Modified Prostatectomy Technique Reduces Incontinence

MARINA DEL REY, Calif--By modifying the standard "Walsh procedure"for radical retropubic removal of the prostate, UCLA researchershave seen a much faster and more complete return of urinary continence,Jean B. deKernion, MD, chief, Division of Urology, UCLA Schoolof Medicine, reported at a conference jointly sponsored by UCLAand the Clark Urological Cancer Center.

The causes of long-standing or permanent stress incontinence followingprostatectomy are not always clear, although most studies showthat it is secondary to sphincter incompetence, Dr. deKernionsaid. In the past, researchers thought the bladder neck was themost important anatomic structure involved in continence, he said,but "for years we preserved the bladder neck, and it neverhad an impact."

In exploring other options to improve continence after surgery,UCLA researchers considered the rhabdosphincter, which is distalto the prostatic apex. Dr. deKernion stated that numerous studieshave described the rhabdosphincter and have demonstrated thaturinary continence after total prostatectomy is a complex mechanismthat is affected by the urethral and periurethral tissues.

Although the degree to which urethral suspension is importantto continence has not yet been defined, the urethra is naturallyvery well suspended, so the researchers deemed the preservationof this suspension as a "reasonable objective." Dr.deKernion said that during the Walsh procedure, "we oftendisrupt the peri-urethral tissues," and in doing so "we'vetorn out the basic mechanism of urinary continence."

Two Goals for New Technique

The UCLA surgeons had two goals for their modified technique:to preserve all the layers and length of the rhabdosphinc-ter,and to preserve urethral support by leaving the puboprostaticligaments in place. Dr. deKernion also said that as a safeguard,researchers marked the anterior portion of the prostate with inkin many of the early surgeries, to help ensure that all of theprostate was removed during the modified procedure.

"We're convinced that you can do this procedure safely, withoutleaving any anterior prostatic tissue," he said.

Early results from a retrospective study of 50 patients who haveundergone the modified technique have been very promising. Ofthese 50 patients, immediately after catheter removal, 57% wereeither totally continent or used only a single small pad.

By three months, 95% of the patients had total continence. This95% rate can be compared to 73% with complete continence followingradical prostatectomy at UCLA using the standard procedure.

Dr. deKernion observed that "long term we don't know howit's going to work out. But certainly patients regain their urinarycontrol much faster than we've ever had in the past." Toobtain more data on the long-term results of the modified procedure,the group recently began a prospective evaluation of continenceusing a validated questionnaire.

Dr. deKernion said that "at least in the short term, potencyalso appears to be improved, but we have to follow them for ayear." With the modified procedure, he said, "we'vesaved the nerves involved in potency much more certainly thanwe did before."