Intussusception of the bladder neck does not promote early restoration to urinary continence after non-nervesparing radical retropubi c prostatectomy

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1 Blackwell Science, LtdOxford, UKIJUInternational Journal of Urology Blackwell Publishing Asia Pty LtdMarch Original ArticleIntussusception of the bladder neck and early continencei Sakai et al. International Journal of Urology (2005) 12, Original Article Intussusception of the bladder neck does not promote early restoration to urinary continence after non-nervesparing radical retropubi c prostatectomy IORI SAKAI, 1 KEN-ICHI HARADA, 1 ISAO HARA, 2 HIROSHI ETO 1 AND HIDEAKI MIYAKE 1 1 Department of Urology, Hyogo Medical Center for Adults, Akashi and 2 Department of Urology, Kobe University School of Medicine, Kobe, Japan Abstract Key words Background: The objectives of the present study were to investigate whether buttressing sutures, which prevent the bladder neck from pulling open as the bladder fills, can promote earlier recovery from urinary incontinence after radical retropubic prostatectomy (RRP) and to identify possible risk factors associated with urinary incontinence after RRP. Methods: The present study included 72 patients who underwent non-nerve-sparing RRP without neoadjuvant therapy between January and December Among these 72 patients, intussusception of the bladder neck was performed in 24 who consented to this procedure. In the present series, continence was defined as the absence of any need to use sanitary pads or diapers. Continence was evaluated by a patient interview 1, 3 and 6 months after RRP. Results: There were no significant differences in clinicopathological characteristics between patients with and without intussusception of the bladder neck. The percentage of continent patients 1, 3 and 6 months after RRP was 34.7%, 63.9% and 95.8%, respectively, and there were no significant differences in continence between the two groups at any time point. Among several factors examined, only bladder neck preservation was an independent predictor of recovery from urinary incontinence 1 and 3 months after RRP. Conclusions: These findings suggest that it would be important to preserve the bladder neck for early return to continence after non-nerve-sparing RRP; however, intussusception of the bladder neck may not offer significant improvement in earlier return of urinary control. prostate cancer, radical prostatectomy, continence, intussusception of the bladder neck. Introduction The anatomical approach to radical retropubic prostatectomy (RRP) and the subsequent improvement of surgical techniques have resulted in a decrease in surgical complications, including urinary incontinence. 1 However, urinary incontinence remains one of the most troubling side-effects associated with a significant deterioration in quality of life. 2 Although it is difficult to assess the rate of urinary incontinence after RRP from Correspondence: Hideaki Miyake MD, Department of Urology, Hyogo Medical Center for Adults, Kitaohji-cho, Akashi , Japan. hideakimiyake@hotmail.com Received 1 September 2004; accepted 17 September the literature for several reasons, such as a lack of a consistent definition of incontinence and variations in surgical procedure, the incidence of postoperative incontinence has been reported to range from 5 to 20%. 1,3 7 Despite the absence of clearly established risk factors for urinary incontinence after RRP, a number of published series have reported various factors that might be implicated in the regulation of postoperative continence. 1 These include patient age, size and configuration of the prostate, length of the membranous urethra, size and location of the tumor, preoperative bladder outlet obstruction and detrusor dysfunction, prior surgery for prostate and features of surgical technique itself (such as bladder neck preservation, control of the deep dorsal vein and sparing of the neurovascular bundles). 1,4,6,7

2 276 I Sakai et al. Consistent with these studies, Walsh and Marschke recently reported the usefulness of buttressing sutures, which prevent the bladder neck from pulling open as the bladder fills to promote earlier return of urinary control. 8 Since this technique is comparatively simple and supported by several theoretical concepts, 3,5,9,10 we compared the recovery of urinary continence after nonnerve-sparing RRP between patients with and without intussusception of the bladder neck and subsequently identified risk factors associated with urinary incontinence using multivariate analyzes. Patients and methods In the present study, we included 72 patients who underwent non-nerve-sparing radical prostatectomy and pelvic lymphadenectomy for clinically localized prostate cancer without neoadjuvant therapy between January and December Characteristics of these patients are summarized in Table 1. Data concerning continence were obtained by the attending physician during patient interviews 1, 3 and 6 months after RRP. Continence was defined simply as the absence of any need to wear sanitary pads or diapers. All patients underwent bilateral pelvic lymphadenectomy targeting the external iliac, internal iliac and obturator lymph nodes and an anatomic RRP as described by Walsh et al. 11 and Myers et al. 12 with several modifications. Briefly, the dorsal vein complex was approximated with the endopelvic fascia and suture-ligated. A wide resection of neurovascular bundles on both sides was then performed by dissecting the lateral pelvic fascia containing the neurovascular bundles on both sides of the urethra. The posterior bladder neck was exposed from the prostate after complete dissection of the seminal vesicles. The prostate was dissected away from the bladder neck to preserve the anatomic integrity of the vesical neck as described by Gaker et al.; 13 however, the bladder neck was excised and reconstructed as described previously in patients with severe hypertrophy of the prostate middle lobe or those suspicious of disease invasion into the bladder neck. 11 Individual sutures were placed through the urethral wall at the 1, 3, 5, 7, 9 and 11-o clock positions, subsequently placed at the corresponding positions in the vesical neck and tied over a new Foley catheter to complete the vesicourethral anastomosis. The Foley catheter was removed 8 days after RRP if there was no urine leakage observed at the vesicourethral anastomosis site. In the present series of 72 patients, intussusception of the bladder neck as reported by Walsh and Marschke 8 with minor modifications was performed in 24 patients who consented to this procedure. The surgical technique for this procedure is as follows: A 2 0 Vicryl suture is placed in the edge of the posterior bladder wall, where the bladder was previously attached to the prostate, approximately 2 cm from the bladder neck and tied loosely in the midline. A second 2 0 Vicryl suture is placed approximately 2 cm lateral to the bladder neck on each side and is again tied loosely. The association of some factors with urinary incontinence was assessed by multivariate logistic regression model. Differences between the two groups were compared using Fisher s exact test, c 2 test or unpaired t-test. P-values <0.05 were considered significant. Results As shown in Table 1, there were no significant differences in clinicopathological characteristics between the Table 1 Patient characteristics Variables Intussuception of the bladder neck P-value Yes (n = 24) No (n = 48) Age (years) 69.1 ± ± Blood loss (ml) ± ± Bladder neck preservation No Yes Pathological stage pt pt3 or pt Weight of the prostate (g) 41.9 ± ± Time to urethral cathetar removal (days) Values are presented as mean ± SD.

3 Intussusception of the bladder neck and early continence patients who received intussusception of the bladder neck and the 48 who did not undergo this procedure. The percentage of patients with continent status 1, 3, and 6 months after RRP was 34.7%, 63.9% and 95.8%, respectively, and there was no significant difference in the ratio of continence at any time point between these two groups (Table 2). During the observation period, vesicourethral anastomotic stricture developed in two (8.3%) of the 24 patients with intussusception of the bladder neck and one (2.1%) of the 48 patients without this procedure. We then evaluated the relationship between recovery from urinary incontinence and several factors 1 and 3 months after RRP, as the majority of patients recovered urinary continence 6 months after RRP. As shown in Table 3, continent status was significantly associated with whether the bladder neck was preserved or excised both 1 and 3 months after RRP. Furthermore, multivariate analyses using Cox regression hazards model showed that whether the bladder neck was preserved could be used as an independent predictor of continence at 1 and 3 months after RRP (Table 4). Discussion With improved understanding of the precise anatomy of the prostate and its surrounding structures, surgical techniques of radical retropubic prostatectomy have been refined, resulting in a marked decrease in morbidity, including urinary incontinence; 11 that is, the reported incidence of urinary incontinence after RRP ranges from 5% to 20%. 1,3 7 In fact, the continence rate in the present series at a minimum follow-up of 6 months after RRP was 95.8%. Thus, since overall urinary continence rates have become satisfactory, a recent interest has developed in achieving earlier restoration of continence after RRP. To date, various surgical techniques have been performed to promote early restoration of continence, 1 such as bladder neck preservation, 4 puboprostatic ligament sparing, 6 seminal vesicle sparing 7 and continence nerve preservation. 14 However, none of these methods have been completely successful in eliminating incontinence after RRP. Recently, Walsh and Marschke reported the usefulness of intussusception of the bladder neck for earlier Table 2 Changes in continence rate 1, 3 and 6 months after radical retropubic prostatectomy Time after surgery Number of patients with continence (%) P-value Total (n = 72) Intussuception of the bladder neck Yes (n = 24) No (n = 48) 1 month 25 (34.7) 9 (37.5) 16 (33.3) months 46 (63.9) 16 (67.7) 30 (62.5) months 69 (95.8) 23 (95.8) 46 (95.8) 1.00 Table 3 Association between several factors and continent status 1 and 3 months after radical retropubic prostatectomy (RRP) Variables 1 month after RRP 3 months after RRP Continent (n = 25) Incontinent (n = 47) P-value Continent (n = 25) Incontinent (n = 47) P-value Age (years) 69.9 ± ± ± ± Blood loss (ml) ± ± ± ± Bladder neck preservation No Yes Pathological stage pt pt3 or pt Weight of the prostate (g) 38.9 ± ± ± ± Time to urethral cathetar removal (days) Values are presented as mean ± SD.

4 278 I Sakai et al. Table 4 Multivariate analysis in predicting sontinent status 1 and 3 months after radical retropubic prostatectomy (RRP) Variables 1 month after RRP 3 months after RRP Relative risk (95% CI) P-value Relative risk (95% CI) P-value Age (years) (<70 versus 70) ( ) ( ) Blood loss (ml) (<500 versus 500) ( ) ( ) Bladder neck preservation (yes versus no) ( ) ( ) Intussusception of the bladder neck (yes versus no) ( ) ( ) Pathological stage (pt2 versus pt3 or pt4) ( ) ( ) Weight of the prostate (g) (<40 versus 40) ( ) ( ) Time to urethral catheter removal (days) (8 versus 9) ( ) ( ) CI, confidence interval. restoration of continence after RRP; that is, at 3 months. In that study, 82% of patients who received anatomical RRP with this procedure were continent, compared with 54% undergoing anatomical RRP alone. 8 However, in the present series, there was no significant difference in continent status between patients with and without intussusception of the bladder neck. This discrepancy could be explained by several reasons as follows: (i) bilateral neurovascular bundles were resected in all cases in the present series; (ii) in the present study, the bladder neck was preserved in 56.9% and the remaining 43.1% underwent tennis racket reconstruction; however, Walsh and Marschke performed tennis racket reconstruction for all patients; and (iii) among the factors available in the report by Walsh and Marschke, the mean patient age in their series was significantly younger than in the current series. Considering these findings, to determine whether this approach contributes to early recover from urinary incontinence after RRP, a prospective randomized study including a larger number of patients with a longer follow-up may be needed. We subsequently analyzed the significance of several factors, which may be involved in restoration of continence after RRP to identify potential risk factors associated with urinary incontinence. In the present series, only bladder neck preservation was significantly associated with an increased chance of early recovery from urinary continence. Furthermore, intussusception of the bladder neck did not have significant impact on continent status, irrespective of whether the bladder neck was preserved (data not shown). Multivariate analyses also demonstrated that whether the bladder neck was preserved could be used as an independent predictive factor of continence after RRP. However, it remains controversial whether bladder neck preservation is useful for the recovery of continence after RRP. For example, bladder neck preservation has been shown to offer an earlier return to continence compared with bladder neck excision by Gaker et al., 13 Lowe 15 and Klein, 16 while Poon et al. 4 and Licht et al. 17 reported that preservation of the bladder neck does not have an impact on restoration of urinary control. Moreover, several studies using multivariate analysis in a large series of patients undergoing RRP demonstrated different risk factors for urinary incontinence irrespective of whether the bladder neck was preserved. 18,19 Collectively, these findings suggest that the mechanism regulating continence following RRP seems to be multifaceted; therefore, it would be difficult to draw conclusive findings based solely on the present findings. In conclusion, a randomized prospective study would be required to critically assess the significance of each factor, including surgical technique, in restoring early continence after RRP and a more suitable method for evaluating continent status after RRP in association with the effects on patients quality of life should be explored. However, the present findings show that preservation of the bladder neck would be important for early restoration of continence after non-nerve-sparing RRP, while intussusception of the bladder neck may not contribute to significant improvement in earlier return of urinary control. References 1 Moinzadeh A, Shunaigat AN, Libertino JA. Urinary incontinence after radical retropubic prostatectomy: the

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