Preservation Of Continence Research Articles

Supra-ampullar cystectomy with preservation of sexual function and ileal orthotopic reservoir for bladder tumor: twenty years of experience.

We describe the original surgical technique of supra-ampullar cystectomy associated with ileal neobladder, and present our results in terms of preservation of sexual potency, urinary continence and cancer control along twenty years of experience. Twenty-eight consecutive patients with bladder tumor-27 transitional cell carcinomas (TCC) and 1 leiomyosarcoma-underwent supra-ampullar cystectomy with ileal orthotopic neobladder (2 Camey I and 26 Camey II) between May 1984 and June 1999. The median age of the patients was 51.0 years (range 23-65). Preoperatively 24 patients had superficial high-risk TCC. Involvement of prostatic urethra was excluded by means of preoperative endoscopic biopsies. The bladder, part of the prostate with the prostatic urethra and regional lymph nodes were removed, while the vas deferens with deferential ampullae, seminal vesicles, ejaculatory ducts and the peripheral portion of the prostate were maintained. Median followup was 90.5 months (range 10-228). Out of 28 patients 6 died of bladder cancer (all with metastases, 2 also with local recurrence); 4 out of the 22 patients who were free of disease at followup died of other causes. Potency was preserved in 26 patients (92.8%), reporting satisfactory sexual intercourses; 15 patients (53.5%) also maintained antegrade ejaculation allowing procreation in 3 cases. In one patient the orthotopic neobladder according to Camey I was converted into an ileal conduit because of the excessive capacity of the reservoir, high post-void residual and recurrent pyelonephritis. Of the remaining 27 patients 16 showed both daytime and nighttime urinary continence (average interval between micturitions = 3 hours), 6 were continent during the day and 5 performed self-intermittent catheterization. Supra-ampullar cystectomy with detubularized ileal orthotopic neobladder allows to preserve sexual function in nearly all the cases and to maintain urinary continence in most patients, without compromising oncological outcome. The indication must be restricted to highly selected cases, without potential risk of local recurrences and concomitant prostatic carcinoma.

Incidence and Location of Prostate and Urothelial Carcinoma in Prostates From Cystoprostatectomies: Implications for Possible Apical Sparing Surgery

Prostatic carcinoma (Pca) at cystoprostatectomy is usually an incidental finding with the majority thought to be clinically insignificant. Most studies have not specifically addressed the location of Pca or the incidence and location of in situ or invasive urothelial carcinoma (Uca) in prostates of cystoprostatectomy specimens. The frequency of involvement of the apex with these processes has clinical implications. Specifically urinary continence following orthotopic diversion may be enhanced by prostate apical sparing. In this study the pathological features of Pca and Uca, and the frequency of apical involvement were investigated in prostates from cystoprostatectomy specimens. Whole mounted prostates from 121 consecutive cystoprostatectomy specimens were analyzed. Pca location, tumor volume, grade, stage, surgical margin and pelvic lymph node status of Pcas were assessed. Clinically insignificant Pcas had a volume of less than 0.5 cc without Gleason pattern 4, extracapsular extension, seminal vesicle invasion, lymph node involvement or positive surgical margins. Prostate involvement by Uca or urothelial carcinoma in situ (CIS)/severe dysplasia and its location were assessed. Of 121 prostates 50 (41%) had unsuspected Pca, of which 24 (48%) were clinically significant. Of Pcas 30 of 50 (60%) involved the apex, including 19 of 24 (79%) that were significant and 11 of 26 (42%) that were insignificant. Of 121 prostates 58 (48%) had Uca involving the prostatic stroma, noninvasive Uca or urothelial CIS/severe dysplasia in the prostatic urethra or periurethral ducts, of which 19 (33%) had apical involvement. Overall only 32 of 121 patients (26%) had no Pca or prostate Uca/CIS and only 45 (37%) had no clinically significant Pca or Uca/CIS in the prostate. However, 74 of the 121 patients (61%) had no prostatic apical involvement by Pca or Uca/CIS and 85 (70%) had no apical involvement by clinically significant Pca or Uca/CIS. Patients with prostatic apical involvement by invasive or in situ Uca uniformly had involvement of more proximal (toward the base) portions of the prostate. The majority of prostates from cystoprostatectomies had no involvement of the prostatic apex by Uca or clinically significant Pca. Hence, most patients may be candidates for prostate apical sparing. However, involvement of the apex by Uca in any patient raises concern about procedures that leave portions of the prostate urethra after cystectomy in an effort to improve continence. In candidates for orthotopic neobladder reconstruction removing all of the prostatic urethra and sparing the remainder of the prostatic apex may allow improved preservation of urinary continence with an acceptable low risk of clinical Pca progression. Whether future strategies for preoperative exclusion of apical Pca and intraoperative assessment of more proximal prostate to help exclude apical urothelial disease may identify patients suitable for prostatic apical sparing remains to be determined. The impact on functional outcomes and cancer control also require additional study.

254 Radiotherapy for rectal cancer causes acute and prolonged impairment of cobalamin status

Aims: Dissection of the lower rectum in some low rectal and pararectal pathologies can be technically difficult that it ends up in abandoning the procedure or raising a permanent stoma. The recently described combined abdomino-perineal approach allows completion of rectal dissection from the perineal route and preservation of the anal sphincters. Patients requiring the combined approach are not seen frequently and reports on this new technique are scarce. The purpose of this study is to analyze our results of using the combined abdomino-perineal approach in different benign and malignant low rectal pathologies, and to describe two new indications for the technique. Patients and methods: This is a retrospective analysis of prospectively collected data of 10 patients (8 males, age range 22–75 years), including 7 cancer patients who required the combined abdomino-perineal approach for completion of their procedures. Previously unreported indications for the technique included iatrogenic rectovaginal fistula and presacral tumor. The study was conducted in a tertiary referral colorectal unit in a university hospital. Results: The procedure was completed and the sphincters preserved in all patients. All cancer patients had adequate resection with good quality mesorectum. Continence was preserved in 4 patients. Three patients are living with permanent stoma. Anastomotic perineal fistula requiring dismantling the anastomosis and raising a permanent stoma occurred in one patient. Conclusions: The combined abdomino-perineal approach is useful to complete rectal resection in a highly selected group of patients with technically difficult low rectal pathologies. The technique is probably safe in cancer patients and new indications are evolving. Expectations for preservation of continence are disappointing.

Radical cystectomy with preservation of sexual function and urinary continence: description of a new technique

To describe the original cystoprostatectomy technique which allows the preservation of sexual and urinary function in the majority of treated patients. The described technique presents some details that distinguish it from classic cystectomy: 1) a more efficient control of prostate venous and arterial tributaries; 2) preservation of prostatic capsule and enucleation of prostatic parenchyma, which is removed in block together with the bladder, without violating the vesical neck; 3) no manipulation of the distal urethral sphincteric complex; 4) preservation of seminal vesicles and maintenance of cavernous neurovascular bundles; 5) wide anastomosis between the ileal neobladder and the prostatic capsule. The proposed maneuvers allow the performance of radical cystectomy with integral preservation of distal urethral sphincter and of cavernous neurovascular bundles, without jeopardizing the oncological principles.

Fate of the pouch in 151 pediatric patients after ileal pouch anal anastomosis

Background/Purpose: Ileal pouch anal anastomosis (IPAA) offers many pediatric patients a surgical cure for mucosal ulcerative colitis (MUC) with preservation of anal continence. However, some patients incur serious problems after surgery including chronic pouchitis and pouch failure. The goal of this study is to identify clinical and pathologic factors that are associated with an adverse outcome of IPAA. Methods: A retrospective analysis of outcome was performed in 151 consecutive patients ≤ 21 years of age who underwent IPAA with a mean follow-up of 7.24 years (range, 2 to 15 years). Patients were categorized into 4 outcome groups: A, no pouchitis; B, mild, acute pouchitis; C, chronic refractory pouchitis; and D, pouch failure. Pairwise comparisons were used to test the association between the groups and clinical and pathologic variables including age, sex, duration of symptoms, perianal disease, colonoscopic histology, terminal ileitis, operation type, staged versus unstaged IPAA, colonic specimen histology, early postoperative complications defined as less than 31 days postsurgery, late postoperative complications defined as 31 or more days postsurgery, and pouch fistulae. Crohn's disease as a definitive diagnosis and indeterminant colitis, a histologic diagnosis, also were tested for association with the above variables and outcome groups. Results: One hundred and fifty-one pediatric patients underwent IPAA utilizing mucosectomy and hand-sewn S or J (n = 44) and stapled J or S-W anastomosis (n = 107) with 0% mortality rate and outcome as follows: group A, n = 54; group B, n = 73; group C, n = 11; group D, n = 13. Variables strongly associated with poor outcome, groups C and D, were duration of symptoms (P =.03), perianal disease (P =.03), late complications (P <.001), pouch fistulae (P <.001), and Crohn's disease (P <.0001). Furthermore, Crohn's disease was associated strongly with female gender (P =.01), perianal disease (P =.004), early (P =.006) and late (P <.001) complications, and pouch fistula (P <.001). The findings of indeterminant colitis, terminal ileitis, and early postoperative complications did not show significant differences between the 4 outcome groups. Conclusions: Crohn's disease appears to be an important determinant of postoperative complications, chronic pouchitis, and pouch failure and occurred in 15% of the authors' patients after IPAA. Indeterminant colitis and the intraoperative findings of terminal ileitis are not associated with Crohn's disease or adverse outcome after IPAA in pediatric patients. Operation type and stage do not alter the clinical course after IPAA in pediatric patients. J Pediatr Surg 38:78-82. Copyright 2003, Elsevier Science (USA). All rights reserved.

Impact of Prenatal Diagnosis on the Morbidity Associated With Ureterocele Management

We postulated that prenatal detection of ureteroceles has a positive impact on the natural history and clinical outcome of ureteroceles in duplex system. Between 1992 and 2000, 95 children underwent surgery for a ureterocele in a duplex system. We evaluated the impact of prenatal diagnosis in 40 cases versus postnatal diagnosis in 55 on morbidity, as measured by postoperative urinary tract infection and secondary procedures, while controlling for ureterocele type and the initial surgical approach. Mean followup in the 2 groups was 3.9 years. Preoperatively the reflux rate was 51% in the prenatal and 66% in the postnatal groups. Preoperatively urinary tract infections were less common in the prenatal group (12% versus 84%). Mean age at initial intervention in prenatally and postnatally diagnosed patients was 6 and 31 months, respectively. Postoperatively the urinary tract infection rate was double in postnatally diagnosed patients. Overall postoperatively reflux was similar in the 2 groups and grades III to V reflux with urinary tract infection accounted for 14 of the 21 secondary bladder procedures (67%). After initial endoscopic decompression none of the prenatally diagnosed patients with intravesical ureteroceles required reoperation, whereas 6 (50%) with extravesical ureteroceles required reoperation. All 10 prenatally diagnosed extravesical ureteroceles treated with partial nephrectomy were cured. Overall the secondary procedure rate in the postnatal group was higher than in the prenatal group (46% versus 20%, p = 0.02). Also, there was a difference in the reoperation rate in the endoscopic decompression group according to mode of presentation (p = 0.03) and a difference when comparing endoscopic treatment with partial nephrectomy in all patients (p = 0.02). Prenatal diagnosis decreases morbidity and potential adverse outcomes related to infection. Overall prenatal diagnosis is associated with a decreased rate of secondary procedures independent of the type of ureterocele. Prenatally diagnosed intravesical ureteroceles may be cured by endoscopic incision alone but for extravesical ureteroceles partial nephrectomy appears to be more definitive.

Variations in morbidity after radical prostatectomy.

Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after radical prostatectomy for prostate cancer. We used the Surveillance, Epidemiology, and End Results-Medicare linked data base to evaluate health-related outcomes after radical prostatectomy. The rates of postoperative complications, late urinary complications (strictures or fistulas 31 to 365 days after the procedure), and long-term incontinence (more than 1 year after the procedure) were inferred from the Medicare claims records of 11,522 patients who underwent prostatectomy between 1992 and 1996. These rates were analyzed in relation to hospital volume and surgeon volume (the number of procedures performed at individual hospitals and by individual surgeons, respectively). Neither hospital volume nor surgeon volume was significantly associated with surgery-related death. Significant trends in the relation between volume and outcome were observed with respect to postoperative complications and late urinary complications. Postoperative morbidity was lower in very-high-volume hospitals than in low-volume hospitals (27 percent vs. 32 percent, P=0.03) and was also lower when the prostatectomy was performed by very-high-volume surgeons than when it was performed by low-volume surgeons (26 percent vs. 32 percent, P<0.001). The rates of late urinary complications followed a similar pattern. Results for long-term preservation of continence were less clear-cut. In a detailed analysis of the 159 surgeons who had a high or very high volume of procedures, wide surgeon-to-surgeon variations in these clinical outcomes were observed, and they were much greater than would be predicted on the basis of chance or observed variations in the case mix. In men undergoing prostatectomy, the rates of postoperative and late urinary complications are significantly reduced if the procedure is performed in a high-volume hospital and by a surgeon who performs a high number of such procedures.

Japanese experience with radical prostatectomy.

Laparoscopic prostatectomy has become an established treatment option for localized prostate cancer in France, where open prostatectomy is now the gold standard. The main purposes of treatment for prostate cancer are cancer control and preservation of urinary continence and sexual function. To become a standard treatment option for organ-confined prostate cancer, laparoscopic prostatectomy has to show equal or better clinical outcome in these areas than its open counterpart. Many institutes in other countries are now trying to perform this surgery. There are, however, some negative reports, mainly because of the difficulty of the procedure. In Japan, more than 250 patients have undergone this surgery. It seems that satisfactory results in terms of positive surgical margin rate, bleeding volume, recovery from surgery, and urinary continence have been obtained so far. We need longer follow-up to assess recurrence rate and sexual function. The main obstacles for this surgery are the long operative time and the difficulty of the procedures. Although it will take time until laparoscopic prostatectomy becomes an approved treatment modality, we are gradually conquering these problems. In this paper, we review the current situation facing laparoscopic prostatectomy in Japan.

RADICAL PROSTATECTOMY IN A COMMUNITY PRACTICE

We report the experience of a community based urologist with anatomical retropubic radical prostatectomy. We compared outcome data with that reported experience at several well-known academic institutions. Between May 1986 and December 2000, 382 consecutive patients underwent anatomical radical retropubic prostatectomy performed by a single community based urologist. Charts were reviewed to determine the positive margin rate, urinary continence, potency, hospitalization and the prostate specific antigen (PSA) recurrence rate. The positive margin rate was 9% overall but in the last 5 years it was 7% compared with 7% to 40% in previous studies at academic institutions. The urinary continence rate was 90% overall and 93% in the last 5 years when excluding men older than 70 years old, compared with 85% to 94% in the academic urological literature. The potency rate after the bilateral nerve sparing technique was 79% compared with 54% to 86% in academic series. Average hospitalization in the last 5 years was 1.5 days. Overall PSA recurrence rate and the rate of PSA recurrence as a function of preoperative PSA, postoperative stage and grade were similar to those at academic institutions. Anatomical radical prostatectomy can be performed at nonacademic institutions with results comparable to those at academic institutions.

INEFFICIENT URETHRAL MILKING SECONDARY TO URETHRAL DYSFUNCTION AS AN ADDITIONAL RISK FACTOR FOR INCONTINENCE AFTER RADICAL PROSTATECTOMY

Continence after radical prostatectomy is thought to depend completely on the striated urethral sphincter. However, some patients complain only of occasional post-void dribbling. Therefore, we determined whether urethral dysfunction may be another cause of incontinence. The sensory threshold of electric stimulation was measured by double ring electrodes in the membranous urethra and 2.5 cm. distal in 29 men before and in 29 after radical retropubic prostatectomy. In addition, voiding cystourethrography was performed in 66 patients before and in 49 after surgery to determine complete post-void urethral emptying or milking. The mean sensory threshold of the membranous urethra was 15 +/- 3 mA. preoperatively versus 38 +/- 17 postoperatively (p <0.0001). The sensory threshold 2.5 cm. further distal was 12 +/- 5 mA. before and 10 +/- 4 after radical prostatectomy, which was not statistically significant. Postoperatively in completely continent patients and in those with dribbling the mean threshold was 32 +/- 12 and 43 +/- 18 mA. in the membranous urethra (p = 0.09), and 11 +/- 4 and 9 +/- 4 mA. in the bulbar urethra, respectively, which was not statistically significant. Of the 66 patients 36 (55%) showed post-void urethral milking before surgery but only 8 of 49 (16%) showed it postoperatively (chi-square test p <0.0001), including 7 who were completely continent and 1 who complained of occasional post-void dribbling. After radical prostatectomy sensitivity of the membranous but not of the bulbar urethra is affected, correlating with postoperative continence. In addition, post-void dribbling seems to be associated with the loss of urethral milking. We conclude that preserving urethral function is another important continence factor after radical prostatectomy.

Contemporary Surgical Techniques for Continent Urinary Diversion: Continence and Potency Preservation

Radical cystectomy with urinary diversion remains the primary form of therapy for appropriate candidates with high-grade, invasive bladder cancer. Several important advances have been made in an attempt to improve the clinical and functional outcomes of patients following bladder removal. These technical advances primarily have involved improvements in lower urinary tract reconstruction, as well as enhancement of the continence mechanism and preservation of potency. Quality-of-life issues are clearly important factors and are becoming more important, as patients are living longer with higher expectations; however, must not override the need to provide sound oncologic surgical extirpation. Orthotopic lower urinary tract reconstruction to the intact native urethra has revolutionized urinary diversion following cystectomy in male7 and femaleI9 patients. The ultimate goal of lower urinary tract reconstruction has evolved from merely providing a means to divert the urine and protecting the upper urinary tract from significant damage over the patient’s lifespan. Current advantages of orthotopic diversion should allow patients to store urine and void in a nearly normal physiologic manner through the intact urethra. In an effort to provide patients a more normal lifestyle with an improved self-image, preservation of sexual function and potency has also gained increasing importance in the management of patients requiring bladder removal.

Laparoscopic Radical Prostatectomy

Objectives: In an effort to reduce the morbidity associated to radical prostatectomy, we implemented laparoscopic surgery to this advanced ablative and reconstructive procedure. In our study, we describe our operative technique and assess our results in terms of oncologic cure, continence and potency. Methods: 200 patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy. 66 of these patients were either referred, or operated during surgical demonstrations. Thus, complete evaluation is based on a homogenous personal series of 134 patients and was performed by an independent clinical analyst. There were 91 T1 and 43 T2. We did not perform pelvic lymph node excision in 78 patients whose PSA was less than 10 ng/ml and the Gleason score of endorectal biopsies was below 7. The surgical procedure recapitulated the steps of traditional retropubic prostatectomy with one basic difference however: the first step of the technique consisted in a rectoprostatic cleavage, which was done transperitoneally. Except for the first 10 patients, the vesicourethral reconstruction was performed either with two hemi–circumferential or a single circumferential running suture. Results: All interventions were performed as planned, no conversions were necessary, and only 4 patients required blood transfusion. Operating time decreased with growing experience; after the first 20 patients the usual operating time was 3.5 h without and 4 h with lymphadenectomy. The surgical complication rate was 22.5% in the first 40 patients, and 3.2% in the remaining 94 patients. Except for the first 10 patients, the mean hospital stay was 6.1 days and bladder catheterization 4.8 days. Median catheterization time was 4 days. Histological study of the specimen showed pT2 disease in 101 patients and pT3 in 33 patients, the rate of positive margins was 16.8 and 48.8%, respectively. At 1 year, overall erection rate (with or without sexual intercourse) was 56%, the rate of patients without pad was 86.2% during the day and 100% during the night. Conclusions: Laparoscopic environment seems to comply with the oncologic goals of radical prostatectomy. Improved intraoperative visualization and magnification may provide benefits for the preservation of continence and potency by allowing a more precise dissection and vesicourethral reconstruction. Despite longer operative times and the steep learning curve this new technique is currently proliferating due to expectations of decreased postoperative morbidity and better quality of life.

Dysplasia Risk in Ileal Pouches after Reconstructive Surgery for Ulcerative Colitis

An important goal for the surgeon after performing proctocolectomy for ulcerative colitis is the preservation of continence, with the formation of a pelvic ileal pouch. In most patients who have required this procedure, clinical results have been satisfactory. In recent years, it has become appreciated that many patients with a satisfactory surgical result are still at risk for pouchitis and pouch neoplasia. This is not surprising because creation of a pouch leads to an environment characterized by stasis, with associated mucosal adaptive changes. In some patients, the ileal mucosa in the pouch may assume the appearance of colonic mucosa.

PROSPECTIVE ASSESSMENT OF PATIENT REPORTED URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY

PROSPECTIVE ASSESSMENT OF PATIENT REPORTED URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY

Endoscopic reconstruction of vesicourethral obliteration after retropubic prostatectomy

Complete vesicourethral obliteration after retropubic prostatectomy presents a challenging reconstructive problem. We report on 4 men with complete vesicourethral obliteration after radical (n = 3) or simple (n = 1) retropubic prostatectomy in which an antegrade-retrograde endoscopic approach was used to obtain durable urethral patency, with preservation of urinary continence and potency.

Permanent stomata

The implantation of preternatural orifices is a procedure frequently performed by the visceral surgeon in spite of the advances of modern surgery concerning preservation of continence. In order to avoid unnecessary complications, certain strict principles of operating technique must be followed. The cumulative rate of complications is found to be at least 50%. Especially prolapse, peristomal hernias and stenoses are of profound surgical relevance. A well-implanted and adequately cared for stoma will have a positive influence on a patient's quality of life.

Long-term outcome of continence function after ileo-anal pouch reconstruction

An important aim of proctocolectomy with ileal pouch-anal anastomosis (IPAA) is to maintain anal continence. Anal sphincter disruption during IPAA is felt to play an important role in loss of continence, which is described in up to 30% of the treated patients in the early postoperative period. Although sphincter function recovers gradually after surgery, some patients stay incontinent. In our investigation of possible parameters involved in preservation of continence after this operative procedure, we focused on changes in anal manometry. We compared these findings with the functional results obtained by questioning the patients and physical examination. Anal manometry was performed with a low-compliance hydraulic perfusion system. All patients underwent a J-pouch procedure with a short rectal cuff for ileoanal reconstruction. We examined 25 patients, 13 underwent operation for the treatment of ulcerative colitis, 12 because of adenomatous polyposis. In the colitis and polyposis group, 28% of the patients reported events of soiling. Three patients (12%) were incontinent. The remaining 15 patients were completely continent. The median time after operation was 58 months, ranging from 12 to 96 months. Comparing the results of anal manometry with standard values of ten age- and gender-matched healthy volunteers, it was found that there was a significant increase in the threshold of balloon awareness and urge to defecate. These sensations were sometimes elicited by pouch contractions. Median pouch-compliance was also clearly elevated in comparison to rectal compliance (P < 0.005). Inhibitory reflexes during balloon inflation could not be evoked in any of the patients. Comparing continent with incontinent patients there were significant differences in balloon awareness, urge to defecate, and stool frequency (P < 0.01, P < 0.01 and P < 0.001, respectively). But in contrast to other publications, we could not find significant differences in anal sphincter length, resting and squeezing, anal canal pressure. Pouch compliance was lowered in incontinent patients and negatively correlated with stool frequency (P < 0.001, r = -0.82). In conclusion, our study indicates that anal sphincter resting pressure alone is not a crucial factor in continence preservation in the long-term after total proctocolectomy and IPAA. Poor pouch-compliance and concomitant higher stool frequencies seem to be related to incontinence in this patient group.

Spontaneous bladder perforation in paraplegia as a late complication of augmentation enterocystoplasty: Case report

The management of spinal cord injured (SCI) patients with small capacity, noncompliant bladders has focused on the preservation of renal function and social continence. When conservative management is unsuccessful, surgical intervention may prove beneficial. Augmentation enterocystoplasty is a reliable method of achieving increased bladder capacity while decreasing intravesical filling pressure. Spontaneous bladder rupture is a rare complication of augmentation enterocystoplasty. Because the urine is often colonized with bacteria, bladder rupture may result in chemical and bacterial peritonitis, which is associated with a 25% mortality rate. SCI patients may not present with the classic signs of an acute abdomen. Early diagnosis is critical so that aggressive management may be instituted. The case of late spontaneous perforation of an augmentation enterocystoplasty in a 33-year-old man with T7 complete paraplegia is presented, and the literature discussing the etiology, diagnosis, management, and prevention of augmented bladder perforation is reviewed.

Radical prostatectomy with preservation of urinary continence.

In an effort to improve postoperative urinary continence after radical retropubic prostatectomy, a new operation to preserve the bladder neck and a significant portion of the prostatic urethra has been developed. The prostatic urethra is dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis. A total of 24 patients who underwent the new continence sparing radical retropubic prostatectomy was compared retrospectively to 80 who previously underwent a nerve sparing procedure. Total continence was noted immediately in 11 patients, within 9 days in 15 and within 7 weeks in 21 of 24 who underwent the new operation, compared to 1, 5 and 33, respectively, of 80 who underwent the standard operation. Microscopic positive margins were noted in 2 of 24 patients with the new continence sparing operation. Early results of cancer control were good. Early followup of this new technique of radical retropubic prostatectomy suggest that preservation of the continence mechanism at the level of the bladder neck and prostatic urethra results in significantly improved postoperative urinary continence without adversely affecting cancer control.

Preservation of Continence After Posterior Sagittal Surgery

Purpose An animal study was performed to evaluate the effect of posterior sagittal pararectal mobilization on anorectal sphincter function. Materials and Methods We initially divided 11 juvenile pigs into 3 groups: group 1–anesthesia alone (3), group 2–posterior sagittal incision alone (4) and group 3–posterior sagittal incision with unilateral pararectal dissection (4). Two animals in group 1 subsequently underwent posterior sagittal incision with circumferential pararectal dissection (group 4). The anal canal was preserved intact in all animals. Anorectal sphincter manometry was performed preoperatively, and 2, 4, 8 and 12 weeks postoperatively. Electromyography was performed 12 weeks postoperatively. Anorectal sphincter muscle complexes were harvested for histological examination. Results All animals had postoperative bowel continence. Postoperatively manometry revealed no difference from preoperative measurements in all study groups (p = 0.90). Electromyography and histological examination of the anorectal sphincters were normal in all but 2 animals. Denervation injury and histological atrophy were detected after repair of inadvertent enterotomy in 1 animal following unilateral pararectal dissection, and polyphasic motor unit potentials implying reinnervation were detected in another after circumferential pararectal mobilization. Conclusions These results indicate that posterior sagittal incision and unilateral pararectal mobilization cause no permanent injury to the anorectal sphincter. However, circumferential pararectal dissection or repair of a rectal injury may cause measurable changes in sphincter function.