UROLOGICAL ONCOLOGY Does Presence of a Median Lobe Affect Perioperative Complications, Oncological Outcomes and Urinary Continence Following Robotic-assisted Radical Prostatectomy? Nurullah Hamidi1*, Ali Fuat Atmaca2, Abdullah Erdem Canda3, Murat Keske1, Bahri Gok2, Erdem Koc1, Erem Asil1, Arslan Ardicoglu2 Purpose: To evaluate of the presence of a median lobe(ML) affect perioperative complications, positive surgical margins(PSM), biochemical recurrence(BCR) and urinary continence(UC) following robotic-assisted radical pros- tatectomy(RARP). Materials and Methods: Data of 924 consecutive patients who underwent RARP for prostate cancer (PCa) and who have at least 1-year follow-up were evaluated retrospectively. All patients were divided into two groups: Group 1(n=252) included patients with ML and Group 2 (n=672) included patients without ML. The primary endpoint of this study was to compare complication rates between two groups. The secondary endpoints were to compare PSM, BCR and UC rates. Result: Both groups were statistically similar in terms of demographics and variables about PCa. Mean prostate volume was higher in Group 1 vs. Group 2 (69 ± 31 vs. 56 ± 23 mL, p < .001). Total operative time was longer in Group 1 vs. Group 2 (144 ± 38 vs. 136 ± 44 min, p = .01). Biochemical recurrence, PSM, perioperative and post- operative complication rates of our population were 13.6%, 14.9%, 1.7% and 8.7%, respectively. There were no statistical differences in terms of perioperative complication, PSM and BCR rates between the groups(p > 0.05). At the first month after RARP, total continence rate was statistically significant lower in Group 1 vs. Group 2 (49.2% and 56.5%, p = .03), respectively. However, there were no significant differences in terms of continence rates at 3rd month, 6th month and 1st-year follow-up. Conclusion: Due to our experience, the presence of ML does not seem to affect perioperative complication, intra- operative blood loss, PSM and BCR following RARP. However, the presence of ML seems to be a disadvantage in gaining early UC following RARP. Keywords: Clavien-Dindo; Complication; Median lobe; Robotic; Radical prostatectomy; Urinary incontinence INTRODUCTION Prostate cancer surgery is trending toward robotic-as-sisted radical prostatectomy (RARP) by developing technology. The main advantages of RARP compared to open radical prostatectomy are better magnification, filtering the tremors of the surgeon's hand and better ability of surgical instruments movement in narrow pel- vic area. However, contrary to open surgery, there are some technical difficulties such as tactile sense absent and limited exposure angle in RARP procedures. The presence of a ML is one of the most common challenge that frequently encountered during RARP. Sarle et al. firstly reported the difficulty of dissection in a patient who has large ML.(1) In patients with ML, the technical difficulty arises by poor exposure (due to laparoscopic camera view angle) during posterior vesi- co-prostatic junction incision and posterior prostate base dissection stages, especially from base to apex ap- proaches. This difficulty can cause longer total operat- 1Department of Urology, Ankara Atatürk Training and Research Hospital, Cankaya, Ankara 06430, Turkey 2Department of Urology, Ankara Yildirim Beyazit University Faculty of Medicine, Cankaya, Ankara 06430, Turkey 3Department of Urology, Koc University School of Medicine, Maltepe, Istanbul 34010, Turkey *Correspondence: Department of Urology, Ankara Atatürk Training and Research Hospital, Cankaya, Ankara 06430, Turkey. Tel: +90 553 205 0307, Fax: +90 312 508 2147, e-mail: dr.nhamidi86@gmail.com. Received December 2017 & Accepted July 2018 ing time(2), higher blood loss(3), increased potential com- plication (like ureteral orifice injury)(4) and increased PSM rates(5) especially in base or posterior surgical margins of prostate. In addition, a wide excision of the bladder neck is needed during enlarged ML removing and it can lead to wide defect in bladder neck. To date, the effect of the presence of ML during RARP on perioperative complication was discussed in a few articles and it was reported that the ML does not affect the complication rates.(2,3,6-8) However, the complica- tions were compared without a standardized classifi- cation system in these previous studies. The modified Clavien classification system (MCCS) has been widely used for standardization of complications in surgical procedures after gaining popularity.(9) This is important, because, it may help us to evaluate the safety of sur- gery, to analyze learning curves of surgical techniques, to compare different approaches and different patient population based on standardized classification, there- Urological Oncology 248 Vol 15 No 05 September-October 2018 249 by improving management and prevention.(10) In this study, we aimed to compare perioperative com- plications between RARP patients with and without ML based on MCCS. To the best of our knowledge, the present study is the first to evaluate the applicability of the MCCS to compare complications between RARP patients with and without ML. Furthermore, we com- pared positive surgical margin (PSM), biochemical re- currence (BCR) and urinary continence (UC) rates. MATERIALS AND METHODS Ethical approval for this retrospective study was ob- tained from the Institutional Review Board (IRB Deci- sion no: 95 Decision date: 14.04.2017). Study population, inclusion and exclusion criteria: We evaluated the data of consecutive patients who under- went RARP at our institution between Feb 2009-Jan 2016 and who had at least 12 months follow up. Patients who had neoadjuvant androgen deprivation therapy and 5-alpha reductase inhibitor treatment history during the last 6 months were excluded. In all patients, data regarding age, body mass index (BMI), ASA(American Society of Anesthesiologists) score, total pre-operative Prostate-specific antigen (PSA), prior prostate surgery history, Gleason score (GS) at biopsy, tumor involvement per core and number of positive cores at biopsy, clinical and pathological dis- ease stage, total operation time (from last port insertion to prostatectomy specimen removal, min), estimated blood loss (EBL) volume (ml) during RARP, intra-op- erative and post-operative blood transfusion (unite), bladder neck and nerve sparing during RARP, hospi- tal stay (day), drainage and urethral catheter removal time (day), GS at surgical specimen, prostate volume at surgical specimen, PSM, localization of PSM, Bio- chemical recurrence (BCR) and total continence rate were collected prospectively. All data were recorded prospectively during RARP. Complications within 30 days after surgery were classified based on MCCS. Surgical technique: All RARP procedures were per- formed by two experienced surgeons (AFA, AEC). A transperitoneal approach was used in the steep (30) Trendelenburg position. Totally, 5 ports were placed, a 12-mm port for the camera, three 8-mm ports for the robotic arms, and a 12-mm port for bedside assistance. The procedure was started by making an incision on the anterior peritoneal covering of the Douglas pouch, ap- proximately 1 cm proximal to its reflection on the rec- tum. Denonvilliers fascia was opened after vas defer- entia and seminal vesicles dissection. Then, we incised the anterior peritoneum wall. Anterior attachments be- tween the bladder and abdominal wall were taken down by monopolar scissors and the Retzius space was en- tered. After defatting, the endopelvic fascia was opened and levator ani muscle fibers were dissected off all the way along the lateral prostatic fascia. The dorsal venous complex was identified and suture tied distal to the apex of the prostate. Then, the detrusor apron overlying the prostate anteriorly was identified and dissected superi- orly until the entrance of the urethra into the prostate at the bladder base was observed where its anterior bladder neck was incised. The posterior neck area was Table 1. All demographics and comparison between groups. Parameters Overall (n=924) Without ML (n=672) With ML (n=252) p value Age, year; Mean ± SD 62.2± 6.8 62± 6.8 62.7 ± 6.7 .18 BMI, kg/m2; Mean ± SD 27.1 ± 2.7 27± 2.7 27.2±2.8 .37 Total PSA, ng/mL; Mean ± SD 9.6 ± 9.5 9.3 ± 9.6 10.3 ± 9.1 .17 Prostate volume at surgical specimen, gr; Mean ± SD 60 ± 26 56 ± 23 69 ± 31 < .001 Prior prostate surgery history, n (%) .61 None 869 (94) 629 (93.6) 240 (95.2) Transurethral resection 49 (5.3) 38 (5.7) 11 (4.4) Transvesical prostatectomy 6 (0.7) 5 (0.7) 1 (0.4) Number of positive biopsy cores; Mean ± SD 3.5 ± 2.7 3.6 ± 2.6 3.3 ± 2.6 .12 Percent positive biopsy core; Mean ± SD 39.4 ± 24.7 39.7 ± 24.3 38.4 ± 25.6 .49 GS at biopsy, n (%) .7 GS 3+2 4 (0.4) 3 (0.4) 1 (0.4) GS 3+3 584 (63.2) 422 (62.8) 162 (64.3) GS 3+4 149 (16.1) 107 (15.9) 42 (16.7) GS 4+3 80 (8.7) 63 (9.4) 17 (6.7) GS 3+5 12 (1.3) 11 (1.6) 1 (0.4) GS 4+4 64 (6.9) 46 (6.8) 18 (7.1) GS 4+5 17 (1.8) 11 (1.6) 6 (2.4) GS 5+4 10 (1.1) 7 (1) 3 (1.2) GS 5+5 4 (0.4) 2 (0.3) 2 (0.8) Clinical T stage .69 T1a 6 (0.6) 5 (0.7) 1 (0.4) T1b 10 (1.1) 8 (1.2) 2 (0.8) T1c 640 (69.3) 471 (70.1) 169 (67.1) T2a 177 (19.2) 128 (19) 49 (19.4) T2b 14 (1.5) 9 (1.3) 5 (2) T2c 77 (8.3) 51 (7.6) 26 (10.3) ASA score, n (%) <.001 ASA 1 310 (33.5) 194 (28.9) 116 (46) ASA 2 595 (64.4) 462 (68.8) 133 (52.8) ASA 3 19 (2.1) 16 (2.3) 3 (1.2) ASA 4 - - - ASA 5 - - - Abbreviations: ASA, American Society of Anesthesiologists; BMI, Body mass index; GS, Gleason score; ML, median lobe; PSA, Prostate specific antigen The association between median lobe and perioperative outcomes- Hamidi et al. checked for the presence of the ML and the presence of a ML (yes or no) was confirmed by the operating surgeon. The ML is grasped and elevated out of the bladder by using the fourth robotic arm which was de- scribed by Patel et al.(11) Subsequently, high anterior re- lease and neurovascular bundle (NVB) dissections were carried out. The procedure was completed after division of dorsal venous complex and vesicourethral anastomo- sis with the use of the van Velthoven technique with or without posterior Rocco construction. The prostate was extracted from the abdomen after the enlargement of the supra-umbilical port site following inclusion into the endobag. An abdominal drain was left in place. Patients underwent follow-up visits at first month after urethral catheter removal, then every 3 months in the first year after RARP, then every 6 months in years 2 to 5 and annually thereafter. Total PSA values were recorded at every patient visit. BCR was defined by two consecutive PSA measurements of ≤ 0.2 ng/mL after RARP.(12) Total urinary continence was defined as the use of “0-1 pad”. Total continence rates were recorded during 1st, 3rd, 6th and 12th months visits. Statistical analysis: SPSS 16.0 (Chicago, Illinois, USA) was used for all statistical analysis. Data were present- ed as mean ± SD. Comparisons between groups were performed with Chi-square and T tests. Univariate and multivariate logistic regression analyses were conduct- ed to identify variables predictive of GS upgrading. For statistical significance p value of < .05 was accepted. RESULTS Overall 924 patients included to this study. The mean age, BMI, total PSA and prostate volume of our pop- ulation were 62.2 ± 6.8 year, 27.1 ± 2.7 kg/m2, 9.6 ± 9.5 ng/ml and 60 ± 26 gr, respectively. The mean total operative time, EBL, drainage catheter removal, hospi- Table 2. Comparison of pathological, perioperative and postoperative characteristics between patients with and without median lobe Parameters Overall (n=924) Without ML (n=672) With ML (n=252) p value Total operative time, minute; Mean ± SD 138 ± 43 136 ± 44 144 ± 38 .01 Estimated blood loss, mL; Mean ± SD 144 ± 138 142 ± 138 149 ± 136 .44 Intraoperative blood transfusion, n(%) .43 No, 910 (98.5) 661 (98.4) 249 (98.8) 1 unit 8 (0.9) 5 (0.7) 3 (0.2) 2 unit 4 (0.4) 4 (0.6) - 3 unit 2 (0.2) 2 (0.3) - Postoperative blood transfusion, n (%) .72 No, 891 (96.5) 650 (96.7) 241 (95.6) 1 unit 30 (3.2) 20 (3) 10 (4) 2 unit 3 (0.3) 2 (0.3) 1 (0.4) Drainage catheter removal time, day; Mean ± SD 2.6 ± 1.5 2.6 ± 1.6 2.5 ± 1.4 .84 Hospital stay, day; Mean ± SD 4.8 ± 2.5 4.7 ± 2.5 4.9 ± 2.4 .16 Urethral catheter removal time, day; Mean ± SD 8.6 ± 3.9 8.7 ± 4.1 8.5 ± 3.4 .58 GS at surgical specimen, n (%) .06 Not detected 17 (1.8) 15 (2.2) 2 (0.8) GS 3+3 417 (45.1) 289 (43) 128 (50.8) GS 3+4 239 (25.9) 181 (26.9) 58 (23) GS 4+3 126 (13.6) 92 (13.7) 34 (13.5) GS 3+5 22 (2.4) 15 (2.2) 7 (2.8) GS 4+4 38 (4.2) 34 (5.1) 4 (1.6) GS 4+5 32 (3.5) 25 (3.7) 7 (2.8) GS 5+4 28 (3) 19 (2.7) 9 (3.5) GS 5+5 5 (0.5) 2 (0.3) 3 (1.2) Pathological T stage, n (%) .09 T0 17 (1.8) 15 (2.3) 2 (0.8) T2a 135 (14.6) 91 (13.5) 44 (17.5) T2b 64 (7) 49 (7.3) 15 (6) T2c 389 (42.1) 289 (43) 100 (39.7) T3a 217 (23.5) 162 (24.1) 55 (21.8) T3b 100 (10.8) 64 (9.5) 36 (14.2) T4a 2 (0.2) 2 (0.3) - Lymphadenectomy during RARP, n (%) 682 (73.8) 498 (74.1) 184 (73) .73 Presence of positive lymph node, n (%) 219 (23.7) 154 (22.9) 65 (25.7) .36 Bladder neck sparing, n (%) 683 (73.9) 528 (78.6) 155 (61.5) <.001 Nerve sparing approach, n (%) .07 Non-nerve sparing 79 (8.5) 51 (7.6) 28 (11.1) Unilateral nerve sparing 81 (8.8) 43 (6.4) 38 (15.1) Bilateral nerve sparing 764 (82.7) 578 (86) 186 (73.8) PSM, n (%) 138 (14.9) 100 (14.9) 38 (15.1) .9 Localization of PSM, n (%) Apex 81 (8.7) 58 (8.6) 23 (9.1) .81 Base 66 (7.1) 50 (7.4) 16 (6.3) .56 Lateral 25 (2.7) 21 (3.1) 4 (1.5) .2 Posterior 58 (6.2) 37 (5.5) 21 (8.3) .12 Anterior 25 (2.7) 21 (3.1) 4 (1.5) .2 BCR, n (%) 126 (13.6) 94 (14) 32 (12.7) .6 Receiving adjuvant radiotherapy, n (%) 248 (26.6) 184 (27.3) 64 (25.4) .54 Receiving androgen deprivation therapy, n (%) 238 (25.7) 170 (25.2) 68 (26.9) .8 Abbreviations: BCR, Biochemical recurrence; GS, Gleason score; ML, median lobe; PSM, Positive surgical margin; RARP, Robot-as- sisted radical prostatectomy The association between median lobe and perioperative outcomes- Hamidi et al. Urological Oncology 250 Vol 15 No 05 September-October 2018 251 talization and urethral catheter removal time were 138 ± 43 min, 144 ± 138 mL, 2.6 ± 1.5 day, 4.8 ± 2.5 day and 8.6 ± 3.9 day, respectively. Bladder neck was sparred in 683 (73.9%) of all patients. PSM was detected in 138 (14.9 %) patients. PSM was detected in 81 (8.7 %) pa- tients at apex side, in 66 (7.1 %) patients at base, in 25 (2.7 %) patients at lateral side, in 58 patients (6.2 %) at posterior side and in 25 (2.7 %) patients at anterior side of prostate. During the follow-up (median 51 months), BCR was observed in 126 (13.6 %) patients. Intraoper- ative and postoperative complications were observed in 16 (1.7 %) and 81 (8.7 %) of all patients, respectively. The continence rates at 1st, 3rd, 6th, and 12th months after RARP in all patients were 54.5%, 69.9%, 82.4% and 91.3%, respectively. All patients were divided into two groups according to presence of ML during RARP. Group 1 (patients with ML) consist of 252 patients and Group 2 (patients with- out ML) consist of 672 patients. The mean prostate vol- ume was statistically higher in patients with ML than patients without ML (69 ± 31 vs. 56 ± 23, p < .001). Patients with ML has lower ASA score than patients without ML. Other patient demographics and preop- erative characteristics were comparable between two groups and all details were given in table 1. There were no statistically significant differences in term of mean EBL, mean intraoperative and postopera- tive blood transfusion rates, mean drainage and urethral catheter removal time, mean hospitalization time, GS at surgical specimen, pathological T stage and PSM rates between two groups. However, the mean total opera- tive time (144 ± 38 min vs. 136 ± 44 min, p=.01) was statistically longer in patients with ML than without ML. Bladder neck sparing (61.5% vs 78.6%, p < .001) rate was statistically higher in patients without ML than with ML. All perioperative and postoperative compari- sons were detailed in table 2. Logistic regression analyzes includes age, total PSA, BMI, prostate volume, prior prostate surgery history, presence of a ML, Gleason grade, pathological stage, Table 3. Univariate analysis for urinary incontinence. Univariate analysis Variables OR 95% CI p value Age (Advanced) 1.3 0.648-2.802 .61 Total PSA (Higher) 1.1 0.256-1.392 .7 BMI (Higher) 1.4 0.564-3.21 .33 Prostate volume (Higher) 1.2 0.43-5.148 .09 Gleason grade (≥ 8) 1.4 0.184-1.436 .07 Pathological stage (≥ T3a) 1.1 0.532-1.498 .3 Prior prostate surgery history (Yes) 2.2 1.028-3.13 .001 Presence of a median lobe(Yes) 3.9 2.134-4.918 .001 Total operative time (Longer) 1.5 0.768-1.898 . 42 Urethral catheter removal time (Longer) 2.4 0.672-3.09 .85 Bladder neck preserving (No) 2.8 1.238-4.026 .001 Nerve sparing (No) 1.6 0.412-2.392 .5 Receiving adjuvant radiotherapy (Yes) 3 1.165-4.784 .01 Receiving androgen deprivation therapy (Yes) 1.1 0.754-1.856 .57 Abbreviations: BMI; Body mass index; OR, Odds ratio; CI, Confidence interval; PSA, Prostate-specific antigen The association between median lobe and perioperative outcomes- Hamidi et al. Figure 1. Continence rates in patients with and without median lobe total operative time, urethral catheter removal time, bladder neck sparing, nerve sparing, adjuvant radio- therapy and androgen deprivation therapy variables were performed to determine factors associated with urinary incontinence. Presence of prior prostate sur- gery history, presence of a ML, bladder neck preserv- ing and receiving adjuvant radiotherapy were found to be associated with increased risk of GS upgrading in univariate analysis. Outcomes of univariate analysis are summarized in table 3. Multivariate analysis was per- formed to determine the independent predictors of uri- nary incontinence. Presence of a ML (OR: 4.1, 95% CI: 2.804-5.14, p < .001), non-preserving of bladder neck (OR: 2.2, 95% CI: 1.014-4.138, p = .001) and receiving adjuvant radiotherapy (OR:3, 95% CI: 1.413-5.458, p < .001) were found to be significant predictors of urinary incontinence. Intraoperative and postoperative complications were developed in 14 (1.5 %) and 81 (8.7 %) of all patients. As intraoperative complication; Rectal injury, bladder perforation, ileum injury and ureteral orifice injury were developed in 3 (0.3 %), 9 (% 1), 1 (0.1 %) and 3 (0.3 %) of all patients, respectively. Postoperative com- plications were classified based on MCCS and grade I, grade II, grade IIIa, grade IIIb and grade IVa compli- cation were developed in 28 (3 %), 32 (3.5 %), 7 (0.7 %), 9 (1 %) and 5 (0.5 %) patients, respectively. There were no statistically significant differences in terms of intraoperative and postoperative complication rates be- tween two groups. All complications and comparisons of complications were shown in table 4. The continence rates at 1, 3, 6, and 12 months after RARP in patients with ML were 49.2%, 67.8%, 81.3% and 89.2 respectively. At the same postoperative inter- vals, the continence rates in the group without ML were 56.5%, 70.6%, 82.8% and 92.1%, respectively. At first visit (1 month after RARP), continence rate was statis- tically significant higher in patients without ML than with ML (56.5% vs. 49.2%, p = .03). At subsequent pa- tient visits, there were no statistically significant differ- ences on continence rates between two groups. All con- tinence rates and comparisons were detailed in figure 1. DISCUSSION The first comparison between patients with and without ML was reported by Jenkins et al(7). They emphasized in their small sample (totally 58 patients) sized study that there was no significant difference in term of total operative time in patients with and without ML.(7) In Jenkins et al.’s(7) study, the mean total operative times were 289 min and 274 min in patients with and without ML, respectively. Although approximately 15 min dif- ference was observed between the two groups, this dif- ference was not statistically significant (p = .61). These outcomes may depend on small number of patient. Con- trary to Jenkins et al.’s study, it was observed that total surgery time is longer in patients with ML than patients Table 4. Comparison of intraoperative and postoperative complications between patients with and without median lobe Overall (n=924) Without ML (n=672) With ML (n=252) p value Intraoperative complications, n(%) 16 (1.7) 12 (1.7) 4 (1.6) .27 Rectal injury 3 2 1 Bladder perforation 9 7 2 Ileum injury 1 1 - Ureteral orifice injury 3 2 1 Postoperative complications, n(%) 81 (8.7) 54 (8) 27 (10.7) .2 MCCS Grade I 28 (3) 17 (25) 11 (4.4) .14 Postoperative pain (managed by nonopioid analgesics) 3 2 1 Postoperative fever (>38.0 °C) (managed by observation without antibiotics) 9 6 3 Urine leakage (managed by watchful waiting) 4 1 3 Ileus (spontaneously resolved) 6 3 3 Wound infection (managed by observation without antibiotics) 4 3 1 Intraabdominal fluid collection (managed by observation) 2 2 - MCCS Grade II 32 (3.5) 21 (3.1) 11 (4.3) .78 Symptomatic UTI (managed with antibiotics) 7 5 2 Postoperative fever (>38.0 C) managed with antibiotics 2 2 - Arrhythmia 1 - 1 Bleeding requiring blood transfusion 150 10 5 Epileptic seizure (managed by anticonvulsant) 1 1 - Positional vertigo attack (managed by medical drug) 1 1 - Ileus (managed by nasogastric decompression) 2 1 1 Wound infection (managed by antibiotics) 3 1 2 MCCS Grade IIIa 7 (0.7) 5 (0.7) 2 (0.8) .93 Intraabdominal abscess or urine collection (requiring percutaneous drainage) 3 2 1 Intraabdominal fluid/ lymphocele collection (requiring percutaneous drainage) 4 3 1 MCCS Grade IIIb 9 (1) 7 (1.1) 2 (0.8) .73 Wound evisceration (requiring primary closure under GA) 3 Ileus (requiring laparotomy) 1 1 - Bleeding (requiring laparotomy) 1 1 - Necrosis of glans penis (requiring grafting) 1 1 - Urethro-vesical anastomosis leakage (repeat urethral catheterization under GA) 3 2 1 MCCS Grade IVa 5 (0.5) 4 (0.6) 1 (0.4) .7 Acute renal failure (requiring ICU management) 1 - 1 Acute myocardial infarction (requiring ICU management) 1 1 - Cerebrovascular accident 1 1 - Pulmonary thromboembolism 1 1 - Hyposaturation requiring ICU management Abbreviations: GA, General anesthesia; ICU, intensive care unit; MCCS, modified Clavien classification system; ML, Median lobe; UTI, urinary tract in- fection The association between median lobe and perioperative outcomes- Hamidi et al. Urological Oncology 252 Vol 15 No 05 September-October 2018 253 without ML in many studies with high number of pa- tients.(2,3,6). Meeks et al.(2) reported that approximately 70 min additional time required in patients with ML compared to patients without ML. They emphasized that this additional time required for posterior bladder neck and seminal vesicle dissection and as well as for bladder neck reconstruction.(2) Our outcomes support- ed these previous studies(2,3,6) in term of total operation time and we observed statistically significant longer total operation time (approximately 8 min) in patients with ML. Our additional required time in patients with ML is shorter than that of Meeks et al.’s (8 vs. 70 min). Meeks et al.(2) performed RARP in this order: incision and dissection of the anterior bladder neck, identifying of the ML (if presence), incision and dissection of the posterior bladder neck, dissection of the seminal vesi- cles and posterior surface of the prostate dissection. We think, the seminal vesicles dissection can be difficult and time consuming at Meeks at al.’s dissection direc- tions in patients with ML. Differently from Meeks et al.’s RARP technique, the seminal vesicles dissection is performed at the beginning of the RARP procedure. After dissection of the seminal vesicles and posterior surface or the prostate, we dissected and incised the an- terior bladder neck. Jenkins et al.(7) compared EBL volume between patients with and without ML and they reported that there was no statistically significant difference (296 ml in patients without ML and 304 ml in patients with ML, p = .46). Coelho et al.(6) also reported similar outcomes in term of EBL (100 vs. 100 ml, p = .15). We observed statistical- ly similar mean EBL volumes, intraoperative and post- operative blood transfusion rates for our both groups. Conversely, it has been reported that statistically sig- nificant lower EBL volume was observed in patients without ML compared to patients with ML by Meeks et al.(2)(380 vs. 464 ml, p = .05), Huang et al.(3) (236 vs. 193 ml, p = .002) and Jung et al.(8) (the rate of >300 mL bleeding, 8.4% vs. 4.2%, p = .004). The main point of interest of these studies(2,3,8) is that the definition and dissection of plane between the posterior bladder neck and prostate basis can be difficult in patients with large ML and this condition can lead excessive bleeding dur- ing dissection. In our population, PSM rates (14.9% vs. 15.1% p = .9) were comparable between two groups. Similarly, it has been reported that PSM rates were comparable between patients with and without ML in the majority of previous studies.(2,3,6,7) In a small sample sized study, Jenkins et al. reported PSM rates as 10% and 21% in patients with and without ML.(7) Although PSM rate is twice as high in the patients without ML compared the patients with ML, there was no statistically significant difference (p = .47). Similarly, statistically similar PSM rates were reported by Coelho et al.(6) (9.7% vs. 10.2%, p = .884), Huang et al.(3) (9.5% vs. 13.6%, p = .45) and Meeks et al.(2) (11% vs. 10%, p = .89). Meeks et al.(2) em- phasized that the presence of the ML appears to affect PSM around seminal vesicle and posterior bladder neck localization, however, positive surgical margins occur at the apex of prostate in the majority of PCa patients, as known. Strangely, Jung et al.(8) observed statistical- ly significant lower PSM rates (16% vs. 24%, p=.044) in patients with ML compared to patients without ML. When they compared the PSM rates at different local- ization of the prostate, they observed that the patients with ML were less likely to have positive margins at posterior side of prostate (21% vs. 47%, p = .034).(8) They explained this finding that the surgeon provid- ed more exposure during posterior prostate dissection when the surgeon retracts the ML to more anteriorly which described by Patel and coworkers(11). Previous studies(3,6-8) demonstrated that the presence of a ML does not affect complication rates. Huang et al.(3) reported statistically similar anastomosis stricture (p = .78), rectal injury (p = .12), inadvertent cystotomy (p = .27), urine leakage (p = .64), ureteral injury (p = .95) and urinary tract infection (p = .72) rates for patients with and without ML. The similar overall complication rates were also reported by Jenkins et al.(7) (10.3% vs. 13.7%, p > .05) and Coelho et al.(6) (5.3% vs. 4.6%, p = .719). Differently, Jung et al.(8) grouped complications as intraoperative and postoperative and they observed statistically similar intraoperative (2.5% vs. 3.3%, p = .66) and postoperative complication (11.6% vs. 7.5%, p = .36) rates between patients with and without ML. Similarly to previous studies(3,6-8), the overall complica- tion rates were comparable between patients with and without ML in our patients. The main difference of our study from previous studies is that we compared the complications objectively based on MCCS. In previous studies, the complications were compared according to number and percentage of complicated patients with- out standardized classification system. Recently, Euro- pean Association of Urology (EAU) guidelines panel emphasized the importance of standardized, systematic and objective classification system like MCCS using to evaluate of complications.(13) Because, it allows more accurate definition of complication of various surgi- cal approach, earlier recognition of the complication’s pattern, for comparing the surgical outcomes between institutions or individual surgeons, and for comparing techniques in case randomized trials are either lacking or difficult to perform. In our population, intraoperative and postoperative complications rates were 1.7% and 8.7%. Recently, The Pasadena Consensus Panel considered patients with a large ML as one of the challenging cases and it was emphasized that RARP procedures in patients with ML should be performed by experienced surgeons which are doing at least 40 cases per year.(14) Also, it was sup- ported by some authors that experience of the surgeon can significantly affect functional, oncologic outcomes, complication rates and the incidence of urethro-vesical junction anastomosis leakage after RP, especially in pa- tients with a challenging anatomy, such as the presence of a ML.(6,15) Our institution is one of the referral centers in our region and our surgeons perform about 100 cases per year and we think that low complication rates de- pend on the surgeon’ experience. In previous studies(3,6,7), there was no difference in term of UC rates between patients with and without ML. Huang et al.(3) reported their mid and long term (up to 24th months) UC rates. They reported that there were no statistically significant differences in term of mid and long term UC rates between patients with and without ML (at 5th month p = .48, at 12th month p=.58 and at 24th month p = .12). Similarly, Jenkins et al.(7) compared UC between patients with and without ML. They recorded the mean interval to recovery of full con- tinence to evaluate UC. Their mean interval to recovery of full continence 183 and 128 days in patients with The association between median lobe and perioperative outcomes- Hamidi et al. and without ML, respectively.(7) Although there was 55 days of difference between two groups, this difference was not statistically significant (p = .36).(7) Moreover, their bladder neck reconstruction rate was statistically significant higher in patients with ML compared to pa- tients without ML (55% vs. 3%, p < .001). In Coelho et al.’s(6) study, early and late UC rates were compara- ble between patients with and without ML (at 4 week 42.3% vs. 48%, at 24 week 91.5% vs. 94.1%, for all comparisons p > .05). Similarly to Jenkins et al.’s study, in Coelho et al.’s(6) study, the bladder neck reconstruc- tion rate was statistically higher in patients with ML than without ML (93% vs. 65%, p < .001). In our series, total urinary continence was defined as the use of 0-1 pad. The continence rate of our population at early term after RARP (at first month visit) was statisti- cally significant lower in patients with ML compared to patients without ML (49.2%, vs. 56.5%, p = .03) while no statistically significant difference was found at sub- sequent follow-up periods. We also observed patients with ML had lower bladder neck sparing rate (61% vs. 78%, p < .001). We think that the difference of early UC rates between our groups may depend on lower bladder neck preservation rate during RARP in patients with ML. The impact of bladder neck sparing and re- construction on recovery of urinary continence after RP is still unclear. Srougi and coworkers concluded that preservation of the bladder neck does not significant- ly affect recovery of urinary continence after RRP.(16) However, many authors considered that the patients who bladder neck preserved regained UC earlier com- pare to patients who bladder neck unpreserved despite similar long term UC rates.(17,18) Our study has several limitations. First, our study is ret- rospective. Second, the presence of ML during RARP was evaluate subjectively and it considered based on surgeon perspective. We could use radiological imaging technique (like preoperative magnetic resonance imag- ing or ultrasound of prostate) for objective evaluation of presence of ML. Third, time to urinary continence was not assessed in this study and we did not use objective asking forms for evaluation of UC. Finally, we do not have data about patient symptoms before RARP such as voiding or obstructive lower urinary tract symptoms. We could exclude symptomatic patients. This may af- fect our urinary continence rates. CONCLUSIONS The presence of a ML does not seem to affect perioper- ative complication, intraoperative blood loss, PSM and BCR following RARP especially in experienced hands. However, the presence of a ML seems to be a disadvan- tage in gaining early UC following RARP. ACKNOWLEDGEMENT None declared. CONFLICT OF INTEREST No conflict of interest was declared by the authors. REFERENCES 1. Sarle R, Tewari A, Hemal AK, Menon M. Robotic-assisted anatomic radical prostatectomy: Technical difficulties due to a large median lobe. Urol Int. 2005; 74: 92-4. 2. Meeks JJ, Zhao L, Greco KA, Macejko A, Nadler RB. Impact of prostate median lobe anatomy on robotic-assisted laparoscopic prostatectomy.Urology. 2009; 73: 323-7. 3. Huang AC, Kowalczyk KJ, Hevelone ND, et al. 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