Minimally Invasive Radical Prostatectomy After Previous Bladder Outlet Surgery: A Systematic Review And Pooled Analysis Of Comparative Studies.

Prostate cancer surgery after previous Bladder Outlet Surgery (BOS) for Benign Prostate Hypertrophy (BPH) is an uncommon yet challenging scenario. Aim of this study was to perform a systematic review, and pooled analysis of comparative studies on minimally invasive (laparoscopic and robotic) radical prostatectomy (MIRP) after BOS.

A literature search was conducted on PubMed, Embase®, and Web of Science up to February 2019 according to Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA Statement) to identify eligible studies. Surgical, oncological, and functional outcomes of patients undergoing MIRP after BOS and those without history of BOS were assessed for comparison. Sensitive analysis according to surgical technique (laparoscopic or robotic) was performed. Review Manager 5.3 software was used to perform statistical analysis.

Twelve comparative studies were identified and included in the analysis. Patients who underwent MIRP after BOS were older (p=<0.00001), had smaller prostate size (p=0.04), and lower PSA (p=0.003). Previous BOS group presented lower odds of nerve-sparing procedures (p<0.00001), longer operative time (OT) (p<0.0001), higher rate of bladder neck reconstruction (p<0.0001), longer catheter time (p=0.03), and higher risk of intraoperative (p=0.001), overall (p<0.00001), and major complications (0.0008), higher Positive Surgical Margins (PSM) rate (p=0.0005), and higher risk of biochemical recurrence (p=0.05). Moreover, potency (p=0.03), and continence recovery rate (p=0.007) at 12 months were lower in the previous BOS group. Robotic surgery seems to offer better outcomes compared to laparoscopy.

MIRP after previous BOS represents a challenging surgical task with higher risk of complications, and higher odds of worse functional and oncological outcomes. Patients should be aware of these drawbacks, and these factors should be considered in the equation during patient counseling. Whenever surgery is pursued, RARP should be preferred over LRP as it can offer superior outcome. Overall, literature on this topic remains of low quality, and further effort should be made to obtain higher level of evidence.

The Journal of urology. 2019 Apr 30 [Epub ahead of print]

Alessandro Veccia, Alessandro Antonelli, Simone Francavilla, Francesco Porpiglia, Claudio Simeone, Estevao Lima, Homayoun Zargar, Daniel Eun, Lance J Hampton, Riccardo Autorino

Division of Urology, Department of Surgery, VCU Health , Richmond , VA , USA., Urology Unit, ASST Spedali Civili Hospital, Brescia, Italy, Department of Medical and Surgical Specialties, Radiological Science, and Public Health, University of Brescia , Italy., Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital , Orbassano , Italy., Department of Urology, Hospital of Braga , Braga , Portugal., Department of Urology, Royal Melbourne Hospital , Melbourne , Victoria , Australia., Department of Urology, University of Pennsylvania , Philadelphia , Pennsylvania , USA.