Xu Zhibin, Zhao Jie, Guan Zhenghui, Guo Maomao, Bian Hao, Li Zhenchi, Zhao Wenchao, Liang Sudong, Liu Yu, Zhang Siyang, Wang Jiangping
Department of Urology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, China.
Transl Androl Urol. 2024 Jun 30;13(6):994-1003. doi: 10.21037/tau-23-583. Epub 2024 Jun 26.
In recent years, despite several surgical techniques having been applied, the early incontinence rate after radical prostatectomy (RP) remains high. In this study, we reconstructed an internal urethral sphincter (IUS) with anterior bladder neck tube (ABNT) to improve early return of continence and find a more effective technique for early urinary incontinence after RP.
In this study, 96 previous patients who did not receive an ABNT between October 2018 and May 2020 were compared as historical controls (the control group). A total of 210 consecutive patients underwent robotic or laparoscopic RP with ABNT between May 2020 and February 2023 (the ABNT group). The inclusion criteria included Eastern Cooperative Oncology Group (ECOG) score 0-1 and localized prostate cancer (clinical stages cT1-3, cN0, cM0). The exclusion criteria included patients with diabetes, neurologic diseases, previous pelvic operations, symptoms of urinary incontinence, prior radiation, focal therapy, or androgen deprivation therapy for prostate cancer. ABNT was reconducted with a U-shaped flap from the anterior wall of the bladder neck, and was then anastomosed with the urethra. In the control group, the bladder outlet was directly anastomosed with the urethra. Continence, as defined if 0 pads were used per day and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score ≤6, was assessed at 1, 4, 8, 12, and 24 weeks after catheter removal. At 2 weeks after catheter removal, urethral pressure profilometry (UPP) and upright urethrography were performed to evaluate the function of ABNT in the ABNT group.
More patients in the ABNT group were continent than those in the control group at 1 week (85.2% 22.9%, P<0.001), 4 weeks (91.4% 27.1%, P<0.001), 8 weeks (95.2% 40.6%, P<0.001), 12 weeks (100% 71.9%, P<0.001), and at 24 weeks (100% 87.5%, P<0.001) after catheter removal. Stricture was presented in 5.2% and 2.1% (P=0.34) in the ABNT group and control group, respectively. UPP showed that a functional IUS was reconstructed with ABNT. Upright urethrography showed that the ABNT was filled with contrast medium in the urination period and with no contrast medium during the storage period and interruption of urination.
The ABNT technique significantly improved early return of continence in comparison with the no ABNT technique, especially the immediate continence. The ABNT technique reconstructed the functional IUS with acceptable urethral stricture. The limitations of the present study include that the comparison was conducted retrospectively with a historical cohort and lack of randomization, and the single center setting. A prospective, randomized, and multicenter evaluation is expected.
近年来，尽管已应用多种手术技术，但根治性前列腺切除术（RP）后早期尿失禁发生率仍居高不下。在本研究中，我们采用膀胱颈前管（ABNT）重建尿道内括约肌（IUS），以改善控尿功能的早期恢复，并寻找一种更有效的RP术后早期尿失禁治疗技术。
本研究将2018年10月至2020年5月期间96例未接受ABNT的既往患者作为历史对照（对照组）。2020年5月至2023年2月期间，共有210例连续患者接受了机器人或腹腔镜下ABNT辅助的RP手术（ABNT组）。纳入标准包括东部肿瘤协作组（ECOG）评分为0 - 1分且为局限性前列腺癌（临床分期cT1 - 3、cN0、cM0）。排除标准包括患有糖尿病、神经系统疾病、既往盆腔手术史、尿失禁症状、既往放疗、局部治疗或前列腺癌雄激素剥夺治疗的患者。采用膀胱颈前壁的U形皮瓣重建ABNT，然后与尿道吻合。对照组则将膀胱出口直接与尿道吻合。拔除导尿管后1、4、8、12和24周评估控尿情况，定义为每日使用尿垫数为0且国际尿失禁咨询委员会简表（ICIQ - SF）评分≤6。在拔除导尿管后2周，对ABNT组患者进行尿道压力测定（UPP）和直立尿道造影，以评估ABNT的功能。
ABNT组在拔除导尿管后1周（85.2%对22.9%，P < 0.001）、4周（91.4%对27.1%，P < 0.001）、8周（95.2%对40.6%，P < 0.001）、12周（100%对71.9%，P < 0.001）和24周（100%对87.5%，P < 0.001）时，控尿患者均多于对照组。ABNT组和对照组尿道狭窄发生率分别为5.2%和2.1%（P = 0.34）。UPP显示ABNT重建了功能性IUS。直立尿道造影显示，排尿期ABNT内充满造影剂，储尿期及排尿中断时无造影剂。
与未使用ABNT技术相比，ABNT技术显著改善了控尿功能的早期恢复，尤其是即刻控尿。ABNT技术重建了功能性IUS，尿道狭窄发生率可接受。本研究的局限性在于采用历史队列进行回顾性比较且缺乏随机分组，以及为单中心研究。期待进行前瞻性、随机、多中心评估。
