Korean J Urol.  2009 Oct;50(10):935-941.

Improving Urinary Continence after Radical Prostatectomy: Review of Surgical Modifications

• Hwang JJ
• Kim BY
• Uchio EM

Abstract

PURPOSE
Urinary incontinence remains the most feared long-term complication following radical prostatectomy with potentially devastating psychosocial consequences. In recent years, several surgical techniques have been introduced during radical prostatectomy, both open and laparoscopic/robotic, in the hope of improving urinary continence outcomes. Herein, we review the various surgical modifications that have shown a benefit in minimizing post-prostatectomy urinary incontinence (PPI).
MATERIALS AND METHODS
A comprehensive review of the current urologic literature was conducted to identify surgical techniques that have been correlated with improved continence following radical prostatectomy.
RESULTS
Over the years, several surgical modifications have been incorporated into radical prostatectomy in order to minimize the risk of prolonged PPI. Most techniques emphasize the importance of restoring the "normal" pelvic anatomy after removal of the prostate gland. In addition, certain patient factors such as preoperative posterior urethral length and patient age appear to have an independent prognostic value in predicting PPI. Postoperatively, bladder neck contracture remains the most consistent complication leading to PPI.
CONCLUSIONS
The present findings suggest that the risk of PPI can be minimized, or even eliminated, through careful patient selection and surgical modifications during radical prostatectomy.

Keyword

Prostatectomy; Urinary incontinence; Prostatic neoplasms

MeSH Terms

Contracture
Humans
Neck
Patient Selection
Prostate
Prostatectomy
Prostatic Neoplasms
Urinary Bladder
Urinary Incontinence

Reference

1. Kielb S, Dunn RL, Rashid MG, Murray S, Sanda MG, Montie JE, et al. Assessment of early continence recovery after radical prostatectomy: patient reported symptoms and impairment. J Urol. 2001. 166:958–961.

2. Stanford JL, Feng Z, Hamilton AS, Gilliland FD, Stephenson RA, Eley JW, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000. 283:354–360.

3. Fowler FJ Jr, Barry MJ, Lu-Yao G, Roman A, Wasson J, Wennberg JE. Patient-reported complications and follow-up treatment after radical prostatectomy. The National Medicare Experience: 1988-1990 (updatede 1993). Urology. 1993. 42:622–629.

4. Tewari AK, Bigelow K, Rao S, Takenaka A, El-Tabi N, Te A, et al. Anatomic restoration technique of continence mechanism and preservation of puboprostatic collar: a novel modification to achieve early urinary continence in men undergoing robotic prostatectomy. Urology. 2007. 69:726–731.

5. Fowler FJ Jr, Barry MJ, Lu-Yao G, Wasson J, Roman A, Wennberg J. Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey. Urology. 1995. 45:1007–1013.

6. Lepor H, Kaci L, Xue X. Continence following radical retropubic prostatectomy using self-reporting instruments. J Urol. 2004. 171:1212–1215.

7. Wei JT, Dunn RL, Marcovich R, Montie JE, Sanda MG. Prospective assessment of patient reported urinary continence after radical prostatectomy. J Urol. 2000. 164:744–748.

8. Litwin MS, Lubeck DP, Henning JM, Carroll PR. Differences in urologist and patient assessments of health related quality of life in men with prostate cancer: results of the CaPSURE database. J Urol. 1998. 159:1988–1992.

9. Lepor H, Kaci L. The impact of open radical retropubic prostatectomy on continence and lower urinary tract symptoms: a prospective assessment using validated self-administered outcome instruments. J Urol. 2004. 171:1216–1219.

10. Katz G, Rodriguez R. Changes in continence and health-related quality of life after curative treatment and watchful waiting of prostate cancer. Urology. 2007. 69:1157–1160.

11. Jonler M, Madsen FA, Rhodes PR, Sall M, Messing EM, Bruskewitz RC. A prospective study of quantification of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy. Urology. 1996. 48:433–440.

12. Lee SE, Byun SS, Lee HJ, Song SH, Chang IH, Kim YJ, et al. Impact of variations in prostatic apex shape on early recovery of urinary continence after radical retropubic prostatectomy. Urology. 2006. 68:137–141.

13. Song C, Doo CK, Hong JH, Choo MS, Kim CS, Ahn H. Relationship between the integrity of the pelvic floor muscles and early recovery of continence after radical prostatectomy. J Urol. 2007. 178:208–211.

14. Nguyen L, Jhaveri J, Tewari A. Surgical technique to overcome anatomical shortcoming: balancing post-prostatectomy continence outcomes of urethral sphincter lengths on preoperative magnetic resonance imaging. J Urol. 2008. 179:1907–1911.

15. Coakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol. 2002. 168:1032–1035.

16. Sacco E, Prayer-Galetti T, Pinto F, Fracalanza S, Betto G, Pagano F, et al. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU Int. 2006. 97:1234–1241.

17. Kaye KW, Creed KE, Wilson GJ, D'Antuono M, Dawkins HJ. Urinary continence after radical retropubic prostatectomy. Analysis and synthesis of contributing factors: a unified concept. Br J Urol. 1997. 80:444–501.

18. Steiner MS. Continence-preserving anatomic radical retropubic prostatectomy: the "No-Touch" technique. Curr Urol Rep. 2000. 1:20–27.

19. Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol. 1998. 160:2418–2424.

20. Steiner MS. The puboprostatic ligament and the male urethral suspensory mechanism: an anatomic study. Urology. 1994. 44:530–534.

21. Lowe BA. Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study. J Urol. 1997. 158:2137–2141.

22. Campenni MA, Harmon JD, Ginsberg PC, Harkaway RC. Improved continence after radical retropubic prostatectomy using two pubo-urethral suspension stitches. Urol Int. 2002. 68:109–112.

23. Noguchi M, Kakuma T, Suekane S, Nakashima O, Mohamed ER, Matsuoka K. A randomized clinical trial of suspension technique for improving early recovery of urinary continence after radical retropubic prostatectomy. BJU Int. 2008. 102:958–963.

24. Noguchi M, Shimada A, Nakashima O, Kojiro M, Matsuoka K. Urodynamic evaluation of a suspension technique for rapid recovery of continence after radical retropubic prostatectomy. Int J Urol. 2006. 13:373–378.

25. Patel VR, Coelho RF, Palmer KJ, Rocco B. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol. 2009. 56:472–478.

26. Elbadawi A, Schenk EA. A new theory of the innervation of bladder musculature. 2. Innervation of the vesicourethralction and external urethral sphincter. J Urol. 1974. 111:613–615.

27. Narayan P, Konety B, Aslam K, Aboseif S, Blumenfeld W, Tanagho E. Neuroanatomy of the external urethral sphincter: implications for urinary continence preservation during radical prostate surgery. J Urol. 1995. 153:337–341.

28. Karam I, Droupy S, Abd-Alsamad I, Korbage A, Uhl JF, Benoit G, et al. The precise location and nature of the nerves to the male human urethra: histological and immunohistochemical studies with three-dimensional reconstruction. Eur Urol. 2005. 48:858–864.

29. Menon M, Shrivastava A, Kaul S, Badani KK, Fumo M, Bhandari M, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol. 2007. 51:648–657.

30. van der Poel HG, de Blok W, Joshi N, van Muilekom E. Preservation of lateral prostatic fascia is associated with urine continence after robotic-assisted prostatectomy. Eur Urol. 2009. 55:892–900.

31. Oelrich TM. The urethral sphincter muscle in the male. Am J Anat. 1980. 158:229–246.

32. Myers RP. Male urethral sphincteric anatomy and radical prostatectomy. Urol Clin North Am. 1991. 18:211–227.

33. Soloway MS, Neulander E. Bladder-neck preservation during radical retropubic prostatectomy. Semin Urol Oncol. 2000. 18:51–56.

34. Deliveliotis C, Protogerou V, Alargof E, Varkarakis J. Radical prostatectomy: bladder neck preservation and puboprostatic ligament sparing-effects on continence and positivegins. Urology. 2002. 60:855–858.

35. Srougi M, Nesrallah LJ, Kauffmann JR, Nesrallah A, Leite KR. Urinary continence and pathological outcome after bladder neck preservation during radical retropubic prostatectomy: a randomized prospective trial. J Urol. 2001. 165:815–818.

36. Walsh PC, Marschke PL. Intussusception of the reconstructed bladder neck leads to earlier continence after radical prostatectomy. Urology. 2002. 59:934–938.

37. Woodside JR, Borden TA. Pubovaginal sling procedure for the management of urinary incontinence in a myelodysplastic girl. J Urol. 1982. 127:744–746.

38. Elder JS. Periurethral and puboprostatic sling repair for incontinence in patients with myelodysplasia. J Urol. 1990. 144:434–437.

39. Jorion JL. Rectus fascial sling suspension of the vesicourethral anastomosis after radical prostatectomy. J Urol. 1997. 157:926–928.

40. Altinova S, Demirci DA, Ozdemir AT, Akbulut Z, Atmaca AF, Caglayan A, et al. Incorporation of anterior rectus fascial sling into radical retropubic prostatectomy improves postoperative continence. Urol Int. 2009. 83:19–21.

41. Westney OL, Scott S, Wood C, Eddings T, Johnson MM, Taylor JM, et al. Suburethral sling at the time of radical prostatectomy in patients at high risk of postoperative incontinence. BJU Int. 2006. 98:308–313.

42. Poore RE, McCullough DL, Jarow JP. Puboprostatic ligament sparing improves urinary continence after radical retropubic prostatectomy. Urology. 1998. 51:67–72.

43. Presti JC Jr, Schmidt RA, Narayan PA, Carroll PR, Tanagho EA. Pathophysiology of urinary incontinence after radical prostatectomy. J Urol. 1990. 143:975–978.

44. Kaye KW, Creed KE, Wilson GJ, D'Antuono M, Dawkins HJ. Urinary continence after radical retropubic prostatectomy. Analysis and synthesis of contributing factors: a unified concept. Br J Urol. 1997. 80:444–501.

45. van Randenborgh H, Paul R, Kubler H, Breul J, Hartung R. 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. 2004. 7:253–257.

46. Coakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol. 2002. 168:1032–1035.

47. Hammerer P, Huland H. Urodynamic evaluation of changes in urinary control after radical retropubic prostatectomy. J Urol. 1997. 157:233–236.

48. Rocco F, Carmignani L, Acquati P, Gadda F, Dell'Orto P, Rocco B, et al. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol. 2006. 175:2201–2206.

49. Rocco F, Carmignani L, Acquati P, Gadda F, Dell'Orto P, Rocco B, et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007. 52:376–383.

50. Menon M, Muhletaler F, Campos M, Peabody JO. Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol. 2008. 180:1018–1023.

51. Berry T, Tepera C, Staneck D, Barone B, Lance R, Fabrizio M, et al. Is there correlation of nerve-sparing status and return to baseline urinary function after robot-assisted laparoscopic radical prostatectomy? J Endourol. 2009. 23:489–493.

52. John H, Hauri D. Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence. Urology. 2000. 55:820–824.