:: Asian Journal of Andrology ::

Pressure assessment in intercavernous embedding of bulboperineal urethra for treatment of urinary incontinence after prostatic operation

Li-Xin QIAN, Hong-Fei WU, Yuan-Geng SHUI, Wei ZHANG, Shuang-Guan CHENG, Min GU, Zheng-Quan XU

Department of Urology, First Affiliated Hospital, Nanjing Medical University, Nanjing 210029, China

Asian J Androl 2001 Sep; 3: 235-237

Keywords: prostatic operation; urinary incontinence; intercavernous embedding; pressure assessment

Abstract

Aim: To put forward criteria for the pressure assessment in the operation of intercavernous embedding of bulboperineal urethra for the treatment of urinary in continence after prostatic operation. Methods: A F14 urethral catheter is inserted during the operation and upon suturing the corpora cavernosa centrally, the catheter is slowly pushed in and pulled out in order that the operator feels a certain degree of close-fit resistance. The degree of tightness of the stitches, which regulate the compression pressure, is adjusted in accordance with this close-fit sensation. To further ascertain the adequacy of the force of compression, the bladder is filled with 300 ml physiological saline and observe the appropriateness (size and continuity) of the outflow stream when the lower abdomen is depressed with a pressure of 80-90 cm H₂O. The operation was given to six patients suffered from urinary incontinence for 20 or more months after prostatic operation. Results: Five cases achieved complete recovery, while the therapeutic effect of the 6th one was not satisfactory. A second stage operation was carried out 3 months later with the addition of one more stitch both proximally and distally to reinforce the compression force. The condition was improved dramatically.The follow-up period averaged 3.5 years. Conclusion: The adequacy of the compression pressure exerted by the juxtaposed corpora cavernosa is the key point deter mining the outcome of the operation. The measures for assessing the compression pressure suggested by the authors are helpful in obtaining the good results of the present paper (6/6 success) as compared with 25/34 success in the previous report.

1 Introduction

In the recent decade in China, the incidence of benign prostate hyperplasia (BPH) in people aged 60-90 years has been increased to 50-83%, the incidence of prostatic carcinoma (PCa), to 2.41 per 100,000 men, the incidence of latent PCa has reached 25% in people 70 years or older, and incidental PCa has been found in 4.9% of BPH surgical specimens^[1]. Data indicate that they are already common diseases in China. Urinary incontinence is not a rare complication after surgical operation for BPH or PCa, whether it is an open prostatectomy or a transurethral prostectomy. As a routine, urinary incontinence patients should first be given conservative treatment. If the urinary incontinence is caused by instability of the detrusor urniae, a cholinolytic or smooth muscle depressant may be helpful. In case of asthenia of the detrusor with a large amount of residual urine, indwelling catheter may be introduced and kept there until the gradual recovery of detrusor contractility. Dilatation of urethra may break the adhesions around the external sphincter. If these measures do not work and the history is more than 12 months, surgical intervention may be considered. There are several operative approaches reportedly for the treatment of male urinary incontinence^[2]: the Marshell-Marchetti operation does not bring about satisfactory result; although the Scott artificial urinary sphincter may ideally control urine incontinence, due to the expensive equipment, the complex surgical operation and the susceptibility to mechanical faults, it has not been widely used. Hauri^[3] and Lenzi et al^[4] de signed a surgical procedure of intercavernous embedding of the bulboperineal urethra with a good result of 73.5% (25/34) complete restoration of continence. In this operation, the intensity of the compressional force exerted by the juxtaposed corpora carvenosa on the bulboperineal urethra is the decisive factor for the success of the surgery. We raised a couple of measures to semi-quantitatively assess this force.

2 Materials and methods

2.1 Patients

From February 1993 to December 1998, 6 patients, aged 58-67 (mean 63.5) years, with urinary incontinence after various prostatic operations were admitted to this Department. The history of urinary incontinence varied from 16 to 28 months, with an average of 20.5 months. Two patients had undergone suprapubic transvesical prostatectomy, two, transurethral resection of prostate, one, radical prostate ctomy due to PCa and one, transurethral dilatation of the prostate with balloon catheter. All of them failed to respond to routine conservative treatment, including Chinese herbal therapy. Before the present operation, patients were subjected to voiding cystourethrography, retrograde urogram and urethroscopic examination. Obstructive pathologic conditions, e.g., prostatic remains, scarring stricture, etc., in the lower urinary tract were excluded or treated endoscopically. The posterior urethra was in a state of relaxation and had no residual urine. Cystometry showed no neurologic problem of the detrusor. Urodynamic study revealed that the compliance and stability of the bladder was normal.

2.2 Surgery

2.2.1 Original surgery

For the detail procedure of the surgery refer to Lenzi et al^[4]. Briefly, a perineal midline incision is made and the bulboperineal urethra and the corpora cavernosa are isolated. After a midline incision at the triangular ligament, the bulboperineal urethra is embedded between the corpora cavernosa with the latter brought together by interrupted silk sutures. A U-shaped suture is placed over the lateral margin of the bulbous urethra and anchored distally to the lower margins of the corpora. In this way the bulbous urethra is wrapped up and pushed forward. The crura penis are partially separated from the ischial tuberosities and the lower margins of the crura are rotated toward the midline. The lateral margins of the crura penis are closed at the midline with interrupted silk sutures, thus exerting a continuous compression on the bulbous urethra. A 14 Ch catheter is left indwelling for 3 days to avoid retention of urine or voiding difficulties because of edema.

2.2.2 Authors' modification

The principal surgical procedure is similar to that of the Lenzi et al^[4]. In this operation, the intensity of the compression force exerted by the juxtaposed corpora carvenosa on the bulboperineal urethra is the decisive factor for the success of the operation. The authors raised a couple of measures to assess the tightness of the stitches put on the corpora cavernosa, and thus the force of compression. A F14 urethral catheter is inserted during the operation and upon suturing the corpora cavernosa centrally, the catheter is slowly pushed in and pulled out in order that the operator feels a certain degree of close-fit resistance.

To further ascertain the adequacy of the force of compression, the bladder is filled with 300 mL of physiological saline and observe the adequacy (size and continuity) of the outflow stream when the lower abdomen is depressed with a pressure of 80-90 cm H₂O. The authors also suggested an embedding length of 3-4 cm.

3 Results

All the 6 patients felt dysuria soon after the removal of the indwelling catheter, one week later their condition gradually improved and a complete restoration of normal urination was achieved in 5 patients. In the sixth case, there was still urinary incontinence. This was the first case we performed the operation of intercavernous embedding and it was possible that the compression pressure might be insufficient due to lack of experience. A second stage operation was performed 3 months later with the addition of one more stitch both proximally and distally to strengthen the compression force when it was found that there was no much resistance as assessed with the F14 catheter. After the second operation, the condition was greatly improved. In all the patients urinary incontinence did not recur during the follow*-up period of 9 months to 6 years (average 3.5 years). Thus the overall result is excellent in all the 6 patients.

4 Discussion

The incidence of urinary incontinence after prostatic operation is about 15.0-18.6%^[5,6]. The effectiveness of the present operation in restoring urinary continence is determined by an adequate compressional force exerted on the bulboperineal urethra by the juxtaposed corpora cavernosa. The length of the urethral tract embedded is one of the factors governing this force. Thus, Hauri^[3] suggested to embed the whole length of the bulboperineal urethra between the corpora. Another important factor affecting the force of compression is the tension of the stitches to juxtapose the corpora cavenosa. The previous reports did not propose any objective measure for the quantification of this tension. The authors' experience of feeling the resistance in sliding the urethral catheter and of observing the size of the stream outflowing from the filling bladder provide semi-quantitative assessment of the compressional force. This may be the main reason that the authors obtained a better result (6/6 recovery) than that reported by Lenzi et al^[4] (25/34 or 73.5% recovery). The difference between the two groups is not significant; one of the factors may be insufficient case number in this series.

References

[1] Gu FL, Xia TL, Kong XT. Preliminary study of the frequency of benign prostatic hyperplasia and prostatic cancer in China. Urology 1994; 44: 688-93.
[2] Theodorou C, Moutzouris G, Floratos D, Plastiras D, Katsifotis C. Incontinence after surgery for benign prostatic hypertrophy: the case for complex approach and treatment. Eur Urol 1998; 33: 370-5.
[3] Hauri D. A new operation for post-prostatectomy incontinence. Urol Int 1977; 32: 284-94
[4] Lenzi R, Barbagli G, Stomaci N, Stomaci N, Selli C. Surgical treatment of male urinary incontinence. J Urol 1982; 130: 463-6.
[5] Gallucci M, Puppo P, Perachino M, Fortunato P, Muto G, Breda G, et al. Transurethral electrovaporization of the prostate vs. transurethral resection. Eur Urol 1998; 33: 359-64.
[6] Theodorou CH, Moutzouris G, Floratos D, Plastiras D, Katisfotis CH, Mertziotis N. Incontinence after surgery for benign prostatic hypertropsy: the case for complex approach and treatment. Eur Urol 1998; 33: 370-5.

home

Correspondence to: Dr. Li-Xin QIAN, Department of Urology, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China.
Tel: +86-25-371 8836 ext 6698 Fax: +86-25-372 4440
E-mail: qianlx@jlonline.com
Received 2001-04-12 Accepted 2001-08-30