature was performed in June 2015, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and searching Medline, Embase, Scopus and Web of Science databases. We searched the terms posterior reconstruction prostatectomy, double layer anastomosis prostatectomy across the 'Title' and 'Abstract' fields of the records, with the following limits: humans, gender (male), and language (English). The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. A meta-analysis of the risk ratios estimated using data from the selected studies was performed. In all, 21 studies were identified, including three randomised controlled trials. The overall analysis of comparative studies showed that PR improved early continence recovery at 3-7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after PR. There were no significant differences for positive surgical margins rates or for complications such as acute urinary retention and bladder neck stricture. The analysis confirms the benefits at 30 days after catheter removal already discussed in the review published in 2012, but also shows a significant advantage in terms of urinary continence recovery in the first 90 days. A multicentre prospective randomised controlled trial is currently being conducted in several institutions around the world to better assess the effectiveness of PR in facilitating an earlier recovery of postoperative urinary continence.

Surgical Techniques to Optimize Early Urinary Continence Recovery Post Robot Assisted Radical Prostatectomy for Prostate Cancer

“…A systematic review by Rocco et al [39] concluded that this was due to the different continence definitions in each analyzed study, several modifications to the original surgical technique, and different surgical approaches. Grasso et al [40] performed a meta-analysis of available studies and concluded that an overall statistically significant advantage in the rate of postoperative UC in favor of posterior reconstruction at 3–7 days after catheter removal (RR 1.90, 95% CI 1:25–2:90; p  = 0.003), at 30 days after catheter removal (RR 1.77, 95% CI 1.43–2.20; p  < 0.001), and at 90 days after catheter removal (RR 1.32, 95% CI 1.10–1.59; p  = 0.003) was found supporting its incorporation into clinical practice.…”

The jury on posterior muscolofascial reconstruction is still out

“…In their systematic review and meta-analysis, Grasso et al [1] address the question of whether posterior muscolofascial reconstruction (PMR), the so-called Rocco stitch, positively affects urinary continence after radical prostatectomy. The relevance of the question to this structured form of inquiry is that individual studies to date have been inconclusive.…”

“…It therefore seems logical to reserve re-TUR only for those patients who truly need it, so that limited resources are focused on ensuring that they receive their operation in a timely manner, ideally within 2-4 weeks. If adopted into day-to-day urological practice, the findings by Gontero et al [1] will allow many patients with HG/G3 T1 and detrusor muscle in the first TURBT specimen to avoid a re-TUR and start intravesical therapy without further delay. Pragmatically, the same should apply to patients with HG/ G3 Ta with detrusor muscle in the specimen.…”

“…The article [1] does have some shortcomings. The study design excludes patients with MIBC, so we do not know by comparison how many patients with MIBC were understaged at the initial TUR based on subsequent re-TUR but as the authors point out, their conclusions would hold true even in this group, as it is very unlikely that one would miss MIBC if there was adequate detrusor muscle in the pathology specimen.…”

Pelvic Floor Reconstruction After Radical Prostatectomy: A Systematic Review and Meta-analysis of Different Surgical Techniques

“…Anterior reconstruction (AR) was introduced by Tewari et al . 8 and later combined with PR to yield an incremental benefit (AR + PR) 9–11 . A simple anterior suspension (AS) technique using sutures anchored to the pubic bone was first described by Sugimura et al .…”