Radical retropubic prostatectomy

We herein present a modification of the Campbell technique for radical retropubic prostatectomy used in 75 consecutive patients undergoing surgical extirpation of the malignant gland. This technique provides for predictable and careful anatomic removal of the prostate. The postoperative complications have been minimal and urinary incontinence has been negligible.     

A continence index predicts the early return of urinary continence after radical retropubic prostatectomy

PURPOSE: We evaluated the ability of a newly developed continence index to predict the return of urinary continence 3 months after radical retropubic prostatectomy. MATERIALS AND METHODS: We developed and used a continence index to determine continence level after removal of the urinary catheter on postoperative day 15 in 145 men. A total of 20 patients were evaluated independently by 2 nurse specialists to assess continence index reliability. We evaluated continence level, pad use and degree of bothersomeness due to incontinence 3 months after catheter removal. The association of continence score with outcome variables was calculated using the Mantel-Haenszel trend test and the predictive ability of the continence score was determined by logistic regression to produce cumulative odds ratios. RESULTS: The intraclass correlation coefficient was 0.995 for the independently assessed continence index ratings and the Cronbach coefficient alpha was 0.65 for the 5 continence index parameters. Complete continence or continence with heavy activity but not always was achieved by 96%, 85% and 68% of the men in tertiles 1 (continence score 18), 2 (continence score 15 to 17) and 3 (continence score 14 or less), respectively. The cumulative odds ratio of 2.9 (95% confidence interval [CI] 1.9 to 4. 6) per tertile indicated a 2.9-fold increased chance of incontinence for each successively lower tertile. In addition, 96%, 82% and 68% of the men in tertiles 1 to 3, respectively, required no or 1 small pad daily. The cumulative odds ratio for pad use was 2.3 (95% CI 1.5 to 3.5) per tertile. Of the patients in tertiles 1 to 3 100%, 97% and 80%, respectively, had no or slight bothersomeness due to urinary incontinence. The cumulative odds ratio for bothersomeness level was 2.7 (95% CI 1.7 to 4.3) per tertile. The Mantel-Haenszel trend test showed a significant association of continence score with all 3 outcome variables (p < or =0.001). CONCLUSIONS: Our continence index is a simple and reliable instrument that provides useful prognostic information on the early return of continence after radical retropubic prostatectomy.     

Radical retropubic prostatectomy. Preoperative management

The morbidity of radical prostatectomy is minimized by identifying men who are at significant cardiovascular risk and excluding them from the procedure. Preoperative management designed to minimize surgical and medical complications and exposure to allogenic blood products increases the benefit-to-risk ratio of radical prostatectomy over other treatment options for localized prostate cancer.     

Improved continence after radical retropubic prostatectomy using two pubo-urethral suspension stitches

OBJECTIVES: To determine if placement of urethral suspension stitches during radical retropubic prostatectomy improves postoperative urinary continence. METHODS: Between January 1997 and January 1998 we performed radical retropubic prostatectomy on 50 men. The first 25 consecutive men had their surgery without urethral suspension stitches while the next 25 received placement of two anastomotic urethral suspension stitches anchored to the lower portion of the pubic bone. Patients were interviewed six months postoperatively and each underwent valsalva leak-point pressure measurement. Patients were categorized as either completely continent (requiring no pads and having no measurable valsalva leak point), socially continent (zero or one pad per day), or incontinent (two or more pads per day). RESULTS: In the urethral suspension group, 8/25 (32%) patients were completely continent and did not have a measurable valsalva leak-point pressure while 3/25 (12%) without urethral suspension were completely continent. Of the remaining patients in the urethral suspension group, 13/17 (76%) patients were socially continent while 4/17 (24%) were incontinent. The mean valsalva leak-point pressure in the 17 patients with suspension stitches was 89.6 +/- 21.6 cm H2O. In the patients without urethral suspension, there were 22 patients who had some degree of incontinence. Among non-stitch patients, 13/22 (59%) were socially continent while 9/22 (41%) were incontinent. The average valsalva leak-point pressure in these patients was 74.0 +/- 16.7 cm H2O, which was significantly lower than those with the suspension (p = 0.015). CONCLUSIONS: Placement of anastomotic urethral suspension stitches during radical retropubic prostatectomy may increase the likelihood of complete postoperative urinary continence. The urethral suspension stitches also increase valsalva leak-point pressure, which may improve the percentage of patients with socially acceptable incontinence.     

保留耻骨前列腺韧带在耻骨后根治性前列腺切除术控尿中的作用

目的 探讨耻骨后根治性前列腺切除术中保留耻骨前列腺韧带(PL)的控尿作用.方法前列腺癌患者74例.年龄52～73岁,平均65岁.术前实验室检查PSA 2.0～23.6 ng/ml,平均16.5 ng/ml.其中64例行经直肠超声引导下前列腺系统穿刺活检,病理证实为前列腺癌;10例行TURP后病理发现前列腺癌.74例均行盆腔MRI及全身骨扫描未见前列腺外转移病灶.A期6例、B期68例.手术方法:常规行双侧盆腔淋巴结清扫,锐性切开盆内筋膜至PL侧缘,50例保留PL,在尿道前方紧贴前列腺尖部的弧形缘放置集束血管钳,控制耻骨后血管复合体(包括PL与背静脉复合体);对照组24例紧贴耻骨切断PL,在尿道前方紧贴前列腺尖部的弧形缘放置集束血管钳,控制背静脉复合体.在集束钳下方用1-0可吸收线分别贯穿缝扎集束血管钳控制的组织,沿前列腺的弧形切断该束组织达前列腺尖部与尿道连接处.离断尿道.采用"网球拍"式的膀胱颈重建.整形后的膀胱颈与尿道黏膜对黏膜于2、5、7和10点分别吻合4针,将保留在复合体上的1-0缝线于重建膀胱颈的12点、距吻合缘0.5～1.0 cm处浆肌层贯穿缝扎,将其与复合体结扎固定.术后保留尿管2周.结果 74例手术均顺利.随访3～12个月.保留PL组及切断PL组年龄分别为(61.3±2.4)和(60.8±2.1)岁,实验室检查PSA分别为(14.3±1.2)和(14.7±1.3)ng/ml,手术时间为(110.5±10.4)和(109.7±10.6)min,术中出血量为(250.5±23.4)和(253.4±22.3)ml,切缘阳性率为6%(3/50)和8%(2/24);2组比较差异均无统计学意义(P>0.05).保留PL组与切断PL组术后拔除尿管不同时间的控尿率分别为:即刻26%(13/50)和0%(0/24),1个月时为50%(25/50)和12%(3/24),3个月时为80%(40/50)和42%(10/24),6个月时为96%(48/50)和67%(16/24),12个月时为100%(50/50)和75%(18/24);2组比较差异均有统计学意义(P<0.05). 结论 PL在耻骨后根治性前列腺切除术后控尿中发挥较大作用,术中应积极保留.     

Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy

OBJECTIVE: To report our experience of the influence of bladder neck preservation on patient continence. MATERIAL AND METHODS: Radical retropubic prostatectomy with bladder neck preservation was performed in 131 patients (age range 48-73 years; mean 64.5 years). Urinary continence was evaluated using a validated questionnaire at follow-up visits and telephone interviews. All patients reporting incontinence were studied using a pad test and urodynamics. RESULTS: After a mean follow-up period of 21.7 months (range 4-47 months), 115 patients were continent (87%) and 16 incontinent. According to the International Continence Society criteria, three had severe, three moderate and 10 mild incontinence. Urodynamics revealed sphincter deficiency in 15 cases, which was associated with decreased bladder compliance in four, while decreased compliance was the only abnormality in one. Continence was recovered 0-27 months after surgery (mean 3.2 months): 40% of men were continent within the first month and 74% within the third. Histopathology revealed positive margins in 30/131 patients (22%), but exclusively at the bladder neck level in only seven (5%), and two also had positive nodes. Six patients (4.5%) presented bladder neck stenosis requiring transurethral incision. No statistically significant differences were found between the ages of continent and incontinent men or between the time to continence recovery with two different techniques of retropubic hemostasis; however, use of a nerve-sparing technique significantly reduced the time to continence recovery. CONCLUSIONS: Bladder neck preservation during radical retropubic prostatectomy does not improve the long-term results of urinary continence but does contribute substantially to its earlier recovery, thus improving the quality of life. With proper patient selection the risk of positive margins at the bladder neck level only is reasonably low.     

Urethrovesical anastomosis in retropubic radical prostatectomy

Urethrovesical anastomosis is the most codified step in radical prostatectomy. Most of the time, the bladder neck diameter makes it possible to carry out a congruent anastomosis. Otherwise one has to resort either to the tennis racket closure or the parachute technique. Stenosis will remain an exceptional complication if the technique is applied with strictness and precision.     

Radical retropubic prostatectomy with running vesicourethral anastomosis and early catheter removal: Our experience

Objectives:   To assess the outcomes of patients undergoing radical retropubic prostatectomy (RRP) with a running vesicourethral anastomosis and catheter removal on postoperative day 3 or 5.
Methods:   From February 2006 through December 2007, 55 patients underwent RRP at our institution. All procedures were performed by a single surgeon using a running suture for the vesicourethral anastomosis. A cystogram was carried out before catheter removal in all patients. The initial 23 of 55 patients (Group 1; n  = 23) had the cystogram on postoperative day 5, the other 32 patients (Group 2; n  = 32) had the cystogram on postoperative day 3. Removal of the catheter was only carried out if there was no anastomotic extravasation.
Results:   The success rate of catheter removal in group 1 and 2 was 100% and 96.9%, respectively. Overall continence rates were 83.3%, 87% and 90.7% at 24, 48 and 72 h after removal of the catheter, respectively. There was no significant difference in terms of continence rate between groups 1 and 2. None of the patients had acute urinary retention and/or anastomotic stricture after catheter removal.
Conclusions:   These findings suggest that an advanced running vesicourethral anastomosis during RRP is technically feasible, allowing safe early catheter removal in most patients.     

Prospective predictors of urinary continence after anatomical radical retropubic prostatectomy: a multivariate analysis

The aim of this work was to evaluate variables that predict time to pad-free urinary continence after anatomical radical prostatectomy (ARP). Sixty consecutive prostate cancer patients who underwent ARP by one surgeon were studied. Pad-free urinary continence was prospectively determined by patient interviews and confirmed on physical examination and by the urinary domain of the Extended Prostate Inventory Composite (EPIC) Health Related Quality of Life questionnaire. A time-dependent Cox multivariate regression analysis was performed to determine which variables significantly correlated with time to pad-free urinary continence. Increasing prostate size (cc), increasing prostate urethral length (cm) and surgical technique (wide excision of the neuro-vascular bundle) correlated with a significantly (P<0.05) prolonged time to achieve pad-free urinary continence. In conclusion, prostate size and surgical technique were the most useful variables in predicting time to pad-free urinary continence after ARP.     

Patient-reported urinary continence (third-party interview): results of post-radical retropubic prostatectomy in Singaporeans

OBJECTIVE: To determine the patient-reported urinary continence rate after retropubic radical prostatectomy (RRP) for prostate carcinoma through a third-party interview and to grade the severity of incontinence. METHODS: Between 1997 and 1999, 34 patients were evaluated through an independent third party about the degree of continence as well as the quality of life after RRP. Patients were interviewed either in person or over the telephone. Urinary continence was defined as wearing no diapers, pads or tissue paper. RESULTS: Of the 34 patients, 44% achieved immediate continence. Urinary incontinence gradually improved with time after surgery and 82% (n = 28) were fully continent at 12 months. Using the quality-of-life index, 91% of patients characterized their urinary incontinence as not or minimally bothersome. There was no significant difference between urologist- and patient-reported continence rates after RRP. CONCLUSION: Based on our grading system, urinary continence gradually improved with time and was 82% at 1 year.     

The mechanism of urinary continence after prostatectomy.

An anatomical and neuropharmacological study of the urethra was performed in 19 patients after prostatetectomy to investigate the mechanism of continence. Anatomically, the urethral segment responsible for the postprostatectomy continence was located distal to the open prostatic fossa in the external sphincter which is comprised of intrinsic striated muscle and is called arbitrarily rhabdosphincter by the author. This unique striated muscle in the rhabdosphinecter appears to be primarily under the alpha-adrenergic influence in view of the change in the urethral pressure profile observed following alpha-adrenergic drugs.     

Radical retropubic prostatectomy after transurethral prostatic resection

In 16 patients who underwent radical retropubic prostatectomy because of adenocarcinoma of the prostate after previous transurethral resection, the difficulty of the operation, the morbidity rate, and the survival time were evaluated. Eleven patients had tumours staged A2, 5 patients tumours staged B1. Duration of the operation and blood loss were almost similar to the group of patients who had not had prior transurethral resection of the prostate. The impotence rate was 100% due to difficulties preparing and preserving the neurovascular bundle. Only 1 patient had stress incontinence. One patient died after 2 years with rapid tumour progression, 1 patient shows local recurrence. Radical prostatectomy may be performed safely with an acceptable morbidity rate following transurethral resection of the prostate.     

Radical retropubic prostatectomy after orthotopic liver transplantation

Radical prostatectomy is a standard treatment option for many patients with clinically localized prostate cancer; however, little information about its safety and efficacy is available to help guide patients who have undergone prior organ transplantation. We present 2 cases of patients with prior hepatic transplantation who each subsequently underwent radical prostatectomy. In each case, the prostate tumor was organ confined, and both patients were biochemically free of disease at last follow-up.