RECONSTRUCTIVE UROLOGY

Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy
Nguyen MM, Kamoi K, Stein RJ, Aron M, Hafron JM, Turna B, Myers RP, Gill IS
Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic, Cleveland, OH, and Department of Urology, Mayo Clinic, Rochester, MN, USA
BJU Int. 2008; Jan 10 [Epub ahead of print]

• Objectives: To detail the technique and evaluate in a preliminary study the effectiveness of posterior reconstruction of Denonvilliers’ musculofascial plate (PRDMP) in enhancing early continence after robotic and laparoscopic radical prostatectomy (RP).
• Patients and Methods: Thirty-two consecutive patients having robotic or laparoscopic RP with PRDMP (group 1). Thirty previous patients not having PRDMP were compared as historical controls (group 2). Continence, as measured by patient self-reporting of the number of pads used/24 h, was assessed at 3 days and 6 weeks after catheter removal, by telephone interview. ‘Continent’ was defined as the use of none or one pads, ‘moderate incontinence’ as two pads, and ‘severe incontinence’ as more than two pads. Intraoperative transrectal ultrasonography (TRUS) was used to measure the membranous urethral length before and after PRDMP.
• Results: At 3 days after catheter removal, more patients in group 1 were continent than in group 2 (34% vs 3%, P = 0.007). At 6 weeks continence was again better in group 1 (56% vs 17%, P = 0.006). The mean length of the membranous urethra on TRUS measured before RP, after RP but before the musculofascial suture, and afterward, was 15.6, 12 and 14 mm, respectively. Thus, reconstruction restored the length of the transected membranous urethra by a mean of 2 mm.
• Conclusions: PRDMP during robotic and laparoscopic RP leads to improved maintenance of membranous urethral length and significantly higher early continence rates.
  
  
• Editorial Comment
  At the end of the 21st century, the first reports about the external urethral sphincter or rabdosphincter can be found which discuss omega-shaped of striated muscle fibers innervated by the pudendal nerves (1,2). With further investigations it was demonstrated that the preservation of the levator ani fascia helps to protect the levator ani muscle, rhabdosphincter with its pudendal nerve branches (3). With the reconstruction of the posterior fibrous raphe, early continence was revealed (4). The propagation of these findings for the robotic or laparoscopic radical prostatectomy (RP) results in similar findings as previously reported for the open RP (5).
  Similar results seem to be achieved with the reported preservation of the periprostatic nerve courses as recently described by Hennenlotter et al. 2007, which might further avoid the discontinuation of the posterior fibrous raphe (6). Therefore it might be suggested that the careful preservation of the extracapsular nerve courses especially at the apex might be supportive for the sphincter function especially in the early postoperative phase.

References
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2. Strasser H, Ninkovic M, Hess M, Bartsch G, Stenzl A: Anatomic and functional studies of the male and female urethral sphincter. World J Urol. 2000; 18: 324-9.
3. Takenaka A, Hara R, Soga H, Murakami G, Fujisawa M: A novel technique for approaching the endopelvic fascia in retropubic radical prostatectomy, based on an anatomical study of fixed and fresh cadavers. BJU Int. 2005; 95: 766-71.
4. Rocco F, Carmignani L, Acquati P, Gadda F, Dell’Orto P, Rocco B, et al.: Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007; 52: 376-83.
5. Nguyen MM, Kamoi K, Stein RJ, Aron M, Hafron JM, Turna B, et al.: Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int. 2008 Jan 10; [Epub ahead of print]
6. Hennenlotter J, Laible I, Merseburger AS, Anastasiadis AG, Nagele U, Kuehs U, Kuczyk MA, Stenzl A, Sievert KD. Anatomical distribution of prostatic peripheral nerve tissue- a notable portion located on the dorsal surface of the apex. Eur Urol Suppl. 2007; 6: 51. [abstract 115]

Dr. Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
E-mail: arnulf.stenzl@med.uni-tuebingen.de