urinary bladder lateral wall diverticular outpouching | Figure 1

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urinary bladder lateral wall diverticular outpouching

A 53 years old male is complaining from overactive bladder causes sudden urgent to urinate , the urge may be difficult to stop and may lead to involuntary loss of urine in additional to nocturia and kidney pain .

He was admitted few months ago to the hospital for neoplasm of uncertain behavior of genitourinary organs and did a cystoscopy to stretch the bladder neck (dilatation) .

He did pelviabdominal ultrasonographic examination lately which revealed evidence of urinary bladder left lateral wall diverticular outpouching measuring about 9.4 6.2 cm . Another right lateral wall smaller one diverticulum is also noted measuring about 3.6 3.3 cm . No stones or masses. Normal size and echogenicity of the prostate measuring 3.3 4.8 2.6 cm with average volume of 23.1 ml . Intact prostatic capsule . Prostatic specific antigen (PSA) total level is 2.710 ng/ml . He is diabetic his A1C level is 7.3 . what do you think?

Review question

In men with prostate cancer who are having their prostate removed using surgery assisted by a robotic device (called robotic‐assisted laparoscopic prostatectomy or RALP), how does an approach that leaves the tissue connections between the front of the bladder to the back of the abdominal wall intact (so‐called Retzius‐sparing RALP) compare to surgery where these connections are cut (standard RALP).

Background

Urologists often use a robot to remove the prostate in men with prostate cancer. After surgery, men have a catheter that drains urine from their bladder. When this is removed, most men leak urine for some time. This problem is called incontinence and usually gets better within six to twelve months in most men. However, it can be very bothersome during this time.

Study characteristics

We included five studies in which chance determined whether men had Retzius‐sparing RALP or standard RALP. These studies included 571 men with an average age of about 65 years. The average prostate‐specific antigen level (PSA; higher levels of which may indicate that the man has prostate cancer) was 6.9 ng/mL and a little over half (54.2%) had prostate cancer that was found based on the PSA level but could not be felt on rectal exam. In 233/331 (70.4%) men, they tried to spare the nerves that are responsible for erections.

Key results

We found that the Retzius‐sparing RALP probably improves continence within one week after the catheter comes out. It may also improve continence three months after surgery. We are very uncertain how serious unwanted effects compare between the two ways of doing the surgery.

Continence after Retzius‐sparing RALP may also be better after six months. At twelve months, continence is probably similar.

Men who have Retzius‐sparing RALP may be more likely to have positive surgical margins, meaning they still have cancer cells right at the cut edge of the prostate when viewed under the microscope. This may make it more likely that the cancer will come back. We are very uncertain about the effect of Retzius‐sparing RALP on PSA level that goes up within twelve months of surgery, which signals that there is cancer left behind. Urinary quality of life at three months may be similar with both types of surgery. We are very uncertain how Retzius‐sparing RALP affects the ability to achieve an erection.

Quality of the evidence

The quality of evidence ranged from moderate to very low depending on the outcome, meaning that we have moderate to very low confidence in the results.