Mucosal Eversion Research Articles

Bladder neck contracture after retropubic radical prostatectomy: incidence and risk factors from a large single‐surgeon experience

To examine a large, single-surgeon series of patients with prostate cancer who underwent retropubic radical prostatectomy (RRP) for men with postoperative bladder neck contractures (BNCs). From 1983 to 2007, 4132 men underwent RRP for prostate cancer by one surgeon. All patients had BN reconstruction with mucosal eversion. The bladder to membranous urethral anastomosis was made using six 2/0 chromic catgut sutures over an 18 F Foley catheter. The catheter was left in place for 10 days. Data from these men is stored in a prospective database, which was reviewed in this study for men with BNCs after RRP. Men with BNCs were compared with all other men in the series to determine risk factors for BNC development. Overall, BNCs developed in 110 patients (2.5%). Examining our last 500 patients there was a contemporary BNC rate of <1%. The median (range) follow-up was 44 (12-233) months. Tumour characteristics were similar in the men with BNCs and those with no BNCs, and the rates of organ-confined disease were also similar (65% vs 70%, P = 0.27). Men with BNCs had higher median preoperative prostate-specific antigen (PSA) levels (6.7 vs 5.7 mg/dL; P = 0.009) and were more likely to have PSA failure after RRP (30% vs 16%, P < 0.001). On multivariate analysis, non-nerve sparing (P = 0.003) and a surgical date before 1992 (P < 0.001) were significant predictors of BNC. Patients with BNCs had lower potency rates (49% vs 63%, P < 0.003) and continence rates (88% vs 94%, P = 0.07) at the 18-month follow-up. BNCs are rare, occurring in <1% in our modern series. The important surgical factors in preventing BNCs are to avoid closing the BN too tightly and attaining good apposition of the BN with the urethral stump with a watertight closure. BNCs are more common with non-nerve-sparing surgery and early in a surgeon's experience.

Scientific and technical advances in continence recovery following radical prostatectomy

The advent of prostate-specific antigen screening has changed the global epidemiology of prostate cancer, with men being diagnosed with organ-confined cancer at a younger age. Radical prostatectomy with curative intent for these patients, while delivering excellent long-term survival outcomes, still has significant side effects, chiefly postprostatectomy incontinence. Increasing age, shorter pre- and post-operative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations of surgical technique and previous prostate surgery have been reported as negative risk factors for delayed continence recovery and/or permanent incontinence following radical prostatectomy. Significant progress in elucidating the functional anatomy and physiology of the male continence mechanism from cadaveric and videourodynamic studies have enabled surgeons to propose innovative surgical techniques during radical prostatectomy for augmenting continence preservation and early return. These have included optimizing the preservation of urethral rhabdosphincter length; avoiding rhabdosphincter injury; posterior reconstruction of Denonvilliers’ musculofascial plate; preservation of the bladder neck and internal sphincter; bladder neck intussusception; bladder neck mucosal eversion; preservation of the puboprostatic ligaments and arcus tendineus; and preservation of putative nerves supplying the continence mechanism. We review the scientific and technical advances in continence recovery following radical prostatectomy, identify the key principles undergirding early return of continence, highlight various treatment strategies for early and refractory postprostatectomy incontinence and describe our experience with a paradigm of these unified key principles. Increasing application of these principles in computer-aided (robotic), minimally invasive and minimal-access (i.e., single-port or natural orifice transluminal) approaches will hopefully enable patients to derive maximal benefit from curative prostatectomy while experiencing early return of continence in the not too distant future.

An analysis of the causes of bladder neck contracture after open and robot‐assisted laparoscopic radical prostatectomy

To evaluate the difference in outcome of bladder neck contracture (BNC) and its causes between large groups of patients undergoing open radical prostatectomy (ORP) and robot-assisted laparoscopic prostatectomy (RALP). We analysed 200 consecutive RPs performed by one surgeon for prostate cancer, 100 by ORP and 100 by RALP, between March 2003 and September 2007. The operative techniques of bladder neck repair and urethro-vesical anastomosis were different. The ORP patients had a conventional stomatization and 'racquet handle' repair of the bladder if necessary, with mucosal eversion and a direct circular interrupted 'end-to-end' suture anastomosis between the bladder and urethra. The RALP patients had no bladder neck reconstruction or mucosal eversion and their anastomosis was by the continuous suture 'parachute' technique. There was no BNC in the RALP group, whilst 9% of the ORP group developed a BNC (P < 0.005). Apart from surgical technique, other variables, including patient age, previous transurethral resection of the prostate, Gleason score, T stage, urine infection rate, urinary leakage, blood loss, drain tube removal, anastomotic suture material, catheter type and catheter removal times were statistically comparable in both groups. This series suggests that the major factor involved in the cause of bladder neck contracture after ORP, relates to the stomatization or 'racquet handle' bladder neck repair, and the end-to-end anastomosis between the urethra and stomatized bladder. Mucosal eversion might also contribute. Normal postoperative urinary leakage when the anastomotic apposition is good seems unlikely to be a significant aetiological factor in the development of BNC. Prolonged urinary leakage results from an anastomotic gap, which heals by second intention, thereby causing scarring and BNC. The RALP 'parachute' technique, which expands the anastomosis towards the bladder, appears to protect against BNC. Mucosal eversion is not necessary in the parachute repair.

Commentary on An analysis of the causes of bladder neck contracture after open and robot-assisted laparoscopic radical prostatectomy

Objectives To evaluate the difference in outcome of bladder neck contracture (BNC) and its causes among large groups of patients undergoing open radical prostatectomy (ORP) and robot-assisted laparoscopic prostatectomy (RALP). Patients and Methods We analyzed 200 consecutive RPs performed by one surgeon for prostate cancer, 100 by ORP, and 100 by RALP, between March 2003 and September 2007. The operative techniques of bladder neck repair and urethrovesical anastomosis were different. The ORP patients had a conventional stomatization and “racquet handle” repair of the bladder if necessary, with mucosal eversion and a direct circular interrupted “end-to-end” suture anastomosis between the bladder and urethra. The RALP patients had no bladder neck reconstruction or mucosal eversion and their anastomosis was by the continuous suture “parachute” technique. Results There was no BNC in the RALP group, whilst 9% of the ORP group developed a BNC (P Conclusion This series suggests that the major factor involved in the cause of bladder neck contracture after ORP relates to the stomatization or “racquet handle” bladder neck repair, and the end-to-end anastomosis between the urethra and stomatized bladder. Mucosal eversion might also contribute. Normal postoperative urinary leakage when the anastomotic apposition is good seems unlikely to be a significant etiological factor in the development of BNC. Prolonged urinary leakage results from an anastomotic gap, which heals by second intention, thereby causing scarring and BNC. The RALP “parachute” technique, which expands the anastomosis towards the bladder, appears to protect against BNC. Mucosal eversion is not necessary in the parachute repair.

BLADDER NECK CONTRACTURE AFTER RADICAL RETROPUBIC PROSTATECTOMY: INCIDENCE AND RISK FACTORS FROM A LARGE SINGLE-SURGEON EXPERIENCE

509 BLADDER NECK CONTRACTURE AFTER RADICAL RETROPUBIC PROSTATECTOMY: INCIDENCE AND RISK FACTORS FROM A LARGE SINGLE-SURGEON EXPERIENCE Bradley A Erickson*, Chris M Gonzalez, Kimberly A Roehl, Jessica T Casey, William J Catalona. Chicago, IL, and St. Louis, MO. INTRODUCTION AND OBJECTIVE: Bladder neck contractures (BNC) have been reported in 0.5-32% of men after radical retropubic prostatectomy (RRP). We examined a large, single-surgeon series of radical prostatectomy patients for men with post-operative bladder neck contractures (BNC). METHODS: From 1983 to 2003, 3487 men underwent radical retropubic prostatectomy (RRP) for prostate cancer by one surgeon. All patients had bladder neck reconstruction with mucosal eversion. Bladder to membranous urethral anastomosis was performed using four to eight 2-0 chromic catgut and one Monocryl suture over an 18 F foley catheter. The catheter was left in place for 10 days. Data from these men is stored in a prospective database and was reviewed in this study for men with post-operative BNC’s. Men with BNC’s (BNC+) were compared to all other men in the series (BNC-) to determine risk factors for BNC development. RESULTS: BNC’s developed in 95 patients (2.7%). Median follow-up time was 65 months (12-233). Tumor characteristics were similar in the BNC+ and BNCgroups, showing comparable rates of

The influence of bladder neck mucosal eversion and early urinary extravasation on patient outcome after radical retropubic prostatectomy: a prospective controlled trial

To evaluate the role of bladder neck (BN) mucosal eversion during retropubic radical prostatectomy (RRP) on the rate of BN sclerosis and urinary incontinence, with the hypothesis that BN mucosal eversion is not essential to improve the clinical outcome after RRP. One hundred patients with stage T1c-T2c prostate cancer had RRP by the same surgeon and were randomly divided in two equal groups; one had a vesico-urethral anastomosis with and one with no BN mucosal eversion. The patients were assessed by retrograde cysto-urethrography 4 days after surgery to evaluate the presence of urinary leakage. The occurrence of BN sclerosis and the rate of urinary incontinence (more than one pad/day) was assessed by double-blind interviews at 2 days, 2 months and 6 months after catheter removal, and the incidence of BN sclerosis was also assessed after 12 months. In the groups with or with no BN mucosal eversion, 48 and 47 patients, respectively, fulfilled the selection criteria. Urinary leakage after vesico-urethral anastomosis was more common after mucosal eversion (33% vs 21%), but not significantly (P = 0.251). BN sclerosis occurred in only one patient, with no mucosal eversion. The rate of urinary continence was similar in both groups at 2 days (69% vs 68%, respectively), 2 months (90% vs 87%) and 6 months (92% vs 92%) after surgery. Urinary extravasation at 4 days after surgery was followed by same rate of BN sclerosis and urinary continence as in patients with no urinary extravasation. BN mucosal eversion before vesico-urethral anastomosis during RRP is not essential to reduce the frequency of BN sclerosis or urinary incontinence. Early radiological urinary extravasation at the vesico-urethral anastomosis did not increase the risk of BN sclerosis or urinary incontinence.

Can leakage at the vesico-urethral anastomosis be predicted after radical retropubic prostatectomy?

To determine if low-risk patients can be identified in whom cystography is unnecessary to assess the integrity of the vesico-urethral anastomosis after radical retropubic prostatectomy (RRP), and thus who can have early catheter removal. In all, 275 RRPs by one surgeon were analysed retrospectively; the surgical technique, blood loss and comorbidity were recorded. Cystograms were taken 8 days after RRP to assess vesico-urethral integrity before catheter removal. Of the 275 patients, 75% and 89% had cystography before 8 and 10 days after RRP, respectively; 71% of patients had no leak on cystography and were catheter-free at 8 days. Eighty-four leaks were identified, of which 25 (9.6%) were moderate or large. Previous transurethral prostatectomy, ischaemic heart disease, blood loss, mucosal eversion and preservation of the prostatic urethra were significant risk factors for developing a leak and were used to create a nomogram to assess the relative risk of leakage. However, none of the variables assessed, either alone or combined, could be used to predict which leaks were clinically significant. Leakage cannot be reliably predicted at the vesico-urethral anastomosis. Cystograms are necessary to identify clinically significant leaks at 8 days and should be taken if early catheter removal is being considered.

Lower Lip Sculpting in African-Americans

Cosmetic lower lip sculpting is useful in the correction of lower lip macrochelia lip eversion that is usually the result of hyperplasia of the minor salivary glands causing mucosal fullness and lip eversion. Forty-eight patients were treated with lip sculpting for this disorder. Two patients developed hypertrophied scars and three patients had small retention cysts treated by marsupialization.

Risk factors for vesicourethral anastomotic stricture after radical prostatectomy

Objectives. Preoperative comorbidities associated with microvascular disease may contribute to the development of bladder neck contracture (BNC) by alteration of anastomotic healing. We investigated potential risk factors for development of BNC after radical prostatectomy (RP) and reviewed management of this complication. Methods. A retrospective review of 467 consecutive patients (mean age 63.2 years) undergoing RP between 1991 and 1999 was performed. In all cases, the bladder neck was tailored to 20 to 22F in a racket handle fashion. After mucosal eversion of the reconstructed bladder neck, a mucosa-to-mucosa vesicourethral anastomosis was created over an 18 to 22F catheter using 4 to 6 anastomotic sutures. The relationship between comorbidities identified preoperatively by patient interview and medical record review (coronary artery disease [CAD], diabetes mellitus [DM], hypertension [HTN], cerebral vascular accident, chronic obstructive pulmonary disease, and smoking history) and the incidence of BNC was determined. Risk factors including prior transurethral prostatectomy (TURP), estimated blood loss (EBL), and operative time (OR time) were also evaluated. Factors were evaluated for their ability to predict BNC using both univariate and multivariate analysis. Treatment results for BNC were also assessed. Results. A total of 52 (11.1%) patients developed BNC. Current cigarette smoking resulted in a significantly higher (26%) rate of BNC ( P <0.001). The BNC rate was also increased in patients with CAD (26%, P <0.001), HTN (19%, P = 0.015), and DM (21%, P = 0.030). Average OR time was longer (271 versus 249 minutes, P = 0.025) and EBL was greater (1639 versus 1092 mL, P <0.001) in patients developing a BNC. In multivariate analysis, current cigarette smoking was the strongest predictor of BNC and independent of other factors ( P <0.001). BNC was not related to prior TURP, type of anastomotic suture used, size of catheter, or duration of catheterization. Patients were treated with transurethral dilation (73%) or transurethral incision (27%) and 58% responded to the initial treatment. No patient became incontinent as a result of the treatment for BNC. Conclusions. Several comorbidities associated with microvascular disease are significant risk factors for development of BNC after RP. Current cigarette smoking in particular is a strong predictor. Transurethral dilation and transurethral incision are equally effective as initial treatment of BNC.

Staple closure of the gullet after laryngectomy: an experimental study.

Traditionally, gullet closure that is done after a laryngectomy has been accomplished with tedious and time-consuming suturing procedures. As an alternative to this, staple closure of the gullet has been growing in acceptance and implementation as a mucosal eversion technique. In this article, we shall present several aspects and considerations of this method of surgical closure.

Temporary colostomy and its closure technic

The object of temporary colostomies is diversion of intestinal content from the lesions in lower bowel and they are predisposed to be closed when the primary object is achieved. Their prerequisite threfore, is easiness and safety in the procedures of construction and closure.For those purposes, loop colostomy is most fitted when the techniques of primary opening, mucocutaneous suturing and mucosal eversion are applied. Instantaneous opening of the stoma immeduately resolves the obstruction in lower bowel and there has not been a case that was complicated with peritonitis or infection of abdominal wall even if the stoma was opened instartly in a patient of bowel obstruction without satisfactory preparation of the bowel.Owing to mucocutaneous suturing, inflammatory reaction around the stoma is minimized with the result of minimal formation of cicatrical tissues. Therefore, stenosis of the stoma is prevented and on the occasion of closure, the possibility of closing the stoma merely by suturing the opening is increased. However, meticulous separation of adhesion and removal of cicatrices are required.No serious complications are yet experienced in our 25 cases of temporary colostomies except 2 cases of herniation around the stoma in elderly patients which was corrected operatively with success.