MARINA DEL REY, Calif--By modifying the standard "Walsh procedure" for radical retropubic removal of the prostate, UCLA researchers have seen a much faster and more complete return of urinary continence, Jean B. deKernion, MD, chief, Division of Urology, UCLA School of Medicine, reported at a conference jointly sponsored by UCLA and the Clark Urological Cancer Center.
The causes of long-standing or permanent stress incontinence following prostatectomy are not always clear, although most studies show that it is secondary to sphincter incompetence, Dr. deKernion said. In the past, researchers thought the bladder neck was the most important anatomic structure involved in continence, he said, but "for years we preserved the bladder neck, and it never had an impact."
In exploring other options to improve continence after surgery, UCLA researchers considered the rhabdosphincter, which is distal to the prostatic apex. Dr. deKernion stated that numerous studies have described the rhabdosphincter and have demonstrated that urinary continence after total prostatectomy is a complex mechanism that is affected by the urethral and periurethral tissues.
Although the degree to which urethral suspension is important to continence has not yet been defined, the urethra is naturally very well suspended, so the researchers deemed the preservation of this suspension as a "reasonable objective." Dr. deKernion said that during the Walsh procedure, "we often disrupt the peri-urethral tissues," and in doing so "we've torn 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 puboprostatic ligaments in place. Dr. deKernion also said that as a safeguard, researchers marked the anterior portion of the prostate with ink in many of the early surgeries, to help ensure that all of the prostate was removed during the modified procedure.
"We're convinced that you can do this procedure safely, without leaving any anterior prostatic tissue," he said.
Early results from a retrospective study of 50 patients who have undergone the modified technique have been very promising. Of these 50 patients, immediately after catheter removal, 57% were either totally continent or used only a single small pad.