Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra as a technical modification to improve the early recovery of continence during retropubic radical prostatectomy, "Beyond the Abstract," by Riccardo Schiavina, et

BERKELEY, CA (UroToday.com) - The maintenance of urinary continence is one of the most important end-points after radical prostatectomy. The improved knowledge of the anatomy of the small pelvis has offered the possibility to better preserve the structures that are essential for good functional results. It is universally accepted that, in order to maintain urinary continence, the main objective of the surgeon should be the preservation of the external urethral sphincter and the pelvic floor muscles, as well as of the surrounding support structures. We consider that the internal sphincter also contributes to the continence mechanism in males. Thus, it was our effort to develop a surgical technique with the aim of also preserving this functional structure. In 2010, we first described our technical modification consisting of the preservation of the internal sphincter, as well as of the proximal urethra.

In detail, during the last part of the radical prostatectomy, we bluntly dissect the ring-shaped vesical sphincter from the prostate and identify the longitudinally-oriented smooth muscle component of the urethral musculature (Figure 1). The entire base of the prostate is gently separated from the urethra until the maximal length of the internal (vesical) sphincter is preserved, and the urethra is incised to remove the catheter.

bta schiavina fig1 
Figure 1: Identification of the ring-shaped vesical sphincter and the longitudinal smooth muscle of the proximal urethra during dissection of the dorsal aspect of the prostate and the bladder neck.

The surgical procedure that we described restores the complete anatomical and functional length of the sphincteric structures in males undergoing radical prostatectomy and it may facilitate a rapid recovery of urinary continence after catheter removal. Recently, others described the first clinical trial of the same technique, with optimal results in terms of early recovery of continence. The results of our clinical trials showed that our modified technique might accelerate the recovery of urinary continence.

We would like to underline that not all patients undergoing RP are optimal candidates because of the anatomical variances of the shape of the prostate and the different oncological characteristics. In fact, it is not possible to obtain a robust and long proximal urethra in all cases, because large prostates and prominent middle lobes can impair the realization of this procedure, and the proximal urethra might remain thin and short. We also excluded those patients submitted to previous surgery for benign prostatic obstruction because of the absence of the internal sphincter. Moreover in our opinion, even if the proximal urethra is essentially surrounded by benign hyperplasia, those patients harboring high-risk PCa should be excluded from this technique because of the risk of positive margins.

In conclusion, in well-selected patients our modified technique might accelerate the recovery of urinary continence and could improve continence when the rabdosphincter has not been perfectly preserved. The technique is also oncologically safe and does not increase the duration of the procedure. Further study must be carried out in order to validate these results.

Written by:
E. Brunocilla,a R. Schiavina,a M. Borghesi,a, b C. Pultrone,a, b M. Cevenini,a V. Vagnoni,a and G. Martoranaa as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

aDepartment of Urology, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
bDepartment of Medical and Surgical Sciences DIMEC, Alma Mater Studiorum, University of Bologna, Italy

Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra during retropubic radical prostatectomy: A technical modification to improve the early recovery of continence - Abstract

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