Radikal Pertineal Prostatektomi Erken Kontinans 120 Olgudaki Sonuçlar
Radical perineal prostatectomy and early continence:
Our results in 120 cases
Albayrak S.; Göktaş C.; Çetinel C.; Canguven Ö.; Horuz R.; Aydemir H.
Dr. Lütfi Kırdar Kartal Education Hospital - Istanbul / TURKEY
ABSTRACT
AIM:
We evaluated the results of early urinary continence on 120 patients undergone radical perineal prostatectomy (RPP) with the diagnosis of localized prostate cancer.
MATERIALS AND METHODS:
We analyzed the continence data of 120 patients undergone RPP between April 2003 and October 2008 in our clinic; with pathology of cT1-cT2N0M0 prostate cancer. Continence was assessed on the day of catheter removal; and at the end of first and third months postoperatively. The data of patients at the end of first year also evaluated. The patients who were continent immediately after catheter removal were classified in the group of “immediate complete continence”; while the patients who became continent during 1-3 months postoperatively were classified as “early complete continence”. In order to see whether the learning curve alters the results of continence; we comparatively analyzed the groups of first; middle and last ten patients of the study. Relationship between the age and continence status was evaluated separately in 4 different age-groups; namely groups of ≤ 49; 50–59; 60–69 and ≥ 70 years old patients.
RESULTS:
Mean duration of catheterization was 10 (10-25) days. Of 120 patients; 44 (36;7%) were completely continent on the day of catheter removal; 65 (54;1%) at the end of first month; and 87 (72;5%) at the end of third month; with use of no pad. At the end of one year follow up 94% of 107 cases; whose 1-year follow up data was available; were completely continent. In the group of first ten patients; immediate complete continence rate was 20% (n=2); and complete continence rate after three months was 40% (n=4). These rates were 30% (n=3) and 70% (n=7) in the middle group; and 70% (n=7) and 90% (n=9) in the last group; respectively. When the relationship between patient s age and continence was analyzed; it was found that the early continence rates were 77;7%; 73;3%; 73;4% and 64;7% in the groups of patients of ≤ 49; 50-59; 60-69; and ≥ 70 years; respectively.
CONCLUSION:
A surgical technique in the treatment of prostate cancer should have perfect functional results in addition to good oncological results. Therefore; RPP is a feasible modality offering considerable early continence results.
Keywords: Early continence; prostate cancer; radical perineal prostatectomy
INTRODUCTION
Table 1: The definitions used in study
Age (mean)
62 (48-75)
PSA (mean; ng/ml)
7.4 (1.5-19.8)
Clinical stage
Table 3: Relation between the age and early continence
Since the patients always seek less invasive and less morbid therapeutic options; and the financial sources supplying the health all around the world tend to support therapeutic modalities resulting in shorter hospitalization and early recovery; interest for radical perineal prostatectomy (RPP) has increased again in recent years. When compared to retropubic approach; laparoscopic; or robotic assisted radical retropubic prostatectomy (RRP) procedures have advantageous outcome data in regarding duration of hospitalization; loss of blood; time needed to recover from the disease and returning to normal daily life. 1 However; these advantages may also be offered by radical perineal prostatectomy; and RPP has some additional advantages such as lesser cost; shorter duration of operation and faster training course. Today; RPP has become a more attractive approach as it has not only good oncological results but also better functional results owing to the facts that a RPP procedure; by providing a clear exposure; preserves the integrity of Santorini’s venous plexus; has lesser chance to cause a surgical injury on accessory pudental arteries; and makes a faultless apical dissection and urethrovesical anastomosis possible.
For long years; postoperative urinary incontinence has been a major factor dissuading urologists and patients from choosing radical prostatectomy (RP) as a therapeutic option. Post-RP incontinence rates vary in the literature. Postoperative urinary incontinence rates have been decreased with the opportunity of being able to detect the disease in relatively early stages and of developed techniques. On the other hand; since the RP numbers are constantly increasing all over the world; the prevalence of post-prostatectomy incontinence have been probably increased.2 In many published literature there is no significant difference in the rates of urinary incontinence between the patients undergone RPP or RRP.3 However the number of studies comparing RPP with other techniques from the point of early incontinence is limited.
In this study; we evaluate early incontinence data of our localized prostate cancer cases undergone RPP.
PATIENTS AND METHODS
We evaluated early incontinence results of 120 RPP patients operated in our clinic between March 2003 and October 2008 with the diagnosis of localized prostate cancer. The patients whose prostate volume were <60 ml; Gleason Score ≤7 (3+4)/10; and PSA level <10 ng/ml were accepted as eligible for RPP. Particularly; morbidly obese patients and those with an history of operation on lower abdominal region were selected for RPP. Partin’s nomogram was used to predict the status of pelvic nodal metastasis. The patients with a probability of nodal metastasis of >5% were excluded from RPP group. Of the patients with a significant risk of pelvic node metastasis; those in whom retropubic approach was considered to be difficult underwent laparoscopic pelvic lymph node dissection; and RPP was performed in the patients whose lymph nodes were reported as negative.
RPP was performed through Belt’s sub-sphincteric route and; whenever possible; uni- or bilateral nerve sparing techniques were applied in eligible patients. In the last 8 patients; the dissection of prostato-vesical junction was achieved under the assistance of endoscopy. Urethrovesical anastomosis was done with using 4/0 double-needle PDS sutures; starting from the point of 6 o’clock and continuing on either direction toward 12 o’clock; in U-shaped manner.
Catheters were removed on the 12th (10-25) day of the operations. Continence was evaluated on the day of catheter removal; and at the end of 1st and 3rd months. Complete continence was defined as no use of pad. The patients that were continent on the day of catheter removal were defined as “immediately continent”; those who became continent in the first 3 months classified as “early continent” (Table 1).
In order to assess a possible relationship between continence rates and surgical experience; 3 different groups were selected according to the date of operation; the first; middle and last 10 patients of the study process. Continence rates of these groups were comparatively analyzed as markers representing surgical learning curve.
In addition; continence status of the patients was analyzed according to different age groups in order to evaluate a possible relationship between the patient age and continence rate. Age groups were classified as ≤49; 50-59; 60-69; and ≥70 years.
RESULTS
In 120 RPP patients the mean age was 62 (48-75) years and the mean PSA level was 7;4 (1;5-21) ng/ml. Of 120 patients; clinical stage was cT1a in 1 (0;8%); cT1c in 100 (83;3%); cT2 in 19 (15;8%). The average of Gleason Score of patients was 6 (4-7)/10.
Mean duration of operation was 120 (90-270) minutes. While nerve sparing technique was applied in 73 (60;8%) as bilateral and 12 (10%) as unilateral; non-nerve sparing technique was used in 35 patients (29;2%). Mean duration of hospitalization was 2;8 (1-8) days; and catheter indwelling time was 10 (10-25) days. Demographic and clinical features of the patients are presented in Table 2.
Forty-four of the patients (36;7%) had immediate complete continence. Although there was not any degree of incontinence; 13 of these 44 patients had used pad for a few days as an unnecessary precaution. At the end of first month; 65 patients (54;1%) became early complete continent. It was seen that 87 of the patients (72;5%) had early complete continence by the end of 3rd month with no use of pad. Evaluation of the relationship between the patients age and continence status revealed that the early continence rates were 77;7%; 73;3%; 73;4% and 64;7% in ≤49; 50-50; 60-69 and ≥70 years age groups; respectively. Data showing the relation between continence status and age is shown on Table 3.
The patient groups which were designated to be used in the evaluation of a possible relationship between continence and surgical experience; in other words the effect of learning curve; were analyzed comparatively; and it was found that the immediate and 3rd month early continence rates were 20% (n=2) and 40% (n=4) in first 10 patients; 30% (n=3) and 70% (n=7) in the middle group; and 70% (n=7) and 90% (n=9) in the last group; respectively. Effect of learning curve on continence rates is shown on Table 4 and Figure 1.
DISCUSSION
Despite the fact that the male perineal anatomy and the mechanism of urinary continence have unique features that may not easily be understood; there are limited numbers of studies about this surgical anatomy in the literature. The lack of detailed studies focused on this confusing anatomy may be an explanation of why the most of urologists refrain using perineal approach for radical prostatectomy.
However; with the use of perineal approach; certain important anatomical structures located on the anterior of the prostate can be preserved from surgical trauma. The integrity of Santorini’s venous plexus is not destructed; and the risk of injuring accessory pudental arteries is minimized. The fibers of external urinary sphincter originate dorsally from a point very near to bladder neck; and encircle inferior half of the urethra in a U-shape at the level of end of the prostatic apex (Figure 2). So; at this level; the amount of of external sphincteric fibers on the posterior aspect of prostate is less. Such an anatomic structure may represent an advantage of RPP from the point of continence rates; because a surgeon approaches to the apex firstly from posterior in RPP.
Another muscle responsible for continence is compressor urethral muscle. This muscle is sometimes known as external urethral sphincter. It covers only the upper half of urethra in ∩-shape; leaving inferior of the urethra bare; and extends to the perineal bodies on both sides.4;5 Although this anatomical details continue to remain unclear and mysterious; one may accept that the best approach to the prostate without causing any harm in sphincteric unit appears to be the perineal route.
Lesser rates of urinary incontinence after RPP may be explained with several advantageous anatomosurgical features. First of all; since external sphincter leans against the anterior of prostate and extends on membranous urethra anteriorly in ∩-shape; and since RPP approaches this structures from rectal side; this technique has higher chance in preserving continence. Secondly; the most critical region of the continence mechanism; the prostatic apex; is located in a relatively closer plane to the surgeon; and this location makes apical dissection on rectal aspect possible by giving an opportunity of a safe window of exposure. When this anatomical relations of the structures of continence are remembered; we may conclude that the sphincteric unit and compressor urethral muscle can be protected from surgical trauma more easily in RPP technique when compared to others.
In addition to difficulties during dissection; an effort to make an anastomosis in an insufficient exposure also carries a risk of that the fibers of external sphincter may be compressed under anastomotic suture line. If it occurs; external sphincter may loose its strength required to obstruct urethra. While one may commonly encounter this situation during either retropubic or laparoscopic techniques; this risk is largely eliminated by perineal approach. On the other hand; robotic surgery has also favorable early urinary continence rates by the means of a safe anastomosis performed with robotic arms under a 3D and enlarged view.6;7
When the continence results of different radical prostatectomy techniques are compared; it is seen that the perineal approach provides favorable outcomes.8-11 This is; of course; not an incidental finding; and; as the technique develops; the results will continue to get even better. Surgical experience is directly related with early continence rates in perineal technique. However; when compared to other techniques; training course is shorter.12;13 In RPP; the mean duration between the catheter removal and continence is also considerably shorter than that of other two techniques.14 This result may be interpreted as that the overall surgical trauma on external sphincter and motor nerves is probably less in RPP.
In order to evaluate the degree of continence; we utilized the use of pad as a parameter. However; with an intent to get a precaution against a possible dripping; several patients had unnecessarily used pads for a few days in spite the fact that there was no; even minimal; incontinence. On the other hand; some of the patients had not used pad despite of some degree of incontinence. These variations may partly explain the differences in the literature relating with the post-prostatectomy incontinence. When a questionnaire will be applied to the patients for incontinence; these factors should be taken into account.
There are some well known risk factors for post-prostatectomy urinary incontinence. Particularly the age of patient; history of TURP; technique of prostatectomy performed; experience of the surgeon; and the extent of the disease are the major determinants of urinary incontinence rates after prostatectomy.15;16
Age of the patient is an important risk factor in post-prostatectomy incontinence.15;17;18 With increasing age; atrophy and neuronal degeneration occurs in rhabdo-sphincteric muscle.19-21 Urinary incontinence frequency is higher in population over the ages of 70 years. In our study; while the rate of early continence was 64;7%; the percentage of “immediately complete continent” patients was only 11;8%; among the 17 patients with age of ≥70 years. On the other hand; in relatively young patients (≤49 years) these rates were 77;7% and 22;2%; respectively.
In large scale studies; no direct relationship has been detected between stage of the disease and continence status.18;22 When the stage is advanced or non-nerve sparing surgery is performed; incontinence rates may be higher. But this result is related with the surgical technique rather than the stage of the disease itself. In the findings of our study; while there was no relation between the stage and continence; early continence rates were 79;4% in the patients of bilateral nerve sparing technique; and 58;3% in unilateral technique. In the group of the patients in whom non-nerve sparing technique was performed; early continence rate was found 54;2%. It was seen that there was a statistically significant difference in continence rate of bilateral nerve sparing technique compared to unilateral or non-nerve sparing techniques (Chi square; p<0;05).
RPP preserves the continence by the mean of its unique anatomosurgical advantages. In RPP apical dissection is made under a better exposure. Since approach to the membranous urethra is from rectal side; there is very low risk of damaging sphincteric unit. After division of membranous urethra; traction of the previously placed Foley catheter should be made in a direction toward bladder neck; not to the surgeon himself. In addition; during the stage of division of Foley; if the surgeon pulls the catheter by forcing the membranous urethra; anatomical structures around the urethra and; so the related continence mechanism; may be damaged. This may result in a detrimental effect on postoperative continence. For that reason; during traction and division of Foley catheter; it should always be pulled with a direction which is particularly safe for membranous urethra; and excessive traction should be avoided.
Excessive traction of the catheter or extensive dissections around apex may cause injury on rhabdo-sphincter. After the prostate is removed; while the surgeon prepares vesico-urethral anastomosis plane by inserting a catheter into the bladder transurethrally; if the catheter spontaneously directs to the bladder neck after leaving the cut end of membranous urethra; it may represent that the integrity of sphincteric unit could be preserved. This may also be accepted as a perioperative predictor of immediate or early continence; because when we reviewed the video records of the cases with immediate/early continence; we constantly recognized this finding.
It is well known that the surgical experience influences postoperative incontinence rates. In many of the related studies; authors have found that the surgical experience and the technical refinements cause a decrease in incontinence rates.23;24 With an aim to evaluate the effects of surgical experience on continence; we selected 3 groups each consisting 10 patients; chronologically first; middle; and last 10 patients of the study. When incontinence status evaluated in this 3 groups; we found that the immediate and early continence rates were as high as 70% (n=7) and 90% (n=9); respectively; in the last group.
CONCLUSION
A valuable therapeutic modality in localized prostate cancer should have not only excellent oncologic results but also flawless functional results. From this point of view; RPP is a good therapeutic option for this group of patients with its “complete urinary continence” results in early postoperative period; as well as on the day of catheter removal.
Table 1: The definitions used in study
Status
Definition
Complete continence on the day of catheter removal
Immediate complete continence
Complete continence at the end of 3rd month
Early complete continence
* No pad use; complete continence
Table 2: Data of 120 localized prostate cancer patients undergone RPP
n:120
Mean
Preoperative dataAge (mean)
62 (48-75)
PSA (mean; ng/ml)
7.4 (1.5-19.8)
Clinical stage
cT1a
1 (%0.8)
cT1c
100 (%83.3)
cT2
19 (%15.8)
>cT2
-
Perioperative dataDuration of operation (mean; minutes)
120 (90-270)
Nerve sparing
Bilateral
73 (%60.8)
Unilateral
12 (%10)
Non-
35 (%29.2)
Complications
Blood loss (ml)
338 (100-1500)
Rectal injury (%)
3 (2.5)
Postoperative dataPostoperative hospitalization (day)
2.8 (1-8)
TU kateterizasyon (day)
10 (10-25)
Drainage (day)
1.9 (1-18)
Prolonged drainage (n)
2 (1;7)
Pathological stage
pT0
2 (%1.7)
pT2
103 (%85.8)
pT3
14 (%11.7)
pT4
1 (%0.8)
Surgical margin positivity
11 (%9.1)
Table 3: Relation between the age and early continence
Range of age
Total
≤49 yrs
n:9(%)
50-59 yrs
n:45(%)
60-69 yrs
n:49(%)
70≥ yrs
n:17(%)
n:120 (%)
Immediate complete continence
2 (22.2)
22 (48.8)