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Full Functional-Length Urethral Sphincter Preservation During Radical Prostatectomy
EUROPEAN UROLOGY 60 (2011) 320–329
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
Full Functional-Length Urethral Sphincter Preservation During Radical Prostatectomy Thorsten Schlomm *, Hans Heinzer, Thomas Steuber, Georg Salomon, Oliver Engel, Uwe Michl, Alexander Haese, Markus Graefen, Hartwig Huland Martini-Clinic, Prostate Cancer Centre, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
Article info
Abstract
Article history: Accepted February 28, 2011 Published online ahead of print on March 22, 2011
Background: A key prerequisite for urinary continence after radical prostatectomy (RP) is the functional length of the urethral sphincter and the stabilisation of its anatomic position within the pelvic floor. Objective: We describe our modified surgical technique for full functional-length urethra (FFLU) preservation during RP. Design, setting, and participants: We analysed 691 consecutive patients who underwent RP over a 12-mo period (285 without and 406 with the FFLU technique). Surgical procedure: The full functional urethra length was preserved by performing an individualised apical preparation strictly along anatomic landmarks, respecting the individual length of the intraprostatically located proportion of the urethral sphincter. Anatomic fixation of the sphincter was reached by a thorough preservation of the pelvic floor and anatomic restoration of the Mueller’s ligaments. Measurements: Continence rates were assessed at 7 d and 12 mo after removal of the catheter. Continence was defined as the use of no pads and no urinary leakage. Results and limitations: The continence rates were 50.1% and 30.9% 1 wk after catheter removal ( p < 0.0001) and 96.9% and 94.7% ( p = 0.59) at 12 mo after surgery in patients operated on with the FFLU technique versus the non-FFLU technique. In multivariate regression analysis, only the surgical technique correlated significantly with the continence status 1 wk after catheter removal. Neither the overall positive surgical margin rates nor the number of positive margins at the urethral resection border differed significantly between the FFLU and non-FFLU groups (13.6% and 0.5% vs 14.9% and 1.3%, respectively). Although the patients’ baseline characteristics were similar in the two surgical groups, the patients were not preoperatively randomised, and the number of patients in the groups was asymmetric. Conclusions: The combination of an FFLU preparation and improved preservation of the anatomic fixation of the urethral sphincter complex resulted in significantly increased early urinary continence results.
Keywords: Prostate cancer Radical prostatectomy Anatomy Surgical technique Continence Quality of life Sphincter Pelvic floor Urethra Please visit www.europeanurology.com and www.urosource.com to view the accompanying video.
# 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Corresponding author. Martini-Clinic, Prostate Cancer Centre, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany. E-mail address: [email protected] (T. Schlomm).
0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2011.02.040
EUROPEAN UROLOGY 60 (2011) 320–329
1.
Introduction
321
prostate develops from the urethra and grows into the overlying striated sphincter muscle, later overgrowing the anterior portion of the urethra
The preservation of urinary continence is a fundamental goal for patients undergoing radical prostatectomy (RP). Anatomic and functional studies have shown that the length of the functional urethra is in the range of 1.5–2.4 cm and that a considerable part is located intraprostatically between the prostatic apex and the colliculus seminalis [1–8]. The anatomic urethral sphincter is an omega-shaped muscle consisting of an outer striated part and an inner smooth layer [6,7,9]. Surrounding anatomic structures aggravate fulllength urethral sphincter preparation during RP. The ventral part of the sphincter is covered by the dorsal vascular complex and ridges of rudimentary striated muscle fibres (detrusor apron) [9,10], and the lateral and posterior aspects are surrounded by the apex and neurovascular tissue [7]. Lee et al impressively illustrated the variability of the prostatic apex shape in pelvic magnetic resonance imaging studies and demonstrated that when the prostatic parenchyma covered the muscular urethra, there was a greater risk of urethral shortening and urinary incontinence [11]. In addition to the functional urethra length, the anatomic fixation of the urethral sphincter is essential to preserving continence after RP. The pelvic floor is a complex system of static and dynamic forces. The insertion of the urethral sphincter into this system is the prerequisite for its adequate muscular function [7]. In this paper, we describe our approach for an individualised apical preparation to preserve the full functional length of the urinary sphincter and its anatomic integrity during RP.
and the associated sphincter muscle. At the onset of puberty, the developing prostate further invades the sphincter muscle while overlying some of the sphincter and incorporating it within the prostatic perimeter, resulting in an intraprostatic and extraprostatic portion of the striated sphincter [6] (Fig. 1). It is important to note that the apical prostate shape varies significantly [11]. As a result, depending on the individual apex shape, between 10% and 40% of the functional urethra is covered by parenchymal apex tissue among individuals [5,8,11] (Fig. 2). To preserve the maximum length of the functional urethra, these anatomic variations have to be considered during individualised preparation of the apical structures. Therefore, it is important to know that because of the above-mentioned developmental processes, the functional parts of the intraprostatically located urethra are not intergrown with the prostatic parenchyma. By thorough anatomic preparation strictly along anatomic landmarks, the intraprostatically located structures of the sphincter can be appropriately and safely separated from the surrounding prostatic tissue without the need for sharp dissection. The function of the urethral sphincter also strongly depends on its anatomic integrity and intact pelvic floor interplay. The posterior and lateral support of the sphincter and its intact integration into the pelvic floor are crucial for its sufficient force development. The posterior part of the male urethral sphincter is connected to the connective tissue raphe (medial dorsal raphe), providing a point of fixation (Fig. 3) [6,13]. The puboperinealis portion of the levator ani (puboperinealis muscle, levator urethrae muscle) forms a hammock around the urethra and terminates at the perineal body between the urethra and the anterior aspect of the rectum (Fig. 3) [14]. Voluntary contraction of the puboperinealis and rectourethralis muscle pulls the urethra forward and upward, resulting in closure and termination of the urinary stream [7]. Further lateral support to the sphincter is provided by the Mueller’s ligaments
[()TD$FIG]
(ischioprostatic ligaments, Walsh’s pillars) [7,10,12,15,16] (Fig. 3), which
2.
Methods and patients
2.1.
Patients
Overall, 691 consecutive patients who underwent RP between May 2008 and May 2009 were analysed. All surgical procedures were performed by three high-volume surgeons (T.S., H.H., M.G.). The prospective collection of data was approved by our internal reviewer board, and all patients provided written informed consent. All surgical cases were performed using an open retropubic approach described by the authors previously [12]. To assess the effect of our surgical modifications on early and longterm continence in a statistically representative cohort, a consecutive series of patients (non–full functional-length urethra [non-FFLU; n = 285] and FFLU [n = 406]) undergoing surgery by the three surgeons within 1 yr was evaluated. Continence rates were assessed using a self-administrated questionnaire 7 d and 12 mo after removal of the catheter. Continence was defined as the use of no pads and no leakage of urine. To assure the oncologic security of our surgical modifications, we performed intraoperative circumferential frozen sections from the cranial and caudal dissection margins of the urethra during the development phase of the FFLU technique. All cryosections showed tumour-free margins. Since July 2008, we have additionally inked the intraprostatic urethral resection border in red to assess exactly the rate of positive surgical margins (PSMs) potentially caused by our modified technique.
2.2.
Anatomic considerations
As demonstrated by anatomic and functional studies, an important functional part of the urethral sphincter is located intraprostatically between the apex and the colliculus seminalis [2,3,6,8,11,13]. The
Fig. 1 – Transversal section of the prostatic apex. A considerable part of the urethral sphincter is located intraprostatically between the prostatic apex and the colliculus seminalis. SMS = smooth muscle sphincter; SS = striated sphincter (rhabdosphincter); CS = colliculus seminalis; PA = prostatic apex.
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EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
Fig. 2 – Anatomic variability of the prostatic apex. Depending on the individual apex shape, between 10% and 40% of the functional urethra is covered by parenchymal apex tissue. Otherwise, the prostatic apex is covered by some muscular tissue on the ventral and rectal aspects as rudiments of embryonic and adolescent prostatic development.
can easily be reconstructed by integration into the ventral anastomotic
puboperinealis portion of the levator ani to the urethra and the perineal
sutures during RP to avoid deviations of the urethra.
body is carefully preserved when it is gently pushed distally, enabling clear visualisation of the circumference of the urethra. During dissection
2.3.
Surgical technique
2.3.1.
Dissection of the puboperinealis muscle and selective ligation
of the dorsal venous complex (DVC), a space between the DVC and the fascia of the rhabdosphincter can be identified by blunt preparation with closed scissors (Fig. 4). The tissue located lateral to the rhabdosphincter
of the dorsal vascular complex
can be safely integrated into the selective ligation suture of the DVC and
After incision of the endopelvic fascia, fibres of the levator ani muscles
carefully dissected until reaching the Mueller’s ligaments. In our opinion,
[()TD$FIG]are
greatest attention should be paid to preserving the fascia of the
pushed laterally. During this procedure, the fixation of the
Fig. 3 – Surgical anatomy of the urethral sphincter complex. (A) Fixation of the urethral sphincter (modified from Luschka [16]). (B) Lateral aspect of the urethral sphincter after nerve sparing. PPL = puboprostatic ligament; PVL = pubovesicalis ligament; PP = puboperinealis muscle; DA = detrusor apron; B = bladder; FSS = fascia of the striated sphincter; ML = Mueller’s ligaments (ischioprostatic ligaments); NVB = neurovascular bundle; R = rectum; MDR = medial dorsal raphe; RU = rectourethralis muscle; OI = Os ischiadicum; SS = striated sphincter (rhabdosphincter); PB = pubis bone.
EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
2.3.2.
323
Intrafascial nerve-sparing procedure
The indication to perform nerve-sparing surgery is based on a nomogram predicting the probability of side-specific extraprostatic extension [17]. To ensure the greatest oncologic safety, frozen sections of the whole laterorectal surface of the prostate corresponding to the separated neurovascular bundles (NVBs) must be performed in every nerve-sparing procedure [12,18]. With regard to our improved sphincter preparation, we modified our previously described technique of an intrafascial nerve-sparing procedure according to an anatomic preparation of the Mueller’s ligaments. During the ligation of the DVC, a substantial part of the Mueller’s ligaments have already been separated from the sphincter. The part of the ligaments close to the apex can be easily dissected after release of the apical part of the neurovascular tissue (Fig. 6). Sometimes, the surgeon may have the impression that the Mueller’s ligaments are in direct contact with the puboprostatic/pubovesical ligaments. For better retrieval of the Mueller’s ligaments as subsequent anchors for the anastomotic sutures, we usually mark the distal parts of the ligaments with one or two small haemoclips (which can easily be removed after placing the anastomotic sutures). After dissection of the Mueller’s ligaments, the NVBs can be completely released, and the periurethral area is Fig. 4 – During dissection of the dorsal venous complex, a space between the DVC and the fascia of the rhabdosphincter can be identified by blunt preparation with closed scissors. DVC = dorsal venous complex; FSS = fascia of the striated sphincter; PP = puboperinealis muscle; ML = Mueller’s ligament.
completely visible.
2.3.3.
Preparation and dissection of the ventral sphincter
The remaining tissue covering the prostatic part of the sphincter (consisting mainly of the remains of the apical part of the DVC and the detrusor apron) [10] are pushed cranially (Fig. 7A). Now, the cranial
rhabdosphincter for maintenance of the sphincter integrity and to
margin of the rhabdosphincter is shown and can be gently pushed
facilitate the following preparation steps.
distally with closed scissors until the underlying longitudinal smooth muscle becomes visible as white longitudinal fibres. The longitudinal
followed from the lateral aspect cranially by blunt dissection of the
smooth muscle fibres are followed intraprostatically by blunt dissection
covering tissue (Fig. 5). The dissected apical tissue is then integrated into
and retraction of the apex tissue (Fig. 7B). In the appropriate surgical
a horseshoe-shaped suture spanning from the right to the left apico-
layer, this preparation can easily be performed without the need
urethral border (Fig. 5). This suture not only helps to control back-
for sharp dissection. Depending on the individual apex shape, after 3–
bleeding from the cranial proportion of the DVC but also enables the
10 mm, the longitudinal fibres start to fuse with periurethral prostatic
following preparation of the intraprostatic portion of the sphincter by
tissue. Reaching this junction, the urethra can be circumferentially
retracting the covering apical tissue.
incised from 8 o’clock to 4 o’clock (Fig. 7C).
[()TD$FIG]
After ligation of the DVC, the rhabdosphincter can be identified and
Fig. 5 – Selective ligation of the dorsal venous complex and preparation of the apex. The dissected tissue is then integrated in a horseshoe shaped suture (*) spanning from the right to the left apico-urethral border.
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EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
2.3.5.
Dissection of the posterior sphincter and posterior
anastomotic sutures After placing the lateral anastomotic sutures, the apex is retracted cranially. After retraction of the catheter, the urothelial lining of the posterior aspect of the sphincter is now clearly visible up to the colliculus seminalis. We avoid passing an instrument like an overhold or right angle below the 6 o’clock position of the urethra so as not to compromise the 6 o’clock part of the rhabdosphincter below the urethra and apex. The urethra is incised cranially to the colliculus and pushed distally to identify the underlying longitudinal smooth muscle fibres (Fig. 9). The longitudinal muscle layer is dissected at the same position and also gently pushed distally with blunt scissors. After this manoeuvre, the striated muscle of the sphincter is usually still connected to the posterior part of the apex by small remaining tissue fibres, which can be safely cut to release the apex. Because of our stringent anatomic preparation, the dorsal insertion (raphe) of the Denonvillier’s fascia is not disrupted, and the preserved urethra is still connected in its full length to the pelvic floor. To retract the preserved sphincter complex towards the bladder and for additional dorsal fixation, the two 6 o’clock posterior anastomotic sutures are passed through the midline of the Denonvillier’s fascia approximately 2 cm proximal to the sphincter (Fig. 8B). To avoid damage of the muscular sphincter, we anchor the 6 o’clock sutures exclusively into the maintained colliculus. Fig. 6 – Dissection of the apex and the Mueller’s ligaments after release of the neurovascular tissue. FSS = fascia of the striated sphincter; ML = Mueller’s ligament; NVB = neurovascular bundle; SS = striated sphincter (rhabdosphincter).
2.4.
Statistical analysis
The two surgical groups were statistically compared using the x2 test or one-way analysis of the variance. Multivariate analysis was performed through a logistic regression model, and significances were tested using
2.3.4.
Ventral and lateral anastomotic sutures and restoration of the
a likelihood ratio test.
Mueller’s ligaments At the 1 o’clock and 11 o’clock positions, a 3-0 PDS suture with a UR6
3.
Results
needle is passed through the caudal tails of the Mueller’s ligaments and used as an anchor (Fig. 8A). Then, the needle is tunnelled separately through the striated and longitudinal part of the sphincter close to the dissection margin. We prefer the Mueller’s ligaments as anchors for the ventral anastomotic sutures instead of the ligated DVC to avoid a deviation and retraction of the urethra. Furthermore, the supporting anatomy of the Mueller’s ligaments can be restored by this technique. The lateral anastomotic sutures are placed at the 3 o’clock and 9 o’clock positions. We try to avoid placement of anastomotic sutures at the 5 o’clock and 7 o’clock positions, because several groups have shown that nerve branches from the nervi erigentes and the pudendus plexus enter
[()TD$FIG]the membranous urethra at these positions [17,19,20].
The FFLU technique was developed and refined by a single surgeon (Surgeon A), and two other surgeons (Surgeons B and C) changed their technique accordingly after a short introduction phase of 5–10 cases. As shown in Figure 10, all surgeons could increase the early continence results of their patients immediately after adapting their surgical technique. To assess the impact of our surgical modifications, we retrospectively evaluated a consecutive 12-mo RP series of all three surgeons (May 2008 to May 2009). During this period, 723 patients were operated on—32 patients in a
Fig. 7 – Preparation and dissection of the ventral aspect of the urethral sphincter. FSS = fascia of the striated sphincter; SS = striated sphincter (rhabdosphincter); SMS = smooth muscle sphincter; C = catheter.
EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
325
Fig. 8 – Principles of the ventral and posterior anastomotic sutures. (A) The ventral sutures (*) are placed through the tails of the Mueller’s ligaments used as anchors. All sutures are passed separately through the striated and longitudinal part of the urethral sphincter close to the dissection margin. The posterior sutures (+) are only anchored in the maintained colliculus seminalis to avoid damage of the muscle. (B) Traction of the urethra is achieved by anchoring of the posterior sutures (+) in the Denonvillier’s fascia 1–2 cm cranially of the urethral stump and deep in the bladder neck. CS = colliculus seminalis; ML = Mueller’s ligament; DV = Denonvillier’s fascia.
[()TD$FIG]
Fig. 9 – Preparation and dissection of the posterior aspect of the urethral sphincter. The urethra is incised cranially of the colliculus and pushed distally to identify the underlying longitudinal smooth muscle fibres. The longitudinal muscle layer is dissected at the same position.
[()TD$FIG]
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EUROPEAN UROLOGY 60 (2011) 320–329
Fig. 10 – Impact of full functional-length urethra preparation on early urinary continence in a consecutive series of 691 radical prostatectomies. Average numbers of pads used in a 24-h period per patient were calculated on a monthly basis and presented for each surgeon. FFLU = full functional-length urethra.
[()TD$FIG]
salvage or palliative setting (not included in the analyses), 406 patients with the FFLU technique, and 285 patients with our conventional (non-FFLU) technique. There were no significant differences in baseline and surgical characteristics between the FFLU and non-FFLU groups (Table 1).
The continence rates at 7 d and 12 mo after catheter removal were 50.1% and 96.9% in the FFLU group and 30.1% and 94.7% in the non-FFLU group, respectively ( p < 0.001, p = 0.59; Fig. 10 and 11; Table 2). The reported number of required pads correlated significantly with the reported urinary leakage during coughing, laughing, sneezing, or
Fig. 11 – Urinary control 1 wk after catheter removal.FFLU = full functional length urethra.
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EUROPEAN UROLOGY 60 (2011) 320–329
Table 1 – Patient characteristics FFLU
Table 3 – Multivariate logistic regression model for the predictive factor of urinary continence 1 wk after catheter removal Non-FFLU
p Parameter
No. of patients 406 285 No. of returned questionnaires (%): 1 wk 404 (99.5) 282 (98.9) 12 mo 324 (79.8) 244 (85.6) Age, yr: Range 42–76 43–77 Mean 63.1 62.8 BMI: Range 20.6–38.8 20.7–39.9 Mean 26.2 26.1 PSA, ng/ml: Range 0.75–100 0.61–75.3 Mean 8.3 8.6 pT stage, no. (%): pT2 297 (73.2) 193 (67.7) pT3a 82 (20.2) 59 (20.7) pT3b 27 (6.7) 33 (11.6) Gleason score, no. (%): 3+3 109 (26.9) 65 (22.8) 3+4 224 (55.2) 162 (56.8) 4+3 64 (15.8) 41 (14.4) 4 + 4 9 (2.2) 17 (6) Nerve sparing, no. (%): Bilateral 282 (69.5) 192 (67.4) Unilateral 101 (24.9) 71 (24.9) None 23 (5.7) 22 (7.7) Prostate volume: Range 15–144 20–118 Mean 44.2 44.8 Blood loss, ml: Range 250–1640 250–2200 Mean 722.4 715.6 Surgical margin (all pT), no. (%): Negative 358 (88.2) 245 (86) Positive 48 (11.8) 40 (14) Surgical margin pT2, no. (%): Negative 275 (92.6) 180 (93.3) Positive 22 (7.4) 13 (6.7) Surgical margin urethral resection border, no. (%): 79* (98.7) Negative 372* (99.5) Positive 2* (0.5) 1* (1.3)
0.397 0.047
pT stage 0.84
0.66
Age, yr
Pads/24 h 0 1–2 3–5 >5
No. (%)
314 7 2 1
(96.9) (2.2) (0.6) (0.3)
FFLU = full functional-length urethra.
231 10 2 1
(94.7) (4.1) (0.8) (0.4)
OR
95% CI
p value
FFLU vs. non-FFLU – Unilateral vs bilateral Non vs bilateral pT3a vs pT2 pT3b vs pT2 – –
3.5
2.13–5.83
<0.0001
1.05 0.68
0.97–1.14 0.35–1.27
0.2319 0.2242
0.74 1.23 0.60 1.01 1.00
0.25–2.10 0.65–2.36 0.19–1.77 0.98–1.04 0.99–1.02
0.5699 0.5251 0.3621 0.669 0.8494
3 + 4 vs 3 + 3
1.70
0.95–3.10
0.0745
4 + 3 vs 3 + 3 4 + 4 vs 3 + 3 60–70 vs <60 >70 vs <60
0.90 3.01 0.68 0.41
0.35–2.28 0.75–12.52 0.41–1.13 0.16–0.97
0.8290 0.1207 0.1363 0.0412
0.13 OR = odds ratio; CI = confidence interval; BMI = body mass index; FFLU = full functional-length urethra; PSA = prostate-specific antigen.
0.39
The 1-wk continence results were stratified by age, extent of nerve sparing (no nerve sparing vs unilateral vs bilateral), body mass index, pT stage, prostatectomy Gleason score, preoperative prostate-specific antigen level, prostate volume, and surgical technique (FFLU vs non-FFLU) in a multivariate logistic regression analysis. Only the surgical technique ( p < 0.001) correlated statistically significantly with the continence status 1 wk after catheter removal (Table 3).
0.78
4.
0.56
0.7
0.86
–
Table 2 – Urinary control 12 months after radical prostatectomy Non-FFLU (n = 282)
PSA level Prostate volume Gleason score
0.12
physical activities (data not shown). The two groups had no significant differences in the overall frequency of PSMs ( p = 0.39), PSMs in pT2 tumours ( p = 0.78), and PSMs in the separately inked intraprostatic urethral resection boarder (Table 1).
No. (%)
Surgical technique BMI Nerve sparing
0.6
FFLU = full functional-length urethra; BMI = body mass index; PSA = prostate-specific antigen. * We introduced our inking technique of the urethral resection border during the study period; therefore, numbers do not add up to 406 and 285, respectively.
FFLU (n = 324)
Variable
–
p
0.59 – – –
Discussion
The urinary continence results obtained with our modified technique support our concept of an FFLU preparation. The complete early continence rate 1 wk after catheter removal—defined as the use of no pad at all and no leakage of urine—was increased from 30.9% to 50.1% in patients operated on using the FFLU technique. Moreover, we could significantly reduce severe continence problems in the early postoperative period. Overall, 89.7% of the patients operated on using the FFLU technique were ‘‘socially dry,’’ with the use of at maximum two pads in 24 h within 1 wk after catheter removal (Fig. 11). Every surgeon improved the 1-wk continence rates of his patients significantly within a learning curve of 20–30 consecutive cases operated on using the FFLU technique, and the results could be stably reproduced (Fig. 10). To measure the effect of our surgical modifications, we introduced a short questionnaire that the patients returned 1 wk after catheter removal, enabling the surgeon to promptly correlate individual features of a surgical procedure with individual functional outcomes. However, it is possible that at only 1 wk after catheter removal, the continence results are biased by remaining anastomotic swelling. The fact that our new technique is rather less traumatic and our observation that patients with good early continence results did not worsen with the time argues against the significant impact of postoperative urethral swelling. Our results are in line with
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EUROPEAN UROLOGY 60 (2011) 320–329
early continence data published in other RP series [21,22]. None of the studies reported any evidence for temporary better continence in the early phase after catheter removal compared to later time points [4,21,23,24]. According to the results published by Lee et al, in >70% of patients who underwent RP, a substantial part of the functional urethra is covered by the prostatic apex (anteriorly, posteriorly, or both) [11]. According to our modified apical preparation, aiming the preservation of the full functional urethral length in every individual case, we hypothesise that our technique has its maximum effect in patients with a long intraprostatically located membranous urethra. We believe that our modified approach to stabilising the muscular sphincter in its anatomic position has rather a consistent positive effect on average early continence. The positive impact of a posterior restoration of the rhabdosphincter (the Rocco stitch) is meanwhile widely accepted [21,25,26]. In our approach, we aim to maintain the anatomic posterior fixation of the sphincter by avoiding interruptions of the dorsal medial raphe and the Denonvillier’s fascia rather than restoring these structures. To fix the sphincter in a more cranial position, we anchor the two posterior anastomotic sutures in the Denonvillier’s fascia 1–2 cm cranially of the urethral stump. In our opinion, this retraction is also useful in cases with an intact Denonvillier’s fascia. In addition, by placing the posterior anastomotic sutures deep into the posterior bladder wall (Fig. 8B), the cranial part of the vesicourethral anastomosis is fixed to the pelvic floor, facilitating a tension-free approximation of the bladder to the urethral stump. Anatomic and functional studies reveal a close proximity of the pudendal nerve branches innervating the urethral sphincter to the puboperinealis muscle, further supporting the concept of a thorough preservation of the puboperinealis muscle and corresponding pelvic floor structures [20,24,27]. Further lateral support of the sphincter is provided by the Mueller’s ligaments. Mueller first described these structures in 1836 as separate ischioprostatic ligaments, spanning from the pubis bone to the lateral circumference of the prostatic apex [28]. Because of marked intraindividual variations, the Mueller’s ligaments do not always appear as separate structures but rather as a thickened continuation of the ventral fascia of the striated sphincter. However, by thorough dissection and selective ligation of the DVC, the ventral border of the Mueller’s ligament structures can always be identified. In our surgical approach, we use the Mueller’s ligaments as anatomic landmarks to identify the border between the DVC and the neurovascular tissue and as guiding structures for the preparation of the intraprostatic sphincter. By integration into the anastomotic sutures, the Mueller’s ligaments further function as an anchor for the anterior sutures and provide additional lateral support to the sphincter complex. Despite the significant improvements of early continence results, we could not increase our long-term continence data significantly with our modified technique. This is mainly because of the already excellent results revealed with our conventional technique, giving only little scope for statistically significant improvements. Although not statistically
relevant, our long-term continence results could be increased by 2.2%. Translated to our surgical volume of approximately 2000 RP procedures per year, this improvement can save 40 men from long-term continence problems. In our institution, each surgeon personally sees most of his or her patients 6 mo after surgery for a follow-up control and interview. In our experience, the coping process and overall quality of life markedly correlate with early recovery of continence. The definition of continence and the best method for measuring it are not standardised. We believe that the number of pads used per day and the information regarding urinary leakage during physical activities assessed by questionnaires are reliable parameters for measuring continence status after RP. In our grading scale, we use the terms continent, socially dry, and incontinent. We defined continent as the use of no pads and no leakage of urine. These are the most objective parameters, having the advantage of a standardised comparability of continence results among different institutions. In the early postoperative recovery phase, patients using one or two pads per day often report that they use these pads for safety reasons only, and they are not limited in their daily activities (‘‘socially dry’’). The strengths of our study are the large consecutive number of patients operated on by only three surgeons and the use of standardised questionnaires to evaluate continence results. Every surgeon could improve his continence results independently, virtually presenting an internal validation of our method. However, our study has some limitations. Although the patients’ baseline and tumour-specific parameters did not differ significantly between the surgical groups, the patients were not preoperatively randomised. Furthermore, because we introduced our 1-wk questionnaire first in May 2008, and then rapidly changed our surgical technique, the number of patients in each group was asymmetric, with relatively few patients in the non-FFLU group. 5.
Conclusions
Our modified technique of retropubic RP towards an individualised apical preparation resulted in significant increased early urinary continence 1 wk after catheter removal. These data support our concept of an improved protection of the urethral sphincter complex by FFLU preparation and preservation of the periurethral anatomical structures. Author contributions: Thorsten Schlomm had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Schlomm, Huland, Graefen. Acquisition of data: Schlomm, Huland, Graefen. Analysis and interpretation of data: Schlomm, Steuber, Haese, Engel. Drafting of the manuscript: Schlomm, Huland, Graefen. Critical revision of the manuscript for important intellectual content: Steuber, Haese, Michl, Salomon, Heinzer, Engel. Statistical analysis: Schlomm, Steuber. Obtaining funding: None. Administrative, technical, or material support: Salomon, Michl, Haese. Supervision: Huland, Graefen, Heinzer. Other (specify): None.
EUROPEAN UROLOGY 60 (2011) 320–329
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Financial disclosures: I certify that all conflicts of interest, including
[12] Buda¨us L, Isbarn H, Schlomm T, et al. Current technique of open
specific financial interests and relationships and affiliations relevant to
intrafascial nerve-sparing retropubic prostatectomy. Eur Urol
the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
2009;56:317–24. [13] Wallner C, Dabhoiwala NF, DeRuiter MC, Lamers WH. The anatomical components of urinary continence. Eur Urol 2009;55:932–44. [14] Myers RP, Cahill DR, Kay PA, et al. Puboperineales: muscular boundaries of the male urogenital hiatus in 3D from magnetic
Funding/Support and role of the sponsor: None. Acknowledgment statement: The authors thank Mr. Hans-Ju¨rgen Koch for creating the anatomical and surgical illustrations.
Appendix A. Supplementary data The Surgery in Motion video accompanying this article can be found in the online version at doi:10.1016/ j.eururo.2011.02.040 and via www.europeanurology.com.
resonance imaging. J Urol 2000;164:1412–5. [15] Walsh P. Urologic surgery: radical retropubic prostatectomy—an anatomic approach with preservation of sexual function. New York: Bristol Laboratories; 1986. ¨ ber den vorderen inneren Teil des Afterhebers [16] Luschka H., U beim Manne. Zeitschrift fu¨r rationelle Medizin Serie 3 1858; 4: 108–16. [17] Steuber T, Graefen M, Haese A, et al. Validation of a nomogram for prediction of side specific extracapsular extension at radical prostatectomy. J Urol 2006;175:939–44, discussion 944. [18] Eichelberg C, Erbersdobler A, Haese A, et al. Frozen section for the management of intraoperatively detected palpable tumor lesions
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[24] Takenaka A, Tewari AK, Leung RA, et al. Preservation of the pubo-
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available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
Full Functional-Length Urethral Sphincter Preservation During Radical Prostatectomy Thorsten Schlomm *, Hans Heinzer, Thomas Steuber, Georg Salomon, Oliver Engel, Uwe Michl, Alexander Haese, Markus Graefen, Hartwig Huland Martini-Clinic, Prostate Cancer Centre, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
Article info
Abstract
Article history: Accepted February 28, 2011 Published online ahead of print on March 22, 2011
Background: A key prerequisite for urinary continence after radical prostatectomy (RP) is the functional length of the urethral sphincter and the stabilisation of its anatomic position within the pelvic floor. Objective: We describe our modified surgical technique for full functional-length urethra (FFLU) preservation during RP. Design, setting, and participants: We analysed 691 consecutive patients who underwent RP over a 12-mo period (285 without and 406 with the FFLU technique). Surgical procedure: The full functional urethra length was preserved by performing an individualised apical preparation strictly along anatomic landmarks, respecting the individual length of the intraprostatically located proportion of the urethral sphincter. Anatomic fixation of the sphincter was reached by a thorough preservation of the pelvic floor and anatomic restoration of the Mueller’s ligaments. Measurements: Continence rates were assessed at 7 d and 12 mo after removal of the catheter. Continence was defined as the use of no pads and no urinary leakage. Results and limitations: The continence rates were 50.1% and 30.9% 1 wk after catheter removal ( p < 0.0001) and 96.9% and 94.7% ( p = 0.59) at 12 mo after surgery in patients operated on with the FFLU technique versus the non-FFLU technique. In multivariate regression analysis, only the surgical technique correlated significantly with the continence status 1 wk after catheter removal. Neither the overall positive surgical margin rates nor the number of positive margins at the urethral resection border differed significantly between the FFLU and non-FFLU groups (13.6% and 0.5% vs 14.9% and 1.3%, respectively). Although the patients’ baseline characteristics were similar in the two surgical groups, the patients were not preoperatively randomised, and the number of patients in the groups was asymmetric. Conclusions: The combination of an FFLU preparation and improved preservation of the anatomic fixation of the urethral sphincter complex resulted in significantly increased early urinary continence results.
Keywords: Prostate cancer Radical prostatectomy Anatomy Surgical technique Continence Quality of life Sphincter Pelvic floor Urethra Please visit www.europeanurology.com and www.urosource.com to view the accompanying video.
# 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Corresponding author. Martini-Clinic, Prostate Cancer Centre, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany. E-mail address: [email protected] (T. Schlomm).
0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2011.02.040
EUROPEAN UROLOGY 60 (2011) 320–329
1.
Introduction
321
prostate develops from the urethra and grows into the overlying striated sphincter muscle, later overgrowing the anterior portion of the urethra
The preservation of urinary continence is a fundamental goal for patients undergoing radical prostatectomy (RP). Anatomic and functional studies have shown that the length of the functional urethra is in the range of 1.5–2.4 cm and that a considerable part is located intraprostatically between the prostatic apex and the colliculus seminalis [1–8]. The anatomic urethral sphincter is an omega-shaped muscle consisting of an outer striated part and an inner smooth layer [6,7,9]. Surrounding anatomic structures aggravate fulllength urethral sphincter preparation during RP. The ventral part of the sphincter is covered by the dorsal vascular complex and ridges of rudimentary striated muscle fibres (detrusor apron) [9,10], and the lateral and posterior aspects are surrounded by the apex and neurovascular tissue [7]. Lee et al impressively illustrated the variability of the prostatic apex shape in pelvic magnetic resonance imaging studies and demonstrated that when the prostatic parenchyma covered the muscular urethra, there was a greater risk of urethral shortening and urinary incontinence [11]. In addition to the functional urethra length, the anatomic fixation of the urethral sphincter is essential to preserving continence after RP. The pelvic floor is a complex system of static and dynamic forces. The insertion of the urethral sphincter into this system is the prerequisite for its adequate muscular function [7]. In this paper, we describe our approach for an individualised apical preparation to preserve the full functional length of the urinary sphincter and its anatomic integrity during RP.
and the associated sphincter muscle. At the onset of puberty, the developing prostate further invades the sphincter muscle while overlying some of the sphincter and incorporating it within the prostatic perimeter, resulting in an intraprostatic and extraprostatic portion of the striated sphincter [6] (Fig. 1). It is important to note that the apical prostate shape varies significantly [11]. As a result, depending on the individual apex shape, between 10% and 40% of the functional urethra is covered by parenchymal apex tissue among individuals [5,8,11] (Fig. 2). To preserve the maximum length of the functional urethra, these anatomic variations have to be considered during individualised preparation of the apical structures. Therefore, it is important to know that because of the above-mentioned developmental processes, the functional parts of the intraprostatically located urethra are not intergrown with the prostatic parenchyma. By thorough anatomic preparation strictly along anatomic landmarks, the intraprostatically located structures of the sphincter can be appropriately and safely separated from the surrounding prostatic tissue without the need for sharp dissection. The function of the urethral sphincter also strongly depends on its anatomic integrity and intact pelvic floor interplay. The posterior and lateral support of the sphincter and its intact integration into the pelvic floor are crucial for its sufficient force development. The posterior part of the male urethral sphincter is connected to the connective tissue raphe (medial dorsal raphe), providing a point of fixation (Fig. 3) [6,13]. The puboperinealis portion of the levator ani (puboperinealis muscle, levator urethrae muscle) forms a hammock around the urethra and terminates at the perineal body between the urethra and the anterior aspect of the rectum (Fig. 3) [14]. Voluntary contraction of the puboperinealis and rectourethralis muscle pulls the urethra forward and upward, resulting in closure and termination of the urinary stream [7]. Further lateral support to the sphincter is provided by the Mueller’s ligaments
[()TD$FIG]
(ischioprostatic ligaments, Walsh’s pillars) [7,10,12,15,16] (Fig. 3), which
2.
Methods and patients
2.1.
Patients
Overall, 691 consecutive patients who underwent RP between May 2008 and May 2009 were analysed. All surgical procedures were performed by three high-volume surgeons (T.S., H.H., M.G.). The prospective collection of data was approved by our internal reviewer board, and all patients provided written informed consent. All surgical cases were performed using an open retropubic approach described by the authors previously [12]. To assess the effect of our surgical modifications on early and longterm continence in a statistically representative cohort, a consecutive series of patients (non–full functional-length urethra [non-FFLU; n = 285] and FFLU [n = 406]) undergoing surgery by the three surgeons within 1 yr was evaluated. Continence rates were assessed using a self-administrated questionnaire 7 d and 12 mo after removal of the catheter. Continence was defined as the use of no pads and no leakage of urine. To assure the oncologic security of our surgical modifications, we performed intraoperative circumferential frozen sections from the cranial and caudal dissection margins of the urethra during the development phase of the FFLU technique. All cryosections showed tumour-free margins. Since July 2008, we have additionally inked the intraprostatic urethral resection border in red to assess exactly the rate of positive surgical margins (PSMs) potentially caused by our modified technique.
2.2.
Anatomic considerations
As demonstrated by anatomic and functional studies, an important functional part of the urethral sphincter is located intraprostatically between the apex and the colliculus seminalis [2,3,6,8,11,13]. The
Fig. 1 – Transversal section of the prostatic apex. A considerable part of the urethral sphincter is located intraprostatically between the prostatic apex and the colliculus seminalis. SMS = smooth muscle sphincter; SS = striated sphincter (rhabdosphincter); CS = colliculus seminalis; PA = prostatic apex.
322
EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
Fig. 2 – Anatomic variability of the prostatic apex. Depending on the individual apex shape, between 10% and 40% of the functional urethra is covered by parenchymal apex tissue. Otherwise, the prostatic apex is covered by some muscular tissue on the ventral and rectal aspects as rudiments of embryonic and adolescent prostatic development.
can easily be reconstructed by integration into the ventral anastomotic
puboperinealis portion of the levator ani to the urethra and the perineal
sutures during RP to avoid deviations of the urethra.
body is carefully preserved when it is gently pushed distally, enabling clear visualisation of the circumference of the urethra. During dissection
2.3.
Surgical technique
2.3.1.
Dissection of the puboperinealis muscle and selective ligation
of the dorsal venous complex (DVC), a space between the DVC and the fascia of the rhabdosphincter can be identified by blunt preparation with closed scissors (Fig. 4). The tissue located lateral to the rhabdosphincter
of the dorsal vascular complex
can be safely integrated into the selective ligation suture of the DVC and
After incision of the endopelvic fascia, fibres of the levator ani muscles
carefully dissected until reaching the Mueller’s ligaments. In our opinion,
[()TD$FIG]are
greatest attention should be paid to preserving the fascia of the
pushed laterally. During this procedure, the fixation of the
Fig. 3 – Surgical anatomy of the urethral sphincter complex. (A) Fixation of the urethral sphincter (modified from Luschka [16]). (B) Lateral aspect of the urethral sphincter after nerve sparing. PPL = puboprostatic ligament; PVL = pubovesicalis ligament; PP = puboperinealis muscle; DA = detrusor apron; B = bladder; FSS = fascia of the striated sphincter; ML = Mueller’s ligaments (ischioprostatic ligaments); NVB = neurovascular bundle; R = rectum; MDR = medial dorsal raphe; RU = rectourethralis muscle; OI = Os ischiadicum; SS = striated sphincter (rhabdosphincter); PB = pubis bone.
EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
2.3.2.
323
Intrafascial nerve-sparing procedure
The indication to perform nerve-sparing surgery is based on a nomogram predicting the probability of side-specific extraprostatic extension [17]. To ensure the greatest oncologic safety, frozen sections of the whole laterorectal surface of the prostate corresponding to the separated neurovascular bundles (NVBs) must be performed in every nerve-sparing procedure [12,18]. With regard to our improved sphincter preparation, we modified our previously described technique of an intrafascial nerve-sparing procedure according to an anatomic preparation of the Mueller’s ligaments. During the ligation of the DVC, a substantial part of the Mueller’s ligaments have already been separated from the sphincter. The part of the ligaments close to the apex can be easily dissected after release of the apical part of the neurovascular tissue (Fig. 6). Sometimes, the surgeon may have the impression that the Mueller’s ligaments are in direct contact with the puboprostatic/pubovesical ligaments. For better retrieval of the Mueller’s ligaments as subsequent anchors for the anastomotic sutures, we usually mark the distal parts of the ligaments with one or two small haemoclips (which can easily be removed after placing the anastomotic sutures). After dissection of the Mueller’s ligaments, the NVBs can be completely released, and the periurethral area is Fig. 4 – During dissection of the dorsal venous complex, a space between the DVC and the fascia of the rhabdosphincter can be identified by blunt preparation with closed scissors. DVC = dorsal venous complex; FSS = fascia of the striated sphincter; PP = puboperinealis muscle; ML = Mueller’s ligament.
completely visible.
2.3.3.
Preparation and dissection of the ventral sphincter
The remaining tissue covering the prostatic part of the sphincter (consisting mainly of the remains of the apical part of the DVC and the detrusor apron) [10] are pushed cranially (Fig. 7A). Now, the cranial
rhabdosphincter for maintenance of the sphincter integrity and to
margin of the rhabdosphincter is shown and can be gently pushed
facilitate the following preparation steps.
distally with closed scissors until the underlying longitudinal smooth muscle becomes visible as white longitudinal fibres. The longitudinal
followed from the lateral aspect cranially by blunt dissection of the
smooth muscle fibres are followed intraprostatically by blunt dissection
covering tissue (Fig. 5). The dissected apical tissue is then integrated into
and retraction of the apex tissue (Fig. 7B). In the appropriate surgical
a horseshoe-shaped suture spanning from the right to the left apico-
layer, this preparation can easily be performed without the need
urethral border (Fig. 5). This suture not only helps to control back-
for sharp dissection. Depending on the individual apex shape, after 3–
bleeding from the cranial proportion of the DVC but also enables the
10 mm, the longitudinal fibres start to fuse with periurethral prostatic
following preparation of the intraprostatic portion of the sphincter by
tissue. Reaching this junction, the urethra can be circumferentially
retracting the covering apical tissue.
incised from 8 o’clock to 4 o’clock (Fig. 7C).
[()TD$FIG]
After ligation of the DVC, the rhabdosphincter can be identified and
Fig. 5 – Selective ligation of the dorsal venous complex and preparation of the apex. The dissected tissue is then integrated in a horseshoe shaped suture (*) spanning from the right to the left apico-urethral border.
324
EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
2.3.5.
Dissection of the posterior sphincter and posterior
anastomotic sutures After placing the lateral anastomotic sutures, the apex is retracted cranially. After retraction of the catheter, the urothelial lining of the posterior aspect of the sphincter is now clearly visible up to the colliculus seminalis. We avoid passing an instrument like an overhold or right angle below the 6 o’clock position of the urethra so as not to compromise the 6 o’clock part of the rhabdosphincter below the urethra and apex. The urethra is incised cranially to the colliculus and pushed distally to identify the underlying longitudinal smooth muscle fibres (Fig. 9). The longitudinal muscle layer is dissected at the same position and also gently pushed distally with blunt scissors. After this manoeuvre, the striated muscle of the sphincter is usually still connected to the posterior part of the apex by small remaining tissue fibres, which can be safely cut to release the apex. Because of our stringent anatomic preparation, the dorsal insertion (raphe) of the Denonvillier’s fascia is not disrupted, and the preserved urethra is still connected in its full length to the pelvic floor. To retract the preserved sphincter complex towards the bladder and for additional dorsal fixation, the two 6 o’clock posterior anastomotic sutures are passed through the midline of the Denonvillier’s fascia approximately 2 cm proximal to the sphincter (Fig. 8B). To avoid damage of the muscular sphincter, we anchor the 6 o’clock sutures exclusively into the maintained colliculus. Fig. 6 – Dissection of the apex and the Mueller’s ligaments after release of the neurovascular tissue. FSS = fascia of the striated sphincter; ML = Mueller’s ligament; NVB = neurovascular bundle; SS = striated sphincter (rhabdosphincter).
2.4.
Statistical analysis
The two surgical groups were statistically compared using the x2 test or one-way analysis of the variance. Multivariate analysis was performed through a logistic regression model, and significances were tested using
2.3.4.
Ventral and lateral anastomotic sutures and restoration of the
a likelihood ratio test.
Mueller’s ligaments At the 1 o’clock and 11 o’clock positions, a 3-0 PDS suture with a UR6
3.
Results
needle is passed through the caudal tails of the Mueller’s ligaments and used as an anchor (Fig. 8A). Then, the needle is tunnelled separately through the striated and longitudinal part of the sphincter close to the dissection margin. We prefer the Mueller’s ligaments as anchors for the ventral anastomotic sutures instead of the ligated DVC to avoid a deviation and retraction of the urethra. Furthermore, the supporting anatomy of the Mueller’s ligaments can be restored by this technique. The lateral anastomotic sutures are placed at the 3 o’clock and 9 o’clock positions. We try to avoid placement of anastomotic sutures at the 5 o’clock and 7 o’clock positions, because several groups have shown that nerve branches from the nervi erigentes and the pudendus plexus enter
[()TD$FIG]the membranous urethra at these positions [17,19,20].
The FFLU technique was developed and refined by a single surgeon (Surgeon A), and two other surgeons (Surgeons B and C) changed their technique accordingly after a short introduction phase of 5–10 cases. As shown in Figure 10, all surgeons could increase the early continence results of their patients immediately after adapting their surgical technique. To assess the impact of our surgical modifications, we retrospectively evaluated a consecutive 12-mo RP series of all three surgeons (May 2008 to May 2009). During this period, 723 patients were operated on—32 patients in a
Fig. 7 – Preparation and dissection of the ventral aspect of the urethral sphincter. FSS = fascia of the striated sphincter; SS = striated sphincter (rhabdosphincter); SMS = smooth muscle sphincter; C = catheter.
EUROPEAN UROLOGY 60 (2011) 320–329
[()TD$FIG]
325
Fig. 8 – Principles of the ventral and posterior anastomotic sutures. (A) The ventral sutures (*) are placed through the tails of the Mueller’s ligaments used as anchors. All sutures are passed separately through the striated and longitudinal part of the urethral sphincter close to the dissection margin. The posterior sutures (+) are only anchored in the maintained colliculus seminalis to avoid damage of the muscle. (B) Traction of the urethra is achieved by anchoring of the posterior sutures (+) in the Denonvillier’s fascia 1–2 cm cranially of the urethral stump and deep in the bladder neck. CS = colliculus seminalis; ML = Mueller’s ligament; DV = Denonvillier’s fascia.
[()TD$FIG]
Fig. 9 – Preparation and dissection of the posterior aspect of the urethral sphincter. The urethra is incised cranially of the colliculus and pushed distally to identify the underlying longitudinal smooth muscle fibres. The longitudinal muscle layer is dissected at the same position.
[()TD$FIG]
326
EUROPEAN UROLOGY 60 (2011) 320–329
Fig. 10 – Impact of full functional-length urethra preparation on early urinary continence in a consecutive series of 691 radical prostatectomies. Average numbers of pads used in a 24-h period per patient were calculated on a monthly basis and presented for each surgeon. FFLU = full functional-length urethra.
[()TD$FIG]
salvage or palliative setting (not included in the analyses), 406 patients with the FFLU technique, and 285 patients with our conventional (non-FFLU) technique. There were no significant differences in baseline and surgical characteristics between the FFLU and non-FFLU groups (Table 1).
The continence rates at 7 d and 12 mo after catheter removal were 50.1% and 96.9% in the FFLU group and 30.1% and 94.7% in the non-FFLU group, respectively ( p < 0.001, p = 0.59; Fig. 10 and 11; Table 2). The reported number of required pads correlated significantly with the reported urinary leakage during coughing, laughing, sneezing, or
Fig. 11 – Urinary control 1 wk after catheter removal.FFLU = full functional length urethra.
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EUROPEAN UROLOGY 60 (2011) 320–329
Table 1 – Patient characteristics FFLU
Table 3 – Multivariate logistic regression model for the predictive factor of urinary continence 1 wk after catheter removal Non-FFLU
p Parameter
No. of patients 406 285 No. of returned questionnaires (%): 1 wk 404 (99.5) 282 (98.9) 12 mo 324 (79.8) 244 (85.6) Age, yr: Range 42–76 43–77 Mean 63.1 62.8 BMI: Range 20.6–38.8 20.7–39.9 Mean 26.2 26.1 PSA, ng/ml: Range 0.75–100 0.61–75.3 Mean 8.3 8.6 pT stage, no. (%): pT2 297 (73.2) 193 (67.7) pT3a 82 (20.2) 59 (20.7) pT3b 27 (6.7) 33 (11.6) Gleason score, no. (%): 3+3 109 (26.9) 65 (22.8) 3+4 224 (55.2) 162 (56.8) 4+3 64 (15.8) 41 (14.4) 4 + 4 9 (2.2) 17 (6) Nerve sparing, no. (%): Bilateral 282 (69.5) 192 (67.4) Unilateral 101 (24.9) 71 (24.9) None 23 (5.7) 22 (7.7) Prostate volume: Range 15–144 20–118 Mean 44.2 44.8 Blood loss, ml: Range 250–1640 250–2200 Mean 722.4 715.6 Surgical margin (all pT), no. (%): Negative 358 (88.2) 245 (86) Positive 48 (11.8) 40 (14) Surgical margin pT2, no. (%): Negative 275 (92.6) 180 (93.3) Positive 22 (7.4) 13 (6.7) Surgical margin urethral resection border, no. (%): 79* (98.7) Negative 372* (99.5) Positive 2* (0.5) 1* (1.3)
0.397 0.047
pT stage 0.84
0.66
Age, yr
Pads/24 h 0 1–2 3–5 >5
No. (%)
314 7 2 1
(96.9) (2.2) (0.6) (0.3)
FFLU = full functional-length urethra.
231 10 2 1
(94.7) (4.1) (0.8) (0.4)
OR
95% CI
p value
FFLU vs. non-FFLU – Unilateral vs bilateral Non vs bilateral pT3a vs pT2 pT3b vs pT2 – –
3.5
2.13–5.83
<0.0001
1.05 0.68
0.97–1.14 0.35–1.27
0.2319 0.2242
0.74 1.23 0.60 1.01 1.00
0.25–2.10 0.65–2.36 0.19–1.77 0.98–1.04 0.99–1.02
0.5699 0.5251 0.3621 0.669 0.8494
3 + 4 vs 3 + 3
1.70
0.95–3.10
0.0745
4 + 3 vs 3 + 3 4 + 4 vs 3 + 3 60–70 vs <60 >70 vs <60
0.90 3.01 0.68 0.41
0.35–2.28 0.75–12.52 0.41–1.13 0.16–0.97
0.8290 0.1207 0.1363 0.0412
0.13 OR = odds ratio; CI = confidence interval; BMI = body mass index; FFLU = full functional-length urethra; PSA = prostate-specific antigen.
0.39
The 1-wk continence results were stratified by age, extent of nerve sparing (no nerve sparing vs unilateral vs bilateral), body mass index, pT stage, prostatectomy Gleason score, preoperative prostate-specific antigen level, prostate volume, and surgical technique (FFLU vs non-FFLU) in a multivariate logistic regression analysis. Only the surgical technique ( p < 0.001) correlated statistically significantly with the continence status 1 wk after catheter removal (Table 3).
0.78
4.
0.56
0.7
0.86
–
Table 2 – Urinary control 12 months after radical prostatectomy Non-FFLU (n = 282)
PSA level Prostate volume Gleason score
0.12
physical activities (data not shown). The two groups had no significant differences in the overall frequency of PSMs ( p = 0.39), PSMs in pT2 tumours ( p = 0.78), and PSMs in the separately inked intraprostatic urethral resection boarder (Table 1).
No. (%)
Surgical technique BMI Nerve sparing
0.6
FFLU = full functional-length urethra; BMI = body mass index; PSA = prostate-specific antigen. * We introduced our inking technique of the urethral resection border during the study period; therefore, numbers do not add up to 406 and 285, respectively.
FFLU (n = 324)
Variable
–
p
0.59 – – –
Discussion
The urinary continence results obtained with our modified technique support our concept of an FFLU preparation. The complete early continence rate 1 wk after catheter removal—defined as the use of no pad at all and no leakage of urine—was increased from 30.9% to 50.1% in patients operated on using the FFLU technique. Moreover, we could significantly reduce severe continence problems in the early postoperative period. Overall, 89.7% of the patients operated on using the FFLU technique were ‘‘socially dry,’’ with the use of at maximum two pads in 24 h within 1 wk after catheter removal (Fig. 11). Every surgeon improved the 1-wk continence rates of his patients significantly within a learning curve of 20–30 consecutive cases operated on using the FFLU technique, and the results could be stably reproduced (Fig. 10). To measure the effect of our surgical modifications, we introduced a short questionnaire that the patients returned 1 wk after catheter removal, enabling the surgeon to promptly correlate individual features of a surgical procedure with individual functional outcomes. However, it is possible that at only 1 wk after catheter removal, the continence results are biased by remaining anastomotic swelling. The fact that our new technique is rather less traumatic and our observation that patients with good early continence results did not worsen with the time argues against the significant impact of postoperative urethral swelling. Our results are in line with
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early continence data published in other RP series [21,22]. None of the studies reported any evidence for temporary better continence in the early phase after catheter removal compared to later time points [4,21,23,24]. According to the results published by Lee et al, in >70% of patients who underwent RP, a substantial part of the functional urethra is covered by the prostatic apex (anteriorly, posteriorly, or both) [11]. According to our modified apical preparation, aiming the preservation of the full functional urethral length in every individual case, we hypothesise that our technique has its maximum effect in patients with a long intraprostatically located membranous urethra. We believe that our modified approach to stabilising the muscular sphincter in its anatomic position has rather a consistent positive effect on average early continence. The positive impact of a posterior restoration of the rhabdosphincter (the Rocco stitch) is meanwhile widely accepted [21,25,26]. In our approach, we aim to maintain the anatomic posterior fixation of the sphincter by avoiding interruptions of the dorsal medial raphe and the Denonvillier’s fascia rather than restoring these structures. To fix the sphincter in a more cranial position, we anchor the two posterior anastomotic sutures in the Denonvillier’s fascia 1–2 cm cranially of the urethral stump. In our opinion, this retraction is also useful in cases with an intact Denonvillier’s fascia. In addition, by placing the posterior anastomotic sutures deep into the posterior bladder wall (Fig. 8B), the cranial part of the vesicourethral anastomosis is fixed to the pelvic floor, facilitating a tension-free approximation of the bladder to the urethral stump. Anatomic and functional studies reveal a close proximity of the pudendal nerve branches innervating the urethral sphincter to the puboperinealis muscle, further supporting the concept of a thorough preservation of the puboperinealis muscle and corresponding pelvic floor structures [20,24,27]. Further lateral support of the sphincter is provided by the Mueller’s ligaments. Mueller first described these structures in 1836 as separate ischioprostatic ligaments, spanning from the pubis bone to the lateral circumference of the prostatic apex [28]. Because of marked intraindividual variations, the Mueller’s ligaments do not always appear as separate structures but rather as a thickened continuation of the ventral fascia of the striated sphincter. However, by thorough dissection and selective ligation of the DVC, the ventral border of the Mueller’s ligament structures can always be identified. In our surgical approach, we use the Mueller’s ligaments as anatomic landmarks to identify the border between the DVC and the neurovascular tissue and as guiding structures for the preparation of the intraprostatic sphincter. By integration into the anastomotic sutures, the Mueller’s ligaments further function as an anchor for the anterior sutures and provide additional lateral support to the sphincter complex. Despite the significant improvements of early continence results, we could not increase our long-term continence data significantly with our modified technique. This is mainly because of the already excellent results revealed with our conventional technique, giving only little scope for statistically significant improvements. Although not statistically
relevant, our long-term continence results could be increased by 2.2%. Translated to our surgical volume of approximately 2000 RP procedures per year, this improvement can save 40 men from long-term continence problems. In our institution, each surgeon personally sees most of his or her patients 6 mo after surgery for a follow-up control and interview. In our experience, the coping process and overall quality of life markedly correlate with early recovery of continence. The definition of continence and the best method for measuring it are not standardised. We believe that the number of pads used per day and the information regarding urinary leakage during physical activities assessed by questionnaires are reliable parameters for measuring continence status after RP. In our grading scale, we use the terms continent, socially dry, and incontinent. We defined continent as the use of no pads and no leakage of urine. These are the most objective parameters, having the advantage of a standardised comparability of continence results among different institutions. In the early postoperative recovery phase, patients using one or two pads per day often report that they use these pads for safety reasons only, and they are not limited in their daily activities (‘‘socially dry’’). The strengths of our study are the large consecutive number of patients operated on by only three surgeons and the use of standardised questionnaires to evaluate continence results. Every surgeon could improve his continence results independently, virtually presenting an internal validation of our method. However, our study has some limitations. Although the patients’ baseline and tumour-specific parameters did not differ significantly between the surgical groups, the patients were not preoperatively randomised. Furthermore, because we introduced our 1-wk questionnaire first in May 2008, and then rapidly changed our surgical technique, the number of patients in each group was asymmetric, with relatively few patients in the non-FFLU group. 5.
Conclusions
Our modified technique of retropubic RP towards an individualised apical preparation resulted in significant increased early urinary continence 1 wk after catheter removal. These data support our concept of an improved protection of the urethral sphincter complex by FFLU preparation and preservation of the periurethral anatomical structures. Author contributions: Thorsten Schlomm had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Schlomm, Huland, Graefen. Acquisition of data: Schlomm, Huland, Graefen. Analysis and interpretation of data: Schlomm, Steuber, Haese, Engel. Drafting of the manuscript: Schlomm, Huland, Graefen. Critical revision of the manuscript for important intellectual content: Steuber, Haese, Michl, Salomon, Heinzer, Engel. Statistical analysis: Schlomm, Steuber. Obtaining funding: None. Administrative, technical, or material support: Salomon, Michl, Haese. Supervision: Huland, Graefen, Heinzer. Other (specify): None.
EUROPEAN UROLOGY 60 (2011) 320–329
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Financial disclosures: I certify that all conflicts of interest, including
[12] Buda¨us L, Isbarn H, Schlomm T, et al. Current technique of open
specific financial interests and relationships and affiliations relevant to
intrafascial nerve-sparing retropubic prostatectomy. Eur Urol
the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
2009;56:317–24. [13] Wallner C, Dabhoiwala NF, DeRuiter MC, Lamers WH. The anatomical components of urinary continence. Eur Urol 2009;55:932–44. [14] Myers RP, Cahill DR, Kay PA, et al. Puboperineales: muscular boundaries of the male urogenital hiatus in 3D from magnetic
Funding/Support and role of the sponsor: None. Acknowledgment statement: The authors thank Mr. Hans-Ju¨rgen Koch for creating the anatomical and surgical illustrations.
Appendix A. Supplementary data The Surgery in Motion video accompanying this article can be found in the online version at doi:10.1016/ j.eururo.2011.02.040 and via www.europeanurology.com.
resonance imaging. J Urol 2000;164:1412–5. [15] Walsh P. Urologic surgery: radical retropubic prostatectomy—an anatomic approach with preservation of sexual function. New York: Bristol Laboratories; 1986. ¨ ber den vorderen inneren Teil des Afterhebers [16] Luschka H., U beim Manne. Zeitschrift fu¨r rationelle Medizin Serie 3 1858; 4: 108–16. [17] Steuber T, Graefen M, Haese A, et al. Validation of a nomogram for prediction of side specific extracapsular extension at radical prostatectomy. J Urol 2006;175:939–44, discussion 944. [18] Eichelberg C, Erbersdobler A, Haese A, et al. Frozen section for the management of intraoperatively detected palpable tumor lesions
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