Transrectal ultrasound navigation during minilaparotomy retropubic radical prostatectomy: Impact on positive margin rates and prediction of earlier return to urinary continence

Objectives:   To assess the impact of transrectal ultrasound (TRUS) navigation on positive margin rates and membranous urethral length (MUL) after minilaparotomy radical retropubic prostatectomy (MRP).
Methods:   Rates of positive distal margins prior to and after the application for TRUS navigation during MRP were assessed. Of the 189 men undergoing MRP at our institution, 70 were evaluated for the clinical usefulness of preoperative and postoperative MUL. Patients filled out self-administrated questionnaires concerning continence status at 1, 3, 6, 9, and 12 months after the MRP. Surgery-related factors including MUL were analyzed for the prediction of urinary continence after MRP.
Results:   With the application of TRUS, the rate of positive distal margins decreased by 14%. Postoperative MUL was an independent variable predictive of urinary continence 1 month after surgery. Patients with a MUL longer than 12 mm showed a significantly more favorable recovery from urinary incontinence after surgery.
Conclusion:   Application of TRUS results in a lower rate of positive margins, and a longer postoperative MUL is associated with an earlier return to urinary continence after MRP.     

Lateral view dissection of the prostato-urethral junction to reduce positive apical margin in laparoscopic radical prostatectomy

Objective:   To assess the impact of lateral view apical dissection in laparoscopic radical prostatectomy (LRP) on the reduction of positive surgical margin rates and recovery of postoperative continence.
Methods:   One hundred and forty-four consecutive patients underwent LRP from October 2004 to March 2008. Lateral view dissection of the prostato-urethral junction was conducted in 76 of them (Group 2). Standard dissection was used in the remaining patients (Group 1). The effect of this technical modification on the reduction of positive surgical margin rates and postoperative recovery of urinary continence was assessed in the two groups.
Results:   Overall, the incidence of positive margins decreased from 23 (35.9%) in Group 1 to 16 cases (21.9%) in Group 2 ( P  = 0.07). Positive margin rates in pT2 decreased from 30.6% to 6.5% ( P  = 0.006). Apical and dorso-apical margins were reduced from 26.5% to 4.3% ( P  = 0.009) and from 10.2% to 0% ( P  < 0.001), respectively. Postoperative recovery of urinary continence improved significantly, with a pad-free rate over the first 3 months of 55.9% in Group 1 vs 71.7% in Group 2 ( P  = 0.01). Multivariate logistic regression analysis showed this modified surgical technique to predict a lower rate of positive margins.
Conclusion:   Lateral view dissection of the prostato-urethral junction is an easily applicable technical modification. It provides better visualization of apical anatomy substantially contributing to the reduction of positive surgical margin rates, especially at the level of prostatic apex.     

The technique of apical dissection of the prostate and urethrovesical anastomosis in robotic radical prostatectomy

OBJECTIVE: To describe the technique of dissecting the apex of the prostate and a modified single running-suture urethrovesical anastomosis in patients undergoing robot-assisted radical prostatectomy for organ-confined prostate cancer. PATIENTS AND METHODS: Over 550 robot-assisted radical prostatectomies have been undertaken using Vattikuti Institute Prostatectomy (VIP) technique in patients with localized carcinoma of the prostate. We present a critical analysis of the first 120 procedures by one surgeon (M.M.) at our institution using this newly developed technique of urethrovesical anastomosis preceded by dissecting the apex of the prostate. RESULTS: The mean time for the urethrovesical anastomosis was 13 min. All but 24 patients had their catheter removed 4 days after surgery, as indicated by a cystogram. The catheter was removed successfully at 7 days in the remaining 24 patients who had a mild leak on cystography. Two patients had urinary retention within a week of removing the catheter and had to be re-catheterized. Continence was evaluated using standardized criteria before and after the procedure. The patients also replied to a mailed validated questionnaire survey; 96% were continent at 3 months and the remaining 4% used a thin pad for security. CONCLUSIONS: We report a technique of dissecting the apex of the prostate and prostatovesical junction for dividing the bladder neck, and a modified single running-suture urethrovesical anastomosis, in patients undergoing robot-assisted radical prostatectomy for organ-confined cancer of the prostate. The same principles can also be applied for the anastomosis during pure laparoscopic procedures and for urethro-neovesical anastomosis in patients undergoing robotic radical cystoprostatectomy for carcinoma of the bladder.     

Percutaneous cystostomy drainage for early removing urethral catheter in robotic-assisted laparoscopic radical prostatectomy: Improving on patients' discomfort

ObjectiveUrethral catheterization is often a major source of discomfort and pain to a patient after a surgical procedure. To better understand the safety and feasibility of the early removal of urethral Foley catheter after robotic-assisted laparoscopic radical prostatectomy by using percutaneous cystostomy drainage, we collected the related data and present our experience.Patients and methodsThis study involved 20 patients. In the study group (10 patients), we used the percutaneous cystostomy device (PCD) and an 18 French urethral catheter together. The urethral catheter was removed at postoperative day (POD) 3 and the PCD was removed at POD 7. In the control group (10 patients), they had standard urethral catheterization with an 18 French catheter and the catheter was removed at POD 7. Demographic and outcome data were measured and analyzed. Urethral pain was recorded using the visual analog scale.ResultsThe two groups were comparable in terms of age, serum prostate specific antigen level, body mass index, clinical tumor stage, surgical duration, estimated blood loss, and surgical times. The study group had significantly less penile pain in POD 3 and POD 7 (mean visual analog scale: 0.9 vs. 2.2, p < 0.001 at POD 3; 0.1 vs. 1.4, p = 0.002 at POD 7). All patients had good urinary continence within 30 days and no urethra stricture was found during the follow up period.ConclusionThe use of a percutaneous cystostomy device is feasible and safe for the early removal of urethral Foley catheter in robotic-assisted laparoscopic radical prostatectomy to decrease penile pain and patient discomfort.     

Successful treatment of recurrent vesicourethral stricture after radical prostatectomy with holmium laser: Report of three cases

We report three cases with severe anastomotic strictures, which recurred several times after radical prostatectomy despite repeated treatments of urethral dilation, internal urethrotomy and/or transurethral resection. All three cases were finally treated with holmium laser successfully without any intraoperative or postoperative complications after repeated failures of each treatment. There were two specific characteristics in these three cases: the early onset of the stricture and the pinhole opening located on the top (12-o'clock) of the stricture wall.     

Bladder neck contracture after radical retropubic prostatectomy using an intussuscepted vesico‐urethral anastomosis: incidence with long‐term follow‐up

OBJECTIVE

To evaluate the incidence of bladder neck contracture (BNC), a known complication of radical retropubic prostatectomy (RRP), after a 9‐year experience by one surgeon using a novel approach to lower urinary tract reconstruction, the intussuscepted vesico‐urethral anastomosis (IVUA).

PATIENTS AND METHODS

After institutional review board approval, the charts of 406 patients who had RRP for clinically localized prostate cancer from March 1998 to July 2007 were reviewed retrospectively. All patients had lower urinary tract reconstruction using the IVUA technique, which involves a looped urethral suture using six double‐armed sutures that are drawn ‘inside‐to‐out’ from staggered points on the urethral stump through the bladder neck opening. When the sutures are tied down, the urethra is intussuscepted into the bladder neck opening.

RESULTS

At a median follow‐up of 48 months, three patients developed BNC: one was at increased risk secondary to a previous TURP; one had his catheter removed on the second day after RRP in the presence of a suprapubic tube and developed a BNC at his ‘dry’ anastomosis; and one with no risk factors developed a BNC. Balloon dilatation, laser incision and self obturation were successful in stabilizing the strictures while preserving continence. Overall, the incidence of BNC in this series was three of 406 (0.74%).

CONCLUSIONS

IVUA gives a lower incidence of BNC over a long‐term follow‐up than rates cited in previous reports. IVUA is a valuable technique for lower urinary tract reconstruction in patients undergoing RRP.     

Prostate shape, external striated urethral sphincter and radical prostatectomy: the apical dissection

In an anatomical study of 64 gross specimens the external striated urethral sphincter was reconfirmed to extend as a single unit from the proximal penile urethra to the bladder base. The configuration of the external striated urethral sphincter was variable and was related to the shape of the apical prostate. Two basic prostatic shapes were recognized, distinguished by the presence or absence of an anterior apical notch. Whether a notch existed depended upon the degree of lateral lobe development and the position of its anterior commissure. In radical prostatectomy knowledge of the variation in the shape of the prostatic apex can help the surgeon to achieve optimal urethral transection with maximal preservation of the external striated urethral sphincter and other tissues of the continence mechanism.     

Intrinsic neuromuscular defects in the neurogenic bladder: V. Autonomic re-innervation of the male feline rhabdosphincter following somatic denervation by bilateral sacral ventral rhizotomy

We have shown previously that myofibers of the male feline rhabdosphincter are innervated by somatomotor end-plates as well as nonspecialized surface junctions by autonomic cholinergic and adrenergic axons. Shortly after sacral ventral rhizotomy, the somatomotor cholinergic axons innervating the plates disappear, but the autonomic cholinergic and adrenergic surface junctions are preserved. In the present study, the eventual pattern of innervation of the somatically denervated rhabdosphincter is described. Four to ten weeks after denervation there was (1) progressively marked sprouting of nonmyelinated cholinergic and adrenergic axons, with an increasingly prominent probable copeptidergic component of both axon types; (2) preservation and possibly increase in the number of autonomic surface junctions; and (3) re-innervation of the initially nerveless end-plates by autonomic cholinergic and/or adrenergic axons, occasionally with cholinergic/adrenergic axoaxonal synapses. Based on these and our previous observations, it is concluded that any neural control that the denervated rhabdosphincter may eventually have is purely autonomic, and may in part be achieved via its original end-plates. The significance of our findings with respect to the physiology and pharmacology of the rhabdosphincter (incontrast to other striated muscle) and its possible role in lower-motor neurogenic voiding dysfunction are analyzed.     

Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra during retropubic radical prostatectomy: Description of the technique

We describe our technique for preservation of the smooth muscular internal (vesical) sphincter and proximal urethra during radical retropubic prostatectomy. The first steps of the prostatectomy reflect the standard retropubic prostatectomy; whereas for the final phases, the procedure continues in an anterograde manner with incision of the fibers of the detrusor muscle at the insertion of the ventral surface of the base of the prostate. At this level, the inner circular muscle of the bladder neck forms a sphincteric ring of smooth muscle that covers the longitudinally‐oriented smooth muscle component of the urethra that extends distally to the verumontanum; these two proximal structures represent the internal sphincter that envelops and locks the proximal urethra. A blunt dissection is continued until the ring‐shaped vesical sphincter is separated from the prostate and the longitudinally‐oriented smooth muscle component of the urethral musculature is identified. The base of the prostate is then gently separated from the urethra and from the bladder until the maximal length of the urethral musculature is isolated and preserved. Finally, a urethra‐urethral anastomosis is carried out and the ventral stitches are placed through the circular fibres of the bladder neck. In all cases we carry out circumferential biopsies of the proximal urethra and of the base of the prostate. The described technique is a feasible and safe method for preservation of the internal urethral sphincter. Despite the enthusiasm regarding our positive functional results, further studies with larger series are required to confirm these findings.     

Observations on the function of the female urethra: I: relation between maximum urethral closure pressure at rest and urethral hypermobility

AIMS: To study the relation between maximum urethral closure pressure at rest and urethral hypermobility in female patients. PATIENTS AND METHODS: We selected 255 patients aged 20 years and older, with a stable bladder on multichannel urodynamics, without known neurological pathology, and without a history of pelvic or anti-incontinence surgery. A resting urethral pressure profile and the degree of urethral hypermobility were registered. Two-tailed analyses of variance (ANOVA) with Fisher's post-hoc tests were used to detect any statistically significant difference (P < 0.05) in urethral closure pressure between groups with varying degrees of urethral hypermobility. RESULTS: Mean age was 45.6 +/- 12.7 (range 20-77) years. Mean maximum urethral closure pressure for the entire group was 62.7 +/- 29 (range 10-150) cm of water. A statistically significant inverse relationship was found between age and maximum urethral closure pressure (r = 0.489, P < 0.0001) when both analyzed as continuous variables, and with age categorized in 10-year increments (P < 0.0001). When comparing mean urethral closure pressure in each group examined for urethral hypermobility, a statistically significant difference was noted when grades I, II, and III were compared to grade 0 hypermobility. No significant difference was observed when grades I, II, and III were compared to each other. Even if statistically non-significant, there exists an inverse relationship between the degree of urethral hypermobility and the maximum urethral closure pressure: a higher hypermobility is associated with a lesser urethral closure pressure. CONCLUSIONS: Urethral closure pressure falls significantly when urethral hypermobility is present. This decrease is not related to patient's age or parity. Our observations demonstrate an inverse relation between urethral closure pressure and the degree of cysto-urethrocele. As hypermobility increases, closure pressure decreases, even if this decrease does not reach the level of statistical significance.     

Influence of bladder neck suspension stitches on early continence after radical prostatectomy: a prospective randomized study of 180 patients

Several techniques have been introduced to improve early postoperative continence. In this study, we evaluated the impact of bladder neck (vesicourethral anastomosis) suspension on the outcome of extraperitoneal endoscopic radical prostatectomy (EERPE). In this research, a total of 180 patients underwent EERPE. Group 1 included patients who underwent nerve-sparing EERPE (nsEERPE) (n=45), and Group 2 included patients who underwent nsEERPE with bladder neck suspension (BNS, n=45). Groups 3 (n=45) and 4 (n=45) included patients who received EERPE and EERPE with BNS, respectively. Patients were randomly assigned to receive BNS with their nsEERPE or EERPE procedure. Perioperative parameters were recorded, and continence was evaluated by determining the number and weight of absorbent pads (pad weighing test) on the second day after catheter removal and by a questionnaire 3 months postoperatively. Two days after catheter removal, 11.1% of Group 1, 11.1% of Group 2, 4.4% of Group 3 and 8.9% of Group 4 were continent. The average urine loss was 80.4, 70.1, 325.0 and 291.3 g for the each of these groups, respectively. At 3 months, 76.5% of Group 1 and 81.3% of Group 2 were continent. The continence figures for Group 3 and 4 were 48.5% and 43.8%, respectively. Similar overall rates were observed in all groups. In conclusion, although there are controversial reports in the literature, early continence was never observed to be significantly higher in the BNS groups when compared with the non-BNS groups, regardless of the EERPE technique performed.