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Reevaluation of vest technique of vesicourethral reconstruction in radical retropubic prostatectomy
REEVALUATION
OF VEST TECHNIQUE
VESICOURETHRAL RADICAL
OF
RECONSTRUCTION
RETROPUBIC
IN
PROSTATECTOMY
ANSAR U. KHAN, M.D. FRED
M. TOMERA,
CHARLES
C. RIFE,
M.D. M.D.
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT - Vesicourethral reconstruction after radical retropubic prostatectomy was done by the Vest technique in 36 patients and by direct vesicourethral anastomosis in 100 patients. Complications resulting from the two methods of vesicourethral reconstruction were similar. Zncontinence after radical retropubic prostatectomy appears not to be related to the method of vesicourethral reconstruction but occurs because of damage during surgery or postoperative scarring of the distal sphincter-k mechanism.
The difficulties encountered in attempting a primary anastomosis of the bladder neck with the urethra after radical retropubic prostatectomy prompted surgeons to devise alternative methods. In 1940, Vest’ employed traction sutures after radical perineal prostatectomy and pulled the bladder neck firmly against the urogenital diaphragm, thus reinforcing the vesicourethral reconstruction. As retropubic prostatectomy became accepted, this technique was modified and adapted for vesicourethral reconstruction.2 This modified Vest procedure has been reported to be associated with an increased incidence of complications, such as urinary extravasation, incontinence, and vesical neck contractures.3 At our institution, both methods of vesicourethral reconstruction have been employed, and thus we had the opportunity to compare retrospectively the surgical results of each procedure. Material and Methods
Presented at the meeting of the North Central Section of the American Urological Association, San Diego, November 6, 1977.
/ FEBRUARY1979
/ VOLUMEXIII,
TABLE
Grades and stages of lesions treated by radical retropubic prostatectomy
I.
and Grade
Stage
NUMBER2
Group A* (36 Patients)
Group Bi
(100 Patients)
Stage A
0
0
BI
13
43
B2
14
36
C
9
17
DI
0
4
D2
0
0
Grade (Broders)
From 1967 to 1976, 270 radical retropubic prostatectomies were performed for clinically
UROLOGY
localized prostatic carcinoma at the Mayo Clinic. In 36 (group A), the vesicourethral reconstruction was done exclusively by the modified Vest technique .’ From the remaining 234 patients in whom vesicourethral reconstruction was accomplished by primary anastomosis, 100 were randomly selected (group B). The surgical stages and the grades of the lesion in the two groups are shown in Table I. Vesical neck
1
2
11
2
31
81
3
3
8
4
0
0
*Vest technique of vesicourethral reconstruction. tPrimary anastomosis for vesicourethral reconstruction.
149
Bladder Membranous
reconstruction was attempted in 9 patients of of group B. group A and in 42 patients Preoperative therapeutic radiation (6,000 rads) was given to 1 patient in group A and to 4 patients in group B. Modified Vest Technique of Vesicourethral Reconstruction After radical extirpation of the prostate and seminal vesicles, the vesical neck is examined. If the vesical neck is wide open, it is reconstructed so as to reduce the diameter of the vesical neck to between 1.5 and 2 cm. A 1-O chromic suture is placed lateral to the reconstructed vesical neck and is threaded on a long, straight Keith needle. A similar suture is placed diametrically opposite, close to the vesical neck. The straight needles are threaded 1 cm. lateral to the membranous urethra, through the urogenital diaphragm, and are passed straight through and out onto the skin of the perineum lateral to the midline beneath the scrotum. A Foley catheter is passed through the urethra and guided into the vesical neck. The balloon is inflated to 30 ml., and with gentle traction on the Foley catheter, the vesical neck is brought near the cut end of the membranous urethra. Traction is placed on the Vest sutures, and they are tied over gauze bolsters (Fig. 1). Before wound closure, Hemovacs are placed and drain the retropubic and perivesical spaces. The Vest bolster sutures are left in place for fourteen days unless the patient has received preoperative radiation, in which situation the sutures are left in for as long as four weeks. The urethral catheter is removed after ten or twelve days unless there is prolonged urinary extravasation, as noted in the Hemovac drainage or demon-
150
FIGURE 1. Diagram showing Vest traction sutures passed through urogenital diaphragm lateral to membranous urethra. (From Chute,* by permission of Williams & Wilkins Company.)
strated on cystogram. The Hemovacs are removed after the drainage has ceased. When primary anastomosis of the vesical neck and the urethra is performed, four to six 2-O chromic catgut sutures are placed circumferentially, avoiding the ureteral orifices. The difficulty of placing the urethral sutures is overcome by the use of a five-eighth circle needle (U-245 Ethicon) on a Strate needle holder. Complications of Surgery Complications relating to the vesicourethral reconstruction after a radical retropubic prostatectomy were divided into those occurring in the early postoperative period and those occurring late (Table II). Early complications
Prolonged urinary extravasation from the anastomotic site was defined either as drainage of more than 100 ml. of urine during a twentyfour-hour period for fourteen or more days after surgery or as extravasation demonstrated on a cystogram to such a degree that the patient had to be left with an indwelling urethral catheter for more than two weeks. One patient in group A who had undergone 6,000 rads to the prostate earlier and had recurrent tumor three years later had prolonged anastomotic urinary leakage. Seven patients in group B had prolonged urinary extravasation. Of these, 3 patients had previous radiation to the prostate. Four patients in group B were dismissed from the hospital with indwelling urethral catheters but were kept under close observation until urinary extravasation had ceased. Superficial wound infection was noted in 3 patients of group A and in 3 patients of group B. Two patients in group A also had ulceration of the perineal skin at the site of the Vest bolster. While no patients in group A had thromboembolic problems, 3 patients in group B had clinical thrombophlebitis that required anticoagulation, and 2 additional patients had documented pulmonary emboli.
UROLOGY
/ FEBRUARY
1979 / VOLUME XIII, NUMBER 2
TABLE II.
Complications after radical retropubic prostatectomy
Complication Early Prolonged urinary extravasation Superficial wound infection Ulceration of perineal skin at site of Vest bolsters Thrombophlebitis Pulmonary embolism Late Incontinence Mild stress Moderate stress Total Vesical neck contracture Urethral stricture Osteitis pubis Recurrent tumor Penoscrotal edema
Group A Group B (36 Patients) (100 Patients) No. % No. %
1
2.7
7*
7
3
8.3
3
3
2 0 0
5.5 0 0
0 3 2
0 3 2
2 2 1
5.5 5.5 2.7 11
8.3 0 0 0
9 4 3
9 4 3
8
8
2 0 3 2
2 0 3 2
*Includes 4 patients dismissed from hospital with indwelling catheters.
Most patients had stress incontinence at dismissal from the hospital. This, however, resolved in a few days to a few months. Permanent urinary incontinence was defined as that occurring one year after surgery. Late complications Urinary incontinence was evaluated one year after surgery. Grade 1 was defined as mild stress incontinence that did not require the patient to wear pads; grade 2 was defined as moderate stress incontinence that required the patient to wear pads when ambulant; and grade 3 was defined as total urinary incontinence that required the use of an appliance such as a condom catheter or a Cunningham clamp. The 3 patients in group B who had total incontinence eventually underwent implantation of an inflatable prosthetic genitourinary sphincter or had a Kaufman anti-incontinence procedure. Two of the 3 patients had both of these procedures done, and their continence eventually improved. Vesical neck contractures were noted three months to three years after the procedure. In 4 patients of group A, vesical neck contracture developed; 3 had a favorable response to resection of dilation, while 1 patient underwent the vesical neck contracture. In group B, 8 pa-
UROLOGY /
FEBRUARY 1979 / VOLUME XIII, NUMBER 2
tients had vesical neck contractures; 7 were treated with dilation, while 1 patient had transurethral incision of the contracture. Anterior urethral strictures were noted in 3 patients in group A and in 2 patients in group B. The urethral strictures were managed with dilation alone or by internal urethrotomy and dilation. Three patients had local tumor recurrence one to six years after the procedure. Two patients in group B had penoscrotal edema; both had previous preoperative radiation to the pelvis. Comment Primary anastomosis of the bladder neck with the membranous urethra after a radical retropubic prostatectomy can be a technically difficult procedure,4 especially when the membranous urethra tends to retract in the urogenital diaphragm and the patient’s bony pelvis is narrow and deep. Atherton4 is credited with applying the Vest technique that had been used in vesicourethral reconstruction after radical perineal prostatectomy and adapting it for reconstruction after radical retropubic prostatectomy. Kopecky, Laskowski, and Scott3 in a retrospective comparison of the two methods of vesicourethral reconstruction, reported a high incidence of urinary extravasation and urinary incontinence with the Vest technique. Although a primary watertight repair should be achieved if urinary extravasation is to be minimized at the site of the anastomosis, only prolonged urinary extravasation probably is significant. Prolonged extravasation not only would cause periurethral scarring but also would result in delay in removal of the urethral catheter, and thus would increase the risk of a urethral stricture developing. Only 1 patient in the group that underwent the Vest procedure had prolonged extravasation. This patient had undergone preoperative radiation to the pelvis, which may have accounted for the delayed healing. The high incidence of prolonged urinary extravasation in patients undergoing primary anastomosis in our study is difficult to explain, except perhaps that tying the sutures too tight could have caused ischemic necrosis of the tissues, resulting in delayed healing. Similarly, ulceration of the skin at the site of the Vest bolsters possibly could have been prevented by tying the sutures with gentle traction only. The most distressing complication of radical retropubic prostatectomy, except for impotence (which is almost uniformly present), is incontinence. Assessment of incontinence may be
151
difficult. Most patients had stress incontinence at dismissal from the hospital, but this rapidly improved in a few days. In some patients, it takes six to nine months before the pattern of incontinence stabilizes. Hence, persistent incontinence is evaluated at one year after surgery and is arbitrarily divided into three grades, depending on severity. Grade 1 is minimal leakage associated with stress but not sufficient to cause concern to the patient; grade 2 is severe stress incontinence requiring the wearing of pads for protection; and grade 3 is total incontinence in which the patient constantly dribbles while standing. The sphincteric mechanisms involved in urinary continence have been well described by Turner-Warwick et al. ’ Continence after radical retropubic prostatectomy appears to be dependent on the integrity of the distal sphincteric complex, which includes the intact segment of the urethra between the verumontanum and the urogenital diaphragm. 6 If this area is damaged during surgery or the wall of the membranous urethra becomes irregular and rigid owing to scar tissue, incontinence results. The amount of incontinence depends on the degree of functional integrity of the distal sphincteric complex. In attempting to achieve a watertight primary anastomosis for vesicourethral reconstruction, multiple sutures may have been placed through the distal sphincteric complex, and this residual sphincter mechanism may be damaged if the sutures are tight and ischemic necrosis and scarring occur. The procedure of choice should be close approximation of the cut end of the urethra to the reconstructed vesical neck by means of Vest traction sutures placed at least 1 cm. lateral to the membranous urethra so as not to disturb the residual sphincteric mechanism. Prolonged urinary extravasation may cause periurethral scarring and rigidity of tissues in this region and thus contribute to the impaired continence. The region of vesicourethral reconstruction must be well drained with Hemovacs or Penrose drains. Some surgeons have stated that, if the vesical neck can be preserved by careful dissection from the prostate, a higher incidence of continence may be achieved.’ In fact, in more than half the patients, the vesical neck was preserved and vesical neck reconstruction was not considered necessary. There was, however, no demonstrable relationship between subsequent incontinence and preservation of the vesical neck. Our study shows no significant
152
difference in the incidence of incontinence between the group that underwent the Vest procedure and the group that underwent primary anastomosis. The study tends to support recently published data stating that the incidence of incontinence after radical prostatectomy (incorporating both the retropubic and perineal approaches) is 10.3 per cent.8 The incidence of vesical neck contracture has ranged from 6.4 per cent8 to 12.3 per cent.3 Our results are within this range. Most vesical neck contractures occur at the site of the vesicourethral reconstruction and usually are noted three to six months after surgery. If vesical neck obstruction occurs late, the possibility of recurrent carcinoma must be ruled out. Vesical neck contracture usually responds to simple dilation, but in 2 of our patients (one in each group), resection or incision of the contracture was necessary. The incidence of urethral stricture due to prolonged indwelling urethral catheter remains significant. The strictures usually occurred in the bulbous urethra and were of large caliber, responding favorably to urethral dilation. The study showed no significant differences in complications after vesicourethral reconstruction between the Vest procedure and the primary anastomosis. Incontinence after radical retropubic prostatectomy appears not to be related to the method of vesicourethral reconstruction but occurs because of damage during surgery or postoperative scarring of the distal sphincteric mechanism. Section of Publications Mayo Clinic Rochester, Minnesota 55901 (DR. KHAN) References 1. Vest SA: Radical perineal prostatectomy: modification of closure, Surg. Gynecol. Obstet. 70: 935 (1949). 2. Chute R: Radical retropubic prostatectomy for cancer, J. Ural. 71: 347 (1954). 3. Kopecky AA, Laskowski TZ, and Scott R, Jr: Radical retropubic prostatectomy in the treatment of prostatic carcinoma, ibid. 103: 641 (1970). 4. Atherton L, and Atherton LD: Radical retropubic prostatectomy for carcinoma, ibid. 75: 111 (1956). 5. Turner-Warwick R, et al: A urodynamic view of prostatic obstruction and the results of prostatectomy, Br. J. Ural. 45: 631 (1973). 6. Caine M, and Edwards D: The peripheral control of micturition: a tine-radiographic study, ibid. 36: 34 (1958). 7. Parry WL: Prostate malignancies, in Glenn JF, Ed: Urologic Surgery, 2nd ed., Hagerstown, Maryland, Harper C Row, 1975, n. 569. 8. Boxer RJ, Kaufman JJ, and Goodwin WE: Radical prostatectomy for carcinoma of the prostate: 1951-1976. A review of 329 patients, J. Ural. 117: 268 (1977).
UROLOGY
/
FEBRUARY
1979
/
VOLUME XIII,
NUMBER 2
OF VEST TECHNIQUE
VESICOURETHRAL RADICAL
OF
RECONSTRUCTION
RETROPUBIC
IN
PROSTATECTOMY
ANSAR U. KHAN, M.D. FRED
M. TOMERA,
CHARLES
C. RIFE,
M.D. M.D.
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT - Vesicourethral reconstruction after radical retropubic prostatectomy was done by the Vest technique in 36 patients and by direct vesicourethral anastomosis in 100 patients. Complications resulting from the two methods of vesicourethral reconstruction were similar. Zncontinence after radical retropubic prostatectomy appears not to be related to the method of vesicourethral reconstruction but occurs because of damage during surgery or postoperative scarring of the distal sphincter-k mechanism.
The difficulties encountered in attempting a primary anastomosis of the bladder neck with the urethra after radical retropubic prostatectomy prompted surgeons to devise alternative methods. In 1940, Vest’ employed traction sutures after radical perineal prostatectomy and pulled the bladder neck firmly against the urogenital diaphragm, thus reinforcing the vesicourethral reconstruction. As retropubic prostatectomy became accepted, this technique was modified and adapted for vesicourethral reconstruction.2 This modified Vest procedure has been reported to be associated with an increased incidence of complications, such as urinary extravasation, incontinence, and vesical neck contractures.3 At our institution, both methods of vesicourethral reconstruction have been employed, and thus we had the opportunity to compare retrospectively the surgical results of each procedure. Material and Methods
Presented at the meeting of the North Central Section of the American Urological Association, San Diego, November 6, 1977.
/ FEBRUARY1979
/ VOLUMEXIII,
TABLE
Grades and stages of lesions treated by radical retropubic prostatectomy
I.
and Grade
Stage
NUMBER2
Group A* (36 Patients)
Group Bi
(100 Patients)
Stage A
0
0
BI
13
43
B2
14
36
C
9
17
DI
0
4
D2
0
0
Grade (Broders)
From 1967 to 1976, 270 radical retropubic prostatectomies were performed for clinically
UROLOGY
localized prostatic carcinoma at the Mayo Clinic. In 36 (group A), the vesicourethral reconstruction was done exclusively by the modified Vest technique .’ From the remaining 234 patients in whom vesicourethral reconstruction was accomplished by primary anastomosis, 100 were randomly selected (group B). The surgical stages and the grades of the lesion in the two groups are shown in Table I. Vesical neck
1
2
11
2
31
81
3
3
8
4
0
0
*Vest technique of vesicourethral reconstruction. tPrimary anastomosis for vesicourethral reconstruction.
149
Bladder Membranous
reconstruction was attempted in 9 patients of of group B. group A and in 42 patients Preoperative therapeutic radiation (6,000 rads) was given to 1 patient in group A and to 4 patients in group B. Modified Vest Technique of Vesicourethral Reconstruction After radical extirpation of the prostate and seminal vesicles, the vesical neck is examined. If the vesical neck is wide open, it is reconstructed so as to reduce the diameter of the vesical neck to between 1.5 and 2 cm. A 1-O chromic suture is placed lateral to the reconstructed vesical neck and is threaded on a long, straight Keith needle. A similar suture is placed diametrically opposite, close to the vesical neck. The straight needles are threaded 1 cm. lateral to the membranous urethra, through the urogenital diaphragm, and are passed straight through and out onto the skin of the perineum lateral to the midline beneath the scrotum. A Foley catheter is passed through the urethra and guided into the vesical neck. The balloon is inflated to 30 ml., and with gentle traction on the Foley catheter, the vesical neck is brought near the cut end of the membranous urethra. Traction is placed on the Vest sutures, and they are tied over gauze bolsters (Fig. 1). Before wound closure, Hemovacs are placed and drain the retropubic and perivesical spaces. The Vest bolster sutures are left in place for fourteen days unless the patient has received preoperative radiation, in which situation the sutures are left in for as long as four weeks. The urethral catheter is removed after ten or twelve days unless there is prolonged urinary extravasation, as noted in the Hemovac drainage or demon-
150
FIGURE 1. Diagram showing Vest traction sutures passed through urogenital diaphragm lateral to membranous urethra. (From Chute,* by permission of Williams & Wilkins Company.)
strated on cystogram. The Hemovacs are removed after the drainage has ceased. When primary anastomosis of the vesical neck and the urethra is performed, four to six 2-O chromic catgut sutures are placed circumferentially, avoiding the ureteral orifices. The difficulty of placing the urethral sutures is overcome by the use of a five-eighth circle needle (U-245 Ethicon) on a Strate needle holder. Complications of Surgery Complications relating to the vesicourethral reconstruction after a radical retropubic prostatectomy were divided into those occurring in the early postoperative period and those occurring late (Table II). Early complications
Prolonged urinary extravasation from the anastomotic site was defined either as drainage of more than 100 ml. of urine during a twentyfour-hour period for fourteen or more days after surgery or as extravasation demonstrated on a cystogram to such a degree that the patient had to be left with an indwelling urethral catheter for more than two weeks. One patient in group A who had undergone 6,000 rads to the prostate earlier and had recurrent tumor three years later had prolonged anastomotic urinary leakage. Seven patients in group B had prolonged urinary extravasation. Of these, 3 patients had previous radiation to the prostate. Four patients in group B were dismissed from the hospital with indwelling urethral catheters but were kept under close observation until urinary extravasation had ceased. Superficial wound infection was noted in 3 patients of group A and in 3 patients of group B. Two patients in group A also had ulceration of the perineal skin at the site of the Vest bolster. While no patients in group A had thromboembolic problems, 3 patients in group B had clinical thrombophlebitis that required anticoagulation, and 2 additional patients had documented pulmonary emboli.
UROLOGY
/ FEBRUARY
1979 / VOLUME XIII, NUMBER 2
TABLE II.
Complications after radical retropubic prostatectomy
Complication Early Prolonged urinary extravasation Superficial wound infection Ulceration of perineal skin at site of Vest bolsters Thrombophlebitis Pulmonary embolism Late Incontinence Mild stress Moderate stress Total Vesical neck contracture Urethral stricture Osteitis pubis Recurrent tumor Penoscrotal edema
Group A Group B (36 Patients) (100 Patients) No. % No. %
1
2.7
7*
7
3
8.3
3
3
2 0 0
5.5 0 0
0 3 2
0 3 2
2 2 1
5.5 5.5 2.7 11
8.3 0 0 0
9 4 3
9 4 3
8
8
2 0 3 2
2 0 3 2
*Includes 4 patients dismissed from hospital with indwelling catheters.
Most patients had stress incontinence at dismissal from the hospital. This, however, resolved in a few days to a few months. Permanent urinary incontinence was defined as that occurring one year after surgery. Late complications Urinary incontinence was evaluated one year after surgery. Grade 1 was defined as mild stress incontinence that did not require the patient to wear pads; grade 2 was defined as moderate stress incontinence that required the patient to wear pads when ambulant; and grade 3 was defined as total urinary incontinence that required the use of an appliance such as a condom catheter or a Cunningham clamp. The 3 patients in group B who had total incontinence eventually underwent implantation of an inflatable prosthetic genitourinary sphincter or had a Kaufman anti-incontinence procedure. Two of the 3 patients had both of these procedures done, and their continence eventually improved. Vesical neck contractures were noted three months to three years after the procedure. In 4 patients of group A, vesical neck contracture developed; 3 had a favorable response to resection of dilation, while 1 patient underwent the vesical neck contracture. In group B, 8 pa-
UROLOGY /
FEBRUARY 1979 / VOLUME XIII, NUMBER 2
tients had vesical neck contractures; 7 were treated with dilation, while 1 patient had transurethral incision of the contracture. Anterior urethral strictures were noted in 3 patients in group A and in 2 patients in group B. The urethral strictures were managed with dilation alone or by internal urethrotomy and dilation. Three patients had local tumor recurrence one to six years after the procedure. Two patients in group B had penoscrotal edema; both had previous preoperative radiation to the pelvis. Comment Primary anastomosis of the bladder neck with the membranous urethra after a radical retropubic prostatectomy can be a technically difficult procedure,4 especially when the membranous urethra tends to retract in the urogenital diaphragm and the patient’s bony pelvis is narrow and deep. Atherton4 is credited with applying the Vest technique that had been used in vesicourethral reconstruction after radical perineal prostatectomy and adapting it for reconstruction after radical retropubic prostatectomy. Kopecky, Laskowski, and Scott3 in a retrospective comparison of the two methods of vesicourethral reconstruction, reported a high incidence of urinary extravasation and urinary incontinence with the Vest technique. Although a primary watertight repair should be achieved if urinary extravasation is to be minimized at the site of the anastomosis, only prolonged urinary extravasation probably is significant. Prolonged extravasation not only would cause periurethral scarring but also would result in delay in removal of the urethral catheter, and thus would increase the risk of a urethral stricture developing. Only 1 patient in the group that underwent the Vest procedure had prolonged extravasation. This patient had undergone preoperative radiation to the pelvis, which may have accounted for the delayed healing. The high incidence of prolonged urinary extravasation in patients undergoing primary anastomosis in our study is difficult to explain, except perhaps that tying the sutures too tight could have caused ischemic necrosis of the tissues, resulting in delayed healing. Similarly, ulceration of the skin at the site of the Vest bolsters possibly could have been prevented by tying the sutures with gentle traction only. The most distressing complication of radical retropubic prostatectomy, except for impotence (which is almost uniformly present), is incontinence. Assessment of incontinence may be
151
difficult. Most patients had stress incontinence at dismissal from the hospital, but this rapidly improved in a few days. In some patients, it takes six to nine months before the pattern of incontinence stabilizes. Hence, persistent incontinence is evaluated at one year after surgery and is arbitrarily divided into three grades, depending on severity. Grade 1 is minimal leakage associated with stress but not sufficient to cause concern to the patient; grade 2 is severe stress incontinence requiring the wearing of pads for protection; and grade 3 is total incontinence in which the patient constantly dribbles while standing. The sphincteric mechanisms involved in urinary continence have been well described by Turner-Warwick et al. ’ Continence after radical retropubic prostatectomy appears to be dependent on the integrity of the distal sphincteric complex, which includes the intact segment of the urethra between the verumontanum and the urogenital diaphragm. 6 If this area is damaged during surgery or the wall of the membranous urethra becomes irregular and rigid owing to scar tissue, incontinence results. The amount of incontinence depends on the degree of functional integrity of the distal sphincteric complex. In attempting to achieve a watertight primary anastomosis for vesicourethral reconstruction, multiple sutures may have been placed through the distal sphincteric complex, and this residual sphincter mechanism may be damaged if the sutures are tight and ischemic necrosis and scarring occur. The procedure of choice should be close approximation of the cut end of the urethra to the reconstructed vesical neck by means of Vest traction sutures placed at least 1 cm. lateral to the membranous urethra so as not to disturb the residual sphincteric mechanism. Prolonged urinary extravasation may cause periurethral scarring and rigidity of tissues in this region and thus contribute to the impaired continence. The region of vesicourethral reconstruction must be well drained with Hemovacs or Penrose drains. Some surgeons have stated that, if the vesical neck can be preserved by careful dissection from the prostate, a higher incidence of continence may be achieved.’ In fact, in more than half the patients, the vesical neck was preserved and vesical neck reconstruction was not considered necessary. There was, however, no demonstrable relationship between subsequent incontinence and preservation of the vesical neck. Our study shows no significant
152
difference in the incidence of incontinence between the group that underwent the Vest procedure and the group that underwent primary anastomosis. The study tends to support recently published data stating that the incidence of incontinence after radical prostatectomy (incorporating both the retropubic and perineal approaches) is 10.3 per cent.8 The incidence of vesical neck contracture has ranged from 6.4 per cent8 to 12.3 per cent.3 Our results are within this range. Most vesical neck contractures occur at the site of the vesicourethral reconstruction and usually are noted three to six months after surgery. If vesical neck obstruction occurs late, the possibility of recurrent carcinoma must be ruled out. Vesical neck contracture usually responds to simple dilation, but in 2 of our patients (one in each group), resection or incision of the contracture was necessary. The incidence of urethral stricture due to prolonged indwelling urethral catheter remains significant. The strictures usually occurred in the bulbous urethra and were of large caliber, responding favorably to urethral dilation. The study showed no significant differences in complications after vesicourethral reconstruction between the Vest procedure and the primary anastomosis. Incontinence after radical retropubic prostatectomy appears not to be related to the method of vesicourethral reconstruction but occurs because of damage during surgery or postoperative scarring of the distal sphincteric mechanism. Section of Publications Mayo Clinic Rochester, Minnesota 55901 (DR. KHAN) References 1. Vest SA: Radical perineal prostatectomy: modification of closure, Surg. Gynecol. Obstet. 70: 935 (1949). 2. Chute R: Radical retropubic prostatectomy for cancer, J. Ural. 71: 347 (1954). 3. Kopecky AA, Laskowski TZ, and Scott R, Jr: Radical retropubic prostatectomy in the treatment of prostatic carcinoma, ibid. 103: 641 (1970). 4. Atherton L, and Atherton LD: Radical retropubic prostatectomy for carcinoma, ibid. 75: 111 (1956). 5. Turner-Warwick R, et al: A urodynamic view of prostatic obstruction and the results of prostatectomy, Br. J. Ural. 45: 631 (1973). 6. Caine M, and Edwards D: The peripheral control of micturition: a tine-radiographic study, ibid. 36: 34 (1958). 7. Parry WL: Prostate malignancies, in Glenn JF, Ed: Urologic Surgery, 2nd ed., Hagerstown, Maryland, Harper C Row, 1975, n. 569. 8. Boxer RJ, Kaufman JJ, and Goodwin WE: Radical prostatectomy for carcinoma of the prostate: 1951-1976. A review of 329 patients, J. Ural. 117: 268 (1977).
UROLOGY
/
FEBRUARY
1979
/
VOLUME XIII,
NUMBER 2