From the Department of Surgery, Section of Urology, St. Louis University School of Medicine, St. Louis, Missouri

ABSTRACT - Six patients with a minimum of ten months’follow-up have undergone reconstruction of the urethra by anterior bladder tube after radical retropubic prostatectomy; 4 void well and are continent, 1 is incontinent, and 1 has severe stricture.

The number of patients suffering from urinary incontinence after radical retropubic prostatectomy is difficult to ascertain. In our experience with a limited number of cases over a large number of years about 40 per cent of the patients were either partially or totally incontinent after radical prostatectomy, regardless of whether continuity between the urethra and bladder was established by dire& suture or by traction only. The use of a tube of bladder muscle constructed from the anterior wall of the bladder to bridge the gap between the bladder and the urethra was first described by Flocks and Culp in 1953l but never gained popularity in this country. A number of European centers have, however, used this method for some time with apparent improved rates of continence. In 1972 Tanagho and Smith2a3 proposed the use of an anterior bladder tube as a method of correcting incontinence related to a number of urologic conditions and procedures, and we began to use this method for reconstructing the lower urinary tract at the time of radical retropubic prostatectomy. Our belief was that if the procedure was successful as a secondary method, results should be better when it was used primarily. Technique After radical retropubic prostatectomy a fullthickness flap of detrusor muscle from the anterior bladder wall is raised. The flap is made at


/ MAY 1976 / VOLUME


least 3 cm. long and wide enough to accommodate an 18 F Foley catheter. The flap is tapered distally to maintain adequate blood supply to the distal portion and is tubulated using two layers of 3-O chromic catgut sutures. After placement of a suprapubic catheter, the bladder below the muscle tube is closed transversely with care being taken to avoid the ureteral orifices. The bladder is mobilized sufficiently to allow a tension-free anastomosis between the distal end of the bladder and the remaining urethra. The anastomosis is carried out over an 18 F Foley catheter using four to six sutures of 3-O chromic catgut. The bladder tube is anchored to the symphysis pubis in the midline with one or two sutures to support it and prevent shortening of the tube by collapse into the pelvis. The Foley catheter and cystostomy tube are left in place for two weeks. If no urinary drainage persists at that time, the catheter is removed; and when a satisfactory voiding pattern has been established, the cystostomy tube is removed. Results and Complications Six patients with a minimum follow-up of ten months have undergone radical prostatectomy with bladder tube reconstruction of the urethra: 1 patient is incontinent, 1 (Case 3) has severe urethral stricture and is unable to void per urethra at the present time, and the remaining 4 patients are voiding well and are completely


Postoperative urethrograms.

continent. Two patients have required occasional dilation of a stricture, one requiring hospitalization for the initial dilation under anesthesia. One patient had a prolonged ileus and cecal distention ultimately requiring partial colectomy. The last patient operated on (Case 3) presented a technical problem in that even after removal of the symphysis pubis (which was not routinely carried out and was not used in any other case) the anastomosis between the bladder tube and the urethra was not satisfactory and urinary drainage persisted for four weeks. Severe stricture of the urethra developed and the patient has a cystostomy tube in place. The following are brief summaries of 3 selected cases. Case Abstracts Case 1

A fifty-two-year-old black male found to have a solitary nodule of the prostate underwent radical prostatectomy after biopsy confirmed a well-differentiated adenocarcinoma and no evidence of metastatic disease was found using the usual preoperative studies. The patient now voids satisfactorily, is completely continent, and works as a policeman (Fig. 1A). Case 2

(A) Case 1, (B) Case 2, and (C) Case 3.

time of operation it was necessary to remove the symphysis to complete the anastomosis between the bladder tube and urethra. The anastomosis remained unsatisfactory posteriorly and leakage persisted for four weeks. The patient currently has a severe urethral stricture and is wearing a cystostomy tube (Fig. 1C). Comment The use of an anterior bladder tube has, with one exception, allowed us to reconstruct the urinary tract without tension and with greater facility than with other methods. Although too few procedures have been performed to be of significance, we appear to be having reasonably good rates of continence with somewhat increased incidence of stricture formation. There remains the technical advantage of ease of anastomosis between the bladder tube and the urethra. This method appears to be a reasonable alternative to other methods of anastomosis, and as familiarity with the procedure increases, results may improve. St. Louis, Missouri 63104 (DR. SCHOENBERG) References

A sixty-five-year-old white male underwent radical prostatectomy ten months ago. At the

FLOCKS, R. H., and CULP, D. A.: A modification of technique for anastomosing membranous urethra and bladder neck following total prostatectomy, J. Urol. 69: 411 (1953). TANAGHO,E. A., and SMITH, D. R.: Mechanism ol urinary continence: embryologic, anatomic and patholog ic considerations, ibid. 100: 640 (1968). IDEM: Clinical evaluation of a surgical technique for the correction of complete urinary incontinence, ibid. 107: 402 (1972).



A sixty-three-year-old black male with similar history to Case 1 underwent radical prostatectomy in November, 1972. He now voids well and is completely continent (Fig. 1B). Case 3


Anterior bladder tube in radical retropubic prostatectomy.

Six patients with a minimum of ten months' follow-up have undergone reconstruction of the urethra by anterior bladder tube after radical retropubic pr...
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