Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection

A novel approach for ameliorating apical margin positivity during robotic radical prostatectomy

Ashutosh K. Tewari, Abhishek Srivastava, Kumaran Mudaliar, Gerald Y. Tan, Sonal Grover, Youssef El Douaihy, David Peters, Robert Leung, Rajiv Yadav, Majnu John, James Wysock, E. Daracott Vaughan, Sara Muir, Mahul Amin, Mark Rubin, Jiangling Tu, Mohammed Akthar, Maria Shevchuk

Research output: Contribution to journalArticle

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Abstract

OBJECTIVE: To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS: Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS: Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P= 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥pT3a) documented on final specimen pathology (16% vs 10%, P= 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION: Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.

Original languageEnglish (US)
Pages (from-to)1364-1373
Number of pages10
JournalBJU International
Volume106
Issue number9
DOIs
StatePublished - Nov 1 2010

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Robotics
Prostatectomy
Urethra
Ligation
Dissection
Pathology
Neoplasms
Anatomy
Urinary Bladder
Recurrence
Control Groups
Incidence
Margins of Excision

All Science Journal Classification (ASJC) codes

  • Urology

Cite this

Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection : A novel approach for ameliorating apical margin positivity during robotic radical prostatectomy. / Tewari, Ashutosh K.; Srivastava, Abhishek; Mudaliar, Kumaran; Tan, Gerald Y.; Grover, Sonal; El Douaihy, Youssef; Peters, David; Leung, Robert; Yadav, Rajiv; John, Majnu; Wysock, James; Vaughan, E. Daracott; Muir, Sara; Amin, Mahul; Rubin, Mark; Tu, Jiangling; Akthar, Mohammed; Shevchuk, Maria.

In: BJU International, Vol. 106, No. 9, 01.11.2010, p. 1364-1373.

Research output: Contribution to journalArticle

Tewari, AK, Srivastava, A, Mudaliar, K, Tan, GY, Grover, S, El Douaihy, Y, Peters, D, Leung, R, Yadav, R, John, M, Wysock, J, Vaughan, ED, Muir, S, Amin, M, Rubin, M, Tu, J, Akthar, M & Shevchuk, M 2010, 'Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: A novel approach for ameliorating apical margin positivity during robotic radical prostatectomy', BJU International, vol. 106, no. 9, pp. 1364-1373. https://doi.org/10.1111/j.1464-410X.2010.09318.x
Tewari, Ashutosh K. ; Srivastava, Abhishek ; Mudaliar, Kumaran ; Tan, Gerald Y. ; Grover, Sonal ; El Douaihy, Youssef ; Peters, David ; Leung, Robert ; Yadav, Rajiv ; John, Majnu ; Wysock, James ; Vaughan, E. Daracott ; Muir, Sara ; Amin, Mahul ; Rubin, Mark ; Tu, Jiangling ; Akthar, Mohammed ; Shevchuk, Maria. / Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection : A novel approach for ameliorating apical margin positivity during robotic radical prostatectomy. In: BJU International. 2010 ; Vol. 106, No. 9. pp. 1364-1373.
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abstract = "OBJECTIVE: To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS: Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS: Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4{\%} vs 4.4{\%}, P= 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥pT3a) documented on final specimen pathology (16{\%} vs 10{\%}, P= 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION: Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.",
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T1 - Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection

T2 - A novel approach for ameliorating apical margin positivity during robotic radical prostatectomy

AU - Tewari, Ashutosh K.

AU - Srivastava, Abhishek

AU - Mudaliar, Kumaran

AU - Tan, Gerald Y.

AU - Grover, Sonal

AU - El Douaihy, Youssef

AU - Peters, David

AU - Leung, Robert

AU - Yadav, Rajiv

AU - John, Majnu

AU - Wysock, James

AU - Vaughan, E. Daracott

AU - Muir, Sara

AU - Amin, Mahul

AU - Rubin, Mark

AU - Tu, Jiangling

AU - Akthar, Mohammed

AU - Shevchuk, Maria

PY - 2010/11/1

Y1 - 2010/11/1

N2 - OBJECTIVE: To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS: Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS: Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P= 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥pT3a) documented on final specimen pathology (16% vs 10%, P= 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION: Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.

AB - OBJECTIVE: To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS: Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS: Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P= 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥pT3a) documented on final specimen pathology (16% vs 10%, P= 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION: Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.

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