PRESERVATION OF PUTATIVE CONTINENCE NERVES DURING RADICAL RETROPUBIC PROSTATECTOMY LEADS TO MORE RAPID RETURN OF URINARY CONTINENCE

Objectives. Urinary incontinence is a significant complication of radi cal pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary contro l. Methods. Mock radical retropubic prostatectomy was performed on fre sh cadavers to determine which surgical maneuvers could injure what ma y be the continence nerves. To assess the clinical significance of mod ifying the radical retropubic prostatectomy based on these anatomic st udies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation wa s compared with a control group of 38 consecutive patients who had a s tandard anatomic radical retropubic prostatectomy. Results. At the lev el of the prostatic apex, both the pelvic and pudendal nerves gave int rapelvic branches that bilaterally coursed to the external urinary sph incter to enter at the 5 and 7 o'clock positions. The mock radical pro statectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the Sand 7 o'clock positions. In addition, blunt dissection of the tips of the seminal v esicles injured the inferior hypogastric plexus. Modifications to pres erve the continence nerves were incorporated in the anatomic radical p rostatectomy. Although overall continence rates were similar for the t wo groups (98.3% for continence nerve-preserving radical prostatectomy versus 92.1% for standard prostatectomy), continence nerve preservati on decreased the time to achieve continence. Conclusions. During radic al retropubic prostatectomy, surgical maneuvers that avoid injury to t he continence nerves resulted in the more rapid return of urinary cont rol. (C) 1998, Elsevier Science Inc. All rights reserved.