Rocco F, Carmignani L, Acquati P, Gadda F, Dell'Orto P, Rocco B, Bozzini G, Gazzano G, Morabito A
Clinica Urologica I, Università degli Studi, Fondazione Ospedale Maggiore Policlinico, Mangiagalli Regina Elena Ricovero e Cura a Carattere Scientifico, Milano, Italy.
J Urol. 2006 Jun;175(6):2201-6. doi: 10.1016/S0022-5347(06)00262-X.
Prolonged postoperative incontinence is a major drawback of RRP. Age, scars in the rhabdosphincter, nonnerve sparing surgery and postoperative sphincter insufficiency can cause temporary or definitive urinary incontinence. We believe that sphincter deficiency is the main cause of early incontinence. Urinary leakage results from the shortening of anatomical and functional sphincter length due to caudal retraction of the urethral sphincteric complex and disruption of the median posterior fibrous raphe. We describe a modification of the Walsh RRP that overcomes caudal retraction, reconstructs the posterior fibrous raphe and decreases time to continence. The primary study end point was early continence rate assessment. Long-term continence (1 year) and erectile function assessment were secondary end points.
To avoid caudal retraction of the urethrosphincteric complex, before completing the vesicourethral anastomosis the posterior semicircumference of the sphincter is joined to the residuum of Denonvilliers' fascia and fixed to the posterior bladder wall 1 to 2 cm cranial and dorsal to the new bladder neck. Vesicourethral anastomosis is subsequently performed with care taken not to involve the neurovascular bundles. A total of 161 patients with clinically confined disease underwent modified RRP (group 1). They were compared with a historical series of 50 patients who underwent standard RRP (group 2). Early continence was defined as no pad use but patients using 1 diaper were also considered continent. Continence, assessed prospectively as the number of pads daily, was evaluated 3, 30 and 90 days, and 1 year after catheter removal. The continence state was assessed by a multivariate logistic model. Erectile function was evaluated using the International Index of Erectile Function questionnaire preoperatively and after 18 months in patients younger than 65 years who underwent nerve sparing surgery.
In group 1, 116 (72%), 127 (78.8%) and 139 patients (86.3%) were continent 3, 30 and 90 days after catheter removal compared with 7 (14%), 15 (30%) and 23 (46%), respectively, in group 2. One-year continence rates were 96% and 90%, respectively. Erectile function was similar in groups 1 and 2 (46% and 42%, respectively). Multivariate analysis showed that continence was significantly influenced by operation type, stage and patient age.
Careful reconstruction of the posterior aspect of the rhabdosphincter markedly shortens time to continence.
术后长期尿失禁是根治性耻骨后前列腺切除术（RRP）的一个主要缺点。年龄、横纹括约肌瘢痕、非保留神经手术以及术后括约肌功能不全可导致暂时性或永久性尿失禁。我们认为括约肌功能缺陷是早期尿失禁的主要原因。由于尿道括约肌复合体向尾侧回缩以及正中后纤维缝的破坏，导致解剖学和功能性括约肌长度缩短，从而引起尿液渗漏。我们描述了一种对Walsh RRP的改良方法，该方法可克服向尾侧回缩、重建后纤维缝并缩短恢复控尿的时间。主要研究终点是早期控尿率评估。长期控尿（1年）和勃起功能评估为次要终点。
为避免尿道括约肌复合体向尾侧回缩，在完成膀胱尿道吻合之前，将括约肌的后半周与Denonvilliers筋膜残端相连，并固定于新膀胱颈头侧和背侧1至2厘米处的膀胱后壁。随后小心进行膀胱尿道吻合，避免累及神经血管束。共有161例临床局限性疾病患者接受了改良RRP（第1组）。将他们与一组50例接受标准RRP的历史患者系列（第2组）进行比较。早期控尿定义为不使用尿垫，但使用1片尿布的患者也被视为控尿。前瞻性评估为每日使用尿垫数量，在拔除导尿管后3天、30天、90天和1年进行控尿评估。通过多变量逻辑模型评估控尿状态。对年龄小于65岁且接受保留神经手术的患者，在术前和术后18个月使用国际勃起功能指数问卷评估勃起功能。
在第1组中，拔除导尿管后3天、30天和90天分别有116例（72%）、127例（78.8%）和139例（86.3%）患者控尿，而在第2组中分别为7例（14%）、15例（30%）和23例（46%）。1年控尿率分别为96%和90%。第1组和第2组的勃起功能相似（分别为46%和42%）。多变量分析表明，控尿受手术类型、分期和患者年龄的显著影响。
仔细重建横纹括约肌后部可显著缩短恢复控尿的时间。
