Posterior Muscolofascial Reconstruction Incorporated into Urethrovescical Anastomosis During Robot-Assisted Radical Prostatectomy

Abstract

The rationale of posterior musculofascial plate reconstruction during radical prostatectomy is to shorten the time to reach urinary continence recovery and to reduce the risk of bleeding and anastomosis leakage. We describe our original technique incorporating the posterior muscolofascial reconstruction into urethrovesical anastomosis using robot-assisted radical prostatectomy (RARP). For this reconstructive step, we use a 30-cm V-Loc 90 3-0 barbed suture (V-20 tapered needle). Specifically, the free edge of the posterior layer of the Denonvilliers fascia is approximated to the posterior part of the sphincteric apparatus in a running fashion from left to right. The musculature of the urethral wall is incorporated in this first layer of the running suture. This suture is then continued back to the left in a second layer incorporating the anterior layer of the Denonvilliers fascia (or prostatovesical muscle), the bladder neck, and again the urethra, this time also with urethral mucosa. The urethrovesical anastomosis is completed using a second running barbed suture (15-cm V-Loc 90 3-0 barbed suture, V-20 tapered needle). No intraoperative complications were observed during this step of the procedure. Anastomotic leakages were observed only in 2% of cases. Only 12.5% showed urinary incontinence after catheter removal (1–2 pads). At mean follow-up of 9 months, the urinary continence recovery was 95%, and an anastomosis stricture necessitating an endoscopic incision developed in only three (1.5%) patients. Recent systematic reviews of the literature showed only a minimal advantage in favor of posterior musculofascial reconstruction in terms of urinary continence recovery within 1 month after radical prostatectomy. We support the use of this step of RARP because it is simple, reproducible, with a very limited increase in operative time, and with only a slight risk of potential harm to the patient. Moreover, it could improve hemostasis and provide greater support for a delicate anastomosis.

Introduction

P osterior musculofascial reconstruction was advocated as surgical step potentially able to reduce the risk of bleeding, anastomosis leakage, and early urinary incontinence in patients who underwent radical prostatectomy (RP) for clinically localized prostate cancer.^1
–3 Different techniques were initially described to perform the posterior reconstruction during retropubic radical prostatectomy (RRP). Specifically, Klein⁴ in 1992 described a technique including the distal edge of the Denonvilliers fascia in urethrovesical anastomosis, and later in 2006, Rocco and associates⁵ described an original technique in which the posterior part of the rhabdosphincter was joined with the proximal cutting edge of the Denonvilliers fascia. Moreover, in this technique the urethral sphincteric complex was suspended from the bladder.

In the next years, the posterior musculofascial reconstruction proposed by Rocco and colleagues⁵ was replicated also in traditional laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP).^6,7 The aim of this maneuver is to restore the length of the urethrosphincteric complex, prevent its caudal retraction, avoid undue tension on the subsequent vesicourethral anastomosis, and provide a posterior buttress to the urethrosphincteric complex to facilitate its effective contraction.

Recent systematic reviews of the literature showed a small statistical but not clinical advantage in favor of posterior reconstruction only 1 month after RP.^1,3 Although the impact of posterior musculofascial reconstruction on early continence is possibly less accentuated than initially thought, the technique is simple and reproducible, with a very limited increase in operative time and with only a slight risk of potential harm to the patient. Moreover, it could improve hemostasis and provide greater support for a delicate anastomosis.^2,3 Indeed, the Pasadena Consensus Panel considered the posterior musculofascial plate reconstruction optional according to the unanimous agreement that it may facilitate performing the urethrovesical anastomosis and reduce bleeding. No specific indications, however, were made about the best technique to perform this reconstructive step of RARP.⁸

In this study, we describe a personal surgical technique in which the posterior musculofascial reconstruction is included in the urethrovesical anastomosis using a barbed running suture.

Methods

Indications and contraindications

In our experience, the posterior musculofascial reconstruction is indicated for all patients in whom, during the posterior dissection of the prostate, we chose to follow a plane between the Denonvilliers fascia and prostate capsule (Denonvilliers preservation). According to the Pasadena recommendations, we preserve the Denonvilliers fascia in patients with low- or intermediate-risk prostate cancer.⁸ This surgical strategy is finalized to spare the nerve fibers covering the posterior surface of the prostate.⁹ Conversely, the posterior reconstruction is not indicated in high-risk patients in whom a plane between the Denonvilliers fascia and rectum (Denonvilliers resection) is preferred. In these cases, the Denonvilliers fascia is left on the specimen, and reconstruction is not possible.

Preoperative workup

A standard workup for patients undergoing RP for prostate cancer is recommended. Preoperative oncologic variables were baseline total prostate-specific antigen, clinical stage, bioptical Gleason score, and number of positive cores. All the patients were stratified according to the D'Amico risk classification. Patients with high-risk prostate cancer underwent abdominal CT and nuclear bone scan.

All the patients were evaluated preoperatively using a symptom-specific, validated questionnaire such as the International Prostate Symptom Score, Expanded Prostate Cancer Index Composite, and the Sexual Health Inventory for Men.

Patient preoperative preparation

We prefer to schedule the procedure 4 to 6 weeks after the biopsy. Mechanical bowel preparation is performed using magnesium citrate—two bottles the evening before surgery. Our standard procedure consists of advising patients to stop taking all anticoagulants a week before surgery. A half dose of low molecular weight heparin is given before surgery, a full dose is administered the next day, and treatment is continued for 4 weeks after surgery to reduce the risk of deep vein thrombosis and pulmonary embolus. Antibiotic prophylaxis is performed using a bolus injection of a second-generation cephalosporin before the induction of anesthesia.¹⁰

Demolitive surgical steps

Our surgical technique was extensively described in 2007 and updated in a recent article published in 2012.^10,11 Briefly, we perform a transperitoneal, antegrade approach using the four-arm da Vinci system. Interestingly, in the last year, we used the minimum possible degree of the Trendelenburg inclination to minimize the potential anesthesiology issues and to reduce the traction during the urethrovesical anastomosis step. Currently, we decide the degree of the Trendelenburg position looking inside before docking the robot. When the peritoneal area at the level of the triangular space, which is defined by the umbilical ligament, the vas deferens, and the abdominal wall, appears to be sufficiently free from the bowel, we stop the patient inclination.

After incision of the endopelvic fascia, the bladder neck is dissected using hot shears with a lateral approach. After the incision of the bladder neck, the anterior muscular layer of the Denonvilliers fascia (also called the vesicoprostatic muscle) is encountered and preserved to facilitate the following posterior reconstruction of the musculofascial plate. After vasal isolation and seminal vesicle athermal dissection, in low- and intermediate-risk patients, the posterior layer of the Denonvilliers fascia is left on the rectum developing a surgical plane between the Denonvilliers fascia and prostate capsule.

The next step of the procedure is represented by the antegrade release of the lateral cavernous nerves. Then, the prostatic vascular pedicles are separated by a thin fat plane from the posterolateral neurovascular bundles. To complete the preservation of the neurovascular bundles, the athermal dissection is carried along the lateral aspect of the prostate toward the apex under the endopelvic fascia. The dissection is continued on both sides until the prostatic apex is reached, ensuring the complete release of the neurovascular bundles.

After increasing the intra-abdominal pressure to 20 mm Hg, the puboprostatic ligaments and the dorsal vein complex are divided tangentially close to the prostate until the avascular plane separating the urethra from the venous complex is reached. This approach is considered really important to spare as much as possible the urethroprostatic ligaments and to improve urinary continence recovery. The dorsal venous complex is ligated in a running fashion with a 3-0 poliglecaprone suture on an UR-6 needle. The anterior urethral wall is opened just below the apical limit, exposing the Foley catheter. The posterior wall and the underlying rectourethralis muscle are then divided close to the prostate with a cold knife while retracting the prostate cephalad. The division of the rectourethralis muscle completely frees the specimen, which is placed in an Endobag. The prostate gland is left inside for removal at the end of procedure through the supraumbilical port.

Posterior musculofascial plate reconstruction and urethrovesical anastomosis

To perform this step of RARP, the following instruments are used: One needle driver (in the correct hand) and one fenestrated bipolar forceps (contralaterally). The monopolar curved scissors are placed in the fourth arm to cut the suture when necessary.

With a 30-cm V-Loc^™ 90 3-0 barbed suture (V-20 tapered needle), the free edge of the posterior layer (fibrous layer) of the Denonvilliers fascia is approximated to the posterior part of the sphinteric complex in a running fashion from left to right, incorporating the fibrous posterior part of the rhabdosphincter, remnants of the rectourethralis muscle, and the Denonvilliers fascia as well as the muscular part of the urethral wall. Usually, four bites are taken. High tension should be prevented, and the sutures are alternately gradually pulled. This suture is then continued back to the left in a second layer incorporating the anterior layer of the Denonvilliers fascia (muscular), the bladder neck, and again the urethra, this time with mucosa to align mucosa on both sides of the anastomosis. Therefore, this second layer represents the posterior plate of the urethrovesical anastomosis. This restores the posterior anatomy connecting the fascia to the urogenital diaphragm. Typically four to six bites are taken.

The urethrovesical anastomosis is completed using a second running barbed suture (15-cm V-Loc 90 3-0 barbed suture, V-20 tapered needle), starting from the left 8 o'clock position, continuing anticlockwise crossing the posterior reconstruction, and ending at the 12 o'clock position. The 30-cm V-Loc 90 3-0, previously used for the two-layered posterior reconstruction, is then used to complete the anastomosis running clockwise to meet the other suture at the 12 o'clock position.

The two barbed sutures can be used also to perform a double layer bladder neck anterior reconstruction whenever necessary (wide bladder neck in patients with a large prostate or medium lobe). An 18F catheter is placed into the bladder, and the balloon is filled with 10 mL of water. Usually no drain is positioned at the end of the procedure. A drain is placed only in patients who underwent an extended pelvic lymph node dissection or who had significant intraoperative bleeding.

Postoperative care

Early mobilization is encouraged to reduce the risk of venous thromboembolism complications. Usually, oral intake restarts on the day of surgery with a full diet on postoperative day 2. If placed, the drain is removed on postoperative day 1. The transurethral catheter is removed after 5 to 6 days if cystography shows no signs of leakage.

Management of intraoperative complications

The posterior musculofascial reconstruction and the urethrovesical anastomosis are two safe steps of the RARP procedure. Indeed, considering the last 200 consecutive cases performed by two different surgeons (AM, VF), we did not observe any specific intraoperative complications. High tension on the tissue or vulnerable tissue can impair the posterior rhabdosphincter reconstruction. This situation could happen in large prostates and can be solved by applying perineal external pressure, moving the bladder caudally, or lowering abdominal pressure. In a very few cases showing minimal leakage during the anastomosis water test, we placed one or more additional interrupted stitches to close the anastomosis.

Management of postoperative complications

Few (6%) patients had referred perineal pain during the postoperative period. It always resolved within a few weeks postoperatively. Leakage of the anastomosis seen on cystography is managed conservatively by maintaining an indwelling catheter for an additional period according to the grade of leakage. Looking at the last 200 consecutive cases, this complication happened only in four (2%) cases. In all cases, the leakage was approximately 10% of the introduced contrast medium, and the catheter was definitively removed after 10 days.

After catheter removal, only 25 (12.5%) patients needed 1 to 2 pads for urinary incontinence. Therefore, the immediate urinary continence recovery was 87.5%. At a mean follow-up of 9 months, the urinary continence recovery was 95%, and an anastomosis stricture necessitating an endoscopic incision developed in only three (1.5%) patients.

Conclusions

The aim of posterior musculofascial reconstruction is to restore the length of the sphincteric complex, prevent its caudal retraction, avoid undue tension on the subsequent vesicourethral anastomosis, and provide a posterior buttress to the urethrosphincteric complex to facilitate its effective contraction. Therefore, the immediate clinical benefit should be represented by the achievement of early urinary continence recovery in comparison with patients receiving a standard urethrovesical anastomosis without posterior reconstruction. The role of posterior reconstruction on early urinary continence recovery, however, remains one of the most investigated surgical aspects.

An initial review of the literature showed inconclusive results in terms of early urinary continence recovery, mainly because of the lack of a uniform surgical technique, continence definitions, and methods used in the few analyzed studies comparing posterior reconstruction with the standard technique.¹² In that review of the literature, the authors also included in the analysis some clinical series in which the posterior reconstruction was associated with an anterior restoration of the pelvis.^13,14 Recently, two systematic reviews of the literature took into consideration the potential benefit of posterior reconstruction techniques in terms of early and intermediate urinary continence recovery.^1,3

Rocco and coworkers¹ selected 11 studies that compared posterior reconstruction techniques with standard technique regardless of an open, laparoscopic, or robot-assisted approach. The cumulative analyses of both observational studies and randomized controlled trials (RCTs), showed that posterior reconstruction improves significantly early urinary continence recovery only within the first month after RP. Conversely, no differences were estimated after a longer follow-up.¹ Looking at the forest plots, these positive results are because of the favorable data reported in three observational studies, including patients who underwent mainly RRP and LRP.^6,15,16 Conversely, the only two available RCTs failed to demonstrate any significant advantages in favor of posterior musculofascial plate reconstruction.^17,18

In their systematic review of the literature concerning the urinary continence recovery after RARP, Ficarra and associates³ selected seven studies that compared posterior reconstruction vs the standard technique. Specifically, this cumulative analysis showed a small statistical advantage in favor of posterior reconstruction only after 1 month (odds ratio 0.76; 95% confidence interval [CI], 0.59–0.98; P=0.04). The reported 95% CI, however, questioned the real clinical benefit of this difference. Conversely, current evidence clearly showed that posterior reconstruction during RARP did not influence 3-month and 6-month urinary continence recovery.

Therefore, we believe that the impact of posterior musculofascial plate reconstruction on early continence remains controversial and difficult to demonstrate also considering that other steps of RP, such as bladder neck preservation, nerve-sparing technique, tangential division of dorsal venous complex, apical dissection, and section of the urethral stump, were advocated as surgical aspects able to influence the urinary continence recovery after RP.

We continue to include the posterior musculofascial plate reconstruction in our technique because this step is simple, reproducible, with a very limited increase in operative time, and with only a slight risk of potential harm to the patient. Moreover, it could improve hemostasis and provide greater support for a delicate anastomosis.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

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