3. Results

Patients were similar in terms of age and preoperative and postoperative predictive factors. The data are summarised in Table 1. The most significant disparities concerned positive lymph nodes (3.2% in group A vs. 12.9% in group B) and high Gleason scores (Gleason score 8–10: group A 12.9% vs. group B 3.2%). In terms of overall positive margins, in both groups seven patients (22.5%) presented positive margins. However, for pT2 patients, men in group A had 14.2% positive margins, whereas those in group B had 5.3%. With respect to operative times, the median was 230min for both groups.

Table 2 reports the continence rate at 3, 30, and 90 d from catheter removal. At 90 d, only 26 of 31 patients per group were evaluable after surgery.

Continence recovery was more rapid in the group of patients who underwent the modified technique. Even at 3 d after catheter removal, 74.2% of the patients who underwent surgery with modified technique were continent versus 25.8% of the subjects who underwent standard surgery. At 30 d, these percentages were 83.8% and 32.3% and at 3 mo, 92.3% versus 76.9%, respectively.

At statistical analysis, the difference between group A and group B was statistically significant at discharge and at 30 d after the procedure. At 90 d, group A had a larger number of continent patients, but the difference from group B was not statistically significant.

4. Discussion

The VLRP performed in specialised centres is now considered a safe, established procedure [10], [11], [12].

With the laparoscopic technique the rate of continent patients at 1 yr varies from 50% to 91.7% according to a recent review by Rassweiler [13] and from 83% to 100% according to a review by Trabulsi and Guilloneau [14]. These authors underline the correlation between postoperative continence and the progress along the learning curve of the surgeon. In particular, Rassweiler argues that the surgeon's experience has a significant impact on the time to continence recovery.

Stolzenburg et al. have published a study on preservation of puboprostatic ligaments for a quicker recovery of continence [12]. According to these authors, at 2 wk after surgery, 24% of the subjects with puboprostatic ligament preservation were continent (0–1diaper/d) versus 12% of other subjects. At 3 mo the rates were 76% and 48%, respectively. This study was the first to focus on rapid recovery of continence with the laparoscopic technique, and it considered anterior anchorage of the urethral-sphincter complex to be the key element for continence.

As Rassweiler and Guilloneau emphasise in the editorial comment [12], however, the study presents some controversial aspects. It is based on two consecutive series of patients, it is not randomised and, furthermore, the preservation of puboprostatic ligaments can increase the risk of impairing radicality.

The technique of Rocco we performed laparoscopically is based on the anatomic-functional assumption that it is especially the reconstruction of the posterior insertion of the RS that ensures continence. In particular, Rocco and colleagues report that Denonvilliers fascia, the dorsal aspect of the prostate, and the posterior median raphe with the connected dorsal wall of the RS form a unique musculofascial plate that constitutes an important support structure within the pelvis and “appears to serve as a fixation point for the muscle fibres of the rhabdosphincter […]. The musculofascial plate is a dynamic suspensory system for the prostatomembranous urethra” [9], [15]. In light of this, the re-creation of this musculofascial plate with the simple placement of two sutures between the posterior portion of the striated sphincter, the remaining portion of Denonvilliers fascia, and the bladder, 1–2cm dorsally to the bladder neck, appears able to significantly speed up the recovery of continence.

Rocco and coworkers reported that 72% of patients were continent with the modified technique at 3 d from catheter removal versus 14% of those with the standard technique. At 30 and 90 d the difference remains significant. It must be noted that Rocco's technique is carried out without preservation of the puboprostatic ligaments and without conservation of the bladder neck, therefore with the utmost effort to achieve radicality.

The above-mentioned study, however, is not randomised and the population of patients undergoing the unmodified technique had a more advanced pathologic/disease stage that in a multivariate analysis appears to be associated with a less rapid recovery of continence.

Our prospective randomised study, although limited in the number of cases, confirms a very significant difference, both statistically and clinically, similar to that obtained by Rocco et al. with the open surgery technique.

We learned about this technique from a preliminary report [16] and since 2002 we have tried to introduce it in our surgical practice in well-selected patients with favourable anatomic characteristics, in whom the dissection of the apex and isolation of the urethra were particularly apt to application of the open surgery technique in a laparoscopic setting.

In 2004, we therefore carried out a small pilot study on 17 consecutive nonselected cases (15 assessable, 4 with the Da Vinci robot) [17] with the Rocco technique, obtaining early continence at catheter removal in 40% of the cases. Although satisfactory, this percentage was not exceptionally different from the results obtained in our global population [18].

We attributed the reasons for this result to the fact that in the Rocco technique the sutures were placed in all the described structures and then tied in a single step. Although in the patients selected from the global population this had not created any particular difficulty, in the nonselected population of the pilot study, in some cases we encountered major difficulties in tightening the sutures correctly without tearing the tissues. We therefore subsequently tried to join the structures in two different steps. First we joined the RS with Denonvilliers fascia (Fig. 3) and then the RS-Denonvilliers fascia complex with the bladder. This allowed us to carry out all the manoeuvres under vision and controlling tension, so that the procedure became much easier and more reproducible. All the patients included in this study underwent two-step suturing.

The end point of this study, early continence, was significantly improved at catheter removal in the patients who underwent the modified technique, both from a statistical and clinical viewpoint, with results basically identical to those of the open surgery technique. The difference remained statistically significant at 1 mo, whereas at 3 mo, with only 26 patients assessable for each group, the difference was still present but was no longer statistically significant.

With respect to complications, Rocco et al. [9] describe bladder-neck strictures and acute urinary retention in <5% of patients in both groups. Probably due to the much smaller number of cases, to date neither of these complications occurred in the patients we treated.

With regards to operative times, there was no significant difference between standard technique and the modified technique.

Furthermore, the reconstruction of the musculofascial plate seems to be helpful for the urethrovesical anastomosis, which can be carried out in tension-free conditions.

We carry out the Rocco reconstruction pushing the perineal plane from the exterior. Once the posterior plate is reconstructed it is possible to continue with the anastomosis and it is not necessary to keep pushing the perineal plane any longer.

Our study has some limitations.

First, the patient assignment to the two groups was very elementary and consisted in alternating patients according to their order of arrival to the hospital.

Second, the methodology for continence assessment is imperfect. No information on continence baseline evaluation nor information on the impact of postoperative incontinence on quality of life of the patients were provided. Furthermore, questionnaire administration by e-mail would have been more desirable than third-party interviews [19]. However, certain methodologic flaws seem common to the existing laparoscopic literature [20]. In addition, in this study, we tried to reproduce an open surgical technique, and therefore we used the same continence indicator as used in the original study [9].

Third, the number of cases is very small. If, on the one hand, this does not appear to be a significant limitation for evaluation of the main end point, which is the recovery of early continence, considering the marked difference that was seen in the two groups, on the other hand it may conceal the possible appearance of side-effects such as acute urinary retention or urethral stenosis, though these were very rare even in the larger number of cases presented by Rocco et al. with the open surgery technique.

Fourth, the follow-up period was short. However, because the aim of the study was the evaluation of early continence, this limitation, too, does not appear to have particular bearing on the end point. Nevertheless, we have not been able to verify whether this technique also allows improvement in long-term continence.

5. Conclusions

Posterior reconstruction of the RS is a simple and effective technique. It allows for a much more rapid recovery of continence after laparoscopic RP compared to the standard technique. To be performed correctly, the structures involved in the reconstruction must be sutured together in two separate steps, so as to not tear the tissues or, on the other hand, to not leave surgical knots loose. A longer follow-up and a greater number of cases could help clarify any risks of complications, none of which have been found to date, and perhaps to obtain a higher percentage of continent patients in the long term.

Conflicts of interest

Authors declare no consultancies, stock ownership or other equity interests, patents received and/or pending, or any commercial relationship which might be in any way considered related to a submitted article.