Assessment of bladder and urethral sphincter function before and after radical retropubic prostatectomy

PURPOSE: In a prospective study we analyzed the effects of radical retropubic prostatectomy (RRP) on detrusor and urethral sphincter function by comparing urodynamic status preoperatively with that during longitudinal followup. MATERIALS AND METHODS: A total of 49 consecutive patients underwent urodynamics with pressure flow studies and Valsalva leak point pressure measurements 3 to 7 days before RRP (baseline), and then 1 and 8 months after surgery. We assessed bladder compliance, detrusor overactivity, detrusor contractility and intrinsic sphincter deficiency (ISD). RESULTS: There was no significant change in detrusor overactivity at 1 and 8 months of followup. Decreased bladder compliance was observed in 20.4% of patients at baseline, and in 38.7% and 30.6% at 1 and 8 months, respectively. De novo decreased compliance was detected in 18.4% and 10.2% of patients at the same points. Impaired bladder compliance was comparable to that before surgery in 20% of cases. Impaired detrusor contractility was detected in 42.8% of patients at baseline, and in 61.2% (p <0.05) and 42.8% at 1 and 8 months, respectively. De novo hypocontractility was observed in 28.6% and 10.2% of patients at 1 and 8 months, respectively. A strong association between detrusor overactivity and ISD was observed at 1 and 8 months (p <0.01). CONCLUSIONS: Following RRP detrusor hypocontractility and decreased bladder compliance represent de novo transient dysfunction probably due to bladder denervation and an established condition not influenced by the operation. The strong association between overactivity and ISD suggests that stress urinary incontinence increases urethral afferent nerve activity and induces involuntary detrusor contractions.     

Bladder neck contracture after radical retropubic prostatectomy

OBJECTIVE: To examine the incidence, management and outcome of vesico-urethral anastomotic strictures after bladder-neck sparing radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: We assessed the incidence, management and outcome of anastomotic strictures in 510 consecutive patients (mean age 61 years, range 45-76) who had open RRP by one surgeon between 1994 and 2003. RESULTS: The mean (range) follow-up was 30 (2-89) months; 48 patients (9.4%) developed an anastomotic stricture. Dilatation of the stricture was an effective treatment, with few patients requiring further treatment. CONCLUSION: Stricture of the vesico-urethral anastomosis after bladder-neck sparing RRP is relatively frequent but can usually be successfully managed with one graduated dilatation under light sedation.     

Intussusception of the bladder neck does not promote early restoration to urinary continence after non-nerve-sparing radical retropubic prostatectomy

BACKGROUND: The objectives of the present study were to investigate whether buttressing sutures, which prevent the bladder neck from pulling open as the bladder fills, can promote earlier recovery from urinary incontinence after radical retropubic prostatectomy (RRP) and to identify possible risk factors associated with urinary incontinence after RRP. METHODS: The present study included 72 patients who underwent non-nerve-sparing RRP without neoadjuvant therapy between January and December 2003. Among these 72 patients, intussusception of the bladder neck was performed in 24 who consented to this procedure. In the present series, continence was defined as the absence of any need to use sanitary pads or diapers. Continence was evaluated by a patient interview 1, 3 and 6 months after RRP. RESULTS: There were no significant differences in clinicopathological characteristics between patients with and without intussusception of the bladder neck. The percentage of continent patients 1, 3 and 6 months after RRP was 34.7%, 63.9% and 95.8%, respectively, and there were no significant differences in continence between the two groups at any time point. Among several factors examined, only bladder neck preservation was an independent predictor of recovery from urinary incontinence 1 and 3 months after RRP. CONCLUSIONS: These findings suggest that it would be important to preserve the bladder neck for early return to continence after non-nerve-sparing RRP; however, intussusception of the bladder neck may not offer significant improvement in earlier return of urinary control.     

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.     

Urodynamic evaluation of a suspension technique for rapid recovery of continence after radical retropubic prostatectomy

BACKGROUND: We investigated urodynamic findings involved in the rapid recovery of urinary continence after radical retropubic prostatectomy with a suspension technique. METHODS: A total of 45 consecutive patients (mean age 67.6 years) who had undergone radical retropubic prostatectomy for localized prostate cancer were evaluated with multichannel urodynamics including the maximal urethral pressure (MUP), functional urethral length (FUL), maximal cystometric capacity (MCC) and abdominal leak point pressure (ALPP) at base line, 1 week, 1 month, and 3 months postoperatively. The suspension of vesicourethral anastomosis preserving anterior attachments of puboprostatic ligaments to pubic bone was performed in 33 patients. Twelve patients did not undergo the suspension technique. RESULTS: The continence rates at 1 week, 1 month, and 3 months after radical prostatectomy in the suspension group were significantly higher than those in the non-suspension group: 67% versus 0% at 1 week (P < 0.001), 82% versus 25% at 1 month (P < 0.001), and 91% versus 50% at 3 months (P < 0.01), respectively. Postoperative ALPP at all points of measurement was significantly higher in the suspension group than in the non-suspension group (P < 0.0002). There was no difference in MUP, FUL or MCC at each point following radical prostatectomy between the two groups. CONCLUSIONS: These observations suggest that preserving anterior attachments of puboprostatic ligaments to pubic bone and fixation of urethral hyper-mobility by the suspension of vesicourethral anastomosis promotes rapid recovery of urinary continence after radical retropubic prostatectomy.     

Urinary continence and pathological outcome after bladder neck preservation during radical retropubic prostatectomy: a randomized prospective trial

PURPOSE: Bladder neck preservation during radical prostatectomy has been advocated for improving urinary continence. We compared bladder neck preservation and resection in a randomized trial, looking at continence rates and surgical cancer control. MATERIALS AND METHODS: Patients with stage T1c-T2c prostate cancer underwent radical retropubic prostatectomy with maximal preservation of the external urinary sphincter. Bladder neck preservation or resection was chosen by chance during surgery. Urinary continence (1 or no protective pad daily) was assessed by interview 2 days after catheter removal, and 2 and 6 months after surgery. The surgeon, pathologist and interviewer were the same throughout. Neither patient nor interviewer knew which procedure was done. Planned enrollment was 120. RESULTS: Enrollment was stopped after 70 patients because surgical margins were positive only at the bladder neck in 10% of the preservation group but in none of the resection group (p = 0.08). Each group was assigned 35 patients but the bladder neck could not be preserved in 4 and 1 died, leaving 31 in the preservation group and 38 in the resection group. There were no statistically significant differences between groups in early or late urinary continence rates. Two days after catheter removal, and 2 and 6 months after surgery the respective rates were 79%, 87% and 95% with resection, and 67%, 87% and 97% with preservation. CONCLUSIONS: In our opinion bladder neck preservation during radical retropubic prostatectomy does not improve urinary continence and might compromise cancer control. The external sphincter appears more important for continence after radical prostatectomy.     

Delayed recovery of urinary continence after laparoscopic radical prostatectomy

AIM: To study the rate at which patients regained urinary continence during our institution's early experience with laparoscopic radical prostatectomy. METHODS: The urinary continence of 34 patients was recorded at various intervals following laparoscopic radical prostatectomy. These data were compared with those from 49 patients who had undergone radical retropubic prostatectomy. RESULTS: For laparoscopic prostatectomy patients, 2.9% had regained urinary continence at 1 month, 29.4% at 3 months, 46.9% at 6 months, 56.0% at 9 months and 60.0% at 12 months. For retropubic prostatectomy patients, the corresponding rates were 22.4% at 1 month, 63.3% at 3 months, 84.1% at 6 months, 92.9% at 9 months and 92.9% at 12 months. Backward stepwise logistic regression analysis indicated that laparoscopic surgery itself significantly predicted urinary incontinence at every interval from 1 to 9 months following surgery (P < 0.05). CONCLUSION: Patients' postoperative recovery of urinary continence was not satisfactory in our early experience with laparoscopic radical prostatectomy. Further efforts to elucidate the reason for this poor functional outcome are mandatory before the procedure is accepted as part of standard practice.     

Factors predicting continence recovery 1 month after radical prostatectomy: Results of a multicenter survey

Objectives: To assess the factors associated with continence recovery 1 month after radical prostatectomy (RP) and to identify the correlation between these factors. Methods: In total, 2408 men treated with RP for prostate cancer (PCa) were enrolled in the present multicenter prospective study. Clinical (age, body mass index) and urological (catheterization or transurethral resection of the prostate) records, quality of life (QOL) scores determined using various instruments (including the International Index of Erectile Function [IIEF] and University of California Los Angeles, Prostate Cancer Index [UCLA‐PCI]), PCa characteristics (clinical stage [cT], prostate‐specific antigen, biopsy Gleason score), surgical features (surgical approach, nerve and bladder neck sparing, catheterization), and pathologic outcomes (pT, pN+, Gleason score, positive surgical margins) were recorded. Continence status prior to surgery and at 1 month after RP was assessed and classified as followed: (i) full continence; (ii) 0–1 pads/day; or (iii) >1 pad/day. Only patients determined to have full continence prior to surgery were included in the analysis. Data were evaluated using Spearman's correlation analysis and multivariate logistic regression. Results: Data from 1972 patients with full continence preoperatively and complete postoperative data were analyzed. At 1 month after RP, 644 patients (32.7%) were fully continent, 810 (41.1%) were using 0–1 pads/day, and 518 (26.3%) were using >1 pad/day. Univariate analysis indicated that clinical and urological data, QOL, PCa characteristics, surgical features, and pathologic outcomes were determinants for continence recovery. Multivariate analysis indicated that preoperative sexual activity (UCLA‐PCI Sexual Function P = 0.005; IIEF P = 0.040), bladder neck sparing (P = 0.003), catheterization time (P = 0.007), and catheter diameter (P = 0.046) were associated with 1 month continence recovery. Conclusions: Age and nerve sparing are not significant predictors of continence recovery 1 month after RP. Preoperative erectile function can predict post‐prostatectomy incontinence. Bladder neck preservation has a significant effect on early continence recovery after RP.     

Improving the preservation of the urethral sphincter and neurovascular bundles during open radical retropubic prostatectomy

OBJECTIVES: To describe a technique for open nerve-sparing radical retropubic prostatectomy. METHODS: The technique basically implies incising the levator and prostatic fasciae high anteriorly (1 and 11 o'clock positions) over the prostate, developing the plane between the prostatic capsule and prostatic fascia, and displacing the neurovascular network localized between the two fasciae laterally. This allows for a minimal-touch dissection of the external urethral sphincter and a very efficient dissection of the neurovascular bundles at the level of membranous urethra and prostatic apex. RESULTS: Forty-two patients underwent a bilateral nerve-sparing operation and were followed- up for 6 months. Six patients (14.3%) had positive margins: 4 patients had pT2 disease (in all, the positive margin was monofocal) and 2 patients had pT3 disease (both had multifocal positive margins). Continence (defined as being dry or having one pad remain dry for 24 hours) was achieved in 44% of patients at catheter removal, and in 60%, 72%, and 90% of patients at the 1-, 3-, and 6-month follow-up visits. Potency (defined as an erectile function domain score > or =26) was obtained in 15%, 40%, and 52% of patients at the 1-, 3-, and 6-month follow-up visits. All patients used a PDE5-inhibitor during the investigation period. CONCLUSIONS: These preliminary results suggest that the high incision of the levator and prostatic fasciae may facilitate efficient preservation of the external urethral sphincter and the neurovascular bundles innervating the corpora cavernosa and the sphincter.     

Bladder neck contracture after retropubic radical prostatectomy: incidence and risk factors from a large single‐surgeon experience

OBJECTIVE

To examine a large, single‐surgeon series of patients with prostate cancer who underwent retropubic radical prostatectomy (RRP) for men with postoperative bladder neck contractures (BNCs).

PATIENTS AND METHODS

From 1983 to 2007, 4132 men underwent RRP for prostate cancer by one surgeon. All patients had BN reconstruction with mucosal eversion. The bladder to membranous urethral anastomosis was made using six 2/0 chromic catgut sutures over an 18 F Foley catheter. The catheter was left in place for 10 days. Data from these men is stored in a prospective database, which was reviewed in this study for men with BNCs after RRP. Men with BNCs were compared with all other men in the series to determine risk factors for BNC development.

RESULTS

Overall, BNCs developed in 110 patients (2.5%). Examining our last 500 patients there was a contemporary BNC rate of <1%. The median (range) follow‐up was 44 (12–233) months. Tumour characteristics were similar in the men with BNCs and those with no BNCs, and the rates of organ‐confined disease were also similar (65% vs 70%, P = 0.27). Men with BNCs had higher median preoperative prostate‐specific antigen (PSA) levels (6.7 vs 5.7 mg/dL; P = 0.009) and were more likely to have PSA failure after RRP (30% vs 16%, P < 0.001). On multivariate analysis, non‐nerve sparing (P = 0.003) and a surgical date before 1992 (P < 0.001) were significant predictors of BNC. Patients with BNCs had lower potency rates (49% vs 63%, P < 0.003) and continence rates (88% vs 94%, P = 0.07) at the 18‐month follow‐up.

CONCLUSIONS

BNCs are rare, occurring in <1% in our modern series. The important surgical factors in preventing BNCs are to avoid closing the BN too tightly and attaining good apposition of the BN with the urethral stump with a watertight closure. BNCs are more common with non‐nerve‐sparing surgery and early in a surgeon’s experience.     

根治性前列腺切除术中保护尿控功能的理论与实践

根治性前列腺切除术是目前治疗局限性前列腺癌的首选方法,尿失禁仍是该手术术后最常见的并发症之一。随着手术技术的进步,近些年来不断有研究者提出关于术中如何保护尿控功能的观点和看法。本文现将根治性前列腺切除术中保护尿控功能的理论与实践做一介绍。     

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.     

A randomized clinical trial of suspension technique for improving early recovery of urinary continence after radical retropubic prostatectomy

OBJECTIVE

To evaluate, in a prospective, single‐blind, randomized trial, the safety and efficacy of a suspension technique for improving early recovery of continence after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

We randomly assigned 60 men with clinically localized prostate cancer to RRP; 30 were treated with the suspension technique and the remaining 30 were not. All patients had RRP by the same surgeon followed by early catheter removal on the third day after RRP. The primary outcome measures were the interval to recovery of continence, and the positive margin rates. The continence status was evaluated by a third party using validated questionnaires at baseline before RRP and at 4 and 7 days, and 2 weeks, 1, 3, 6 and 12 months after RRP.

RESULTS

The suspension technique resulted in significantly greater continence rates at 1, 3 and 6 months after RRP of 53% vs 20%, 73% vs 47% and 100% vs 83%. Kaplan‐Meier curves also showed that patients in the suspension group had a significantly earlier recovery of continence than in the no‐suspension group; the median (95% confidence interval) interval for recovery was 31 (12–74) days in the suspension group and 90 (65–150) days in the no‐suspension group (log rank test, P = 0.002). The groups had no significant differences in their histological status.

CONCLUSIONS

The suspension technique had a significant effect on the earlier recovery of urinary continence within 6 months after RRP, without compromising the oncological outcome of RRP.