172
EUROPEAN UROLOGY 67 (2015) 171–175
Re: Comparison of 2 Transvaginal Surgical Approaches and Perioperative Behavioral Therapy for Apical Vaginal Prolapse: The OPTIMAL Randomized Trial Barber MD, Brubaker L, Burgio KL, et al JAMA 2014;311:1023–34 Experts’ summary: This well-designed, multicentre, randomised trial evaluated a very interesting and clinically relevant topic: the comparison between two different transvaginal surgical techniques to repair apical vaginal prolapse. Moreover, the authors assessed the impact of the behavioural therapy and the pelvic floor muscle training on the outcomes of these surgical procedures. In the present paper, a total of 374 patients with apical prolapse, with or without concomitant prolapse of the other vaginal compartment, were enrolled in the study: 188 in the uterosacral ligament vaginal vault suspension (ULS) group and 186 in the sacrospinous ligament fixation (SSLF) group. The cure rate was assessed at 24 mo using a very strict and rigorous definition of overall surgical success. At 2-yr followup, no differences were found in terms of anatomic, functional, or adverse-event outcomes of the two groups. The overall surgical success rate was 59.2% for USL and 60.5% for SSLF. In addition, the authors observed that behavioural therapy and pelvic floor muscle training did not influence the surgeryrelated outcomes of these two procedures.
utilisation, it could be clinically important to detect an effective and safe surgical reconstructive vaginal procedure for the correction of apical vaginal compartment prolapse. Unfortunately, very few data with medium- to long-term follow-up still exist. In the present study, Barber et al. reported overall surgical success of 60%. Although the success rate reported in this series is lower than success rate reported in the literature (about 70–90%), this series considered a very rigorous definition of cure. In fact, at 24 mo of follow-up, only 16–20% of patients reported prolapse symptoms and, even more relevant, 130 patients with results comparable to open series [3]. We have also experienced little difficulty adopting robotic surgery to intracorporeal conduits. Finally, by opting to present their data in a letter to the editor, granular details were lacking. Although Bochner et al discuss a modest reduction in blood loss, the details regarding complication type are not described. If the distribution of grade 3–5 complications were skewed toward higher-grade complications in the open arm, that would challenge their conclusions.
N Engl J Med 2014;371:389–90 Experts’ summary: Recently Bochner and colleagues from Memorial Sloan Kettering Cancer Center published a randomized trial of 118 patients, comparing complications 90 d after robotic radical cystectomy (RRC) or open radical cystectomy (ORC). The primary aim of their study was to compare 90-d complications (Clavien grade 2) in patients treated with radical cystectomy. Those who enrolled were randomized to either ORC and urinary diversion or RRC and open urinary diversion. In both arms, only experienced surgeons (10 yr of postfellowship experience) and robotic surgeries performed by clinicians experienced in pelvic robotic surgery were included. No benefit was seen in the robotic surgery arm when analyzed for overall complications (Clavien grade 2–5; 62% RRC vs 66% ORC) or for high-grade complications (Clavien 3–5; 22% RRC vs 21% ORC). Interim analysis demonstrated futility, and the study was closed. Experts’ comments: The authors should be applauded for conducting a prospective randomized trial to examine the utility of RRC. Efforts are needed to lower the high complication rates seen following
Conflicts of interest: The authors have nothing to disclose.
References [1] Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernias. Ann Surg 2004;240:578–85. [2] Beck S, Skarecky D, Osann K, Juarez R, Ahlering TE. Transverse versus vertical camera port incision in robotic radical prostatectomy: effect on incisional hernias and cosmesis. Urology 2011;78:586–90. [3] Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 2001;167:260–7. [4] Brown SR, Goodfellow PB. Transverse versus midline incision for abdominal surgery. Cochrane Database Syst Rev 2005:CD005199. Thomas E. Ahlering*, Blanca E. Morales Department of Urology, University of California, Irvine Medical Center, Orange, CA, USA *Corresponding author. Department of Urology, University of California, Irvine Medical Center, 333 City Boulevard West Suite 2100, Orange, CA 92868-3298, USA. E-mail address: [email protected] (T.E. Ahlering).
http://dx.doi.org/10.1016/j.eururo.2014.09.045
Conflicts of interest: The authors have nothing to disclose.
EUROPEAN UROLOGY 67 (2015) 171–175
Re: Comparison of 2 Transvaginal Surgical Approaches and Perioperative Behavioral Therapy for Apical Vaginal Prolapse: The OPTIMAL Randomized Trial Barber MD, Brubaker L, Burgio KL, et al JAMA 2014;311:1023–34 Experts’ summary: This well-designed, multicentre, randomised trial evaluated a very interesting and clinically relevant topic: the comparison between two different transvaginal surgical techniques to repair apical vaginal prolapse. Moreover, the authors assessed the impact of the behavioural therapy and the pelvic floor muscle training on the outcomes of these surgical procedures. In the present paper, a total of 374 patients with apical prolapse, with or without concomitant prolapse of the other vaginal compartment, were enrolled in the study: 188 in the uterosacral ligament vaginal vault suspension (ULS) group and 186 in the sacrospinous ligament fixation (SSLF) group. The cure rate was assessed at 24 mo using a very strict and rigorous definition of overall surgical success. At 2-yr followup, no differences were found in terms of anatomic, functional, or adverse-event outcomes of the two groups. The overall surgical success rate was 59.2% for USL and 60.5% for SSLF. In addition, the authors observed that behavioural therapy and pelvic floor muscle training did not influence the surgeryrelated outcomes of these two procedures.
utilisation, it could be clinically important to detect an effective and safe surgical reconstructive vaginal procedure for the correction of apical vaginal compartment prolapse. Unfortunately, very few data with medium- to long-term follow-up still exist. In the present study, Barber et al. reported overall surgical success of 60%. Although the success rate reported in this series is lower than success rate reported in the literature (about 70–90%), this series considered a very rigorous definition of cure. In fact, at 24 mo of follow-up, only 16–20% of patients reported prolapse symptoms and, even more relevant, 130 patients with results comparable to open series [3]. We have also experienced little difficulty adopting robotic surgery to intracorporeal conduits. Finally, by opting to present their data in a letter to the editor, granular details were lacking. Although Bochner et al discuss a modest reduction in blood loss, the details regarding complication type are not described. If the distribution of grade 3–5 complications were skewed toward higher-grade complications in the open arm, that would challenge their conclusions.
N Engl J Med 2014;371:389–90 Experts’ summary: Recently Bochner and colleagues from Memorial Sloan Kettering Cancer Center published a randomized trial of 118 patients, comparing complications 90 d after robotic radical cystectomy (RRC) or open radical cystectomy (ORC). The primary aim of their study was to compare 90-d complications (Clavien grade 2) in patients treated with radical cystectomy. Those who enrolled were randomized to either ORC and urinary diversion or RRC and open urinary diversion. In both arms, only experienced surgeons (10 yr of postfellowship experience) and robotic surgeries performed by clinicians experienced in pelvic robotic surgery were included. No benefit was seen in the robotic surgery arm when analyzed for overall complications (Clavien grade 2–5; 62% RRC vs 66% ORC) or for high-grade complications (Clavien 3–5; 22% RRC vs 21% ORC). Interim analysis demonstrated futility, and the study was closed. Experts’ comments: The authors should be applauded for conducting a prospective randomized trial to examine the utility of RRC. Efforts are needed to lower the high complication rates seen following
Conflicts of interest: The authors have nothing to disclose.
References [1] Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernias. Ann Surg 2004;240:578–85. [2] Beck S, Skarecky D, Osann K, Juarez R, Ahlering TE. Transverse versus vertical camera port incision in robotic radical prostatectomy: effect on incisional hernias and cosmesis. Urology 2011;78:586–90. [3] Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal surgery. Eur J Surg 2001;167:260–7. [4] Brown SR, Goodfellow PB. Transverse versus midline incision for abdominal surgery. Cochrane Database Syst Rev 2005:CD005199. Thomas E. Ahlering*, Blanca E. Morales Department of Urology, University of California, Irvine Medical Center, Orange, CA, USA *Corresponding author. Department of Urology, University of California, Irvine Medical Center, 333 City Boulevard West Suite 2100, Orange, CA 92868-3298, USA. E-mail address: [email protected] (T.E. Ahlering).
http://dx.doi.org/10.1016/j.eururo.2014.09.045
Conflicts of interest: The authors have nothing to disclose.
