RU2809655C1 - Method of prevention of urinary incontinence after radical prostatectomy - Google Patents

Abstract

FIELD: medicine; operative urology and oncology.

SUBSTANCE: surgical laparoscopic extraperitoneal pelvic lymphadenectomy and radical prostatectomy are performed. The defect in the fascial plate above the rectum is closed by suturing the edges of the visceral part of the endopelvic fascia covering the levator ani muscle, stitched together with V-loc 3-0 thread with a continuous longitudinal suture. Then a vesicourethral anastomosis is formed.

EFFECT: method allows to prevent urinary incontinence after radical prostatectomy, thereby improving the quality of life of patients, the method allows to perform the full restoration of the function of urinary continence after radical prostatectomy, has no intraoperative complications, is universal, technically easily reproducible in specialized clinical departments.

1 cl, 1 ex

Description

The invention relates to medicine, namely to urology, and can be used to prevent urinary incontinence after radical prostatectomy.

Urinary incontinence is a fairly common complication of the postoperative period after radical prostatectomy (see Kogan M.I. Radical surgery for prostate cancer / M.I. Kogan, O.B. Laurent, S.B. Petrov. - M.: GEOTAR-Media , 2006. - 352 pp.). It is mainly due to insufficiency of the urethral sphincter (see Kielb SJ, Clemens JQ. Comprehensive urodynamics evaluation of 146 men with incontinence after radical prostatectomy. Urology. 2005 Aug;66(2):392-6. doi: 10.1016/j.urology. 2005.03.026. PMID: 1604010.). As is known, continentality is achieved by the combined function of the internal urethral sphincter and the external striated rhabdosphincter. The internal sphincter is localized at the level of the bladder neck and consists of smooth muscle fibers. Its function is controlled involuntarily, and its significant role is in the obturator function during exercise (see Chao R, Mayo ME. Incontinence after radical prostatectomy: detrusor or sphincter causes. J Urol. 1995 Jul; 154(1):16-8. doi: 10.1016/s0022-5347(01)67212-4 PMID: 777641). Through anatomical studies, it has been established that the anterior supporting structures in the pelvis in men include the puboprostatic and pubovesical ligaments and the tendinous arch, endopelvic fascia (see Kojima Y, Takahashi N, Haga N, Nomiya M, Yanagida T, Ishibashi K, et al. Urinary incontinence after robot-assisted radical prostatectomy: pathophysiology and intraoperative techniques to improve surgical outcome. Int J Urol 2013;20:1052-63). The posterior supporting structures are represented by Denovillier's fascia, which passes between the rectum and the prostate gland, the levator ani muscle and the pelvic diaphragm muscles (see Heesakkers J, Farag F, Bauer RM, Sandhu J, De Ridder D, Stenzl A. Pathophysiology and contributing factors in postprostatectomy incontinence: a review. Eur Urol 2017;71:936-44). It is generally accepted that the cause of urinary incontinence after radical prostatectomy is damage to the external striated sphincter, damage to the smooth muscles of the urethra when performing urethro-vesical anastomosis, damage to the nervous structures during mobilization of the urethra and prostate gland (see Chao R, Mayo ME. Incontinence after radical prostatectomy: detrusor or sphincter causes. J Urol. 1995 Jul; 154(1):16-8. doi: 10.1016/s0022-5347(01)67212-4. PMID: 777641). Damage to the neurovascular lateral bundle, which includes the pudendal nerve, its intrapelvic part, also contributes to urinary incontinence after radical prostaectomy. The pudendal nerve is involved in the innervation of the striated external urethral sphincter (see Narayan R, Konety B, Aslam K, Aboseif S, Blumenfeld W, Tanagho E. Neuroanatomy of the external urethral sphincter: implications for urinary continence preservation during radical prostate surgery. J Urol 1995;153:337-4).

Thus, restoration of the anterior and posterior supporting-fascial structures of the pelvis after their damage during surgery, along with the preservation of neurovascular bundles, can contribute to the prevention and early restoration of urinary continence function after radical prostatectomy (see Van der Poel HG, de Blok W, Joshi N, van Muilekom E. Preservation of lateral prostatic fascia is associated with urine continence after robotic-assisted prostatectomy. Eur Urol 2009;55:892-900).

The following methods for preventing urinary incontinence are known from patent sources.

1. “Method for the prevention of urinary incontinence after radical prostatectomy” (see invention patent RU 2434586 C1, published on November 27, 2011, Bulletin No. 33), which involves removing the prostate gland while preserving the puboprostatic plate and tendon arch, restoring the peritoneal perineal fascia (Denonvilliers aponeurosis) with the subsequent imposition of urethrocystoneostomy, suturing of the pelvic fascia, the anterior third of the tendinous arch and puboprostatic ligaments to the detrusor, characterized in that the type of pelvic topography is determined in the patient before surgery, and in the case of the sacropetal type of pelvic topography, the cranial end is peritoneal - the perineal fascia (Denonvilliers aponeurosis), if it is not long enough for suturing with the distal end of the peritoneal-perineal fascia, is fixed alternately on the left and right together with the parietal pelvic fascia to the border of the anterior and middle third of the tendinous arch of the pelvic fascia at an angle of 120° to the horizontal of the pelvis, and with the symphysopetal type of pelvic topography, the cranial end of the peritoneal-perineal fascia (Denonvilliers aponeurosis), if it is not long enough for suturing with the distal end of the peritoneal-perineal fascia, is fixed to the border of the middle and posterior third of the tendinous arch of the pelvic fascia at an angle of 90° to the horizontal of the pelvis, and the distal end of the peritoneal-perineal fascia (Denonvilliers aponeurosis) is fixed on both sides to the anterior third of the tendinous arch of the pelvic fascia. The method makes it possible to stabilize urethrocystoneoanastomosis, prevent or significantly reduce the period of urinary incontinence after radical prostatectomy, restore sexual activity as early as possible while maintaining erectile function and helps improve the quality of life of patients, however, in our opinion, this method is difficult to perform, depends on the type of pelvic anatomy, and the need to fix tissue structures of different histological types.

2. “Method for the prevention of urinary incontinence after retropubic prostatvesiculectomy” (see patent for invention RU 2559588 C1, published on August 10, 2015, Bulletin No. 22), including bilateral pelvic lymphadenectomy, isolation of the bladder, prostate gland, dissection of the pelvic fascia and pubic - prostatic ligaments, isolation and intersection of the dorsal venous complex, cutting off the prostate gland from the urethra, removal of the prostate gland along with the seminal vesicles with the formation of a urethrovesical anastomosis, characterized in that during surgery the missing fragment of Denonvilliers’ fascia is replaced between the cranial and caudal ends, using the lateral right and left sheets of the visceral fascia of the bladder, which are sutured behind its posterior wall for posterior stabilization of the urethrovesical anastomosis during restoration of the abdominoperineal fascia of the pelvis. The method makes it possible to achieve stabilization of the urethrovesicular anastomosis while restoring the fascial anatomical formations of the pelvis, however, this method does not involve restoring the integrity of the pelvic floor, between the rectum and the removed prostate.

3. “Method for the prevention of urethrovesical anastomosis failure and urinary incontinence after radical prostatectomy” (see invention patent RU 2733694 C1, published 10/06/2020, Bulletin No. 28), including simultaneous removal of the patient’s areas of the endopelvical, peritoneal-perineal fascia and formation of urethrocystoneoanastomosis, characterized in that a three-layer graft consisting of parietal peritoneum, preperitoneal tissue and transverse fascia with a width of at least 4 cm and a length of at least 10 cm is first prepared from the patient’s anterior abdominal wall, after which the graft with its fascial side is placed in the transverse direction on the anterior wall of the rectum into the area of the defect of the peritoneal-perineal fascia and additionally the edges of the latter are sutured with an absorbable suture with the corresponding edges of a three-layer graft, then the free ends of the three-layer graft are brought together over the anterior wall of the urethrovesical anastomosis and sutured together with an absorbable suture, while closing the fascial ring over the zone urethrocystoneoanastomosis, after which the anterior semicircle of the graft is fixed to the puboprostatic ligaments and the bladder wall using separate absorbable sutures. The method helps to increase the efficiency of surgical intervention and reduce the incidence of postoperative complications through the use of a three-layer graft, including the parietal peritoneum, preperitoneal tissue and transverse fascia, taken from the anterior abdominal wall. The disadvantages of this method are the technical complexity of implementation, the need to open a second anatomical space - the abdominal cavity, and the use of other tissue that differs in histological structure from the removed tissue to replace the Denonvilliers fascia defect.

The objective of our proposed method is to improve the patient’s quality of life after radical prostatectomy by completely restoring the function of urinary continence in the postoperative period.

The technical result is the development of a method that allows you to fully restore the function of urinary continence after radical prostatectomy.

The method is performed as follows.

Performing surgical treatment in the following scope: laparoscopic extraperitoneal pelvic lymphadenectomy, radical prostatectomy.

Under endotracheal anesthesia under aseptic conditions, with the patient in the supine position, a 3 cm long skin incision is made in the paraumbilical region, below the navel, the subcutaneous fatty tissue is separated, the aponeurosis is dissected, the rectus abdominis muscles are bluntly separated and a tunnel is created in the prevesical space. A 10 mm balloon trocar is inserted extraperitoneally, and the prevesical space is expanded by inflating the balloon to 600 ml. A camera is inserted into the trocar and the pelvis is examined. Ports are installed in the left and right iliac regions, along the midline between the pubis and the navel, and McBurney's points on both sides.

The operating table is placed in the Trendelenburg position. The obturator nerve is isolated on both sides in turn and lymph node dissection is performed from the obturator fossa using the Ligashu apparatus. Fatty tissue with lymph nodes on both sides is removed and sent for urgent histological examination. The intrapelvic fascia is opened in the anteroposterior direction, after which the puboprostatic ligaments are transected.

The dorsal complex is sutured with a continuous enveloping suture using 15 cm long V-loc 3-0 suture and intersected. The bladder neck is released by the antegrade route. The preprostatic fascia is incised transversely at the junction of the bladder and prostate. Consistently, after dissection of the Denonvilliers fascia, the seminal complex is released along the posterior surface of the prostate. The tissues between the prostate and the bladder are separated to the urethra. When inspecting the bladder cavity, the orifices of the ureters are visualized. The edges of the urethra and bladder neck are sent for urgent histological examination. The isolated preparation (prostate with seminal complex) is immersed in a container.

The edges of the visceral part of the endopelvic fascia covering the muscle that lifts the ani (m. levator ani) with V-loc 3-0 thread are sutured to each other with a continuous longitudinal suture, thus closing the defect of the fascial plate above the rectum.

A vesicourethral anastomosis is formed using a continuous suture using two V-loc 3-0 threads, 23 and 15 cm long, on a siliconized Foley catheter 20 Ch. Monitoring the tightness of the anastomosis - filling the bladder with sterile saline solution up to 150 ml - no leakage of fluid from the anastomosis is observed. Hemostasis control. Tubular drainage is supplied to the urethrovesical anastomosis along the anterior surface through the trocar port in the left iliac region. The container with the macropreparation is removed through the wound in the paraumbilical area. Wounds of the anterior abdominal wall are sutured in layers. Stitches on the skin. Iodine, as. bandages.

The novelty of the proposed method is that the defect of the fascial plate above the rectum is closed in such a way that the edges of the visceral part of the endopelvic fascia covering the muscle that lifts the ani (m. levator ani) with V-loc 3-0 thread are sewn together with a continuous longitudinal suture .

We give a clinical example of the application of the method.

Patient B., 71 years old. I consulted a urologist about an increase in PSA level to 6.7 ng/ml. The patient underwent transrectal polyfocal prostate biopsy. Pathohistological analysis data: moderately differentiated acinar adenocarcinoma Gleasson 7(3+4) occupying 20% of the biopsy volume, localized in the left lobe (two biopsy specimens).

The patient underwent surgical treatment including laparoscopic extraperitoneal pelvic lymphadenectomy, radical prostatectomy.

Under endotracheal anesthesia under aseptic conditions, with the patient in the supine position, a 3 cm long skin incision was made in the paraumbilical region, below the navel, the subcutaneous fatty tissue was separated, the aponeurosis was dissected, the rectus abdominis muscles were bluntly separated and a tunnel was created in the prevesical space.

A 10 mm balloon trocar was inserted extraperitoneally and the prevesical space was expanded by inflating the balloon to 600 ml. A camera was inserted into the trocar and a pelvic examination was performed. Ports were installed in the left and right iliac regions, along the midline between the pubis and the navel, and McBurney's points on both sides.

The operating table was placed in the Trendelenburg position. The obturator nerve was isolated on both sides in turn and lymph node dissection was performed from the obturator fossa using the Ligashu apparatus. The fatty tissue with lymph nodes on both sides was removed and sent for urgent histological examination. The intrapelvic fascia was opened in the anteroposterior direction, after which the puboprostatic ligaments were crossed.

The dorsal complex was sutured with a continuous enveloping suture using 15 cm long V-loc 3-0 suture and divided. The bladder neck was isolated using an antegrade method. The preprostatic fascia was incised transversely at the junction of the bladder and prostate. Consistently, after dissection of the Denonvilliers fascia, the seminal complex was isolated along the posterior surface of the prostate. The tissue between the prostate and the bladder was separated to the urethra. During inspection of the bladder cavity, the orifices of the ureters were visualized. The edges of the urethra and bladder neck were sent for urgent histological examination. The isolated preparation (prostate with seminal complex) was loaded into a container.

The edges of the visceral part of the endopelvic fascia covering the muscle that lifts the ani (m. levator ani) with V-loc 3-0 thread were sutured to each other with a continuous longitudinal suture, thus closing the defect of the fascial plate above the rectum.

The vesicourethral anastomosis was formed with a continuous suture using two V-loc 3-0 threads, 23 and 15 cm long, on a siliconized Foley catheter 20 Ch. We checked the tightness of the anastomosis - filled the bladder with sterile saline solution up to 150 ml - no fluid leakage from the anastomosis was noted. Hemostasis was monitored. Tubular drainage was connected to the urethrovesical anastomosis along the anterior surface through the trocar port in the left iliac region. The container with the macropreparation was removed through the wound in the paraumbilical area. The wounds of the anterior abdominal wall were sutured in layers. The skin was stitched. Iodine, as. bandages.

The postoperative period proceeded without complications.

The emergency drainage from the abdominal cavity was removed on the first day.

The urethral catheter was removed on the eighth day. After removal of the urethral catheter, urine leakage was noted during physical activity, one or two urological pads per day.

The patient completed the ICIQ-SF questionnaire on the first day after removal of the urethral catheter, then after 3, 6 and 12 months. On the first day after removal of the urethral catheter, the patient scored 9 points on the ICIQ-SF scale, which corresponds to a moderate degree of urinary incontinence. At 3 months - 3 points, which corresponds to a mild degree of urinary incontinence. At 6 and 12 months of follow-up, the patient scored 0 on the ICIQ-SF scale, meaning urinary continence function was fully restored.

This method was used to prevent urinary incontinence after radical prostatectomy in 24 patients.

The technical and economic efficiency of the method lies in the fact that its use makes it possible to prevent urinary incontinence after radical prostatectomy, thereby improving the quality of life of patients. The method has no intraoperative complications, is universal, and technically easily reproducible in specialized clinical departments.

Claims (1)

A method for the prevention of urinary incontinence after radical prostatectomy, including surgical treatment in the scope of laparoscopic extraperitoneal pelvic lymphadenectomy, radical prostatectomy, characterized in that the defect of the fascial plate above the rectum is closed: the edges of the visceral part of the endopelvic fascia covering the levator ani muscle - m. levator ani, are sutured together with V-loc 3-0 thread with a continuous longitudinal suture, then a vesicourethral anastomosis is formed.