Posterior Musculofascial Reconstruction After Radical Prostatectomy: A Systematic Review of the Literature

Abstract

Context

In 2001, Rocco et al. described a surgical technique whose aim was the reconstruction of the posterior musculofascial plate after radical prostatectomy (RP) to improve early return to urinary continence. Since then, many surgeons have applied this technique—either as it was described or with some modification—to open, laparoscopic, and robot-assisted RP.

Objective

To review the outcomes reported in comparative studies analysing the influence of reconstruction of the posterior aspect of the rhabdosphincter after RP. The main outcome evaluated was urinary continence at 3–7 d, 30–45 d, 90 d, 180 d, and 1 yr after catheter removal.

Evidence acquisition

A systematic review of the literature was performed in November 2011, searching the Medline, Embase, Scopus, and Web of Science databases. A “free-text” protocol using the terms posterior reconstruction of the rhabdosphincter, posterior rhabdosphincter, and early continence was applied. Studies published only as abstracts and reports from meetings were not included in this review. One thousand seven records were retrieved from the Medline database, 1541 from the Embase database, 1357 from the Scopus database, and 1041 from the Web of Science database. The authors reviewed the records to identify studies comparing cohorts of patients who underwent RP with or without restoration of the posterior aspect of the rhabdosphincter. Only papers evaluating use of this technique as the only technical modification among the groups were included. A cumulative analysis was conducted using Review Manager v.5.1 software (Cochrane Collaboration, Oxford, UK).

Evidence synthesis

Eleven studies were identified in the literature search, including two randomised controlled trials (RCTs), which were negative studies. The cumulative analysis of comparative studies showed that reconstruction of the posterior musculofascial plate improves early return of continence within the first 30 d after RP (p = 0.004), while continence rates 90 d after surgery are not affected by use of the reconstruction technique. The statistical significance of the reconstruction seems to decrease when higher continence rates are reported. Use of posterior rhabdosphincter reconstruction does not seem to be related to positive surgical margin (PSM) rates or with complications like acute urinary retention (AUR) and bladder neck stricture (BNS). Some studies suggested lower anastomotic leakage rates with the posterior musculofascial plate reconstruction technique.

Conclusions

The role of reconstruction of the posterior musculofascial plate in terms of earlier continence recovery is encouraging but still controversial. Methodological flaws and poor surgical standardisation seem to be the major causes. In two RCTs and one parallel (not randomised) group trial, posterior rhabdosphincter reconstruction offered no significant advantage for return of early continence after RP. No significant complications related to the posterior musculofascial plate reconstruction technique have been reported so far. A multicentre RCT is necessary to clarify the possible role of the technique in terms of earlier continence recovery.

Introduction

Incontinence and impotence are the two major drawbacks of radical prostatectomy (RP). According to the European Association of Urology 2011 guidelines [1], incontinence persists 1 yr after RP in 7.7% of cases, while the American Urological Association (AUA) 2007 guidelines (reviewed with validity confirmed 2011 [2]) report post-RP incontinence rates ranging from 3% to 74%.

In 2001, Rocco et al. described a technique for restoration of the posterior aspect of the rhabdosphincter [3] based on study of the anatomy of the rhabdosphincter itself [4]. The rhabdosphincter is a circular structure of striated muscle fibres around the urethra, from its membranous part to the prostatic apex. This muscular structure surrounds the entire length of the urethra; its striated muscle fibres are thicker anterolaterally and thinner posteriorly [5]. The contraction of the rhabdosphincter takes place with the anterolateral walls moving against the less muscular and more rigid posterior wall, which acts as the fulcrum of the muscular action. The rhabdosphincter participates in a musculofascial suspension system that comprises—cephalad to caudad—the Denonvilliers’ fascia, the posterior fascia of the prostate, the median fibrous raphe, and the central tendon of the perineum (Fig. 1).

In 2006, a study conducted on 211 patients showed that posterior musculofascial reconstruction markedly shortened time to continence after radical retropubic prostatectomy (RRP) [6]. Two modifications to the standard Walsh procedure [7] were introduced: the reconstruction of the posterior musculofascial plate and the suspension of the urethral sphincteric complex from the bladder. Before dissecting the prostatic apex, the posterior median raphe is carefully prepared and preserved, separating it from the neurovascular bundles (NVBs) and rectal fascia. Two polyglactin 3-0 sutures are then passed through the median raphe. The apex of the prostate is finally dissected, and the prostatovesiculectomy is completed. Before proceeding to vesicourethral anastomosis, the posterior median raphe is fixed to the cutting edge of the Denonvilliers’ fascia using the two previously placed sutures.

Finally, the posterior median raphe and the Denonvilliers’ fascia are sutured to the posterior bladder wall 1–2 cm cranially and dorsally of the bladder neck. The dorsal aspect of the bladder becomes the new cranial insertion of the sphincter and posterior median raphe, fixing the sphincter (Fig. 2). The anastomosis is then performed.

In 2007, Rocco et al. described the application of the posterior reconstruction technique to transperitoneal laparoscopic radical prostatectomy (LRP) [8] (Fig. 3). Since these descriptions, many authors have applied the prostatic musculofascial plate technique in the hope of improving early continence after RP. The aim of this review is to analyse comparative studies.