URETHRAL PRESERVATION AND ANASTOMOTIC TECHNIQUE DURING OPEN ANTEGRADE RADICAL PROSTATECTOMY: FUNCTIONAL AND ONCOLOGICAL RESULTS

Aim of the study: The aim of the study is to present our technique of urethral preservation and vesico-urethral anastomosis during open antegrade radical retropubic prostatectomy (ARRP) in a series of 936 consecutive patients (pts) evaluating functional and oncological outcome. Material and methods: From January 2000 to December 2008, 936 pts underwent radical prostatectomy for clinically localized prostate cancer. Mean age (range) was 65.2 (42 78) years. The first step of our technique is the dissection of vesicoprostatic junction preserving completely the bladder neck. Once posterolateral neurovascular bundles are dissected or resected, cranial traction of the completely mobilized prostate allows an excellent visualization of the apex and urethral sphincter; at this point urethra can be transected at its origin from prostatic boundaries. Vesico-urethral anastomosis is created using four sutures of 3/0 Polysorb® around a Foley 18 Fr catheter after mucosal eversion of bladder neck and its approximation to the posteroinferior margin of detrusor and perivesical fascia. Catheter is usually removed on postoperative day 10. Results: Mean follow-up (SD, median, range) was 54.7 months (27.6; 51; 16 121). Of the 936 pts, 55 (5.9%) with lymph nodes metastasis at definitive histopathological examination were addressed to early adjuvant therapy and excluded from survival analysis. Tumoral involvement of apex was found in 625/881 (70.9%) cases, while apical positive surgical margins were discovered in 42/625 (6.72%) pts. Of those, 15 (35.7%) developed biochemical recurrence. Overall 892 (95.3%) pts completely fulfilled our continence criteria (no pads) at a minimum follow-up of 12 months; 16 (1.7%) pts developed mid stress incontinence (1 pad/die), while 22 (3.0%) pts used 2-3 pad/die. Continence rates obtained at catheter removal and at 1,3,6,12 months were 54.9% (514/936), 73.5% (688/936), 87.5% (819/936), 93.8% (878/936) and 95.3% (892/936) respectively. Overall 4 pts (0.4%) developed anastomotic contracture at mean 6.5 (5-9) months: of those, 2 pts were non nerve-sparing radical prostatectomized, 1 monolateral and 1 bilateral nervesparing (p=NS). All those pts were treated by endoscopic cold incision of anastomotic stricture: 1 pts developed mid urinary incontinence after endoscopic treatment; at a mean follow-up of 27.7 (15-47) months 3 patients were continent and without signs of obstruction at uroflowmetry. Conclusion: Our antegrade technique allows an excellent definition of prostatic apex preserving the striated sphincter and saving the maximum of urethra with low risk of leaving prostatic tissue in situ. Contextual respect of anatomical boundaries of bladder neck and the mucosal eversion in creating anastomosis were found to be fundamental in prevention of anastomotic contracture