Bladder neck preservation during classic laparoscopic radical prostatectomy - point of technique and preliminary results.

Abstract

IntroductionStress urinary incontinence after radical prostatectomy for prostate cancer organ-confined patients can significantly affect quality of life. The article presents a technique of bladder neck preservation, because it is believed that this point is one of many crucial points responsible for fast recovery of continence after laparoscopic radical prostatectomy (LRP).Material and methodsLaparoscopic radical prostatectomy with the intention of bladder neck preservation was performed in 194 patients of clinically organ-confined prostate cancer (cT2 ≤ N0M0). The working space was done by tissues-fingers dissections and insufflation of the cavity under full visual control, without the Gaur-balloon device. We insert two 10 mm trocars, three trocars of 5 mm and both 0° and 30° laparoscopes. The most important points of technique include: identification of landmarks of bladder neck and prostate base; dissection of muscle fibres of the very superficial bladder wall; mobilization of the posterior part of the urethra and simultaneous seminal vesicles release; neuro-vascular bundles preservation. This procedure resulted in a long bladder neck which can be easily anastomosed with the urethra. Tension-free and end-to-end (bladder neck-urethra) anastomosis are the results.ResultsIn all cases radical prostatectomy was performed laparoscopically in the extraperitoneal space. There were no complications of bladder neck preservation during laparoscopic radical prostatectomy (LRP) apart from 22 cases with a large medium lobe. The mean time of operation was 150 min (110-210 min). The mean blood loss during LRP was 150 ml (110-350 ml). Blood transfusion was not necessary. There were no postoperative complications. Mean hospitalization time was 5 days. Pathological result of the postoperative specimens was pT2a in 30%, pT2b in 60%, pT3a in 6%, and pT3b in 4% of patients. In 7% of patients a positive surgical margin was affirmed, but the bladder neck was not affected in any case. Full continence after 3, 6, and 12 months was observed in 75%, 85%, and 92% of analysed patients, respectively.ConclusionsBladder neck preservation during LRP is an effective, safe procedure that offers good functional results based on fast recovery of continence. Bladder neck preservation offers full tight anastomosis, especially in cases with no large median lobe of prostatic adenoma. Continence of patients who underwent bladder neck preservation was improved during short-term follow-up. Long-term results are still not conclusive. We think that this technique applied to laparoscopy will finally result in real progress of continence preservation after radical prostatectomy, but larger groups of patients have to be compared.

Single Running Suture versus Single-Knot Running Suture for Vesicourethral Anastomosis in Laparoscopic Radical Prostatectomy: A Prospective Randomised Comparative Study

“…It has to be noted that in this study, we preserved the bladder neck using our own technique in all patients to avoid a potential bias that could have affected the analysis of continence outcomes [13,14]. Sparing of bladder neck has been associated with better functional outcomes after surgery due to a lower risk of urethral injury and bladder neck stricture [24,25,26].…”

“…The pre-study second surgeon's experience included 611 LRP cases, with 203 VUA cases performed using the Van Velthoven method. In all cases, a bladder neck preservation technique was applied with a bladder neck circumference approximating the urethral stump before anastomosis, as previously described [13,14]. …”

Male Stress Urinary Incontinence Following Surgical Intervention: Procedures, Technical Modifications, and Patient Considerations

“…Rates of full continence in laparoscopic patient series with bladder neck sparing have been reported for 75 %, 85 %, and 92 % of patients after 3, 6, and 12 months follow-up, respectively [ 90 ]. Retrospective studies on bladder neck preservation have confi rmed good functional outcomes, but have also reported high rates (29.2 %) of positive surgical margins in one single center study for bladder neck preserving technique, a concerning fi nding for acceptable oncological control [ 91 ].…”

Robotic surgery - a taste of Hollywood?

“…The duration of the procedures will surely become shorter, surgeons will learn new techniques faster, but for the time being the situation is as it is. In order not to be overly critical of robotic surgery, positive experiences from two branches – urology [3, 4] and cardiovascular surgery – should be emphasized. It is always about procedures confined to a small space, where surgical robotic tools (360-degree rotation and precision) work perfectly.…”

“…However, one has to consider the benefits of such advances for the patient. For the time being, prostatectomies [3, 4] and some cardiovascular procedures appear rational. Robotic surgical procedures’ economic aspect should be analyzed and we have to reconsider whether our countries (Poland, the Czech Republic, Slovakia) are at such an economic level that they are able to compete with more economically developed countries such as Germany.…”