Reevaluation of vest technique of vesicourethral reconstruction in radical retropubic prostatectomy

Improving early urinary continence recovery after radical prostatectomy by applying a sutureless technique for maximal preservation of the intrapelvic urethra: A 17-year single-surgeon experience

BACKGROUND

There is a growing concern about postsurgical outcomes of radical prostatectomy, especially in the younger population and patients with earlier tumor stages. Here, we present our 17 years' experience of sutureless vesico-urethral alignment after radical prostatectomy with a focus on postoperative functional urinary outcomes.

METHODS

Data of 784 patients who underwent radical prostatectomy during 2001-2017 were evaluated retrospectively. Before surgery, patients' demographic information, pathologic stage, margin of surgery, prostate-specific antigen, and Gleason score were obtained. Then, serum prostate-specific antigen level, urinary continence, potency, and other functional outcomes of surgery were recorded after each postoperative visit.

RESULTS

The mean age (±standard deviation) of patients was 61.3 (±6.30) years. The median (IQ_25-75) duration of follow-up was 30 (12-72) months. Full continence was achieved in 90% and 95.9% of patients at 3 and 6 months post surgery and 96.4% of the patients were continent at the last follow-up visit. Bladder neck stricture occurred in 167 patients (21.3%). During the follow-up period, none of the patients complained of total incontinence and at the last visit, 36.6% of patients reported potency. The frequency of grade 2 continence was significantly higher in patients with high-stage tumors (T3/T4), high Gleason score (⩾8), high preoperative serum prostate-specific antigen (>20 ng/dL), and positive margin of surgery. Potency had a significant relationship with age, stage of the disease, and preoperative prostate-specific antigen.

CONCLUSION

Maximal sparing of intrapelvic urethral length through sutureless vesico-urethral alignment technique results in excellent early urinary continence recovery after radical prostatectomy. A more advanced tumor stage (T1/T2), a higher Gleason score, high preoperative prostate-specific antigen, as well as positive surgical margin are risk factors of postoperative incontinence in patients who undergo radical prostatectomy.

Outcomes with an alternative anastomotic technique after radical retropubic prostatectomy: 10-year experience

OBJECTIVES

To review 10-year outcomes of an alternative vesicourethral anastomotic technique performed after radical retropubic prostatectomy (RRP).

METHODS

With institutional review board approval, 307 consecutive RRPs performed by one surgeon (mean patient age, 63.5 years; range, 35 to 77 years) from November 1994 to December 2004 with an alternative anastomosis were reviewed. Cox proportional hazard models with forward selection were used to investigate associations with outcomes and operative parameters.

RESULTS

Mean estimated blood loss (EBL) was 550 mL. Sixty-three patients (20.5%) required blood transfusion. Mean anastomotic time ranged from 8 to 22 minutes (median, 11 minutes). Nine patients (2.9%) required surgical drain for more than 2 days. A total of 246 patients were available for at least 1-year continence follow-up (mean, 51 months). Of these, 160 patients (65.0%) never leaked or required a pad at point of last follow-up; 25 patients (10.2%) required 1 non-insurance pad or more per day. Only 3 patients (1.2%) have had incontinence interventions (one artificial sphincter and two collagen injections). Operative parameters statistically associated with wearing 1 pad per day or more were EBL (P = 0.035) and time to continence (P <0.001). Forty-three patients (17.5%) required stricture dilation, with a mean time to intervention of 6 months (range, 1 to 33 months). No patient required incision of bladder neck contracture. The only statistically associated factors with stricture formation were increased age and increased EBL.

CONCLUSIONS

The alternative anastomotic technique is efficient and provides proper urethral alignment with a minimal rate of prolonged urinary extravasation. Long-term urinary continence is excellent, and stricture rates are acceptable compared with other anastomotic techniques.

Bladder neck strictures after radical retropubic prostatectomy: still an unsolved problem

OBJECTIVE

To investigate the factors responsible for anastomotic strictures of the bladder neck after radical retropubic prostatectomy.

PATIENTS AND METHODS

Of 239 consecutive patients who underwent radical retropubic prostatectomy between 1987 and 1996, 36 (15%) developed anastomotic strictures after surgery. The influence of tumour stage, previous prostatic surgery, urinary extravasation and postoperative bacteriuria were assessed.

RESULTS

In 21 patients (58%), the bladder neck stricture occurred within 3 months of surgery, in 11 (30%) at 4-12 months after surgery and in four (11%) more than 12 months after surgery; three of these also had local recurrence. Advanced tumour stage and positive margins did not correlate with a higher stricture rate, nor was there a significant difference in stricture rates with three or four anastomotic sutures. However, extravasation at the time of catheter removal (16 of 36 patients (44%) with vs 34 of 183 patients without (19%) stricture, bacteriuria of > 10(6) c.f.u./mL at the time of catheter removal (stricture group 21 of 36 patients (58%) stricture with vs 71 of 203 (35%) without) and previous prostatic surgery (TURP or open surgery, stricture in 28% of those previously operated vs 13% with no previous surgery) were significant risk factors.

CONCLUSION

There are three risk factors for anastomotic stricture after radical prostatectomy: previous operations on the prostate, extravasation and asymptomatic bacteriuria.

Anastomotic strictures following radical prostatectomy: risk factors and management

Stricture of the anastomosis between the bladder neck and membranous urethra after radical prostatectomy can cause significant voiding dysfunction. Of 156 patients undergoing radical prostatectomy for localized prostatic carcinoma 18 had anastomotic stricture for an over-all incidence of 11.5%. The risk factors for anastomotic stricture and the treatment outcome in these patients were analyzed. Excessive intraoperative blood loss, extravasation of urine at the anastomotic site and a prior transurethral prostatic operation significantly contributed to the development of stricture. More than half of the patients did not respond to simple dilation alone. Cold knife incision of the stricture by itself was effective in only 62% of the patients. The remaining patients required periodic dilation to maintain an adequate urine flow. Incision of the stricture with electrocautery resulted in urinary incontinence in all patients.

Comparison of techniques for vesicourethral anastomosis: simple direct versus modified Vest traction sutures

Radical retropubic prostatectomy has become a mainstay surgical procedure in the treatment of cancer of the prostate. There has been controversy, however, regarding the most appropriate method of vesicourethral reconstruction. We examined the records of 692 consecutive patients who underwent a radical retropubic prostatectomy from 1978 through 1984 at the Mayo Clinic. Of these, 416 patients underwent a modified Vest procedure, and in 276 patients a direct simple anastomosis was fashioned. In comparing these two methods, our review showed no substantial difference in complications, including the rate of urinary incontinence.

Technical nuances and surgical results of radical retropubic prostatectomy in 150 patients

We reviewed the surgical results of radical retropubic prostatectomy in 150 patients, of whom 37 had undergone transurethral resection of the prostate. The number and type of complications in our series compared favorably to those reported in other series: only 15 of our last 100 patients had complications, most of which were minor. Incontinence occurred in 2 of our last 100 patients and there were no symptomatic urethral strictures. Complications were similar between patients who had and those who had not undergone transurethral resection of the prostate. Several technical considerations that contribute to these results are discussed, especially the use of perineal pressure to facilitate hemostasis and the technique of vesicourethral anastomosis. Radical retropubic prostatectomy is a relatively well tolerated procedure with low morbidity.

Perioperative and postoperative complications from bilateral pelvic lymphadenectomy and radical retropubic prostatectomy

The complications experienced by 692 consecutive patients who underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy from 1978 through 1984 were analyzed. Four patients (0.6 per cent) died in the perioperative or early postoperative period. Pulmonary embolus developed in 19 patients (2.7 per cent) and severe to total urinary incontinence occurred in 34 (5 per cent). Our large series suggests that radical retropubic prostatectomy with staging bilateral pelvic lymphadenectomy can be performed in a safe manner with minimal postoperative morbidity.

Risk of urinary incontinence following radical prostatectomy

Of 143 prostatic cancer patients treated with radical prostatectomy 38 had undergone transurethral resection of the prostate before the prostatectomy. After radical prostatectomy 5 per cent of the patients who did not have a resection and 8.1 per cent of those who did were severely incontinent. This difference is not statistically significant.

Radical prostatectomy incontinence and the AS791 artificial urinary sphincter

The AS791 prosthetic sphincter was implanted in 66 patients with urinary incontinence after radical prostatectomy. Of these patients 49 (74 per cent) were continent 3 months to 4 1/2 years after implantation. Excluding the 22 patients who had had previous pelvic radiation therapy 41 (93 per cent) were continent. Mechanical problems have been few, establishing the reliability of this unique sphincter mechanism.

Bilateral pelvic lymphadenectomy and radical retropubic prostatectomy for adenocarcinoma of prostate with regional lymph node involvement

Ninety-nine patients with adenocarcinoma of the prostate and regional lymph node involvement underwent pelvic lymphadenectomy. Therapeutic results were analyzed in 70 patients who subsequently underwent radical retropubic prostatectomy with or without concomitant therapy (usually hormonal) and in 29 patients who received radiation or hormonal treatment only but without prostatectomy. Follow-up ranged from one to fourteen and one-half years. The over-all projected survival rates (Kaplan-Meier) at five and ten years (88 per cent and 71 per cent, respectively) in the prostatectomy series were comparable to those of an age-matched control group. Concomitant bilateral orchiectomy provided a high projected (76 per cent at ten years) nonprogression rate. Over-all survival rates in the nonprostatectomy series were poor. Only the number of nodes involved was associated with survival and time to disease progression. Patient age, tumor bulk, seminal vesicle involvement, and tumor grade (Mayo and Gleason scores) had no definite relationship to survival. Pelvic lymphadenectomy and radical retropubic prostatectomy for prostatic adenocarcinoma may be therapeutic in some patients with limited (less than or equal to two positive nodes) nodal disease.

Radical retropubic prostatectomy and pelvic lymphadenectomy for high-stage cancer of the prostate

A series of 340 patients with adenocarcinoma of the prostate treated by bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was reviewed to determine the factors that influence survival and time to progression of disease. Follow-up ranged from 1-12 1/2 years. Factors evaluated were grade, stage, and bulk of tumor; influence of seminal vesical involvement and number of pelvic nodes involved; age of patient; and year of surgery. Tumor grade was the only factor related significantly to patient survival. However, grade, stage, and bulk of tumor were all significantly associated with interval between surgery and disease progression. Furthermore, in Stage C disease, seminal vesical involvement (C+) was an adverse factor for disease progression, particularly among patients with low-grade tumor. This is in contrast to the finding that, among patients with Stage D1 disease, those with seminal vesical involvement experienced more favorable survival times and times to progression of disease when compared with patients without seminal vesical involvement. Overall, patient survival compared favorably with an age-matched control group for all stages, A through D1. Patients with few pelvic nodes involved had a survival experience nearly comparable with that of an age-matched control group. This suggests that pelvic lymphadenectomy might have a therapeutic value and that patients with pelvic nodal disease only, without evidence for metastatic disease, should not be denied radical surgery. The influence of concomitant hormonal manipulation or radiotherapy (or both) on patient survival and disease progression is not conclusively answered in this report.

Radical retropubic prostatectomy after transurethral prostatic resection

The 36 patients who underwent radical retropubic prostatectomy for adenocarcinoma after transurethral resection of the prostate were reviewed to evaluate the difficulty of the radical operation, the rate of morbidity and the survival. In 24 patients (67 per cent) the dissection proved to be routine; 18 patients (50 per cent) had perfect urinary control, whereas 4 were totally incontinent. There appears to be no untoward effect on survival, since all patients remain alive, 22 per cent having had followup for 5 years or more.