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Simple Modification Restores Urinary Continence After Prostatectomy


NEW YORK -- Urinary continence after a robot-assisted radical prostatectomy can be only 10 minutes away, surgeons here reported.

NEW YORK, May 14 -- Urinary continence after a robot-assisted radical prostatectomy can be only 10 minutes away, according to surgeons here.

Urinary incontinence can be prevented with a simple reconstructive technique that adds about 10 minutes to total operative time, reported Ashutosh Tewari, M.D., M.Ch., of Weill Cornell Medical College, and colleagues in the April issue of Urology.

Nearly a third of patients who underwent radical prostatectomy with the technique had achieved urinary continence within a week after catheter removal, and 40 of 50 had regained continence at 16 weeks, they found.

The procedure involves preservation of the entire puboprostatic musculoligamentous complex, and reconstruction of the arcus tendineus and puboprostatic complex, structures key to maintaining urinary continence, the investigators wrote.

"Our technique uses tissues that would normally remain behind after prostatectomy -- tissues that we can flip around and support to our advantage," said Dr. Tewari. "We reconstruct the anterior and posterior parts of the sphincter and surgically join the bladder and the anastomosis?with the surrounding structures. In doing so, we reconstruct the major anatomical players controlling urinary continence."

He cautioned that men with more aggressive, locally invasive tumors would likely not be suitable candidates for the procedure, because their procedures would entail excision of the anatomy required to carry out the reconstruction.

"We avoid this technique in patients with high-risk cancer in which the tissue planes are not easily obtained," Dr. Tewari and colleagues wrote. "The advantage of this technique is that it is simple and effective. It offers both anterior and posterior support to the urethra and restores the vesicourethral angle by suspending the anastomosis after surgery. It only adds an extra two to five minutes to the procedure and no oncologic compromise results."

Still, said a co-author, the availability of the technique may help some men decide to go ahead with surgery rather than an alternative therapy.

"Too often, the threat of incontinence can be a key factor in a patient's decision for or against prostatectomy," said E. Darracott Vaughan, M.D., also of Weill Cornell. "A simple intervention like this could make that choice a lot easier."

The authors hypothesized that preserving a collar of tissues around the urethra after removal of the prostate could help to maintain urinary continence where other procedures have failed. The collar in question includes the puboprostatic ligaments, endopelvic fascia, and the arcus tendinous, which form the fascioligamentous component of the puboprostatic musculoligamentous complex, the authors wrote.

They first tried their technique on 10 cadavers, using the experience to devise methods for reconnecting the severed ligaments to urethrovesical anastamosis, reapproximating the muscles, and then fixng the distal end of the bladder to the arcus tendinus to provide support.

They then applied the technique to 50 consecutive patients who underwent robotic prostatectomy for clinically localized prostate cancer. The men had a mean age of 57.4 years (range 44.9 to 70.46). Patients remained catheterized for seven to 11 days after surgery; no patient required recatherization for either clinically significant urinary leak or for postoperative urinary retention. Exclusion criteria kept eight patients out of the study.

The authors found that 12 of the remaining 42 patients (29%) had regained continence within a week of catheter removal, 26 (62%) achieved it from four to six weeks after removal, 37 (88%) had become continent by week 12, and 40 (95%) had urinary continence restored by 16 weeks.

"This hastened recovery appeared to be a function of our technical modification, because in our own previous 50 consecutive patients who did not undergo the new technique (data not published), only 43% were continent at six weeks and 54% at 12 weeks," the authors noted.

The development of the apical complex during dissection required an additional five minutes of operative time, and the suturing and arcus tendineus reconstruction required another two to five minutes. By delaying suturing of the dorsal vein complex, intraoperative hemostasis was improved, and no patients required a blood transfusion, the authors noted.

The procedure also did not appear to comprise the early oncologic outcome, they added, noting that only one of the patients (2.37%) had a positive apical margin, a rate that compares favorably to that seen in other studies of robot-assisted prostatectomy.

"In radical prostatectomy, maintaining the integrity and innervation of the puboperinealis is important," the authors wrote. "The hammock-like puboperineales, attached to the perineal body, act as a forceful, fast-twitch posterior loop in support of the sphincteric (membranous) urethra. The effect of preservation of this support has not previously been studied clinically. We believe that maintaining the structural integrity of the periurethral tissues is responsible for the improved early continence in our series."

They acknowledged that their study findings are limited by the small series, non-randomized design, and inability to determine which specific aspect or aspects of the technique was responsible for the successful restoration of continence and concluded that a "larger prospective study is required to confirm our results."

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