Improved urinary continence after radical retropubic prostatectomy with preparation of a long, partially intraprostatic portion of the membraneous urethra: an analysis of 1013 consecutive cases

Abstract

Purpose: To improve the rate of full continence in our patients, we performed, since June 1997, a careful preparation of the distally intraprostatic part of the membranous urethra to obtain a long urethral stump for the vesicourethral anastomosis.

Patients and methods: In all, 610 patients without (group 1) and 403 patients with (group 2) a long intraprostatic stump of the urethra were asked by a self-administered questionnaire about their continence status. The rate of positive surgical margins were compared as a marker of local tumour control.

Results: Full continence (no pads) was achieved in 76.02% in group 1 and in 88.84%, of all patients in group 2. Stress incontinence (SIC) I° was found in 12.46% and 7.44% respectiveley, SIC II° was noted in 8.69 and 3.72% and complete incontinence was seen in 2.79% in group 1 and in two patients (0.5%) in group 2. Also the time to reach the final continence status was statistically and highly significantly (P<0.001) shortened. The rate of positive margins decreased in group 2, despite intraprostatic preparation.

Conclusions: The preparation of a long, partially intraprostatic portion of the membranous urethra for vesicourethral anastomosis in radical retropubic prostatectomy leads to a statistically highly significant improvement of full continence and earlier continence in prostate cancer patients without compromising local tumour control.

Introduction

Urinary continence is one of the most important quality-of-life factors and at the same time the major side effect in patients after radical prostatectomy. In literature the achieved continence rates vary between 31 and 98.5% of all patients.1, 2, 3, 4, 5 Also the time to reach the final continence status differs from a few days up to 2 y. An explanation for these discrepancies may be various definitions of continence and differences in physician vs assessment of symptoms. Clinical and urodynamic studies show that different surgical techniques (eg nerve-sparing procedures), patient age, changes in bladder stability and functional urethral length are predictors of postoperative continence. To improve the rate of full continence different techniques of bladder neck preservation and reconstruction were performed. Some of them showed an improvement of the postoperative continence rates6, 7, 8, 9, 10 even when the length of the membranous urethra was shortened.

Since June 1997 we used a careful preparation of a long, partially intraprostatic portion of the membranous urethra to obtain a long urethral stump for vesicourethral anastomosis. Before this time we simply transsected the urethra at the apex of the prostate. This retrospective study was performed to compare the rate and time to reach final urinary continence, catheter duration time and the rate of positive surgical margins in these two groups.

Patients and methods

Study population

Between 1986 and 2002, 1013 patients underwent radical retropubic prostatectomy for localised prostate cancer at our department. In our nonrandomised trial, in 610 of these patients the urethra was transsected at the apex of the prostate (group 1, 1986–1996) and in 403 patients a careful preparation of a long intraprostatic part of the membranous urethra was performed (group 2, 1997–2002). Preoperatively, 95.4% of group 1 and 98.5% of group 2 were fully continent. The preoperative continence status was evaluated by a personal interview and the postoperative continence status was recorded by a validated and self-assessed questionnaire (ICS-Q30 male questionnaire). The mean age of group 1 (42–77) and group 2 (46–78) was 65 y. The median follow-up was 90.1 months (1.1-179) and 28.3 months (1.9–54.7) respectively. Regarding the number of patients younger than 70 y, the mean PSA value before operation and the preoperative continence status, no statistically significant differences between both groups were found. In group 2, we noted more organ-confined prostate cancers (70.9 vs 50.4%) and less lymph node metastasis (3.8 vs 10.1%). The patients characteristics are summarised in Table 1.

Table 1 Patient characteristics

Definition of the continence status

We defined patients as fully continent, if they needed no pads. We classified patients as stressincontinent I° who needed one pad per day, who needed 2–4 pads per day as stressincontinent II° and who needed more than 4 pads per day or any pads at night (Table 2) as stressincontinent III.°

Table 2 Definition of continence status

Histopathological analysis

All radical prostatectomy specimens were analysed at the Department of Pathology, Technische Universität Munich according to the 1997 UICC-TNM-classification.

Technique of preparation of the intraprostatic part of the membranous urethra and catheter duration time

A minilaparotomy is performed through a suprapubic midline incision for 5–7 cm. The rectus fascia is incised and the muscles are separated. The transversalis fascia is incised and the space of Retzius is developed. We use a Balfour-retractor to retract the rectus muscles laterally. After a pelvine lymphadenectomy, the fatty tissue over the endopelvic fascia is removed. After incision of the endopelvic fascia and the puboprostatic ligaments with a bipolar scissors, the dorsal veins are ligated by two 2-0-Monocryl sutures with a UR6-needle. The first half of the venous plexus is divided by an electrocauter, then scissors are used and the plane above the urethra can be developed. Up to this step the technique of preparation did not change. But since June 1997 a careful preparation of the apex and the urethra is performed: By retracting the basis of the prostate craniodorsally an intraprostatic part of the membranous urethra can be prepared and the periurethral and apical tissue carefully dissected (Figure 1). An additional length of the urethra up to 1 cm is achieved. The anterior circumference of the urethra is incised at the level of veromontanum. Frozen sections of the urethral stump at the 3, 12 and 9 o'clock position are obtained. Three interrupted sutures (3-0 PDS, UR6-needle) for the vesico-urethral anastomosis at the 10,12 and 2 o'clock position are inserted carefully through 3–4 mm of the urethra. Then the posterior wall of the urethra is transsected at the level of the veromontanum. By pulling the catheter ventrally, the posterior circumference of the urethra becomes visible and the next sutures at the 4–7 and 8 o'clock position can easily be inserted. For the anastomosis we use 3-0-PDS with a UR 6-needle. An additional length of 1–2 cm of the urethral stump is gained. An ascending preparation of the prostate is performed. The bladder neck is excised by an electrocauter, the bladder mucosa is everted by 3-0-Vicry rapid.

Figure 1
figure1

Technique of preparation of a long and partially intraprostatic part of the membranous urethra.

At 10 days postoperatively a cystogram was performed. If no extravasation was found, the catheter was removed on the same day, otherwise kept in place for a total of 21 days and then removed without further diagnostic procedure.

Statistical analysis

The differences between both groups were analysed by the χ2 and Fishers-exact-test (confidence interval 95%). Differences were considered statistically significant at P<0.05.

Results

Urinary continence and time to reach the final continence status

In all, 464 patients of group 1 (76.07%) and 358 patients (88.84%) of group 2 were fully continent. Stressincontinence I.° was reported in 76 patients of group 1 (12.46%) and in 30 patients of group 2 (7.44%). Stressincontinence II.° was noted in 53 (8.69%) and 15 (3.72%) patients. In all, 17 patients of group 1 (2.79%) and two patients of group 2 (0.5%) suffered From stressincontinence III.° These differences were statistically significant (P<0.05) (Figure 2).

Figure 2
figure2

Postoperative continence status of patients with and without preparation of an intraprostatic urethral stump.

Regarding the time to full continence (fully continent patients only), 15% of patients of group 1 vs 33% of group 2 reached their final continence status within the first 4 weeks; this difference was statistically significant (P<0.05). After 3 months, 44 and 49% patients were fully continent. All fully continent patients of group 2 and 95% of group 1 needed no pads after 6 months and the remaining 5% of patients of group 1 were fully continent after 12 months (Figure 3).

Figure 3
figure3

Time to reach full continence after RRP for patients who achieved full continence with and without preparation of an intraprostatic urethral stump.

Urinary continence and age

A total of 763 patients were younger than 70 y, and 250 patients older. Of the younger patients, 82% were fully continent vs 75% of the older patients. This difference was statistically significant (P<0.05).

Regarding the preparation of an intraprostatic urethral stump, 459 patients (75.25%) of group 1 and 304 patients (75.43%) of group 2 were younger than 70 y. Of these patients, 78.21% of group 1 and 89% of group 2 were fully continent. In the group of patients older than 70 y (group 1 n=151, group 2 n=99), 69.54% and 83.84%, respectively, needed no pads postoperative. The differences were all statistically significant (P<0.05).

Catheter duration time

In all, 67.6% of patients of group 1 and 64.8% of group 2 showed no extravasation in the cystogram after 10 days and the catheter was removed. In 32.4 and 35.2% the catheter was removed after 21 days. This difference was not statistically significant (P=0.83).

Rate of positive surgical margins

Surgical margins were classified in 584 patients (95.74%) of group 1 and in 380 patients (94.29%) of group 2. In group 1 the overall rate of positive surgical margins (R1) was 36.8% (n=215) vs 21.7% (n=81) in group 2. Because of differences in local tumour stage we also analysed subgroups:

15.1% of the organ-confined prostate cancers (pT2b) of group 1 and 14% of group 2 and showed microscopically positive surgical margins. Regarding patients with locally advanced prostate cancer (pT3a), we noted surgical margins in 55.8% and in 41.3% positive; these differences were not statistically significant (P=0.61) (Table 3).

Table 3 Rate of positive surgical margins for patients with and without preparation of an intraprostatic urethral stump for overall patients

Regarding patients with R1-situation, 58.8% of patients with an intraprostatic urethral stump and 74% without showed microscopically positive surgical margins at the apex of the prostate. This difference was statistically highly different (P<0.00017) (Table 4).

Table 4 Rate of positive surgical margins at the apex of the prostate of R1- patients only with and without preparation of an intraprostatic urethral stump

Discussion

The choice of operative technique in radical prostatectomy, the knowledge of anatomical structures and the protection of the striated sphincter are the major mechanisms to prevent patients from postoperative urinary incontinence. Although urinary incontinence after radical prostatectomy is uncommon today, even in the hands of experts 2–18% of patients will suffer from significant long-term incontinence. Also the return of urinary continence can be a slow process.9, 11

This present study showed in patients after preparation of a large portion of the membranous and intraprostatic part of the urethra in radical retropubic prostatectomy a statistically highly significant improvement in the rate of full continence and a shortened time to full continence. We noted only two patients with a grade 3 stress-incontinence in this group. In literature, the achieved rates of full urinary continence after radical prostatectomy differs between 31 and 98.5%.1, 2, 3, 4, 5 One major problem of these discrepancies in the results is the defintion of urinary continence. The majority of the authors use the number of pads needed per day, other study groups define urinary continence according to the situation when patients lose urine (laughing, coughing, etc).2, 12, 13 We defined patients as fully continent, if no pads were needed. That means that patients who also, used a pad for feeling secure but did not lose any urine at all were regarded as stressincontinent I.°

The main reason for improved urinary continence and earlier continence is, in our opinion, the gain in length of the urethra and the enlarged distance to the striated sphincter.14, 15 Coakley et al10 performed preoperatively in 211 patients an endorectal MRI of the prostate to measure the length of the membraneous urethra. He showed that a longer membraneous urethra is associated with a higher rate of full continence and that the continence status was reached earlier.

For some authors the reconstruction of the bladder neck is of major importance.

In our patients, we performed a standard tennis racket closure but prepared a longer urethral stump. Walsh et al9 reported about earlier continence after intussusception of the reconstructed bladder neck. After 3 months 82% were not wearing pads in his study compared to 54% in his prior reports. In our study, 33% of the fully continent patients were not wearing pads within the first 4 weeks, 77% after 3 months and 100% 6 months after preparation of an intraprostatic urethral stump. These results are comparable and underline the importance of the length of the urethra. Nevertheless, the reconstruction and intussusception of the bladder neck can be important in cases of a shortened membraneous urethra.

We also showed that the age of the patient is important for the prognosis of postoperative continence and noted even in the patients younger than 70 y a statistically significant better outcome.

One of the main criticisms of the intraprostatic preparation is the risk of higher rates of positive surgical margins, suggesting decreased local tumour control. In our hands however, the rate of positive surgical margins decreased in patients with an intraprostatic urethral stump. This cannot be only explained by the higher rate of T3-tumours in the group without an intraprostatic urethral stump as our subgroups analysis of organ confined and locally advanced diseases demonstrated similar results.

Salomon et al16, 17 showed in a retrospective analysis of 538 consecutive cases, that a positive surgical margin at the apex was associated with worse clinical prognosis compared to bladder neck or posterolateral locations. He also made clear that the apex of the prostate is a specific high-risk location specifically in retropubic approach. Owing to this fact, we analysed the patients with an apical R1-situation in our study. Also in this subgroup the patients with preparation of an intraprostatic urethral stump showed a significantly better local tumour control and less positive apical surgical margins.

The decrease of positive surgical margins may be attributed to improved surgical skills over the years. The rates of positive surgical margins are comparable to the literature18, 19, 20, 21, 22, 23, 24

Conclusion

The primary aim of surgery is cure of the underlying cancer. The secondary aim is to minimise the complications of surgery. Urinary incontinence is the major side effect of radical prostatectomy that also limits its widespread acceptance by patients. The technique of the preparation of an intraprostatic urethral stump for vesico-urethral anastomosis in radical prostatectomy improves the rate of fully continent patients, shortens the time to full continence and improves the quality of life in prostate cancer patients without compromising local tumour control. The long-term results for PSA-free-survival are still under investigation.

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van Randenborgh, H., Paul, R., Kübler, H. et al. Improved urinary continence after radical retropubic prostatectomy with preparation of a long, partially intraprostatic portion of the membraneous urethra: an analysis of 1013 consecutive cases. Prostate Cancer Prostatic Dis 7, 253–257 (2004). https://doi.org/10.1038/sj.pcan.4500726

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Keywords

  • radical prostatectomy
  • urinary continence

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