C O N T I N E N C E LEVEL F O L L O W I N G RADICAL

PROSTATECTOMY PAT D. O ' D O N N E L L , M.D. T O D D BROOKOVER, M.D. MARK H E W E T T , M.D. AMER Z. AL-JUBURI, M.D. From the D e p a r t m e n t of Urology, University of Arkansas for Medical Sciences, and Department of Veterans Affairs Medical Center, Little Rock, Arkansas

- The relationship of the urethral anastomosis and postoperative continence following tectomy is uncertain. The objective of this study was to determine radiographically l level of continence following radical prostatectomy relative to the site of the in~rethral anastomosis. In 8 patients having a radical prostatectomy, an intraoperative placed at the site of the urethral anastomosis and the postoperative functional level of ~s determined using a standing lateral cystogram. The functional level of continence 9 = 3. O) distal to the site of the urethral anastomosis. The level in the urethra that ,curs may be a function of the intrinsic continence parameters of each individual

,~ieal approach to the treatment of ~inoma of the prostate is one of the d m a n a g e m e n t methods for the functional continence outcome of tateetomy remains one of the most peets of surgical results. Urinary following radical prostatectomy is ;ouree of postoperative morbidity. , k n o w n preoperative parameters [etive of continence outcome postanisms of continence following tteetomy are not well understood, tion of the area has been limited. 3f the pelvic nerves during radical ¢ appears to have a role in the eservation of urinary continence. 4 approach to the prostatic apex aplide optimal urethral transection lm preservation of the urethral ] other tissues of the eontinenee The relationship between the site nosis of the urethra with the bladevel at w h i e h eontinenee oceurs is ~eobjeetive of this study was to de-

)ECEMBER 1990

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termine the funetional level of continence following radical prostateetomy relative to the site of the urethral anastomosis. Material and Methods In 8 patients undergoing a nerve-sparing radical prostateetomy for loealized eareinoma of the prostate, a medium-sized hemoelip was placed intraoperatively at the site of anastomosis anteriorly. The hemoelip was used to mark radiographieally the level of the urethral anastomosis. At approximately three months following the radical prostateetomy, a standing lateral resting eystogram was performed on each patient to determine the radiographic level of continence relative to the urethral anastomosis. A line was d r a w n from the marking hemoelip perpendicular to the axis of the urethra (Fig. 1). With the patient at rest in the standing position, the distal extent of contrast agent was considered the funetional level of continence for that patient. The distance between the radiographic site of the urethral anastomosis and the functional level of continence was measured in eaeh of the patients studied.

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FmURE 1. Medium hemoclip placed intraoperatively at urethral anastomosis anteriorly used to identify radiographically site of urethral anastomosis postoperatively. Distal point of contrast agent within urethra designated as functional level of continence at rest. Results In the 8 patients studied following radical prostatectomy, the mean urethral length between the radiographic hemoelip marker of the u r e t h r a l anastomosis and the r a d i o g r a p h i c functional level of continence was 9.0 m m (SD = 3.0) with a range of 5.0 m m to 12.0 mm. The mean age of the patients was 63.9 years (SD = 6.6), and all patients studied were continent. There was no relationship between the urethral distance measured and age of the patient. Comment This study shows that the functional level of continence following radical prostatectomy appears to be distal to the site of the urethral anastomosis by a distance of almost 1 cm in the patients evaluated. The proximal urethra near the anastomosis has radiographic evidence of a loss of closing pressure. Urethral closing pressure adequate to maintain continence occurred at a point significantly distal to urethral anastomosis. Prior to radical prostatectomy, the segment of u r e t h r a in these p a t i e n t s b e t w e e n t h e urethral anastomosis and the functional level of continence does not normally contain urine at rest. Following radical prostatectomy, urine appears to be present in this segment of the urethra when the patient is standing. If any remaining sensory afferents in this segment of the urethra are intact, the urethral sensation would represent a significant alteration in the normal urethral reflex meehanisms involved in continence. Following a radical prostatectomy, continence is often regained over a period of approximately six months to one year. During that time, varying degrees of incontinence may oc512

cur that seem to improve with time. The mq anism of improvement in continence with t following radical prostateetomy is unclear. eovery of continence following radical pro teetomy may involve neurologie adaptatio: abnormal reflex mechanisms of the urethra generation of lost neurologie function of urethra, development of another distal. tinenee mechanism, or a combination of tl and other factors. T h e u n p r e d i c t a b i l i t y of o c c u r r e n c e severity of incontinence continues to be a e eal problem in the surgical management o ealized prostate cancer. The nerve-spa operative technique and the apical dissec technique appear to provide improvemer~ continence. However, a better understandii the mechanisms of continence following ra~ prostateetomy is needed to modify the sur I technique and postoperative managemen address the factors contributing to postof rive incontinence. Conclusion The functional level of continence was s led radiographically in 8 patients and four~ be located distal to the level of the uret anastomosis by approximately 1 cm. Follo~ radical prostateetomy, the proximal urethr," peared radiographieally to be open at rest. apparent loss of closing pressure and the ] ence of urine in that segment of the urethr! factors that may have a role in the physiol adaptations required to regain continence lowing a radical prostatectomy. The vari, in level of continence relative to the ure anastomosis may result from intrinsic pr posing patient factors associated with post! ative continence. 4301 West Mar] Little Rock, Arkansas :J (DR. O DONN; References 1. Boxer RJ, Kaufman JJ, and Goodwin WE: Radical] tectomy for carcinoma of the prostate 1951-1976, a revie~ patients, J Urol 117:208 (1977). 2. Lindner A, DeKernion JB, Smith RB, and Katske IF/ of urinary incontinence following radical prostatectomy, 129:1007 (1983). 3. Elder JS, Gibbons RP, Correa BJ, and Bramlen GE bidity of radical perineal prostatectomy following tranSU resection of the prostate, J Urol 132:55 (1984). 4. O'Donnell PD, and Finan BF: Continence following sparing radical prostatectomy, J Urol 142:I227 (1989). 5. Myers RP, GoeUner JR, and Cahill DR: Prostate Sh~ ternal striated urethral sphincter and radical prostatect0f apical dissection, J Urol 138:543 (1987).

UROLOGY

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DECEMBER 1990

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VOLUME XXXVi,

Continence level following radical prostatectomy.

The relationship of the urethral anastomosis and postoperative continence following radical prostatectomy is uncertain. The objective of this study wa...
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