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Optimizing radical prostatectomy for the early recovery of urinary continence

Nature Reviews Urology volume 9, pages 189–195 (2012)Cite this article

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Abstract

Radical prostatectomy remains the gold-standard treatment for clinically localized prostate cancer. Although cancer control is the primary goal, secondary outcomes such as continence recovery are of great importance to patients. Thus, it is a challenge for prostate cancer surgeons to optimize continence outcomes without compromising oncologic results. Many high-volume surgeons have demonstrated excellent long-term continence rates in their patients, but early continence is variable and less than ideal even in expert hands. A plethora of individual technical maneuvers exist to optimize early recovery of continence, but as yet there is no composite technique that incorporates the relevant anatomic principles of minimizing damage to the urinary sphincters and their nerves, maximizing functional urethral length, creating a secure and watertight vesicourethral anastomosis, providing circumferential fascioligamentous support to the anastomosis and external sphincter, and ameliorating postoperative bladder descent. Our ten-step approach to collating these individual maneuvers into a unified technique could be used by surgeons to obtain the best possible early recovery of urinary control for their patients, without risking their oncologic outcomes.

Key Points

  • Continence outcomes after radical prostatectomy are excellent in the long term, but there is substantial room for improvement in early outcomes

  • A variety of individual surgical maneuvers have been reported to improve early continence, many of which share common principles

  • These crucial principles are to minimize damage to the urinary sphincters and the neural supply, maximize functional urethral length, create a secure and watertight vesicourethral anastomosis, restore the support structures and prevent bladder descent

  • Our ten recommendations could be used to optimize early continence recovery without compromising oncologic and sexual outcomes after radical prostatectomy

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Figure 1: Biomechanical forces acting on the vesicourethral anastomosis.

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Authors and Affiliations

  1. Cambridge University Hospital, Hills Road, Cambridge, CB2 0QQ, UK

    Harveer S. Dev

  2. James Buchanan Brady Foundation Department of Urology, Lefrak Center of Robotic Surgery and Prostate Cancer Institute, Weill Medical College of Cornell University, New York Presbyterian Hospital, 525 East 68th Street, New York, 10065, NY, USA

    Prasanna Sooriakumaran, Abhishek Srivastava & Ashutosh K. Tewari

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H. S. Dev and A. Srivastava researched data for the article. H. S. Dev, A. Srivastava and P. Sooriakumaran provided substantial contribution to the discussion of content and writing of the article. All authors contributed to the review and editing of the manuscript before submission.

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Correspondence to Ashutosh K. Tewari.

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Dev, H., Sooriakumaran, P., Srivastava, A. et al. Optimizing radical prostatectomy for the early recovery of urinary continence. Nat Rev Urol 9, 189–195 (2012). https://doi.org/10.1038/nrurol.2012.2

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