Brunocilla Eugenio, Schiavina Riccardo, Borghesi Marco, Pultrone Cristian, Cevenini Matteo, Vagnoni Valerio, Martorana Giuseppe
University of Bologna - S. Orsola-Malpighi Hospital, Bologna.
Arch Ital Urol Androl. 2014 Jun 30;86(2):132-4. doi: 10.4081/aiua.2014.2.132.
We describe our technique for preservation of the smooth muscular internal (vesical) sphincter and proximal urethra during radical retropubic prostatectomy (RRP) and present our preliminary clinical results.
The first steps of the prostatectomy reflect the standard RRP, while for the final phases the procedure continues in an anterograde manner with incision of the fibers of the detrusor muscle at the insertion of the ventral surface of the base of the prostate. At this level, the inner circular muscle of the bladder neck forms a sphincteric ring of smooth muscle that covers the longitudinally oriented smooth muscle component of the urethral musculature that extends distally to the verumontanum. These two proximal structures represent the internal sphincter that envelopes and locks the proximal urethra. A blunt dissection is continued until the ring shaped vesical sphincter is separated from the prostate and the longitudinally oriented smooth muscle component of the urethral musculature is identified. The base of the prostate is then gently separated from the urethra and from the bladder until the maximal length of the urethral musculature is isolated and preserved.
After 30 initial set-up procedures, 40 consecutive patients with organ confined prostate cancer were submitted to radical retropubic prostatectomy with the preservation of muscular internal sphincter and the proximal urethra and compared to 40 patients submitted to standard procedure who served as control group. The group of patients submitted to our technical modification had a faster recovery of early continence than control group at 3 and 7 days.
The described technique is a feasible and safe method for preservation of the internal urethral sphincter and allows improving the early recovery of urinary continence. The technique does not increase the rate of positive margins and the duration of the procedure.
我们描述了在耻骨后根治性前列腺切除术（RRP）中保留光滑的肌肉性膀胱内括约肌和近端尿道的技术，并展示我们的初步临床结果。
前列腺切除术的初始步骤遵循标准RRP，而在最后阶段，手术以顺行方式继续进行，在前列腺底部腹侧表面的附着处切开逼尿肌纤维。在此层面，膀胱颈的内环肌形成一个平滑肌括约肌环，覆盖尿道肌肉组织纵向排列的平滑肌成分，该成分向远端延伸至精阜。这两个近端结构代表包裹并锁定近端尿道的内括约肌。继续钝性分离，直到环形膀胱括约肌与前列腺分离，并识别出尿道肌肉组织纵向排列的平滑肌成分。然后将前列腺底部从尿道和膀胱轻轻分离，直到分离并保留尿道肌肉组织的最大长度。
在30例初始设置手术之后，40例连续的局限性前列腺癌患者接受了保留肌肉性内括约肌和近端尿道的耻骨后根治性前列腺切除术，并与40例接受标准手术作为对照组的患者进行比较。接受我们技术改良的患者组在术后3天和7天比对照组更早恢复控尿。
所描述的技术是一种保留尿道内括约肌的可行且安全的方法，有助于改善尿失禁的早期恢复。该技术不会增加切缘阳性率和手术时间。
