May 12, 2007 Thousands of men facing surgical removal of the prostate due to cancer may someday have one less thing to worry about: post-surgical urinary incontinence.
That's because a team of expert urologic surgeons at NewYork-Presbyterian Hospital/Weill Cornell Medical Center has devised a simple, effective means of reconstructing key anatomical structures that ensure continence.
They describe the success of the procedure in the journal Urology. "Modifying existing tissues, our technique added only a few minutes to standard robotic prostatectomy, yet attained a 95 percent continence rate among patients 16 weeks after their surgeries," explains lead researcher Dr. Ashutosh K. Tewari, director of robotic prostatectomy and outcomes research at NewYork-Presbyterian/Weill Cornell and the Ronald P. Lynch Associate Professor of Urologic Oncology at Weill Cornell Medical College.
"This is a real breakthrough in prostate cancer care, as a significant number of patients have post-prostatectomy urinary incontinence," adds senior researcher Dr. E. Darracott Vaughan, attending urologist at NewYork-Presbyterian/Weill Cornell and The James J. Colt Professor of Urology at Weill Cornell Medical College. He is also Weill Cornell's senior associate dean for clinical affairs.
"Too often, the threat of incontinence can be a key factor in a patient's decision for or against prostatectomy," Dr. Vaughan adds. "A simple intervention like this could make that choice a lot easier."
Prostatectomy involves the excision of the prostate gland, as well as some adjacent tissue, depending on the extent and aggressiveness of the tumor. "Unfortunately, this can weaken structures that control the retention and release of urine from the bladder, such as the puboprostatic ligaments, related muscle and other key anatomy," Dr. Tewari explains. "Together, these structures form a kind of sphincter that must remain strong and supported to maintain urinary continence."
Numerous attempts have been made to modify prostatectomy and preserve continence, but none have proven ideal. Trying to find a better way, Drs. Tewari and Vaughan reviewed 3-D videos that detailed the urological anatomy of patients who had retained full continence after prostatectomy. "We were trying to figure out what went right in those cases," Dr. Vaughan says.
Armed with those insights, they devised the new technique, modeling it first in cadaver tissues. They then tested the new procedure in 50 consecutive patients scheduled to undergo robot-guided prostatectomy for the treatment of localized prostate cancer.
The procedure added just two to five minutes to the standard prostate-removing operation.
"Our technique uses tissues that would normally remain behind after prostatectomy — tissues that we can flip around and support to our advantage," Dr. Tewari explains. "We reconstruct the anterior and posterior parts of the sphincter and surgically join the bladder and the anastomosis (the gap in tissues left by prostatectomy) with the surrounding structures. In doing so, we reconstruct the major anatomical players controlling urinary continence."
The post-surgical results were impressive. One week after patients first had their urinary catheters removed, 29 percent were already fully continent; by six weeks, that figure rose to 62 percent; by eight weeks, 88 percent of the men were fully continent; and by 16 weeks, 95 percent had achieved continence.
The researchers stressed that the men involved in the study had all been diagnosed with non-aggressive, localized cancers. "With more aggressive tumors, surgeons must often excise the tissues that we need for reconstruction, so the technique is not useful in those cases," Dr. Vaughan says.
"But those cases are relatively uncommon, so most patients who undergo prostatectomy stand to benefit from the procedure," says co-author Dr. Alexis Te, director of the Brady Prostate Center at NewYork-Presbyterian/Weill Cornell and associate professor of urology at Weill Cornell Medical College.
"The technique entails no extra cost and very little added time in the OR, although surgeons would have to be trained, of course," Dr. Tewari says. "We're confident the procedure will enhance post-prostatectomy recovery, sparing men the significant loss in quality of life that chronic urinary incontinence can bring."
The Urology study was funded by the Ronald P. Lynch Oncologic Endowment and the Brady Urologic Research Foundation at Cornell University. Dr. Tewari is the principal investigator of a separate research study supported by Intuitive Surgical, Inc., makers of the da Vinci Surgical System, the surgical robot used in the current study.
Additional co-authors include Dr. Kevin Bigelow, Dr. Sandaya Rao, Dr. Atsushi Takenaka and Dr. Nasr El-Tab — all of the Department of Urology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and Weill Cornell Medical College.
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