Levy J B, Ramchandani P, Berlin J W, Broderick G A, Wein A J
Department of Radiology and Urology, University of Pennsylvania, Philadelphia.
Urology. 1994 Dec;44(6):888-92. doi: 10.1016/s0090-4295(94)80176-2.
To explore how the occurrence of vesicourethral anastomotic strictures (bladder neck contractures [BNC]) following radical prostatectomy was dependent on these variables: postoperative urine extravasation, type of anastomosis, size of prostate, and surgical approach.
We retrospectively reviewed 143 cases over 36 months for the occurrence of early BNC (6 to 12 months follow-up). Voiding cystourethrograms (VCUC) were performed in all patients at 3 weeks. Radical retropubic prostatectomy (RRP) with direct anastomosis was performed in 93 cases, RRP and Vest anastomosis in 35 cases, and radical perineal prostatectomy (RPP) in 15 cases.
The overall incidence of extravasation was 14.1%. Procedure-specific rates of incidence of extravasation were RPP 33.3%, RRP 18.1%, and radical retropubic with Vest anastomosis (Vest) 6.1%. Mean prostate weight was not significantly different between patients with or without extravasation. The anastomotic site was classified as being irregular (plicated) or smooth in appearance on the VCUG images. An irregular appearance was noted among 81% of the RRP, 42.4% of the Vest, and 40% of the RPP. Bladder neck contractures occurred in 29% of patients with Vest anastomosis, 14.1% with RRP, and none of the patients undergoing RPP. Only 1 patient in both the Vest and RRP group who experienced BNC was noted to have extravasation on VCUG at 3 weeks.
We have noted that the type of anastomosis (Vest traction sutures) significantly increases the likelihood of early bladder neck contracture following radical prostatectomy. The presence of contrast extravasation on the postoperative VCUG study (implying urinary extravasation) did not influence the formation of an anastomotic stricture as long as patients were maintained with catheter drainage until resolution of extravasation. The appearance of the newly constructed bladder neck on the postoperative VCUG image was not predictive of a subsequent contracture.
探讨根治性前列腺切除术后膀胱尿道吻合口狭窄（膀胱颈挛缩[BNC]）的发生如何取决于以下变量：术后尿外渗、吻合方式、前列腺大小和手术入路。
我们回顾性分析了36个月内143例患者早期BNC的发生情况（随访6至12个月）。所有患者在3周时均进行了排尿性膀胱尿道造影（VCUG）。93例行耻骨后根治性前列腺切除术（RRP）并直接吻合，35例行RRP和Vest吻合，15例行会阴根治性前列腺切除术（RPP）。
尿外渗的总体发生率为14.1%。各手术方式的尿外渗发生率分别为：RPP 33.3%，RRP 18.1%，耻骨后根治性前列腺切除术联合Vest吻合（Vest）6.1%。有或无尿外渗患者的平均前列腺重量无显著差异。根据VCUG图像，吻合口部位外观分为不规则（有褶皱）或光滑。RRP患者中81%、Vest患者中42.4%、RPP患者中40%的吻合口外观不规则。Vest吻合患者中29%发生膀胱颈挛缩，RRP患者中14.1%发生膀胱颈挛缩，RPP患者均未发生。Vest组和RRP组中仅1例发生BNC的患者在3周时的VCUG检查发现有尿外渗。
我们注意到，吻合方式（Vest牵引缝线）显著增加了根治性前列腺切除术后早期膀胱颈挛缩的可能性。只要患者持续留置导尿管引流直至尿外渗消退，术后VCUG检查出现造影剂外渗（提示尿外渗）并不影响吻合口狭窄的形成。术后VCUG图像上新构建的膀胱颈外观不能预测随后的挛缩。
