Catheterless Robotic Prostatectomies
Robotic radical prostatectomies can be performed with a new technique that obviates the need for urethral catheters, sparing patients penile shaft and tip pain, according to investigators.
Instead of catheters, the researchers found that they could use a custom-made suprapubic diversion with a urethral split that has multiple holes for drainage. With this approach, it is possible to retract the splint and allow a voiding trial before removing the drainage device.
Compared with traditional surgery, “robotic surgery offers better cosmetic benefits, reduced pain, early continence, a high rate of sexual potency, and minimal blood loss, all without sacrificing the success of cancer elimination,” said lead investigator Ashutosh Tewari, MD, Ronald P. Lynch Associate Professor of Urologic Oncology at Weill Cornell Medical College in New York. “This new technique we are studying may further enhance the comfort of our patients.”
Dr. Tewari and his colleagues conducted a pilot study with 50 patients who had a mean age of 60 years and mean BMI of 26.6 kg/m2. Among these patients, 30 were implanted with the new device and 20 (controls) underwent standard urethral catheterization with an 18 Fr Silastic Foley catheter. The two groups were comparable in age, serum PSA levels, BMI, Gleason scores, tumor stage, operative duration, and other operative measures.
The control group experienced penile pain and discomfort nine times greater than the group treated with the new technique, Dr. Tewari's group reported in BJU International (2008;102;1000-1004). The control group also had seven times greater discomfort walking and sleeping. No patient in either group had hematuria or clot retention requiring irrigation.
“In this small cohort, we didn't see any problems or complications, but larger studies should be conducted to further validate the findings and safety of this approach,” Dr. Tewari said.
Patients who undergo robotic radical prostatectomy often go home within one day, but they often focus on the penile and urinary discomfort caused by the catheter's implantation and anticipated removal. This new approach developed by Dr. Tewari and his team reroutes urine directly from the bladder by way of a narrow tube through a small needle puncture below the gut. The splint also serves to support the internal urinary structures as the patient heals over next few days.
Past studies examining the advantages of avoiding a urethral catheter have indicated that this approach could help lower the risk for bacterial infections, reduce discomfort, and decrease the need for recatheterization.
Not all patients will be candidates for this new option because of their BMI and amount of abdominal fat. Other issues that may preclude use of the new technique include prostate size and use of blood-thinning medications.“This technique is available and it should be used--with caution,” Dr. Tewari said. “It should only be used in men with small prostates and early prostate cancer who are not at high risk for bleeding. Also, a low BMI is better. [The technique] can be adopted by other clinicians and …done by anyone as long as he or she is trained appropriately.”
He also said that in the future this new technique might be used effectively for non-robotic prostate removal.