Dorsal penile nerve block for robot-assisted radical prostatectomy catheter related pain: a randomized, double-blind, placebo-controlled trial.

PURPOSE: Following Robotic-Assisted Radical Prostatectomy (RARP) patients routinely have penile pain and urethral discomfort secondary to an indwelling urethral catheter. Our objective was to assess the effect of dorsal penile nerve block with bupivacaine on urethral catheter-related pain after RARP. METHODS: From 2012-2013, 140 patients with organ-confined prostate cancer were enrolled in an IRB approved double-blinded, randomized control trial comparing a dorsal penile nerve block of bupivacaine versus placebo after RARP performed by a single-surgeon. Patients were asked to complete questionnaires using the Wong-Bakers FACES Pain Rating scale while hospitalized and for 9 days post-operatively, until the catheter was removed. The primary end-points were: catheter-related discomfort, abdominal (incisional) pain, and bladder spasm-related discomfort. Secondary end-points included narcotic and other analgesic usage. RESULTS: 120 patients were randomized to placebo vs. bupivacaine dorsal penile nerve bock. The two arms (n = 56 bupivacaine and n = 60 placebo) did not differ in preoperative, perioperative, or pathological results. There was no difference in narcotic utilization between the two cohorts. Abdominal pain was slightly lower in the bupivacaine arm at 6 hours compared to the placebo arm, but there was no difference in abdominal pain at other time points, and there were no differences in reported catheter-related discomfort or bladder spasm-associated discomfort at any of the measured time points. CONCLUSIONS: The data does not support the routine use of a dorsal penile nerve block with bupivacaine following RARP.

Role of PSA velocity in predicting pathologic upgrade for Gleason 6 prostate cancer.

BACKGROUND: Pathologic upgrading to Gleason 7 or higher on radical prostatectomy (RP) specimens occurs in many patients with Gleason 6 prostate cancer on preoperative biopsy. We evaluated whether biopsy characteristics and preoperative factors, including preoperative PSA velocity (PSAV), are predictive of pathologic upgrading. MATERIALS AND METHODS: We identified 235 consecutive Gleason 6 prostate cancer patients who underwent biopsies at our institution, had multiple pre-biopsy PSA values, and eventually underwent RP. Preoperative biopsy, clinical characteristics, and PSAV were analyzed to determine the risk of pathologic upgrading or extracapsular extension. These clinical factors were evaluated for association with biochemical recurrence following RP. RESULTS: Overall, 48% of patients were upgraded to Gleason grade 7 or higher following RP. Median PSAV was 0.61 ng/mL/y, and PSAV was similar between upgraded and non-upgraded patients (1.01 vs. 0.78, P = 0.1). PSA velocity level was not associated with extracapsular disease (P = 0.4). PSA velocity > 1 was associated with biochemical recurrence (HR 3.23, P = 0.01) but this was not statistically significant in a multivariable model. Increasing PSA density (HR 2.18, P < 0.001), bilateral cores positive (HR 1.89, P < 0.05), and any biopsy core involvement > 50% (HR 2.52, P < 0.05) were most associated with pathologic upgrading. On multivariate analysis, only bilateral cancer detection at biopsy (HR 1.90, P < 0.05) significantly predicted upgrading. CONCLUSIONS: PSAV has a limited role in predicting Gleason 6 upgrading. Patients with bilateral cancer detected on transrectal biopsy should be encouraged to have radical local therapy due to high risk of harboring more aggressive disease.

Posterior support for urethrovesical anastomosis in robotic radical prostatectomy: single surgeon analysis.

INTRODUCTION: Posterior urethrovesical anastomotic support has been reported to improve early return of urinary continence following radical prostatectomy. We adapted this technique to evaluate enhancement of early urinary control in patients undergoing robotic radical prostatectomy. MATERIALS AND METHODS: Forty-two consecutive men undergoing radical prostatectomy by a single surgeon between September and December 2007 received a posterior urethrovesical supporting stitch prior to the standard urethrovesical anastomosis (group 1). Operative data, postoperative complications, and follow up data were compared with those of the 42 consecutive men who underwent robotic radical prostatectomy by the same surgeon between March and August 2007 with a standard urethrovesical anastomosis (group 2). Continence was assessed at routine follow up visit 6 to 8 weeks following catheter removal. Continence was defined as zero pads or small security liner for infrequent urinary leakage in 24 hours. RESULTS: Thirty-four (81%) and 37 (88%) men in groups 1 and 2 respectively had follow up available between 45 and 75 days following prostatectomy. Preoperative demographics were similar between the two groups. At a mean follow up of 60 and 53 days following surgery, 29/34 (85%) of men in group 1 and 32/37 (86%) of men in group 2 were continent. On multivariate logistic regression analysis, no factors were associated with improved continence between the two groups. CONCLUSIONS: Posterior urethrovesical anastomotic support did not result in improved early urinary control following radical prostatectomy. Excellent urinary control can be achieved in the patients undergoing robotic radical prostatectomy without posterior urethrovesical anastomotic support.