The narrow vesicourethral angle measured on postoperative cystography can predict urinary incontinence after robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: Radical prostatectomy is associated with complications including urinary incontinence. A significant association between specific features of the vesicourethral anastomosis and urinary incontinence after radical prostatectomy has been demonstrated. The aim of this study was to identify the most useful predictor of postoperative urinary incontinence after robot-assisted laparoscopic radical prostatectomy (RALP) according to the features of the vesicourethral anastomosis as determined by postoperative cystography. MATERIALS AND METHODS: The final study cohort consisted of 150 patients. Postoperative cystography was performed within 1 week after RALP. The ratio between the longitudinal and horizontal lengths (L/H) of the bladder, the position of the urethrovesical junction (UVJ) and the bladder neck angle as seen on the cystogram were evaluated. Postoperative continence status was evaluated by a 1 h pad test 1 day after catheter removal and by the use of safety pads, retrieved retrospectively from patient records. The association between these variables and urinary incontinence was then analyzed. All patients were followed for at least 1 year postoperatively. RESULTS: The continence rates on the 1 h pad test and 1 month and 1 year after RALP were 31.3%, 56% and 93.3%, respectively. In multivariate analyses, urinary incontinence was significantly associated with nerve sparing, L/H and the vesical angle as determined on the 1 h pad test, but only with the vesical angle at 1 month and 1 year postoperatively. CONCLUSION: A narrow vesical angle measured on cystography is a useful predictor of postoperative urinary incontinence after RALP.

Modified posterior musculofascial plate reconstruction decreases the posterior vesicourethral angle and improves urinary continence recovery in patients undergoing laparoscopic radical prostatectomy.

The aim of this study was to evaluate the efficacy of our modified posterior musculofascial plate reconstruction (PMPR) procedure in laparoscopic radical prostatectomy (LRP). Prior to 2010, four operative procedures were used to expedite continence recovery: preserving the fascia covering the levator ani muscle, preserving the bladder neck, securing a functional urethral length by using a lateral-view dissection technique and suspending the vesicourethral anastomosis from the puboprostatic ligaments. Since February, 2010, a running suture between Denonvilliers' fascia (DF) and the median fibrous raphe (MFR, the fibrous tissue that lies immediately underneath the urethra) has also been used. In vesicourethral anastomosis, a double-armed running suture was performed. At the beginning of the anastomosis, the first stitches (at 1 and 11 o'clock positions on the bladder neck) were placed 1-2 cm dorsocephalad to the bladder neck (first through the seromuscular layer and then through the full thickness of the bladder neck). At the 5 and 7 o'clock positions of the urethra, the stitches were placed through the urethral mucosa as well as the the reconstructed musculofascial plate. The bladder shape was evaluated by postoperative cystography and the clinical results were compared between patients undergoing LRP without PMPR (group A) and those undergoing LRP with PMPR (group B). The cystograms demonstrated that the PMPR significantly shortened the vertical length of the bladder and significantly decreased the posterior vesicourethral angle. At 1, 3 and 6 months after LRP, the number of daily used pads was significantly lower in group B compared to that in group A and the time to achieve a pad-free status was significantly shorter in group B. Our modified PMPR procedure significantly improved the recovery of urinary continence following LRP and this improvement may be due in part to changes of the bladder shape.