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Back to Journal »Cancer Management and Research» Volume 13

The "sandwich" technique of total urethral reconstruction during laparoscopic radical prostatectomy: a prospective study

Authors: Liu Y, Zhao Q, Yang Fei, Wang Min, Xing Ning

Published on March 11, 2021, the 2021 volume: 13 pages 2341-2347

DOI https://doi.org/10.2147/CMAR.S299367

Single anonymous peer review

Editor who approved for publication: Dr. Eileen O'Reilly

Liu Yong,1,2 Zhao Qinxin,3 Yang Feiya,3 Wang Mingshuai, 1 year Zengxing 1,3 1 Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100021; 2 Department of Urology, Weihai Municipal Hospital, Weihai 264200; 3 Chinese Academy of Medical Sciences Peking Union Medical College National Cancer Center/National Cancer Clinical Research Center/Tumor Hospital Department of Urology, Beijing, 100021, People’s Republic of China Corresponding Author: Xing Nianzeng, National Cancer Center/National Cancer Center Urology, Chinese Academy of Medical Sciences and Peking Union Medical College Cancer/ Cancer Hospital Clinical Research Center, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, China, 100021 Email [email protected] Background: The impact of early incontinence on quality of life is one of the common shortcomings after laparoscopic radical prostatectomy (LRP). This prospective study aims to further document the effect of early "sandwich" urethral reconstruction techniques on incontinence after LRP. Methods: Between October 2017 and December 2018, this prospective study recruited 130 patients receiving LRP in our hospital. 66 patients in group A received LRP combined with "sandwich" urethral reconstruction technology, while the remaining 64 patients in group B did not use this reconstruction technology. Analysis and evaluation of basic clinical data, perioperative related data, urinary control status, urodynamic examination, etc. Results: Except for the urethral reconstruction time, there was no significant difference in the basic clinical data and perioperative data of the patients. Group A was 23.49±4.72 minutes, and Group B was 20.16±5.75 minutes (P<0.001). The incontinence rates of group A at 2, 4, 8, and 12 weeks were 54.55%, 83.33%, 93.94%, and 96.97%, respectively. The incontinence rates of group B were 10.94%, 14.06%, 37.50% and 71.88%, respectively. The postoperative urinary incontinence rate in group A was significantly higher than that in group B (P<0.001). The maximum velocity of 12 months before and after the "sandwich" operation was 13.2±2.8 m/s and 15.4±3.6 m/s (P=0.034). In addition, the residual volume for the 12 months before and after the “sandwich” procedure was 15 (0–20) mL and 0 (0–12.5) mL (P=0.107). Conclusion: Our prospective study confirmed that the "sandwich" technique of total urethral reconstruction is safe and feasible. It is also likely to have a significant advantage in the early recovery of urinary control after LRP. However, this final conclusion needs to be further confirmed by multi-center, randomized controlled large-sample randomized controlled trials. Keywords: sandwich, urethral reconstruction, laparoscopic radical prostatectomy, urinary incontinence, urodynamic examination

Prostate cancer is one of the most common cancers in men in the world, 1 and radical prostatectomy is the best standard method for treating patients with localized prostate cancer. With the increasing ageing of the Chinese population, the number of patients diagnosed with prostate cancer has been increasing recently. 2 With the development of minimally invasive techniques, LRP or robot-assisted radical prostatectomy (RALP) has become the preferred surgical method. Many large medical centers. 3 These minimally invasive techniques have also achieved good oncology results. 4,5 Therefore, sexual function and urinary control after LRP or RALP may be the most concerned issues for surgeons and patients. Since the introduction of anatomical methods to radical prostatectomy (RP), surgeons have made many surgical innovations to improve urinary control and sexual function recovery, such as intrafascial nerve preservation techniques6,7 and urethral reconstruction techniques. 8,9 In our study, we designed a prospective study to further verify the effectiveness of our "sandwich" total urethral reconstruction technique, especially in improving incontinence at an early stage.

This prospective study recruited all patients who had received LRP at our institution between October 2017 and December 2018. The study included 130 patients, who were divided into two groups. 66 patients in group A received LRP combined with "sandwich" technique for urethral reconstruction, while the remaining 64 patients in group B did not use this reconstruction technique.

Preoperative protocols include measurement of BMI, preoperative prostate specific antigen (PSA), prostate volume ultrasound, digital rectal examination (DRE), prostate magnetic resonance imaging (MRI), transrectal prostate biopsy using ultrasound, and bone scintigraphy. The exclusion criteria for this study included life expectancy of less than 10 years and patients with metastatic or locally advanced prostate cancer. The study was approved by the Research Ethics Committee of the Cancer Hospital of the Chinese Academy of Medical Sciences and Beijing Chaoyang Hospital of Capital Medical University. All patients in this study provided written informed consent.

Under general anesthesia, first create an extraperitoneal workspace using a five-port method, as described by Stolzenburg et al. 10 and expose the prostate, bladder, and pelvic fascia. Then at the beginning, the pelvic fascia was cut bilaterally and dissected toward the apex of the prostate. Next, cut off the pubic prostate ligament, ligate the dorsal vein complex (DVC) with a 15 cm barbed thread, and then carefully transect and save the bladder neck. After cutting the seminal vesicles from both sides of the vas deferens, it is easy to cut Denonvillier's fascia and dissect it to the top of the prostate. Next, use the Hem-O-Lok clip to preserve the vascular pedicle (including NVB) of the selected patient to the greatest extent, and use cold scissors to sharply cut the prostate fascia at the center of the external urethral sphincter and the tip of the prostate and cut the urethra while retaining the pubic prostate. ligament. All patients underwent bilateral pelvic lymph node dissection. The prostate and lymph node specimens were placed in the specimen bag and taken out through the umbilical incision.

In group A, the first step of "sandwich" total urethral reconstruction is to reconstruct the posterior wall by reconstructing the two layers of Denonvillier's fascia. In the first layer, the upper end of the severed fascia was sutured with MDR (Median Dorsal Raf) (Figure 1); and in the second layer, the MDR was sutured to the bladder wall behind the posterior lip of the bladder neck (Figure 2). Figure 1 "Sandwich" total urethral reconstruction posterior wall reconstruction of the first layer. (A) The structural position of the medial dorsal midstitch (MDR) during surgery. (B) The structural position of the severed end of Denonvillier's fascia. (C) The severed Denonvillier fascia was sutured with MDR. Figure 2 "Sandwich" total urethral reconstruction posterior wall reconstruction of the second layer. (A) The structural position of the MDR during operation. (B) The structural position of the back lip of the trapezoid neck. (C) MDR is sutured to the bladder wall behind the back lip of the bladder neck.

Figure 1 "Sandwich" total urethral reconstruction posterior wall reconstruction of the first layer. (A) The structural position of the medial dorsal midstitch (MDR) during surgery. (B) The structural position of the severed end of Denonvillier's fascia. (C) The severed Denonvillier fascia was sutured with MDR.

Figure 2 "Sandwich" total urethral reconstruction posterior wall reconstruction of the second layer. (A) The structural position of the MDR during operation. (B) The structural position of the back lip of the trapezoid neck. (C) MDR is sutured to the bladder wall behind the back lip of the bladder neck.

Urethra-bladder anastomosis is the second step of reconstruction. Use absorbable barbed sutures for continuous urethral cystostomy, with the posterior wall sutured from 4 to 8 o'clock and the anterior wall from 3 to 9 o'clock (Figure 3). The first suture was sutured at the right back of the bladder neck from the outside to the inside, and the suture was placed on the stump of the urethra from the inside to the outside. Later, the outside-inside of the bladder neck and the inside-outside protrusion of the urethral stump were repeatedly on the left side of the bladder neck. The 18F Silastic Foley catheter has been gently inserted into the bladder. When the bladder neck is sutured continuously in the order from left to right, the urethral bladder anastomosis is completed. Figure 3 "Sandwich" total urethral reconstruction bladder and urethra anastomosis. (A) The structural position of the bladder neck during the operation. (B) The structural location of the urethra. (C) Continuous urethral and bladder anastomosis with posterior wall suture from 4 to 8 o'clock. (D) Urethra-cystostomy with anterior wall suture from 3 o'clock to 9 o'clock.

Figure 3 "Sandwich" total urethral reconstruction bladder and urethra anastomosis. (A) The structural position of the bladder neck during the operation. (B) The structural location of the urethra. (C) Continuous urethral and bladder anastomosis with posterior wall suture from 4 to 8 o'clock. (D) Urethra-cystostomy with anterior wall suture from 3 o'clock to 9 o'clock.

The third step is to rebuild the anterior wall of the urethra, which involves reconnecting the arcuate tendon and pubic prostatic ligament to the bladder neck (Figure 4). Apply a barbed absorbable suture to access the remaining arcuate tendon and distal triangular plate of the urethra, which includes the residual intrapelvic fascia rhabdominal sphincter, the pubic prostatic ligament, and the dorsal vein complex of the bladder neck. In group B, the urethra was reconstructed only in the second step of group A. Figure 4 "Sandwich" full anterior urethral reconstruction. (A) The structural position of the detrusor apron (DA) during the operation. (B) The structural location of the pubic prostatic ligament. (C) The pubic prostatic ligament is sutured to the bladder wall behind the anterior lip of the bladder neck (equivalent to the position of DA).

Figure 4 "Sandwich" full anterior urethral reconstruction. (A) The structural position of the detrusor apron (DA) during the operation. (B) The structural location of the pubic prostatic ligament. (C) The pubic prostatic ligament is sutured to the bladder wall behind the anterior lip of the bladder neck (equivalent to the position of DA).

According to the extended prostate cancer index composite (EPIC-CP) of clinical practice, 11 patients who achieved complete control or occasional bleeding or who needed 0 or 1 pads were considered incontinent; those with normal physical activity (walking) required 2-3 pads People who take more than 3 pads/day are defined as mild incontinence (stress urinary incontinence); patients who require more than 3 pads/day are considered incontinence.

Parametric continuous variables are expressed as mean ± standard deviation; non-parametric continuous variables are shown in the median and interquartile range (IQR); the t-tests of these two groups are used to compare numerical variables. SPSS 21.0 software (IBM Corp, Armonk, NY) was used to process the data. The statistical significance was P<0.05.

No conversion or re-intervention was found in the 130 patients in group A and group B. The perioperative data of the two groups were similar (Table 1). The total operation time, blood loss, catheterization time, and postoperative hospital stay were similar in the two groups (Table 2), but the urethral anastomosis time in group A was longer than that in the other group (Table 2). P<0.01). Both groups were positive in pathological staging and positive surgical margin (PSM) (Table 3). Table 4 shows the postoperative urinary control rate of the two groups. In group A, 54.5% of patients were considered incontinent at 2 weeks. Group B was 10.9%. The difference between the two groups was statistically significant (P<0.01). At 4 weeks, the rates of incontinence in the two groups were 83.3% and 14.1%, respectively, and the difference was statistically significant (P<0.01). The incontinence rates of group A at 8 and 12 weeks were 93.9% and 96.9%, respectively; the incontinence rates of group B were 37.5% and 71.9%, respectively. The incontinence rate is significant (P<0.01, respectively). We followed up the patients undergoing urodynamic examination and found that the maximum flow velocity at 12 months before and after the "sandwich" operation was 13.2±2.8 m/s and 15.4±3.6 m/s, respectively, and the difference was statistically significant (P = 0.034). In addition, the residual volume of 12 months before and after the "sandwich" operation was 15 (0-20) mL and 0 (0-12.5) mL, respectively, and the difference was not statistically significant (P=0.107). Table 1 Patient baseline characteristics Table 2 Patient surgery date Table 3 Patient postoperative data Table 4 Postoperative urinary incontinence rate in the two groups

Table 1 Baseline characteristics of patients

Table 2 Patient surgery date

Table 3 Postoperative data of patients

Table 4 Postoperative urinary incontinence rate in the two groups

Compared with open surgery technology, laparoscopic technology has advantages in hospitalization, blood loss, postoperative complications and recovery time. 12 However, urinary incontinence after LRP surgery may significantly affect the patient's quality of life. They may have feelings of inferiority, anxiety and depression. 13 UI after LRP mainly comes from urethral sphincter deficiency or detrusor overactivity. 14 Therefore, the preservation of many anatomical structures of the prostate and the way in which the urethra is reconstructed are important factors for restoring urine control and even sexual function. 15

After the operation, the anatomical structures that are essential for abstinence are affected to varying degrees, including muscle components, urethral components, and detrusor components. 16 Muscle components include bladder neck, internal and external striated sphincter, urethral membrane and pubis and perineum. And the pelvic floor muscles that support the structure of the sphincter complex, such as the arcuate muscle, pubic prostatic ligament, detrusor apron, denonvilliers fascia and pelvic bone, and pelvic floor levator ani muscle and ligament. The urethral component involved in sphincter insufficiency may be caused by short urethral stump, loss of innervation, muscle damage, and loss of potential surrounding supporting tissues. Due to nerve damage or decreased bladder compliance, the detrusor component involves de novo bladder instability, excessive detrusor activity or insufficient contraction. 17

Preserving anatomical structures such as pelvic fascia and detrusor peripheral nerve through intrafascial anatomy, as well as an appropriate length of urethral membrane can help early recovery of urinary control. 18 The results show that the nerve-preserving bilateral processes can retain the motor control of the functional urethral sphincter, thereby improving postoperative urination control. 19 The detrusor apron extending from the inner wall of the bladder is directly continuous with the pubic bone and has recently attracted widespread attention. The detrusor apron is divided into front, middle and back layers in front of the prostate. The anterior layer passes back to the crossed pubococcygeal fibers, dissolves the anterior inferior, and anchors on the posterior surface of the pubic bone. The middle layer is loose and connected to the fascial sheath of the dorsal vein complex (DVC). Finally, the posterior layer surrounds and extends into the prostate, forming the anterior fibromuscular matrix (AFMS) of the prostate. 20,21 The urethra is also an important anatomical structure, essentially for restraint. Generally, a long urethral stump with lateral support tissue is essential to reduce the risk of incontinence after surgery. The results showed that the membranous urethra immediately retracted proximally after RP, while the urethral stump retracted toward the bladder after the urethral bladder anastomosis. These processes have a negative impact on the function of the urethral sphincter and the closing pressure of the urethra. But over time, this change can be restored to its preoperative position, and urethral closure pressure and urinary incontinence can be restored. twenty two

At present, there are a variety of urethral reconstruction techniques, such as posterior wall reconstruction (represented by Roccostitch), anterior bladder neck suspension and total reconstruction of bladder-urethral anastomosis. 23,24 In our study, the construction of the "sandwich" of the urethra begins with reconstruction of the posterior approach. The main purpose of this procedure is to minimize the sliding of the urethral sphincter after RP to support the VUA, so that the bladder neck can be tightly descended to the urethral stump, and to provide sufficient contraction point for the striated sphincter. It has been reported that posterior striated sphincter reconstruction leads to early recovery of incontinence and reduces anastomotic leakage. 25

The anterior suspension begins after the urethral anastomosis, which is another important step in the reconstruction of the dissection. Fixing the bladder neck to the pubic bone is a recommended anterior suspension technique. The method is to suspend the bladder neck through a ball suture of the urethra or to suspend the bladder neck along the VUA, with or without ligation of the DVC to the pubic symphysis. According to some authors, incontinence rates at 1, 3, and 6 months were 53%, 73%, and 100%, respectively, while incontinence rates in the control group were 20%, 47%, and 83%, respectively. 26 In a meta-analysis, the use of this bimodal reconstruction can increase short-term (defined as 1-12 weeks) and long-term (up to one year after surgery) incontinence rates. In our study, the comparison between posterior reconstruction and non-reconstruction showed that patients' urinary control results were 49% vs. 24% at 3 months, and 92% vs. 79% at 1 year after RP. Once again demonstrated the superiority of using sandwich reconstruction technology. Again, it shows that the "sandwich" technique of total urethral reconstruction is beneficial to the recovery of early urinary control, and does not affect the urodynamic parameters after RP, does not increase bleeding, positive resection margins, prolonged operation time and other complications.

Our prospective studies have confirmed that the "sandwich" technique of total urethral reconstruction is safe and feasible. It is also likely to have a significant advantage in the early recovery of urinary control after LRP. However, this final conclusion needs to be further confirmed by multi-center, randomized controlled large-sample randomized controlled trials.

RALP, robot-assisted radical prostatectomy; LRP, laparoscopic radical prostatectomy; NVB, neurovascular bundle; RP, radical prostatectomy; PSA, prostate specific antigen; EDR, digital rectal examination; MRI, magnetic resonance Imaging; DVC, dorsal vein complex; DF, Denonvilliers fascia; IQR, interquartile range; UI, urinary incontinence; AFMS, anterior fibromuscular interstitium; BMI, body mass index; PSM, positive surgical margin; MDR, median Raf back side.

The trial registration number is ChiCTR-IPR-15005903. The name of the registry is that the "complete reconstruction" of urethral cystostomy contributes to early urinary incontinence during laparoscopic radical prostatectomy. The registration date is October 19, 2017, and the trial registration record website is http://www.medresman.org.cn/uc/project/projectedit.aspx?proj=2912.

The data used and/or analyzed in the current research can be obtained from the corresponding author upon reasonable request.

The test was conducted in accordance with the Declaration of Helsinki. This study was approved by the Ethics Committee of the Cancer Hospital of the Chinese Academy of Medical Sciences and the Research Ethics Committee of Beijing Chaoyang Hospital, Capital Medical University. All patients in this study provided written informed consent. Each registered patient provided written informed consent.

The patient's informed consent was obtained.

All authors have made significant contributions to the concept and design, data acquisition or data analysis and interpretation; participated in drafting articles or critically revised important knowledge content; agreed to submit to the current journal; finally approved the version to be published; and agreed Responsible for all aspects of work.

This research was funded by the Capital Science and Technology Leading Talents Project (project number: Z181100006318007).

The authors declare that they have no competing interests.

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