Stesura Seveso Archivio Italiano di Urologia e Andrologia 2013; 85, 4170 INTRODUCTION It is well-known the importance of urethral sphincter in the preservation of the continence control and it is also known that the “success” of radical prostatectomy for prostate cancer should be defined on the evaluation of five elements including continence that are parts of the so called “pentafecta” (1). In the classic “open” retropubic radical prostatectomy (RRP), bladder dissection from the prostate and bladder neck involves the incision of the bladder neck along its entire circumference and requires the reconstruction according to the so-called “tennis racket” technique or by ORIGINAL PAPER Modified radical retropubic prostatectomy: Personal technical variation “tension free continuum-urethral anastomosis (T.F.C.U.A)” with optical magnification in the preservation of the bladder neck, and estimation of the urinary continence Alberto Roggia 1, Emilio Pozzi 1, Guglielmo Mantica 1, Maurizio Salvadore 2, Dimitrios Choussos 3, Carmelo Di Franco 3, Carlo Maria Bianchi 3 1 Division of Urology - Hospital Sant’Antonio Abate - Gallarate (Va); 2 Division of Anatomopathology - Hospital Sant’Antonio Abate - Gallarate (Va); 3 Graduate School of Urology - University of Pavia. Objective: To reassess the double continence technique for open retropubic radical prostatectomy, proposed by Malizia and employed by Pagano et al., with the “tension free continuum-urethral anastomosis” (T.F.C.U.A.) personal modification and the use of image magnification optical systems and appropriate and delicate surgical tools. Materials and methods: A total of 173 radical retropubic prostatectomies, performed by the same surgeon, were evaluated in terms of early and late continence. Results: The presence of residual prostate cancer cells within the muscle layer was always excluded by the histopathological examination that also demonstrated that the muscle layer was well represented; satisfactory outcomes were obtained in terms of both early urinary con- tinence (60%) and urinary continence at 6-12 month follow-up (92.4% for the whole series and 97.2% for the last series of patients). Conclusions: The “tension free” anastomosis obtained by the suspension of the anterior blad- der wall to the the pubis along the median line allowed to achieve satisfactory outcomes in terms of urinary continence, even if these data obviously need to be confirmed by other series and comparative trials. KEY WORDS: Prostate cancer; Modified radical prostatectomy; Urinary continence; Double continence technique; Tension free anastomosis. Submitted 27 December 2012; Accepted 30 June 2013 No conflict of interest declared Summary multiple sutures along converging lines, in order to obtain a neo-urinary bladder neck with a caliber propor- tionate to the diameter of the membranous urethra. The Urology School of Padova (2) employed the “double continence technique”, proposed by Malizia in 1989 (3), by carrying out a meticulous dissection of the bladder- prostate furrow along its entire circumference during ret- rograde prostatovesciculectomy. In this way the prostate block is excised by the bladder, leaving as much as pos- sible untouched the mucosa of the bladder neck and of the urethra, defined as “epithelial continuum”. DOI: 10.4081/aiua.2013.4.170 Roggia_Stesura Seveso 18/12/13 10:34 Pagina 170 171Archivio Italiano di Urologia e Andrologia 2013; 85, 4 Modified radical retropubic prostatectomy: Personal technical variation “tension free continuum-urethral anastomosis (T.F.C.U.A)” MATERIALS E METHODS From 1st June 2009 to 30th June 2012, 195 open retrop- ubic radical prostatectomies were performed at the Department of Urology of the Gallarate Hospital: out of them 173 prostatectomies performed by a single surgeon (A.R.) were taken into account for this survey in order to obtain a more homogeneous series. Retropubic antegrade prostatovesciculectomy was per- formed after opening of the endopelvic fascia, section of the pubo-prostatic ligaments and double ligature of the dorsal venous plexus. In particular, the surgical technique was aimed to the careful preservation of the bladder-prostatic epithelial continuum (Figures 1, 2) by means of image magnifica- tion by a 9 x autofocus frontal microscope or 6 x tele- scopic lenses, by use of delicate surgical tools such as Metzenbaun-fino scissors and micro pliers for the dissec- tion and at the same time by avoiding use of both mono and bipolar electrosurgical tools (since January 2012 Malis forceps, Jones I.M.A. forceps, micro forceps, Jones I.M.A. scissors, micro Spring scissors were also used in order to reach greater accuracy in the meticulous dissec- tion at the bladder-prostate furrow level). Two stitches , that also incorporated the striated muscle of the urethra, were placed in order to fix firmly the membranous ure- thra to the elevator muscle of the anus; the rabdosphinc- ter was recovered according to the technique used by Rocco (4); the anastomosis between the distal section of the continuum and the membranous urethra was obtained by single stitches after the subversion of the mucous membrane of the continuum. Occasionally an incisional biopsy was obtained in correspondence of the bladder-prostate continuum. During the procedure biop- sies were marked by sutures of different colours in order to allow the pathologist to obtain sections perpendicular to the mucous surface. Histological samples were stained with hematoxylin-eosin (Figure 3) and in some cases with anti-actin and anti-desmin antibodies for the research of muscular antigens (Figure 4). We revisited the technique described by Malizia and Pagano by adding an original modification in order to stabilize the anterior bladder wall to the pubis along the median line: a twisted absorbable suture stitch was placed between the anterior bladder wall and the pubic periosteum at a distance of 20 mm from the anastomo- sis. This original modification (“T.F.C.U.A. = tension free continuum-urethral anastomosis”) aimed to relieve the ten- sion along the anastomotic stitches between the continu- um and the membranous urethra. Urinary continence was evaluated in 171 patients (98.8%), divided into two groups A and B. Continence was considered achieved by the use of no pads or the use of one security liner in 24 hours. In the first group (A) (135 cases), composed by patients subjected to RRP from 1 June 2009 to 31 December 2011, continence was eval- uated at 12 months. In the second group (B) (36 cases), composed by patients subjected to RRP from January 2012 to June 2012, continence was evaluated after 6-12 months but also earlier after 7 days from catheter removal. Two patients were lost at follow up for urinary continence. RESULTS At 6-12 month follow up, out of a total of 171 patients, 158 patients were considered continent (92.4%), while the remaining 13 patients were considered incontinent (7.6%). Continence was higher in patients with organ- confined tumors pT1-pT2, taking into account that patients with pT3-4 stages were also submitted to adju- vant therapies (radiotherapy +/- hormone therapy). Figure 1. Isolation of the bladder-prostate epithelial continuum. Figure 2. Muscular structure of the bladder neck after a complete circular section along the circumference of the continuum. Roggia_Stesura Seveso 18/12/13 10:34 Pagina 171 Archivio Italiano di Urologia e Andrologia 2013; 85, 4 A. Roggia, E. Pozzi, G. Mantica, M. Salvadore, D. Choussos, C. Di Franco, C.M. Bianchi 172 In the 135 patients of Group A, continence was present in 123 (91.1%); in group B, which included 36 patients subjected to RRP in the first semester 2012, continence at 6 -12 month was obtained in 35 (97.2%) while early continence after 7 days from catheter removal was observed in 21 patients (60%) (Table 1). Histological sections, obtained by the incisional biopsies that were taken at the bladder-prostate continuum, were always negative for neoplastic infiltration; in the sections it was possible to identify the mucosa and, below it, cori- on and muscle layer (Figures 3, 4). DISCUSSION The meticulous dissection of the bladder-prostate furrow, using appropriate systems of image magnification (5) such as 6 x telescopic lenses or 9 x autofocus frontal microscope, and delicate surgical tools, and avoiding mono-bipolar electrosurgical tools, allows to isolate care- fully and to maintain the continuity of the bladder-ure- thral mucosa along the entire circumference of the blad- der-prostate furrow. In this personal series, the histopathological evaluation never showed the presence of residual prostate glands or cells in this specific anatomic area, while it was clearly shown the presence of the muscle layer. It is known that the preservation of the urinary bladder neck reduces the incidence of anasto- motic strictures (6) and achieves a greater incidence of early continence (65% vs 25%) at 4 months from the operation (7). The anastomosis between the more distal section of the continuity of the bladder-urethral mucosa and the membranous urethra is possible without reduc- ing the lumen of the bladder neck, as the bladder neck presents a caliber proportionate to that of the urethral stump. Retropubic radical prostatectomy is associated to postoperative bladder descent (8) that could be a con- tributing factor to the onset of urinary stress inconti- nence, due to a compression of the bladder-urethral anastomosis by the bladder and the abdominal organs. In order to improve urinary continence, Tan et al. (9-10) proposed, after a series of 1383 robotic-assisted laparo- scopic prostatectomies, a technical modification entitled A.R.T. (total anatomic restoration technique) which pro- vides an antero-lateral “suspension” of the bladder with some suture stitches between the bladder itself and the pubic tendinous arch: in this way, during the urination, the contractile action of the detrusor would be distrib- uted along several stitches, avoiding increases of pressure on the anastomosis and on the muscular urethral struc- tures (rabdosphincter). The approximating stitch between the anterior wall of the bladder and the pubic periosteum, that we propose (T.F.C.U.A.) in conjunction to the double continence technique used by Malizia, has the same assumption, that is to reduce the tension along the stitches of the anastomosis, but also to reduce compression on the bladder-urethral anastomosis due to the intra-abdominal pressures and the contraction of the detrusor. In literature, rates of continence, after open retropubic surgery and robotic and laparoscopic prostatectomy, range from 38.6% to 98.5% at 3, 6, 12 and 18 months of follow-up (Table 2) in relation to the definition of conti- nence used, the modality of evaluation of the functional outcome (validated questionnaires) and the population studied (multicenter versus single center survey). Hu et al. (11) in a 18-month follow up of a large series of 8.837 radical prostatectomies, including 6899 open radical prostatectomy (RRP) and 1938 minimally invasive radi- Figure 3. Section of an incisional biopsy of the bladder-prostate continuum: in the upper left the mucous surface (hematoxylin-eosin, x40). Figure 4. Histological section of a incisional biopsy of the continuum: in evidence the muscular tunica (anti-desmin, x40). Number of patients n. 171 n. 105 pt 1-2 n. 66 pt 3-4 Continence n. 158 (92,4%) n. 98 (93,3%) n. 60 (90,9%) Group A n. 123 (91,1%) Group B n. 35 (97,2%) Early continence 60,0% Table 1. Personal results. Roggia_Stesura Seveso 18/12/13 10:34 Pagina 172 173Archivio Italiano di Urologia e Andrologia 2013; 85, 4 Modified radical retropubic prostatectomy: Personal technical variation “tension free continuum-urethral anastomosis (T.F.C.U.A)” cal prostatectomy (MIRP), showed a greater incontinence rate in the minimally invasive group compared to the open surgery one: 15.9% incontinence rate in the MIRP against 12.2% in the RRP, with a P value 0.02. In our experience, continence rate at 6-12-month was 92.4%, with a further increase in the last series of patients (group B) in term of both early (60%) and 6-12 month continence rate (97.2%), and can be explained by a greater accuracy in the anatomic dissection by the use of appropriate tools and the greater experience of the surgeon. CONCLUSIONS It is known that optical magnification is considered one of the greater advantage of laparoscopy and that the level of accuracy of the dissection obtained by the robot- ic assisted procedure can make the preservation of the urinary sphincter more manageable (31). However also the open retropubic radical prostatectomy with use of optical image magnification systems and del- icate tools in order to obtain the meticulous preserva- tion of the bladder-prostate epithelial continuum and so the preservation of the muscular sphincterial structure of the bladder neck in conjunction with a tension free anastomosis (“T.F.C.U.A.”) allows to achieve satisfactory outcomes in terms of both early urinary continence (60%) and urinary continence at 6-12 month follow-up (92.4% for the whole series and 97.2% for the last series of patients). However these data obviously need to be confirmed by other series and comparative trials. REFERENCES 1. Patel VR, Sivaraman A, Coelho RF, et al. 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Correspondence Alberto Roggia, MD profroggia@libero.it Director of the Division of Urology Emilio Pozzi, MD (Corresponding Author) pozzi.emilio@libero.it Division of Urology Guglielmo Mantica, MD guglielmo.mantica@gmail.com Division of Urology Maurizio Salvadore, MD maurizio.salvadore@ao.gallarate.it Director of the Division of Anatomopathology Hospital Sant’Antonio Abate via Pastori 4 - 21013 Gallarate (VA), Italy Dimitrios Choussos, MD segreteria.chirgen2@smatteo.pv.it Graduate School of Urology Carmelo Di Franco, MD segreteria.chirgen2@smatteo.pv.it Graduate School of Urology Carlo Maria Bianchi, MD segreteria.chirgen2@smatteo.pv.it Director of the Graduate School of Urology University of Pavia viale Golgi 19 - Pavia, Italy Roggia_Stesura Seveso 18/12/13 10:34 Pagina 174