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Anterior Bladder Tube Flap Reconstruction of the Urethrovesical Neck After Radical Retropubic Prostatectomy
0022-534 7/79/1213-0379$02. 00/0 THE JOURNAL OF UROLOGY Copyright © 1979 by The Williams & Wilkins Co.
Vol. 121, March
Printed in U.S.A.
ANTERIOR BLADDER TUBE FLAP RECONSTRUCTION OF THE URETHROVESICAL NECK AFTER RADICAL RETROPUBIC PROSTATECTOMY PHILLIP H. BECK,* JACK W. MCANINCH
AND
RAYE. STUTZMAN
From the Urology Service, Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, California
ABSTRACT
Difficulty with urethrovesical neck anastomosis after radical retropubic pros-~a1:;ec:tom, led us to form an anterior bladder tube for anastomosis to the transected in 5 selected cases. technique with radical retropubic We found that combining the anterior bladder tube +~-~+,.-"' facilitates the urethrovesical neck anastomosis and the transient ~~~,_,,~ erative incontinence sometimes encountered. Results of the 5 patients used form the basis for a brief discussion of the vvc,,ua'-1 Radical retropubic prostatectomy has 2 important advantages over radical perineal prostatectomy: 1) it allows for staging pelvic lymphadenectomy through the same incision, thus obviating the need for multiple hospitalizations and anesthetics, and 2) it is a surgical approach that is familiar to urologists, whereas perineal prostatectomy requires additional experience and regular application. Anastomosis of the urethrovesical neck is the most difficult step of the radical retropubic prostatectomy. In a patient who has had a previous prostatectomy scarring and fixation of the bladder may inhibit its mobilization and prohibit the achievement of a tension-free anastomosis. Similarly, with a lowlying prostate or deep pelvis, or after the resection of a large block of tissue a large gap may develop. This problem led Flocks and Culp to use an anterior bladder tube flap to bridge the large gap between the membranous urethra and the bladder neck. 1 In 1972 Tanagho and Smith described a technique in which they used the anterior bladder tube flap for the treatment of incontinence. 2 Detailed anatomic study of the region of the bladder neck in a previous report demonstrated a heavy concentration of circularly oriented muscle fibers at the anterior bladder neck. 3 They showed that the urethral sphincter may be replaced efficiently by rolling the circular fibers at the bladder neck into a tube maintaining their orientation. Herein we review this technique and discuss its indications during radical retropubic prostatectomy. TECHNIQUE
As described by Tanagho and Smith, 2 the technique is not technically difficult and adds <30 minutes to the operative procedure. It is important to preserve as much of this anterior bladder neck muscle tissue as possible by dissecting bluntly these fibers off the prostatic capsule before incising the junction of the prostate and bladder neck during radical prostatectomy. After radical retropubic prostatectomy has been completed and hemostasis has been achieved the following technique is performed (figs. 1 and 2). A large retention catheter Accepted for publication June 30, 1978. Read at annual meeting of Western Section, American Urological Association, Seattle, Washington, July 16-20, 1978. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. * Current address: Box 703, USA MEDDAC Fort Ord California 93941. ' ' Requests for reprints: Technical Publications Editor, Letterman Army Medical Center, Presidio of San Francisco, Californir 94129. 379
bag is inflated to 40 to 50 ml. and placed in the bladder neck to simulate a partially distended bladder. A 1 x 1-inch flap is outlined with marking sutures. Two parallel incisions are made just lateral to the marking sutures. A Malecot suprapubic tube is brought out through the dome of the bladder to one side and well away from the base of the tube A 14 or 16F Foley catheter is inserted through the penile urethra and placed in the bladder. The flap is formed into a tube over the catheter, using interrupted, full thickness 3-zero chromic catgut sutures. Starting at the base of the tube the base of the bladder is sutured transversely, using intenupted 2 or 3-zero chromic catgut sutures. The anastomosis of the tube flap to the transected urethra is performed using 4 to 6, 2-zero chromic catgut sutures. If necessary, the new bladder neck may be supported with suspending 2-zero chromic catgut sutures. We leave the Foley catheter in place for 3 weeks and before removing it the bladder is filled with radio-contrast material to assess healing. If it becomes necessary to assess the anastomosis evaluation of the altered anatomy under direct vision is the safest method. Blind passage of sounds is dangerous and should be avoided. We use a l 7F panendoscope to determine the patency of the anastomosis and, if necessary, to dilate tightness at the anastomosis. Some cases are presented in an abbreviated fashion to illustrate instances in which this technique may be useful. CASE REPORTS
Case 1. A 65-year-old man had a 2 cm. low apical adenocarcinoma in a prostate situated deep in the pelvis. After radical retropubic prostatectomy with an adequate margin below this lesion, the resultant defect would have made standard anastomosis difficult to perform and carried a high risk for incontinence. After reconstruction with the anterior bladder tube flap the patient experienced only mild incontinence that completely resolved in 4 months. He has experienced no incontinence or stricture in the 36-month followup period. Case 2. A 52-year-old man had extensive involvement of a large prostate with a poorly differentiated carcinoma. Although the tumor was clinical stage C severe local symptomatology in this patient encouraged the performance of a radical retropubic prostatectomy. The anterior bladder tube flap corrected the resulting large defect. During the 15-month folJowup period after removal of the catheter the patient has remained continent and free of stricture. Case 3. A 65-year-old man had problems similar to those listed previously, in that a low apical lesion would have left a large gap to bridge with a standard anastomosis. Technically, anastomosis of the anterior bladder tube flap to the transected
380
BECK, MCANINCH AND STUTZMAN
FIG. 1. A, orientation diagram of pelvis after pelvic lymphadenectomy from perspective of surgeon. Clamp illustrates circularly oriented bladder neck fibers at junction of bladder neck and prostate. B, after radical retropubic prostatectomy large catheter balloon is inflated in bladder neck to simulate partially distended bladder. Flap is outlined (arrowheads) with marking sutures. C, Malecot tube is brought out well away from and to side of base of flap to preserve its blood supply. D, flap is formed into tube over 14 or 16F catheter.
FIG. 2. Anastomosis using 4 to 6 full thickness sutures of 2-zero chromic catgut. Bladder neck may be suspended from pubis or rectus fascia with 2-zero chromic sutures if necessary for support.
urethra was much easier to perform than are most standard closure techniques in routine cases. Mild extravasation on a retrograde cystogram at 3 weeks necessitated leaving the urethral catheter in place for an additional week. Upon its removal the patient was able to void with a slow stream. Endoscopic evaluation has shown tightness at the anastomosis. After passage of the 17F panendoscope through the area of tightness the stream improved markedly. The suprapubic tube was removed. Only 3 months have elapsed since the operation and, therefore, the postoperative course is not yet resolved. The patient is completely continent. Case 4. A 65-year-old man presented with a nodule on the prostate, which was confirmed on biopsy to be carcinoma. In 1972 he had undergone transurethral resection of the prostate for obstructive benign hyperplasia. Also, during that year a large hydronephrotic right kidney had been removed, which resulted in a right ureteral stump with reflux (fig. 3, A and B). Full upper urinary tract evaluation also revealed left vesicorenal reflux. Because the patient had been followed closely for recurrent urinary tract infections and maintained on long-term prophylactic antibiotic therapy, we decided to correct these problems at the time of the cancer operation. After negative metastatic evaluation he underwent a pelvic lymphadenectomy, distal right ureterectomy, radical retropubic prostatectomy and left ureteroneocystostomy. To reimplant the left ureter we opened the bladder along the incisions outlined for the anterior bladder tube flap. This resulted in excellent exposure and allowed easy anastomosis without tension of the poorly mobile bladder. Postoperatively, the patient has been continent during the 10-month followup period (fig. 3, C).
ANTERIOR BLADDER TUBE FLAP RECONSTRUCTION
381
FIG. 3. Case 4. A, preoperative retrograde cystogram demonstrates reflux into right ureteral stump and grade 2 left vesicorenal reflux. B, oblique view of retrograde cystogram shows deformity at bladder neck 4 after transurethral resection of prostate. voiding
cystournthrogram 7 months postoperatively reveals adequate posterior urethra
Case 5. A 67-year-old man had previously undergone 2 transurethral prostatic resections. Cystoscopy showed the left orifice to be located dangerously near the bladder neck and a retrograde cystogram confirmed left vesicorenal reflux. Reimplantation was done in the same manner as in case 4. This patient has been continent during the 5-month followup period.
deformity at bladder base as result of closure
u~,, .... "'1 - ~
carefully selected patients we believe that it should become a familiar part of the annamentarium of the surgeon performing radical prostatectomy. Mrs. Eddie B. Bennett, Mr. Roscoe Simms, Jr., Mr. Otto P Klein and Ms. Doris M. Jackson provided technical assistance, REFERENCES
DISCUSSION
In these 5 cases we have illustrated the feasibility of using the anterior bladder tube flap for reconstruction of the urethrovesical ju...n.ction in difficult situations after radical retropubic prostatectomy. Of special interest is the problem of incontinence. Nichols and associates reported a 57 per cent incontinence rate in patients whose radical prostatectomy was preceded by simple adenectomy (either transurethral or suprapubic resection). 4 In their series radical perineal (21 patients) and radical retropubic prostatectomy (11 patients) or both routes (1 patient) were used. While the specific rate of incontinence after the radical retropubic approach was not given, the risk of incontinence after radical prostatectomy by either approach may be greater in the patient who has had a prior prostatic operation. 5 • 6 This is in contrast to the normally low incontinence rate encountered when the radical retropubic prostatectomy is performed as the primary procedure. 5 , 7 ' 8 In this situation the use of the anterior bladder tube flap combined with radical retropubic prostatectomy should be considered. However, we recommend the use of this technique only when specific indications are present. Schoenberg and Gregory reported the routine use of the bladder tube flap technique after radical retropubic prostatectomy in 6 patients, of whom 2 had mild strictures, 1 was partially incontinent and 1 had complete failure of anastomosis requiring continual suprapubic drainage 9 months postoperatively. 9 Our own experience has been much more encouraging. No patient is incontinent and only 1 has required dilation. As a result of our favorable experience with this technique in
1. Flocks, R. H. and Culp, D. A.: A modification of technique for
2. 3. 4. 5. 6. 7. 8. 9.
anastomosing membranous urethra and bladder neck following total prostatectomy. J. Urol., 69: 411, 1953. Tanagho, E. A. and Smith, D. R.: Clinical evaluation of a surgical technique for the correction of complete urinary incontinence. J. Urol., 107: 402, 1972. Tanagho, E. A., Smith, D. R., Meyers, F. H. and Fisher, R.: Mechanism of urinary continence. II. Technique for surgical correction of incontinence. J. Urol., 101: 305, 1969. Nichols, R. T., Barry, J.M. and Hodges, C. V.: The morbidity of radical prostatectomy for multifocal stage I prostatic adenocarcinoma. J. Urol., 117: 83, 1977. Campbell, J. L., Thomley, M. W. and Parsons, R. L.: Complications of radical prostatic surgery. J. Urol., 89: 253, 1963. Goodwin, W. E.: Radical prostatectomy after previous prostatic surgery: technical problems encountered in treatment of occult prostatic carcinoma. J.A.M.A., 148: 799, 1952. Hudson, H. C. and Howland, R. L., Jr.: Radical retropubic prostatectomy for cancer of the prostate. J. Urol., 108: 944, 1972. Kopecky, A. A., Laskowski, T. Z. and Scott, R. L., Jr.: Radical retropubic prostatectomy in the treatment of prostatic carcinoma. J. Urol., 103: 641, 1970. Schoenberg, H. W. and Gregory, J. G.: Anterior bladder tube in radical retropubic prostatectomy. Urology, 7: 495, 1976.
EDITORIAL COMMENT In more than 25 consecutive radical retropubic prostatectomies I have found no difficulty in mobilizing the bladder neck to obtain a tension-free anastomosis. Because all patients have had excellent urinary control I have found no need for this additional procedure. P.C.W.
Vol. 121, March
Printed in U.S.A.
ANTERIOR BLADDER TUBE FLAP RECONSTRUCTION OF THE URETHROVESICAL NECK AFTER RADICAL RETROPUBIC PROSTATECTOMY PHILLIP H. BECK,* JACK W. MCANINCH
AND
RAYE. STUTZMAN
From the Urology Service, Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, California
ABSTRACT
Difficulty with urethrovesical neck anastomosis after radical retropubic pros-~a1:;ec:tom, led us to form an anterior bladder tube for anastomosis to the transected in 5 selected cases. technique with radical retropubic We found that combining the anterior bladder tube +~-~+,.-"' facilitates the urethrovesical neck anastomosis and the transient ~~~,_,,~ erative incontinence sometimes encountered. Results of the 5 patients used form the basis for a brief discussion of the vvc,,ua'-1 Radical retropubic prostatectomy has 2 important advantages over radical perineal prostatectomy: 1) it allows for staging pelvic lymphadenectomy through the same incision, thus obviating the need for multiple hospitalizations and anesthetics, and 2) it is a surgical approach that is familiar to urologists, whereas perineal prostatectomy requires additional experience and regular application. Anastomosis of the urethrovesical neck is the most difficult step of the radical retropubic prostatectomy. In a patient who has had a previous prostatectomy scarring and fixation of the bladder may inhibit its mobilization and prohibit the achievement of a tension-free anastomosis. Similarly, with a lowlying prostate or deep pelvis, or after the resection of a large block of tissue a large gap may develop. This problem led Flocks and Culp to use an anterior bladder tube flap to bridge the large gap between the membranous urethra and the bladder neck. 1 In 1972 Tanagho and Smith described a technique in which they used the anterior bladder tube flap for the treatment of incontinence. 2 Detailed anatomic study of the region of the bladder neck in a previous report demonstrated a heavy concentration of circularly oriented muscle fibers at the anterior bladder neck. 3 They showed that the urethral sphincter may be replaced efficiently by rolling the circular fibers at the bladder neck into a tube maintaining their orientation. Herein we review this technique and discuss its indications during radical retropubic prostatectomy. TECHNIQUE
As described by Tanagho and Smith, 2 the technique is not technically difficult and adds <30 minutes to the operative procedure. It is important to preserve as much of this anterior bladder neck muscle tissue as possible by dissecting bluntly these fibers off the prostatic capsule before incising the junction of the prostate and bladder neck during radical prostatectomy. After radical retropubic prostatectomy has been completed and hemostasis has been achieved the following technique is performed (figs. 1 and 2). A large retention catheter Accepted for publication June 30, 1978. Read at annual meeting of Western Section, American Urological Association, Seattle, Washington, July 16-20, 1978. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. * Current address: Box 703, USA MEDDAC Fort Ord California 93941. ' ' Requests for reprints: Technical Publications Editor, Letterman Army Medical Center, Presidio of San Francisco, Californir 94129. 379
bag is inflated to 40 to 50 ml. and placed in the bladder neck to simulate a partially distended bladder. A 1 x 1-inch flap is outlined with marking sutures. Two parallel incisions are made just lateral to the marking sutures. A Malecot suprapubic tube is brought out through the dome of the bladder to one side and well away from the base of the tube A 14 or 16F Foley catheter is inserted through the penile urethra and placed in the bladder. The flap is formed into a tube over the catheter, using interrupted, full thickness 3-zero chromic catgut sutures. Starting at the base of the tube the base of the bladder is sutured transversely, using intenupted 2 or 3-zero chromic catgut sutures. The anastomosis of the tube flap to the transected urethra is performed using 4 to 6, 2-zero chromic catgut sutures. If necessary, the new bladder neck may be supported with suspending 2-zero chromic catgut sutures. We leave the Foley catheter in place for 3 weeks and before removing it the bladder is filled with radio-contrast material to assess healing. If it becomes necessary to assess the anastomosis evaluation of the altered anatomy under direct vision is the safest method. Blind passage of sounds is dangerous and should be avoided. We use a l 7F panendoscope to determine the patency of the anastomosis and, if necessary, to dilate tightness at the anastomosis. Some cases are presented in an abbreviated fashion to illustrate instances in which this technique may be useful. CASE REPORTS
Case 1. A 65-year-old man had a 2 cm. low apical adenocarcinoma in a prostate situated deep in the pelvis. After radical retropubic prostatectomy with an adequate margin below this lesion, the resultant defect would have made standard anastomosis difficult to perform and carried a high risk for incontinence. After reconstruction with the anterior bladder tube flap the patient experienced only mild incontinence that completely resolved in 4 months. He has experienced no incontinence or stricture in the 36-month followup period. Case 2. A 52-year-old man had extensive involvement of a large prostate with a poorly differentiated carcinoma. Although the tumor was clinical stage C severe local symptomatology in this patient encouraged the performance of a radical retropubic prostatectomy. The anterior bladder tube flap corrected the resulting large defect. During the 15-month folJowup period after removal of the catheter the patient has remained continent and free of stricture. Case 3. A 65-year-old man had problems similar to those listed previously, in that a low apical lesion would have left a large gap to bridge with a standard anastomosis. Technically, anastomosis of the anterior bladder tube flap to the transected
380
BECK, MCANINCH AND STUTZMAN
FIG. 1. A, orientation diagram of pelvis after pelvic lymphadenectomy from perspective of surgeon. Clamp illustrates circularly oriented bladder neck fibers at junction of bladder neck and prostate. B, after radical retropubic prostatectomy large catheter balloon is inflated in bladder neck to simulate partially distended bladder. Flap is outlined (arrowheads) with marking sutures. C, Malecot tube is brought out well away from and to side of base of flap to preserve its blood supply. D, flap is formed into tube over 14 or 16F catheter.
FIG. 2. Anastomosis using 4 to 6 full thickness sutures of 2-zero chromic catgut. Bladder neck may be suspended from pubis or rectus fascia with 2-zero chromic sutures if necessary for support.
urethra was much easier to perform than are most standard closure techniques in routine cases. Mild extravasation on a retrograde cystogram at 3 weeks necessitated leaving the urethral catheter in place for an additional week. Upon its removal the patient was able to void with a slow stream. Endoscopic evaluation has shown tightness at the anastomosis. After passage of the 17F panendoscope through the area of tightness the stream improved markedly. The suprapubic tube was removed. Only 3 months have elapsed since the operation and, therefore, the postoperative course is not yet resolved. The patient is completely continent. Case 4. A 65-year-old man presented with a nodule on the prostate, which was confirmed on biopsy to be carcinoma. In 1972 he had undergone transurethral resection of the prostate for obstructive benign hyperplasia. Also, during that year a large hydronephrotic right kidney had been removed, which resulted in a right ureteral stump with reflux (fig. 3, A and B). Full upper urinary tract evaluation also revealed left vesicorenal reflux. Because the patient had been followed closely for recurrent urinary tract infections and maintained on long-term prophylactic antibiotic therapy, we decided to correct these problems at the time of the cancer operation. After negative metastatic evaluation he underwent a pelvic lymphadenectomy, distal right ureterectomy, radical retropubic prostatectomy and left ureteroneocystostomy. To reimplant the left ureter we opened the bladder along the incisions outlined for the anterior bladder tube flap. This resulted in excellent exposure and allowed easy anastomosis without tension of the poorly mobile bladder. Postoperatively, the patient has been continent during the 10-month followup period (fig. 3, C).
ANTERIOR BLADDER TUBE FLAP RECONSTRUCTION
381
FIG. 3. Case 4. A, preoperative retrograde cystogram demonstrates reflux into right ureteral stump and grade 2 left vesicorenal reflux. B, oblique view of retrograde cystogram shows deformity at bladder neck 4 after transurethral resection of prostate. voiding
cystournthrogram 7 months postoperatively reveals adequate posterior urethra
Case 5. A 67-year-old man had previously undergone 2 transurethral prostatic resections. Cystoscopy showed the left orifice to be located dangerously near the bladder neck and a retrograde cystogram confirmed left vesicorenal reflux. Reimplantation was done in the same manner as in case 4. This patient has been continent during the 5-month followup period.
deformity at bladder base as result of closure
u~,, .... "'1 - ~
carefully selected patients we believe that it should become a familiar part of the annamentarium of the surgeon performing radical prostatectomy. Mrs. Eddie B. Bennett, Mr. Roscoe Simms, Jr., Mr. Otto P Klein and Ms. Doris M. Jackson provided technical assistance, REFERENCES
DISCUSSION
In these 5 cases we have illustrated the feasibility of using the anterior bladder tube flap for reconstruction of the urethrovesical ju...n.ction in difficult situations after radical retropubic prostatectomy. Of special interest is the problem of incontinence. Nichols and associates reported a 57 per cent incontinence rate in patients whose radical prostatectomy was preceded by simple adenectomy (either transurethral or suprapubic resection). 4 In their series radical perineal (21 patients) and radical retropubic prostatectomy (11 patients) or both routes (1 patient) were used. While the specific rate of incontinence after the radical retropubic approach was not given, the risk of incontinence after radical prostatectomy by either approach may be greater in the patient who has had a prior prostatic operation. 5 • 6 This is in contrast to the normally low incontinence rate encountered when the radical retropubic prostatectomy is performed as the primary procedure. 5 , 7 ' 8 In this situation the use of the anterior bladder tube flap combined with radical retropubic prostatectomy should be considered. However, we recommend the use of this technique only when specific indications are present. Schoenberg and Gregory reported the routine use of the bladder tube flap technique after radical retropubic prostatectomy in 6 patients, of whom 2 had mild strictures, 1 was partially incontinent and 1 had complete failure of anastomosis requiring continual suprapubic drainage 9 months postoperatively. 9 Our own experience has been much more encouraging. No patient is incontinent and only 1 has required dilation. As a result of our favorable experience with this technique in
1. Flocks, R. H. and Culp, D. A.: A modification of technique for
2. 3. 4. 5. 6. 7. 8. 9.
anastomosing membranous urethra and bladder neck following total prostatectomy. J. Urol., 69: 411, 1953. Tanagho, E. A. and Smith, D. R.: Clinical evaluation of a surgical technique for the correction of complete urinary incontinence. J. Urol., 107: 402, 1972. Tanagho, E. A., Smith, D. R., Meyers, F. H. and Fisher, R.: Mechanism of urinary continence. II. Technique for surgical correction of incontinence. J. Urol., 101: 305, 1969. Nichols, R. T., Barry, J.M. and Hodges, C. V.: The morbidity of radical prostatectomy for multifocal stage I prostatic adenocarcinoma. J. Urol., 117: 83, 1977. Campbell, J. L., Thomley, M. W. and Parsons, R. L.: Complications of radical prostatic surgery. J. Urol., 89: 253, 1963. Goodwin, W. E.: Radical prostatectomy after previous prostatic surgery: technical problems encountered in treatment of occult prostatic carcinoma. J.A.M.A., 148: 799, 1952. Hudson, H. C. and Howland, R. L., Jr.: Radical retropubic prostatectomy for cancer of the prostate. J. Urol., 108: 944, 1972. Kopecky, A. A., Laskowski, T. Z. and Scott, R. L., Jr.: Radical retropubic prostatectomy in the treatment of prostatic carcinoma. J. Urol., 103: 641, 1970. Schoenberg, H. W. and Gregory, J. G.: Anterior bladder tube in radical retropubic prostatectomy. Urology, 7: 495, 1976.
EDITORIAL COMMENT In more than 25 consecutive radical retropubic prostatectomies I have found no difficulty in mobilizing the bladder neck to obtain a tension-free anastomosis. Because all patients have had excellent urinary control I have found no need for this additional procedure. P.C.W.