经精囊面吊带悬吊膀胱颈技术在腹腔镜前列腺根治切除术中的应用

目的:探讨经精囊面吊带悬吊膀胱颈技术在腹腔镜前列腺癌根治术中的应用,评价其效果。方法:2013年10月~2014年6月,在12例前列腺癌根治手术中采用经精囊面吊带悬吊膀胱颈技术行膀胱颈离断。记录手术时间、术中出血量、膀胱颈切缘阳性率、术后短期尿控情况及术后并发症的发生。结果:12例患者,平均手术时间(98±21.5)min,平均术中出血量(134±26.4)ml。术后病理报告示膀胱颈切缘均为阴性。术后3个月仅1例发生轻度尿失禁。无尿漏、肾积水等并发症发生。结论:经精囊面吊带悬吊膀胱颈技术用于腹腔镜前列腺癌根治术中膀胱颈的离断安全性好,更好地保留了膀胱颈口,易于其与尿道的吻合,减少了术后并发症的发生。     

Modified anterior approach to the bladder neck: Simple and reproducible procedure for anterior bladder neck transection during robot‐assisted radical prostatectomy

To evaluate the feasibility and reproducibility of a simple technique for identifying the initial cutting point of the bladder neck during robot‐assisted radical prostatectomy. To precisely identify the prostatovesical junction, we first pulled the anterior bladder wall in an upward direction with the second arm to identify the precise location of the prostatovesical junction where anterior bladder neck dissection is initiated. After one experienced surgeon had established this technique, three surgeons who were less experienced in robot‐assisted radical prostatectomy utilized this method for 50 consecutive robot‐assisted radical prostatectomy cases. The pathological results and the time required to transect the anterior bladder wall were evaluated. There were no cases of positive resection margin on the site of bladder neck. The mean resection time was not significantly different when comparing less experienced surgeons with the experienced surgeon (P = 0.29). In conclusion, this method is a simple and reproducible way to identify the bladder neck during robot‐assisted radical prostatectomy. This technique is also useful (for laparoscopic or open radical prostatectomy) even in difficult scenarios, such as post‐transurethral resection of prostate cases.     

The management of stress urinary incontinence after radical prostatectomy

Up to 30% of patients complain about urine leakage after radical prostatectomy, but persistent stress incontinence (beyond 1 year) affects <5% of them. This complication is mainly caused by sphincter dysfunction. Some preventive measures have been described to decrease the risk of incontinence after radical prostatectomy, but with conflicting results. The effectiveness of preoperative and early postoperative physiotherapy is controversial. Moreover, while meticulous apical dissection of the prostate significantly improves postoperative continence, the benefit of other surgical techniques, e.g. preserving the bladder neck and the neurovascular bundles, is under debate. The treatment of persistent stress urinary incontinence is mainly based on surgery, as this type of incontinence usually does not respond to physiotherapy and anticholinergic medication. While injection therapy is safe and well tolerated, its effect on postoperative continence is limited and decreases with time. The best results are achieved by implanting an artificial urinary sphincter, but with significant complication and revision rates.     

Variaciones de la prostatectomía radical para una recuperación de la continencia urinaria precoz: una revisión sistemática

Background and objectiveUrinary incontinence is the adverse effect with more impact on patients’ quality of life after undergoing radical prostatectomy. The objective of this study is to review the present evidence that describes the variations on surgical techniques which aim to preserve urinary continence after radical prostatectomy.Evidence acquisitionWe searched the literature on PubMed, Cochrane, and ScienceDirect according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement, using the PICO review protocol. The search terms were urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot-assisted laparoscopic prostatectomy, robotic prostatectomy. We identified 1,603 registers, and 27 articles were reviewed for meeting the inclusion criteria. Six of them are randomized clinical trials and 4 of them, meta-analysis.Evidence synthesisThe surgical techniques more frequently used to achieve early urinary continence are bladder neck and neurovascular bundles preservation, as well as the reconstruction of the rhabdosphincter. The latter has been presented in three randomized clinical trials. Even though some approaches have obtained improved functional outcomes, the lack of consensus on the definition of urinary incontinence and its measurement methods have not advocated for the creation of technical recommendations based on scientific evidence.ConclusionsThe reconstruction of the rhabdosphincter is the only technique that has shown improved functional results through randomized trials. The current evidence is limited and heterogenous, and more studies with consistent criteria are needed in order to establish a standard surgical technique.     

Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy

PURPOSE: Salvage prostatectomy after full dose radiation therapy is associated with a high risk of urinary incontinence. We evaluated the complications of salvage prostatectomy with continent catheterizable reconstruction and its impact on urinary incontinence. MATERIALS AND METHODS: Between August 1995 and February 1999, 13 patients with biopsy proved, locally recurrent prostate cancer after radiation therapy underwent salvage prostatectomy with complete bladder neck closure and reconstruction with an appendicovesicostomy to the native bladder in 9 and ileovesicostomy in 4. RESULTS: There were no intraoperative complications. Four patients had serious complications necessitating reoperation, including a vesicourethral fistula requiring delayed cystectomy, wound dehiscence with disruption of the appendicovesical anastomosis, leakage from the small bowel anastomosis that resulted in sepsis and death, and stomal stenosis requiring delayed stomal revision in 1 each. Of 12 patients 2 (17%) used pads for incontinence, while 10 were dry during the day and night with a catheterization interval of 2 to 6 hours. CONCLUSIONS: Salvage prostatectomy with continent catheterizable reconstruction is a technically challenging operation with the potential for serious complications. The postoperative continence rate is excellent and appears superior to those in the literature for salvage prostatectomy and vesicourethral anastomosis.     

Ätiologie und Pathophysiologie der Belastungsinkontinenz beim Mann

Stress urinary incontinence is rare in men. Despite the improvements in diagnostic approaches to prostate diseases and surgical interventions on the prostate, stress incontinence has tended to increase in recent decades. The most frightening operative complication for both the patient and the surgeon is incontinence, which is one of the important factors in the treatment of the affected patients. The limited degree of continence considerably lowers the quality of life for the affected men and their partners. There is little information available about the pathophysiology of iatrogenic stress incontinence, which more likely affects older men rather than young men. The available information is based on a few experimental studies. Besides the direct damage to the muscular or neurological component of the external sphincter, insufficient length of the functional urethra and impaired bladder function seem to play an important role in the genesis of postoperative incontinence. In order to improve the postoperative continence status after radical prostatectomy a number of different operative modifications have been introduced. Preservation of the bladder neck, puboprostatic ligaments, and the neurovascular bundle as well as leaving the tips of the seminal vesicles seem to have a positive impact on the degree of postoperative continence.     

Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial

Study Type – Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Urinary incontinence is one of the major drawbacks of radical prostatectomy, regardless of the procedure used (i.e. open, laparoscopic or robotic‐assisted). Several technical modifications have been described to improve postoperative continence, highlighting the role of puboprostatic ligaments and posterior reconstruction of the rhabdomyosphincter. The results obtained are inconsistent when applied to robotic surgery. The present multicentre randomized study shows that anterior suspension combined with posterior reconstruction is a safe and easy‐to‐perform technique for improving early continence after robotic‐assisted laparoscopic prostatectomy.

OBJECTIVE

• ? To assess the impact on urinary continence of anterior retropubic suspension with posterior reconstruction during robot‐assisted laparoscopic prostatectomy (RALP).

PATIENTS AND METHODS

• ? In total, 72 patients who were due to undergo prostatectomy between July 2009 and July 2010 were prospectively randomized into two groups: group A underwent a standard RALP procedure and group B had anterior suspension and posterior reconstruction during RALP.
• ? The primary outcome measure was urinary continence, assessed using the University of California Los Angeles Prostate Cancer Index questionnaire at 15 days, and at 1, 3 and 6 months, after surgery. Other data recorded were operation duration, blood loss, length of hospital stay, duration of bladder catheterization, complications and positive margin rate.

RESULTS

• ? The continence rates at 15 days, and at 1, 3 and 6 months, after surgery were 3.6%, 7.1%, 15.4% and 57.9%, respectively, in group A, and 5.9%, 26.5%, 45.2% and 65.4%, respectively, in group B. The continence rates differed statistically between groups at 1 and 3 months (P = 0.047 and P = 0.016, respectively).
• ? There was no significant difference between groups regarding complications (P = 0.8) or positive margin rate (P = 0.46).

CONCLUSION

• ? Anterior suspension associated with posterior reconstruction during RALP improved the early return of continence, without increasing complications.

     

Radical retropubic prostatectomy: bladder neck preservation versus reconstruction

PURPOSE: We compare bladder neck contracture, urinary continence and positive surgical margin rates after bladder neck preservation and excision with radical retropubic prostatectomy. MATERIALS AND METHODS: A retrospective analysis of clinical and pathological findings, and followup of 220 patients who underwent radical retropubic prostatectomy was performed. Patients were divided into 3 groups of bladder neck preservation (101), "tennis racket" reconstruction (63) and anterior bladder tube reconstruction (56). RESULTS: Mean followup was 19.7, 36.7 and 16.2 months, respectively, for bladder neck preservation, tennis racket reconstruction and anterior bladder tube reconstruction. Overall, bladder neck contracture occurred in 22 of 220 cases (10%), including 5 of 101 (5%) with bladder neck preservation, 7 of 63 (11%) with tennis racket reconstruction and 10 of 56 (18%) with anterior bladder tube reconstruction, which approached statistical significance (p = 0.061). Urinary continence was assessed by a third party telephone interview of 165 patients. Continence rates at 1 year were 93% for bladder neck preservation, 96% for tennis racket reconstruction and 97% for anterior bladder tube reconstruction, which was not statistically significant (p = 0.68). Positive margin rates were 27.4% with bladder neck preservation versus 30.5% with excision, which was not significantly different. CONCLUSIONS: There are no statistically significant differences in return of urinary continence, bladder neck contracture rates or positive margins between bladder neck preservation and excision.     

提高前列腺癌根治术后尿控能力的临床研究

目的：探讨提高前列腺癌根治术后尿控能力的方法。方法：对15例前列腺癌采用保留尿道膜部括约肌及前列腺侧旁神经血管束的方法进行前列腺癌根治术。结果：经6—45个月随访，15例患者排尿通畅，无肿瘤复发，除1例有轻度尿失禁外，余14例6个月内均恢复尿控能力。结论：保留尿道膜部括约肌及前列腺侧旁神经血管束的方法能减低前列腺癌根治术后尿失禁。     

What is the long‐term relevance of clinically detected postoperative anastomotic urine leakage after robotic‐assisted laparoscopic prostatectomy?

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? The use of a drain to detect and evacuate anastomotic urine leakage after radical prostatectomy is a common clinical practice. The use of such drains, traditionally, attempts to avoid the short‐term risks of urinoma, ileus, and infection, but little is known on the long‐term complications of such leakage on functional outcomes, such as erectile function, continence, and bladder neck contracture. This study shows that after a mean of two years of follow‐up, patients with clinically detected anastomotic urine leakage after robotic‐assisted laparoscopic radical prostatectomy do not have worse erectile function, incontinence or risk of bladder neck contracture than patients who had no clinical evidence of leakage.

OBJECTIVE

? To determine whether patients with postoperative clinically detected anastomotic urine leaks are at increased risk for poorer erectile function, urinary incontinence and bladder neck contracture (BNC) after robotic‐assisted laparoscopic radical prostatectomy.

PATIENTS AND METHODS

? A retrospective review of all patients undergoing RALRP from October 2005 until December 2009 by a single surgeon (R.B.N.) was conducted. Clinically detected anastomotic urine leak was defined as drain output consistent with urine at more than 24 h postoperatively. The presence of BNC was identified on cystoscopy. ? Erectile function was measured with the Sexual Healthy Inventory for Men (SHIM) questionnaire. Incontinence was measured by patient‐reported daily pad use. ? Univariate and multivariate analyses were performed. Outcomes were assessed at the most recent follow‐up.

RESULTS

? Among 213 patients eligible for inclusion, 27 experienced an anastomotic urine leak (12.7%). ? At a mean long‐term follow‐up of 24.2 months, there was no difference in SHIM scores (7.0 vs 13.1; P= 0.101), continence rates (87.5% vs 85.2%; P= 0.999) or risk of BNC (7.4% vs 3.2%; P= 0.268) between patients with and without postoperative anastomotic urine leaks, respectively. ? The results did not change after controlling for covariates in a multivariate analysis.

CONCLUSION

? The present study suggests that patients with clinically detected postoperative anastomotic urine leaks do not necessarily have worse long‐term outcomes of erectile function, continence and risk of BNC.     

保留膀胱颈环状肌和前列腺侧旁神经血管束的前列腺癌根治术

为减少或避免前列腺癌根治术后尿失禁和阳萎的发生，采用保留膀胱颈环状纤维和前列腺侧旁神经血管束的方法行前列腺癌根治术１３例，结果１３例术后无尿失禁９例，轻度可复性尿失禁４例；保留性神经手术８例，术后有性功能７例；术前内分泌疗法９例，术后病理均可见肿瘤细胞退变，萎缩改变。结论：前列腺癌膀胱颈无浸润者适宜作本术式。由于术后保留括约肌功能，尿失禁发生率低。因此，对癌前病变及术前难以定性的高危患者可扩大手术适应证     

中老年人行前列腺癌根治术后发生尿失禁的高危因素分析

目的 分析中老年人行前列腺癌根治术后发生尿失禁的高危险因素。方法 选取2014年至2020年福建省内5家综合性医院泌尿外科行前列腺癌根治术的626例中老年人患者作为研究对象,根据入组患者术后是否发生尿失禁将患者分为对照组（术后未发生尿失禁者,526例）和观察组（术后并发尿失禁者,100例）。分析两组患者的一般资料、临床资料、手术治疗、护理资料的各指标间差异,采用多因素logistic分析前列腺癌根治术后发生尿失禁的高危因素。结果 共100例患者术后发生尿失禁,尿失禁发生率为15.97%。中老年人行前列腺癌根治术患者术后发生尿失禁与年龄、体重指数（BMI）、术前前列腺增生、术前膀胱功能、前列腺癌病理分期、既往尿道前列腺手术史、放疗史、手术者的手术台数、手术损伤括约肌、术中神经损伤、术后康复锻炼依从性均有相关性（均P<0.05）。多因素logistic结果分析显示,年龄≥75岁、前列腺增生、术前膀胱失代偿、手术损伤括约肌、术中神经损伤、既往有尿道前列腺手术史、术后康复锻炼依从性低均为中老年人行前列腺癌根治术患者术后发生尿失禁的独立危险因素（均P<0.05）。结论 中老年人行前列腺癌根治术后发生尿失禁的概率高,影响术后尿失禁危险因素主要是患者病情、手术质量,临床制定围手术期治疗和护理方案应充分考虑其危险因素,制定针对性措施预防尿失禁,提高患者术后病情康复及生活质量水平。     

Posterior musculofascial plate reconstruction promotes early restoration of continence and prevents severe incontinence in patients undergoing laparoscopic radical prostatectomy

The objective of the present study was to assess the efficacy of posterior reconstruction of Denonvilliers' musculofascial plate for restoring urinary continence after laparoscopic radical prostatectomy. A total of 48 consecutive patients who underwent laparoscopic radical prostatectomy were retrospectively reviewed. Of them, 23 underwent laparoscopic radical prostatectomy without posterior reconstruction of Denonvilliers' musculofascial plate (group 1) and 25 underwent laparoscopic radical prostatectomy with posterior reconstruction of Denonvilliers' musculofascial plate (group 2). Patients' demographics were analyzed and continence rates between the two groups at 1, 3, 6 and 12 months after surgery were compared. Patients in group 2 had significantly larger prostates than in group 1. There were no significant differences between the two groups in terms of the other patient characteristics. The urinary continence rates were significantly higher in group 2 than in group 1 at 1, 3 and 12 months after surgery, and the rates of severe incontinence were significantly lower in group 2 at all time‐points considered. These findings suggest that posterior reconstruction of Denonvilliers' musculofascial plate helps in restoring early continence and decreasing severe incontinence in patients undergoing laparoscopic radical prostatectomy.     

Nerve-sparing open radical retropubic prostatectomy

INTRODUCTION: In recent years, the surgical technique for open radical prostatectomy has evolved and increasing attention is paid to preserving anatomic structures and the impact on outcome and quality of life. METHODS: Technical aspects of nerve-sparing open radical retropubic prostatectomy (RRP) are described. Patient selection criteria and functional results are discussed, focusing on postoperative urinary continence. RESULTS: The video demonstrates the nerve-sparing open RRP and important steps are elucidated with schematic drawings. The value of nerve sparing, not only for preserving erectile function, but also for preserving urinary continence is discussed and results from our institution are presented. In our series, urinary incontinence was present in 1 of 71 patients (1%) with attempted bilateral nerve-sparing, 11 of 322 (3%) with attempted unilateral nerve-sparing, or 19 of 139 (14%) without attempted nerve-sparing surgery. In multiple logistic regression analysis, the only statistically significant factor influencing urinary continence after open RRP was attempted nerve sparing (odds ratio, 4.77; 95% confidence interval, 2.18-10.44; p=0.0001). CONCLUSIONS: Nerve-sparing surgery has a significant impact on erectile function and urinary continence and should be performed in all patients provided radical tumour resection is not compromised. For successful nerve preservation we advocate a lateral approach to the prostate to improve visualisation and simplify separation of the neurovascular bundles from the dorsolateral prostatic capsule. Bunching, ligating, and incising Santorini's plexus over the prostate and not over the sphincter ensures a bloodless surgical field. Mucosa-to-mucosa adaptation of the reconstructed bladder neck and the urethra is another important factor to be observed.     

Katheterisierbarer Kontinenzmechanismus für verschiedene Harnableitungsreservoire

In a retrospective multicenter study of four clinics perioperative complications as well as incontinence and stoma stenosis of serosa-lined tapered ileum as catheterizable continence mechanisms for different urinary diversions were analyzed. Between 2008 and 2012 a total of 40 patients received a continent catheterizablestoma, 15 (37.5%) in combination with continent vesicostomy and closure of the bladder neck due to postoperative incontinence and recurrent stenosis including radical prostatectomy, transurethral resection (TUR) of the prostate, bladder neck incision (n=11), neurogenic bladder with reduced capacity and incontinence (n=2), interstitial cystitis (n=1) and recurrent urethral tumor following ileal neobladder (n=1). Of the patients 25 (62.5%) received this continence mechanism in combination with a modified Mainz pouch I, in 19 patients as primary and in 6 patients as secondary efferent segment for trouble shooting. The complications were subdivided according the Clavien classification. In 29 patients information concerning continence and stenosis were obtained, the median follow-up was 25 months (range 1-111 months). In patients with continent vesicostomy (n=11) the incontinence rate was 9.1% (1/11) and the stenosis rate 18.2% (2/11). In 18 patients with an ileocecal pouch, incontinence and stenosis rates were 0% and 11.1% (2/18), respectively. The presented technique is a safe continence mechanism for various catheterizable continent urinary diversions for both primary and secondary indications.     

盆底筋膜保护与重建对腹腔镜下前列腺癌根治术后早期控尿的影响

目的：了解采用盆底筋膜保护与重建法对腹腔镜下前列腺癌根治术后患者早期控尿的影响.方法回顾性分析自同一术者2013年1月至2015年12月在广东省中医院泌尿外科行腹腔镜下前列腺癌根治术的40例患者资料,其中采用盆底筋膜保护与重建技术的前列腺癌患者17例(治疗组),采用常规腹腔镜下治疗的前列腺癌患者23例(对照组),对两组患者的年龄、术前BMI、术前前列腺体积、术前临床分期、术前 Gleason 评分、手术时间、术中出血量、术后吻合口漏尿率、术后病理切缘阳性率、术后病理分期、术后 Gleason 评分及早期尿控功能恢复的情况等临床指标进行统计学分析.结果40例腹腔镜下前列腺癌根治术均经腹膜外完成,术中无中转开放,无术中输血病例,术后吻合口无漏尿,两组均有1例术后病理切缘阳性.两组在年龄、术前 BMI、术前前列腺体积、术前临床分期、术前 Gleason 评分、手术时间、术中出血量、术后病理分期及术后 Gleason评分方面差异均无统计学意义(P ＞0．05);40例患者均在术后12~16 d 拔除尿管,治疗组拔除尿管后3 d 内、1个月内和3个月内的累积完全控尿比例分别为52．9％、64．7％和82．4％,显著高于对照组(分别为8．7％、26．1％和34．8％),两组差异有统计学意义(P ＜0．05).结论在腹腔镜前列腺癌根治术中使用盆底筋膜保护与重建技术可显著提高患者术后早期的控尿能力.     

The significance of the open bladder neck associated with pelvic fracture urethral distraction defects.

PURPOSE: As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. RESULTS: Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. CONCLUSIONS: Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.     

机器人辅助不同膀胱入路前列腺癌根治术的临床疗效及影响尿控功能的因素分析

研究机器人辅助不同膀胱入路前列腺癌根治术的临床疗效,分析术后尿控功能的影响因素。方法 选取2017年3月至2019年5月本院收治的103例前列腺癌患者为研究对象,根据不同膀胱入路分为膀胱前入路组（A组,53例）与膀胱后入路组（B组,50例）。比较两组围手术期指标、术后1、3个月生活质量（QOL）评分、Gleason评分、前列腺特异抗原(PSA)值、尿控有效率,分析术后尿控功能的影响因素。结果 A组手术时间、术中出血量、住院时间、尿管留置时间显著少于B组(P<0.05);两组术后3个月尿控有效率比较,差异无统计学意义（67.9% vs. 58.0%, P>0.05）;两组术后1、3个月QOL评分、Gleason评分较术前显著升高,PSA值显著降低（P<0.05）,A组术后1、3个月QOL评分、Gleason评分显著高于B组,术后1个月PSA值显著低于B组（P<0.05）;体重指数（BMI）<28 kg/m²、后方颈膜重建及保留膀胱颈、最长尿道及神经血管束患者的尿控率明显高于BMI≥28 kg/m²、未进行后方颈膜重建、未保留膀胱颈、最长尿道及神经血管束患者,且差异有统计学意义（P<0.05）;BMI≥28 kg/m²、神经血管束损伤是影响术后尿控功能的危险因素（P<0.05）。结论 机器人辅助经膀胱前入路前列腺癌根治术出血少,术后尿控功能恢复较好,有助于改善患者生活质量,肥胖和神经血管束损伤对术后尿控功能有不利影响。     

Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence

OBJECTIVES: Urinary incontinence after radical prostatectomy continues to be a distressing problem, even with preservation of the neurovascular bundles and meticulous apical dissection. Recent studies suggest that motor and sensory components of the pelvic nerve may be affected by surgery, since both components are anatomically located in intimate contact with the seminal vesicles. We propose seminal vesicle-sparing radical prostatectomy to preserve pelvic innervation and improve the rate of urinary continence. METHODS: Fifty-four patients were enrolled in this prospective study. A standard retropubic radical prostatectomy was performed in 34 patients. A seminal vesicle-sparing radical prostatectomy was performed in a pilot series of 20 consecutive patients. The seminal vesicle tip and surrounding tissue were preserved and carefully handled. In all patients, a modified pad test and posterior urethral sensory threshold test were performed preoperatively and 6 weeks and 6 months postoperatively and correlated with urinary continence. RESULTS: The intraoperative preservation of the seminal vesicle tip was possible in all patients in this pilot series (n = 20). In the seminal vesicle-sparing radical prostatectomy group, the continence rate was 60% after 6 weeks and 95% after 6 months. These rates were significantly higher than the continence rates in the standard prostatectomy group (18% and 82% at 6 weeks and 6 months, respectively). The sensory threshold levels in the seminal vesicle-sparing group were similar to the preoperative values and were significantly lower than the postoperative threshold levels in the standard prostatectomy group. CONCLUSIONS: Seminal vesicle tip-sparing radical prostatectomy may be a surgical option to preserve pelvic innervation and maintain urinary continence after radical prostatectomy. Further randomized studies are necessary to elucidate the impact of seminal vesicle-sparing radical prostatectomy on restoration of urinary continence.     

Is a cystogram necessary after robot-assisted radical prostatectomy?

PURPOSE: Robot-assisted radical prostatectomy has become an acceptable option for the treatment of clinically localized prostate cancer. The role of cystography in robot-assisted radical prostatectomy was evaluated prospectively. METHODS AND MATERIALS: A total of 80 consecutive patients who underwent robot-assisted radical prostatectomy with an intraperitoneal approach were evaluated. There were 40 patients (group 1/surgeon A) who received a routine postoperative cystogram before Foley catheter removal. An additional 40 patients (group 2/surgeon B) had their catheters removed without radiographic imaging. Patient demographics, intraoperative data, postoperative data, and complications were recorded prospectively. RESULTS: The 2 groups were similar in age, Gleason score, and history of previous urethral/bladder neck surgery. Univariate analysis showed no statistical difference among case duration, estimated blood loss, need for bladder neck reconstruction, presence of visible anastomotic leak, or use of pelvic drains. Anastomosis time was the only variable that reached statistical significance. Mean catheter duration (11 days) was similar between the 2 groups. There were 3 patients from group 1 who had an anastomotic leak identified on a cystogram. In group 2, 1 patient had a persistent mild leak based on a cystogram obtained for urinary symptoms. No patient in either group had urinary retention, urinary tract infection, renal failure, or bladder neck contracture develop. The degree of postoperative urinary incontinence was similar between groups. CONCLUSION: Foley catheter removal on postoperative days 8-10 after robot-assisted radical prostatectomy without routine cystography appears safe.