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Background Urinary continence recovery after radical prostatectomy is a major issue even in the robotic era. Surgical techniques aimed at improving earlier return to continence are continuously sought. Objective To describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy (RARP) and to assess early urinary continence recovery and perioperative complications. Design, setting, and participants A prospective, single-center, single-surgeon cohort of 70 consecutive patients undergoing RARP between January and December 2019 was analyzed. A study group of 35 patients operated on with the urethral fixation technique was compared with a control group of 35 patients receiving standard vesicourethral anastomosis. Surgical procedure Urethral fixation versus standard vesicourethral anastomosis during RARP was evaluated. In the study group, the urethral stump was fixed to the dorsal median raphe posteriorly and to the medial portion of the levator ani muscle posterolaterally. The same posterior musculofascial reconstruction incorporating the vesicourethral anastomosis was performed in both groups. Measurements Urinary continence recovery, perioperative complications, operating room time, and estimated blood loss were recorded and compared between the two groups. Results and limitations The two groups were comparable with regard to all demographic, clinical, and pathological variables. Recovery of urinary continence at 3 mo after catheter removal was reported by 34 (97.1%) patients in the study and 28 (80%) patients in the control group (p = 0.02). Patients in the study group reported significantly higher rates of urinary continence even at 1 wk and 1 mo after catheter removal compared with the control group (68.6% vs 45.7%, p = 0.04, and 80% vs 54.3%, p = 0.04, respectively). No differences were observed in operating room time (p = 0.7) or estimated blood loss (p = 0.65). Ninety-day postoperative complications were observed in one (2.9%) patient in the study and in four (11.4%) in the control group (p = 0.3). The main limitation is the nonrandomized comparison of relatively small cohorts. Conclusions In our study, we observed a significant improvement in early urinary continence recovery, with no increase in operating room time or perioperative complications, using the novel urethral fixation technique compared with the standard vesicourethral anastomosis during RARP. Patient summary We describe our novel surgical technique of urethral fixation during robot-assisted radical prostatectomy. Compared with the standard technique, utilization of our technique was found to be associated with an improved early recovery of urinary continence, with no increase in operating room time or perioperative complications.

ContextMembranous urethral length (MUL) measured prior to radical prostatectomy (RP) has been identified as a factor that is associated with the recovery of continence following surgery.ObjectiveTo undertake a systematic review and meta-analysis of all studies reporting the effect of MUL on the recovery of continence following RP.Evidence acquisitionA comprehensive search of PubMed, EMBASE, and Scopus databases up to September 2015 was performed. Thirteen studies comprising one randomized controlled trial and 12 cohort studies were selected for inclusion.Evidence synthesisFour studies (1738 patients) that reported hazard ratio results. Every extra millimeter (mm) of MUL was associated with a faster return to continence (hazard ratio: 1.05; 95% confidence interval [CI]: 1.02–1.08, p

Background The precise relationship of the structures dorsal to the membranous urethra, including the rectourethralis muscle, the rhabdosphincter, the deep transverse perineal muscle (DTPM), the perineal body, and Denonvillier's fascia, remains controversial. Objective Our aim was to reexamine the detailed anatomy of the rectourethralis muscle and the deep transverse perineal muscle and their relationship with adjacent structures. Design, setting, and participants The pelvic viscera, including bladder, prostate, and rectum, were obtained from 20 formalin-fixed adult male cadavers. Measurements The pelvic viscera were embedded in celloidin and then cut into successive slices with an immersing-alcohol microtome. All slices were explored with anatomic microscopy. Results and limitations The longitudinal muscle of the anterior rectal wall was divided into anterior and posterior bundles at the junction of the rectum and anal canal. The intermediate fibers of the anterior bundle ended at the perineal body. The lateral fibers of the anterior bundle terminated at the posterior connective tissue of the bulbus penis. The DTPM occupied the space between the rhabdosphincter, rectum, and the bilateral levator ani muscle. Denonvillier's fascia terminated at the junction of the prostate and rhabdosphincter. Numerous slender nerves coming from the neurovascular bundle perforated the DTPM. Conclusions The anterior bundle of the longitudinal muscle of the rectum inserts into the bulbus penis forming the rectourethralis muscle and ends at the perineal body forming the rectoperinealis muscle. The anterior bundle and DTPM together may contribute to the rectal angle of the anterior rectal wall, and they support the posterior border of the rhabdosphincter.

Spheroidal bladder substitutes made from double-folded ileal segments, similar to Goodwin's cup-patch technique, are devoid of major coordinated wall contractions. This, together with the reservoir's direct anastomosis to the membranous urethra, prevents major intraluminal pressure peaks and assures a residue-free voiding of sterile urine. In order to determine whether, under these conditions, an afferent tubular isoperistaltic ileal segment of 20-cm length protects the upper urinary tract as efficiently as an antireflux nipple, 60 male patients who were subjected to radical cystectomy were prospectively randomised to groups in which a bladder substitute was formed together with either of these 2 antireflux devices. An analysis of the results obtained in 20 patients from each group who could be followed for more than 1 year (median observation time 30 and 36 months) showed no differences between the groups in metabolic disturbances, kidney size, reservoir capacity, diurnal and nocturnal urinary continence, the incidence of urinary tract infection or episodes of acute pyelonephritis. Later than 1 year postoperatively, intravenous urograms of the renoureteral units of 25% of the patients with antireflux nipples showed persistent but generally slight dilatation of the upper urinary tracts. This observation was significantly more frequent than it was in patients with afferent tubular segments. Urodynamic and radiographic studies showed that the competence of the antireflux nipples was secured by the raised surrounding intravesical pressure. This, however, also resulted in a transient functional obstruction, and a gradual rise of the basal pressure in the upper urinary tracts was recorded. In patients with afferent ileal tubular segments, contrast medium could be forced upwards into the renal pelvis when the bladder substitutes were overfilled. However, despite raised intravesical pressures, peristalsis in the isoperistaltic afferent tubular segment gradually returned contrast medium back to the reservoir. Our results suggest that the combination of an ileal low-pressure reservoir together with an afferent tubular isoperistaltic limb is at least as good as an antireflux nipple valve. Moreover, the use of the afferent ileal limb makes it possible to resect the distal and often diseased ureters together with the paraureteric lymphatics at a safe distance from the bladder tumor. This avoids also distal ischemic ureteric stenosis and makes possible a simple end-to-side ureterointestinal anastomosis with a small complication rate.

Objectives: To describe a technique for open nerve-sparing radical retropubic prostatectomy. Methods: The technique basically implies incising the levator and prostatic fasciae high anteriorly (1 and 11 o'clock positions) over the prostate, developing the plane between the prostatic capsule and prostatic fascia, and displacing the neurovascular network localized between the two fasciae laterally. This allows for a minimal-touch dissection of the external urethral sphincter and a very efficient dissection of the neurovascular bundles at the level of membranous urethra and prostatic apex. Results: Forty-two patients underwent a bilateral nerve-sparing operation and were followed-up for 6 months. Six patients (14.3%) had positive margins: 4 patients had pT2 disease (in all, the positive margin was monofocal) and 2 patients had pT3 disease (both had multifocal positive margins). Continence (defined as being dry or having one pad remain dry for 24 hours) was achieved in 44% of patients at catheter removal, and in 60%, 72%, and 90% of patients at the 1-, 3-, and 6-month follow-up visits. Potency (defined as an erectile function domain score >= 26) was obtained in 15%, 40%, and 52% of patients at the 1-, 3-, and 6-month follow-up visits. All patients used a PDE5-inhibitor during the investigation period. Conclusions: These preliminary results suggest that the high incision of the levator and prostatic fasciae may facilitate efficient preservation of the external urethral sphincter and the neurovascular bundles innervating the corpora cavernosa and the sphincter. (c) 2005 Elsevier B.V. All rights reserved.

In visual reconstructions, as contained in their remarkable figures, Alsaid and coworkers [1] used computer-aided anatomic ‘‘dissection’’ (CAAD) to follow the nerve fibers distally beyond the prostate apex, finding an anterior division destined for the corpora cavernosa and a posterior division entering the corpus spongiosum. Multiple sequential axial sectionswere obtained from the level of the seminal vesicles to the penis. They stained the sectionswith the silver stain for nerves (S-100), and then they used the computer to sum all the sections to reconstruct the course of the nerves three-dimensionally as they proceeded distally. With this method, identification of a split in nerve-fiber direction was possible. The points of termination beyond the apex of the prostate included an anterior group or division associated with the corpora cavernosa and dorsal sensory nerve of the penis and aposterior division entering the superior surface of the bulb of the penis, or corpus spongiosum. From a physiologic standpoint, just exactly how autonomic nerves of each neurovascular bundle (NVB) [2] heading distally interact and coordinate function, beyond the final result of producing an erection when stimulated, is not precisely clear. ‘‘Pro-erectile’’ nerves accompany other autonomic nerves within the NVBs that depart along the way to innervate seminal vesicles, vasa deferentia, bladder, rectum, and membranous urethra [3]. Some nerves at the apex of the prostate are parasympathetic; some are sympathetic [4]. What then becomes more complicated are concepts such as sympathetic nerves that are not adrenergic, as expected, but cholinergic with vasodilatory potential. To further complicate matters anteriorly at and beyond the penile hilum, there are proven visible neural connections with the dorsal sensory nerve of the penis where direct cavernous nerve penetration begins and proceeds distally [5]. The current study [1] confirms, during radical prostatectomy, the concept of anterior fascial and nerve preservation

The authors describe an anatomical study of total cystoprostatectomy. They show that Denonvilliers' fascia is made up of many membranous layers starting at the bladder. They recall the fact that the preprostatic veins are attached at the bottom, not only to the venae dorsales penis, but also to the venae pudendae internae which runs under the levator ani muscle. These preprostatic veins lie inside a vessel-bearing blade of tissue made of muscular and collagenous tissue derived from the anterior vesical wall. This anatomical study recalls the fact that the interprostatorectal dissection line is behind Denonvilliers' fascia and that the preprostatic vein dissection line is on the anterior aspect of the membranous urethra.

A new type of silicone rubber catheter with two balloons and four channels is introduced for the treatment of chronic bacterial prostatitis. Through this specially conceived catheter, a drug can be instilled in the posterior urethra, the two balloons blocking the drug from passing either into the bladder or the membranous urethra. Treatment has been applied in 212 cases of chronic bacterial prostatitis with very good results.