James F. Borin, MD

Baseline urinary continence status, based on a strict definition of no leakage or pad use, is predictive of improved return of continence following radical prostatectomy, according to University of Chicago researchers. 

Post-prostatectomy continence is variously defined as either requiring no pads, a single non-absorbent security pad, or occasional minimal leakage requiring up to one security pad. Continence rates following surgery are reported to range from 90% to 95% at 1 year. 

A variety of validated questionnaires, including the UCLA Prostate Cancer Index (UCLA-PCI), have been used to assess urinary function and return to baseline; however, there is currently no uniform way to define or assess post-prostatectomy incontinence. This was the focus of the University of Chicago study, led by Kevin C. Zorn, MD, presented at the World Congress of Endourology & SWL. 

Preoperatively, 73% of patients considered themselves LFPF, while 3% reported wearing pads, reported co-author Mark Katz, MD, a fellow in urologic oncology and minimally invasive urology. Patients who were not LFPF at baseline had higher International Prostate Symptom Scores, lower urinary function and bother scores, and larger prostate weights (60 vs. 50 grams). Of the cohort, 17%, 24%, and 28% were LFPF at 6, 12, and 24 months after surgery, respectively. 

Dr. Katz noted that although only 28% of men met the criteria for LFPF at 24 months, 68% wore no pads. In addition, 90% could be considered continent when continence is defined as requiring either no pads or a single security pad. 

When stratifying patients by preoperative LFPF status, there were significant differences between groups in terms of regaining continence. At 24 months after surgery, 33% of men who were LFPF preoperatively were considered LFPF at this time point, compared with 15% who were not LFPF preoperatively (

"Baseline LFPF status predicts earlier and improved return of continence," Dr. Katz concluded. 

This trend held true even with the application of a more liberal definition of continence as the use of zero to one security pads. When stratified by preoperative LFPF status and using the more flexible definition, 94% versus 80% of patients were considered continent at 24 months after surgery. 

The rates of continence investigated in this study are significantly lower than the traditional rates of 90% to 95% that have been quoted in the literature. 

"The 90% to 95% rate is for simple pad free," said Dr. Zorn. "The difference lies in those who still have small leaks, but don't need a pad. LFPF is truly the strictest definition." 

During a discussion of the paper, Thomas E. Ahlering, MD, of the University of California, Irvine, commented that in his experience, men with higher bother scores preoperatively have more leakage postoperatively; therefore, the leakage may be less of a technical issue than a patient issue (ie, overactive bladder), which often will respond to anticholinergic therapy. 

Arieh L. Shalhav, MD, a senior author of the study, concurred. 

"The important thing is to set realistic patient expectations," he said. "Men need to understand that even after more than 1 year after successful surgery when they may be considered dry, when a patient plays golf or makes a strenuous effort, he may lose a drop of urine." 

Articles

Baseline urinary continence status, based on a strict definition of no leakage or pad use, is predictive of improved return of continence following radical prostatectomy, according to University of Chicago researchers.

Pre-radical prostatectomy leakage, pad use predicts post-radical prostatectomy continence

Fascial closure is an effective method to prevent port-site hernias, even when non-bladed trocars are used, according to a study presented at the World Congress of Endourology & SWL. 

Bladed trocars and midline wounds from trocars >5 mm have a higher incidence of herniation; therefore, most laparoscopic surgeons avoid bladed trocars and will close 10/12-mm midline port sites. Although the incidence of hernias is very low in lateral port sites, some advocate closing these as well. 

"Incidence per trocar site is not a valid assessment; incidence per patient is more important," said lead author Thomas Hsu, MD, director of laparoscopic and robotic surgery at Kaiser Permanente Santa Clara Medical Center, Palo Alto, CA. 

The purpose of the study was to compare the incidence of port-site hernias in closed and non-closed trocar sites to measure the fascial defect created by standard trocars and to prospectively evaluate the efficacy of the Carter-Thomason CloseSure XL device (Inlet Medical, Inc., Eden Prairie, MN).

Non-midline port sites were left unclosed in 95 patients, while 78 patients had all port sites closed with the help of a Carter-Thomason device. The incidence of port-site hernias requiring re-operation in unclosed patients was 6.3%, the majority of which were 10/12-mm ports lateral to the umbilicus. One patient in the closed group experienced a subclinical hernia, which was managed conservatively. 

Prior to wound closure, the diameter of the fascial defects of 100 10/12-mm port sites was measured with Hegar dilators. The average width was 15 mm, and there was a correlation between larger fascial defects and longer operative times. Dr. Hsu speculated that hernias might result from pressure secondary to abdominal strain that separates the unclosed fascial edges to their maximum diameter. 

All trocars were of a non-bladed, dilating design.  

In the last 20 port sites closed with the Carter-Thomason device, close visual inspection revealed incomplete fascial closure in 55%, with either one or neither fascial edge included in the closure.  

Dr. Hsu recommended closing all trocar wounds ≥10 mm, even non-midline incisions made with dilating as opposed to bladed trocars. He further reiterated the importance of accurate reporting of hernia incidence. 

"You don't take a trocar site back to the operating room; you take the whole patient," Dr. Hsu said. 

Fascial closure is an effective method to prevent port-site hernias, even when non-bladed trocars are used, according to a study presented at the World Congress of Endourology & SWL.

James F. Borin, MD

Articles

Pre-radical prostatectomy leakage, pad use predicts post-radical prostatectomy continence

Fascial closure helps prevent port-site hernias