249Archivio Italiano di Urologia e Andrologia 2018; 90, 4 ORIGINAL PAPER Vesicourethral anastomosis including rhabdosphincter in retropubic radical prostatectomy: Technique and results Ramazan Topaktaş 1, Ahmet Ürkmez 1, Musab Ali Kutluhan 1, "smail Başıbüyük 2, Şinasi Yavuz Önol 3 1 Haydarpaşa Numune Training and Research Hospital, Department of Urology, Istanbul, Turkey; 2 Beylikdüzü Kolan Hospital, Department of Urology, Istanbul, Turkey; 3 Onol Urology Center, Department of Urology, Istanbul, Turkey. Objective: Retropubic radical prostatectomy (RRP) is still widely used in clinical practice in localized prostate cancer because of its high oncological suc- cess. The aim of this study was to define the continence status in patients where rhabdosphincter was included in the vesi- courethral anastomosis. Materials and methods: Between November 2004 and September 2010, 90 cases who underwent RRP by the same sur- geon in our clinic were taken into the study. In all cases vesi- courethral anastomosis was performed include the rhab- dosphincter. The anastomosis was performed with mean 2.9 (0-7) interrupted no 2-0 vicryl sutures, depending on the angu- lation of symphysis pubis and pelvic cavity. Pad test was per- formed to all patients at 1, 3, 6 and 12 months postoperatively. We defined patients as ‘continent’ when they no need pad, as ‘mild incontinence’ when they use only one pad daily, as ‘moder- ate incontinence’ when they use two or three pads daily and as ‘severe incontinence’ when they use more than three pads daily. Results: Preoperative total PSA value was 12.2 ng/ml (range: 2.7-84 ng/ml). Preoperative prostate biopsy results were found that Gleason scores were 5, 6, 7 and 8 in 7, 53, 21, 9 patients, respectively. Mean operation and urethral catheter removal time was 103 minutes (60-200) and 14,6 days (9-28), respec- tively. Mean hospital stay was 4.6 days (2-20). According to results of postoperative pad tests, 38 (42.2%), 48 (53.3%), 55 (61.1%) and 75 (83.3%) patients were defined as continent in first, third, sixth and twelfth months, respectively. Conclusions: We think that, our novel technique of vesi- courethral anastomosis in standard RRP provides more optimal urethral position during fixation of pelvic floor and urethra, protect caudal retraction, preserve functional urethral length. Also strong full thickness stitch on urethra provides better uri- nary continence by hanging urethra in our patients. Although our early continence rate is better, our long term continence rate is similar to literature. KEY WORDS: Retropubic radical prostatectomy; Vesicourethral anastomosis; Incontinence; Rhabdosphincter. Submitted 3 June 2018; Accepted 19 July 2018 Summary No conflict of interest declared. Prostate cancer is organ defined in almost 40% of cases and gold standard treatment is radical prostatectomy (RP) if patient has ten-year life expectancy (2). After 1970s this procedure has been standard treatment especially after Walsh’s contributions (3). Although this surgical procedure has important efficiencies it has also morbidi- ties that should be considered. To get rid of morbidities and increase efficiency some modified techniques have been tried over years. Although in recent decades, laparoscopic and robot-assisted laparoscopic RP have been utilized as alternatives to traditional open surgery, RRP is still widely used in clinical practice (4). In all surgical techniques main aim is to get oncologic control and at the same time to maintain erectile func- tion and continence which otherwise affected can decrease patient quality of life. Perioperative and post-operative early complications of radical prostatectomy are bleeding, rectal injury, deep venous thrombosis, pulmonary emboli and lymphocele. Late complications are urinary incontinence, erectile dysfunction and anastomotic stricture. Most important complication that affect quality of life is urinary inconti- nence. According to studies incidence is between 5%- 30% (5, 6). Although older studies indicate higher inci- dence of urinary incontinence in recent years with better knowledge about pelvic anatomy this incidence has decreased. Vesicoureteral anastomosis is one of the most important step in radical prostatectomy and if it is not done prop- erly it leads urinary leak, urine accumulation in surgical field and prolonged drainage (7). On the other hand, it leads periurethral fibrosis, bladder neck stricture and urinary incontinence (8). Recently improvements in techniques of vesicoureteral anastomosis provides decrease in incidence of stricture and incontinence. Urinary continence recovery is a fun- damental goal for patients RRP and several surgical techniques, mainly based on musculofascial posterior and/or anterior ligaments reconstructions, have been proposed with the aim of improving urinary continence recovery. Aim of our study is to evaluate post-operative urinary incontinence in patients who underwent RRP and had vesicoureteral anastomosis that includes rhabdosphincter. DOI: 10.4081/aiua.2018.4.249 INTRODUCTION Prostate cancer is common in man and is the second most common cause of death after lung cancer. Incidence of prostate cancer incline after 50 years old and change in different countries according to diet, eth- nicity, life style and screening protocols (1). Topaktas_Stesura Seveso 10/01/19 16:03 Pagina 249 Archivio Italiano di Urologia e Andrologia 2018; 90, 4 R. Topaktaş, A. Ürkmez, M. Ali Kutluhan, ". Başıbüyük, Ş. Yavuz Önol 250 PATIENTS AND METHODS Ninety patient who underwent RRP because of clinically localized prostate cancer between November 2004 and September 2010 in Bezmialem Vakıf University Medicine faculty hospital urology clinic was included in our study. Local ethics committee approval was taken for study and written consent for each patient was also taken. Preoperative and postoperative information of all patient was recorded prospectively. Exclusion criteria were: pre- vious urethral or prostatic endoscopic procedures, pre- operative urinary incontinence and concomitant neuro- logical diseases (e.g. Parkinson disease). Bone scan was performed for intermediate and high-risk prostate cancer group and also patients who were symptomatic. In some patients MRI was used for confirmation of bone scan lesion. One experienced surgeon performed all surgeries and bladder neck preserved as much as possible. When indicated lymph node dissection was performed and in proper patients nerve sparing technique was used 2-0 vicryl suture was used in vesicourethral anastomosis. Sutures placed on urethra including rhabdospinchter from out to in and in to out for bladder (Figure 1). 22 F Foley catheter was placed. A watertight test was per- formed at the end of the procedure. Age, psa levels, prostate volumes and prostate biopsy results of all patients were recorded preoperatively. Operation time, urethral catheterization time, retrivel of drenage time, hospital stay, suture number for vesi- coureteral anastomosis and perioperative bleeding was recorded for all patient. Also, post-operative follow up peri- od, pathological parameters and complications were recorded. For all patients postoperative third-generation cephalosporin, low-molecular-weight heparin, and elas- to-compressive stockings were used for prophylaxis of infections and thromboembolic events, respectively. In postoperative period patients were followed up regularly for urinary incontinence. After retrieval of urethral catheter pad test were used for evaluation of urinary incontinence in 1, 3 and 12 months. Patients who didn’t use pad in a day described as continent, patients who used one pad a day described as mild incontinent, patients who used 2-3 pad a day described as moderate incontinent and patients who used 4 pad and more described as severe incontinent. RESULTS Patient number, age, prostate volume, preop PSA values, prostate biopsy results, surgical parameters, hospitality and follow up period were summarized in Table 1. 48.8% (44) of patient had history of cigarette smoking. Mean operative bleeding was 780 ml (150-3500 ml) and 32,2% (29) of patient had blood transfusion. In one patient myocardial infarction occurred in postop- erative second day and transferred to coronary intensive care unit. In this patient urethral catheter was taken off at postoperative 28th day. Average suture number for vesicourethral anastomosis was 2.9 (0-7) and in two patient there was no suture (Figure 2). In three patients (3.3%) acute urinary retention occurred after urinary catheter retrieval and these patients were catheterized with 12F catheter for three more day. In four patients (4.4%) rectal damage occurred in operation and primer reconstruction with two layers without colostomy was performed. In one patient omental flap with pedicul was used for strengthening rectal repair. In one patient dur- ing bladder neck dissection ureteral damage occurred and repaired intraoperatively with ureteroneocystostomy. Table 1. Preoperative clinical features, operative and early postoperative results of patient. Mean ± Standard deviation (distribution) or number Total number of patients 90 Age (year) 64.3 ± 6.01 (51-78) Prostate volume (ml) 49.2 ± 24.18 (20-160) Preoperative serum PSA level (ng/ml) 12.2 ± 9.54 (2.7-84) Preoperative Gleason score 6.3 ± 0.42 (5-8) Operation time (minute) 103 ± 52 (60-200) "ntraoperative bleeding (ml) 780 ± 723.25 (150-3500) Drainage time (day) 4.3 ± 2.82 (2-19) Urethral catheterization time (day) 14.6 ± 4.39 (9-28) Hospital stay (day) 4.6 ± 7.89 (2-29) Mean follow up (month) 15.3 ± 2.25 (14-25) Figure 1. Suture that involves the rhabdospinchter. Figure 2. Suture numbers for vesicourethral anastomosis. Sutureless 1-3 suture 4-6 suture 7 suture 50 40 30 20 10 0 80 70 60 50 40 30 20 10 0 Continent Mild incontinence Moderate incontinence Severe incontinence 1. ay 3. ay 6. ay 12. ay N um be r of p at ie nt s N um be r of p at ie nt s Topaktas_Stesura Seveso 10/01/19 16:04 Pagina 250 After catheter retrivel bladder neck stenosis developed in 10 patients (11,1%) after a mean of 4.3 months (range 2- 7 months) and treated with endoscopic incision. According to pathologic reports 13 (14.4%) patient had pT2a, 15 (16.6%) had pT2b, 28 (31.1%) had pT2c, 27 (30%) had pT3a and 7 (7.7%) patient had pT3b. On the other hand, 6 (6.6%) patient had positive surgical mar- gin and 84 (93.3%) patient had negative surgical margin. In 6 patients with surgical margin positivity, 4 positivity was in prostatic apex while 2 positivity was in other regions of the prostate At first year of follow up 75 (83.3%) patient was conti- nent, 7 (7.7%) patient had mild urinary incontinence, 5 (5.5%) patient had moderate urinary incontinence and 3 (3.3%) patient had severe urinary incontinence. The continence status of the patients according to the postoperative month was summarized in Figure 3. Seven patients with moderate incontinence and three patients with severe incontinence were found to have endoscopic procedures due to bladder neck stenosis after RRP at the first year of follow-up DISCUSSION The most important factor that affect patient’s quality of life after RRP is urinary continence status and early recovery of continence increases patient satisfaction (9). Although there was high rate of urinary incontinence in first years of radical prostatectomy prevalence has decreased over years with better understanding of pelvic anatomy, increase in experience, technology and surgical techniques. Although there are many studies that try to explain which factors like nerve sparing surgery, tabular- ization of bladder neck, anastomosis suture number and laparoscopic continuous suturing effect post prostatecto- my incontinence, we still can’t estimate which patient has urinary incontinence after radical prostatectomy (10- 12). One of the most important step in radical prostate- ctomy is vesicourethral anastomosis. General principles for good anastomosis are watertight, non-stretch, anasto- moses that provide the best urethral length and mucosa to mucosa anastomosis Several surgical techniques have been proposed in the recent years, with the aim of reducing the urinary conti- nence recovery time and/or improving long-term urinary continence rates. Some authors indicated that nerve sparing surgery had positive affect on recovery of urinary continence (12). On the other hand, few studies indicat- ed that nerve sparing surgery had no effect on urinary continence (13). In summary nerve sparing surgery has positive contribution on urinary continence. In our study we did not evaluate the nerve-sparing technique variable in our study this deficiency can cause miscon- ceptions. Rhabdospinchter is major structure that influence conti- nence anatomically. It extends like Ω-shaped from mem- branous urethra to prostatic apex anterolaterally. In nor- mal conditions, the urethral sphincter is supported ante- riorly by puboprostatic and pubourethral suspensory components, laterally by the medial portion of the leva- tori ani muscle forming a hammock around the urethra, and by the ischioprostatic ligaments. In our study we placed anastomotic sutures deeply unlike the traditional RRP described by Walsh especially in anterior urethra where intense rabdosphincter that surrounds urethra exist (3). We suppose that anastomotic suture that includes rhabdosphincter provides almost original ure- thral length, prevent caudal retraction of urethra and provide better anatomic positioning of urethra and blad- der on pelvic floor. In patients with our technique early functional results are better than literature but long-term outcomes are same. Proper and well done apical dissec- tion leads to a better appearance of rhabdosphincter by protecting it. In 2005 Montorsi et al. demonstrated that well done apical dissection in nerve sparing surgery pro- tects rhabdosphincter and after catheter retrieval 44% of patient was continent (14). In our study apical surgical margin positivity was seen only in four (4.4%) patient. Prevalance of apical surgical margin positivity in litera- ture is between 6.5%-38% (15). We think that well done apical dissection for protecting rhabdospincter provides better continence status. Rocco et al. stated that restoration of rhabdosphincter posteriorly or in other word placing Rocco sutures pro- vides retraction of rhabdospinchter caudally and pre- vents separation at posterior median raphe (16). In this study 250 patient who underwent posterior rhab- dospinchter repair were compared to 50 patient who didn’t. At the third month of follow up incontinence rate was 85.2% in first group who underwent rhabdospincter repair while it was 46% in control group (16). Long term incontinence rate was same in both groups (94% vs 90%) and rhabdospinchter repair didn’t cause additional com- plication. There are conflicts in studies which evaluate the rela- tionship between incontinence and intraoperative hem- orrhage. In some studies, there was no relationship between intraoperative hemorrhage and post prostatec- tomy incontinence. On the other hand, some studies reported that there was significant relationship between intraoperative hemorrhage and post prostatectomy incontinence (13, 17). Intraoperative hemorrhage alone is not a predictive factor for post prostatectomy inconti- nence without evaluation of other surgical factors. In our 251Archivio Italiano di Urologia e Andrologia 2018; 90, 4 Vesicourethral anastomosis including rhabdosphincter in retropubic radical prostatectomy: Technique and results Figure 3. Pad test classification according to months after catheter removal. Topaktas_Stesura Seveso 10/01/19 16:04 Pagina 251 Archivio Italiano di Urologia e Andrologia 2018; 90, 4 R. Topaktaş, A. Ürkmez, M. Ali Kutluhan, ". Başıbüyük, Ş. Yavuz Önol 252 study at first year of follow up only 2 patients out of 15 patient who had mild, moderate and severe incontinence had more than 1000 cc intraoperative bleeding. Some studies stated that urethral length should be kept as long as possible for the recovery of continence after RRP and too many sutures for anastomosis shortens ure- thral length (18). Additionally, some studies indicated that less suture number for vesicourethral anastomosis had positive effects on urinary continence and bladder neck stenosis (19). In our study mean suture number was 2.9 (0-7). We think that too many sutures for anas- tomosis has negative effects on urethral length. Another topic related to continence is preservation of bladder neck in radical prostatectomy. Many authors investigated relationship between urinary continence and preservation of bladder neck. Licht et al. reported in their study which includes 206 patients that preservation of bladder neck didn’t have positive affect on urinary conti- nence, but it was related to less bladder neck stenosis (20). Another study indicated that 24 patient who had bladder preserving radical prostatectomy had early recov- ery of urinary incontinence (21). When we look at these studies, the continence effect of preservation of internal sphincter is to passively keep urine above in the storage phase. In our study we didn’t perform bladder neck pre- serving RRP and widely resected bladder neck with preservation of ureteral orifices. Preservation of pubopro- static ligaments is another topic which can be related to urinary incontinence. Some authors indicated positive effects of preservation of puboprostatic ligaments on post prostatectomy incontinence. Poore et al. preserved pubo- prostatic ligaments in 18 patients and compared them to control group which includes 25 patients (22). As a con- clusion he founded early continence recovery in patients who underwent puboprostatic ligament preservation. In another study patients were divided into three groups. In first group bladder neck preserving surgery was done in second group puboprostatic ligament preserving surgery was done and to last group both bladder neck and pubo- prostatic preserving surgery was performed (23). There was no significant difference between three groups in long term urinary incontinence. But bladder neck pre- serving group had earlier urinary continence than liga- ment preserving group. In another study sling technique was performed by suturing bladder neck to pubic bone and significant earlier continence rates were indicated according to control group (24). In our study we didn’t perform puboprostatic ligament preserving surgery. But we think that wide suturing in anterior urethra provides normal anatomic position of urethra and by this way it can help external sphincter functions by preventing ure- thral hypermobility. Lack of control group, randomiza- tion and the small number of patients included in this preliminary analysis could be considered as the main lim- itations of the present study. CONCLUSIONS Urinary incontinence after radical prostatectomy affects patients’ quality of life and need to be treated early. Recovery of urinary continence depends on patient selection, surgical techniques and definition of conti- nence. We think that by modifications in our vesi- courethral anastomosis technique; urethra is placed more anatomically on pelvic floor; caudal retraction of urethra is prevented and by this way functional urethral length stays long and especially wide suturing on anteri- or urethra sling the urethra anteriorly. 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Urology. 2014; 83:632-9. 253Archivio Italiano di Urologia e Andrologia 2018; 90, 4 Vesicourethral anastomosis including rhabdosphincter in retropubic radical prostatectomy: Technique and results Correspondence Ramazan Topaktaş, MD (Corresponding Author) ramazantopaktas@yahoo.com Ahmet Ürkmez, MD ahmeturkmez@hotmail.com Musab Ali Kutluhan, MD dr.musab151@hotmail.com Haydarpaşa Numune Training and Research Hospital, Clinic of Urology, "stanbul, Turkey Tıbbiye street No:23 - 34668 Uskudar/Istanbul "smail Başıbüyük, MD dr.ismailbb@gmail.com Beylikdüzü Kolan Hospital, Department of Urology, Istanbul, Turkey Şinasi Yavuz Önol, MD onolurology@yahoo.com Onol Urology Center, Department of Urology, Istanbul, Turkey Topaktas_Stesura Seveso 10/01/19 16:04 Pagina 253