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he Case for Posterior Musculofascial Plateeconstruction in Robotic Prostatectomy

obert J. Stein

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argin negative status, maintenance of potency, andreservation of continence are the key components thatonstitute the “trifecta” for an optimal outcome afteradical prostatectomy. A recent study from the Memorialloan-Kettering group reported that early and late con-inence outcomes were worse after laparoscopic radicalrostatectomy (LRP) than after the open technique, al-hough the oncologic and potency results were compara-le.1 The investigators used a strict definition of no padse and noted that at 12 months, 75% and 45% ofatients in the open and LRP groups were continent,espectively.

Aside from the fact that 4 surgeons with differentechniques were being compared, 2 questions remain toe answered: why might continence results be worse foraparoscopic (and presumably robotic) prostatectomy,nd what can be done to improve continence, and par-icularly the earlier return of continence in these pa-ients?

Several possible theories could explain the differencesn continence between the open and laparoscopic ap-roaches; however, no consensus has yet been reached.he possibilities include more aggressive apical dissectionuring laparoscopy and changes in the angle of the ure-hral position with pneumoperitoneum (pneumoretro-eritoneum). Another explanation pertains to 1 of theerceived benefits of robotic prostatectomy: the creationf an exact, often running, watertight anastomosis. Thencidence of bladder neck contracture is significantlyower for patients undergoing robotic prostatectomy thanor those undergoing open prostatectomy, likely owing tohe decreased incidence of urinary extravasation with aower periurethral inflammatory response. Severe bladdereck contracture requires dilation or incision; however,he rate of mild to moderate bladder neck contracture inatients undergoing open prostatectomy is likely greaternd serves a beneficial role as a continence mechanism.

Short of creating a less-watertight anastomosis duringP (which could prolong the catheter dwell time), whatan be done to improve continence rates and allow an

rom the Glickman Urological Institute, Cleveland Clinic, Cleveland, OhioReprint requests: Robert J. Stein, M.D., Department of Urology, Cleveland Clinic,

l100, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: steinr@ccf.org.Submitted: June 21, 2008; accepted (with revisions): August 26, 2008

2009 Elsevier Inc.ll Rights Reserved

arlier return of continence in patients undergoing ro-otic prostatectomy? In a 2006 editorial, Guillonneauas skeptical that “The Trick” would be discovered thatould suddenly make us better surgeons and able to boastrastically improved continence results.2 Just 2 yearsater, it seems several of the highest volume centers havedopted just that proverbial “Trick” that has been solusive, yet is so simple.

Posterior musculofascial plate reconstruction (PMPR),s first described by Rocco et al.,3,4 involves the recon-truction of Denonvilliers fascia after prostatectomywith or without nerve sparing) and before the vesicoure-hral anastomosis. The repair has been described in sev-ral reports and can be performed during open, LRP, orobotic prostatectomy.3,4 Essentially, the cranial cut edgef Denonvillier’s fascia is sutured to the distal end of thisayer (median raphe/central tendon), which lies posterioro the urethra. The remainder of this layer is adherent tohe posterior aspect of the prostate and has been removedr disrupted by excision of the prostate. An additional setf sutures anchors the Denonvillier’s median raphe com-lex to the detrusor fibers of the posterior bladder neck,hich might provide additional support for the bladderut also eases the tension on the vesicourethral anasto-osis.In their open series, Rocco et al.3 reported a conti-

ence rate (0-1 pad/d) of 62.4%, 74%, and 85.2%, at 3,0, and 90 days, respectively, in 250 patients who hadndergone PMPR vs 14%, 30%, and 46% in 50 patientsho had not. For LRP, a prospective trial, with or with-ut PMPR, was performed alternately in 62 patients, 31n each group.4 At Foley catheter removal, 74.2% ofatients after reconstruction vs 25% without reconstruc-ion were continent (0-1 pad/d). At 30 days, 83.8% and2.3% and at 90 days 92.3% and 76.9% of patients whoad or had not undergone PMPR were continent, respec-ively. In the discussion section, the investigators relatedhat the continence rates were lower in their early expe-ience when they performed both layers of the recon-truction simultaneously, using the same sutures. Theyeported that it was more difficult to regulate the tensionn each of the layers and that the tissues were more likelyo tear. From experience, I agree with this finding andlso suggest that the initial Denonvillier’s median raphe

ayer and the second layer involving the attachment of

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he first layer to the detrusor fibers of the posterior blad-er neck should be performed separately with separateutures.

We learned of this repair in late 2007 and immediatelyncorporated it into our standard LRP and robotic pros-atectomy procedures. To assess the benefits of this pro-edure, we compared the first 32 patients with PMPRith the last 30 patients before urethral reconstruction.5

t 3 days after Foley catheter removal, 34% were conti-ent (0-1 pad/d) after urethral reconstruction vs only 3%ithout reconstruction. At 6 weeks, the correspondingercentages of continent patients were 56% and 17%.wo points to highlight are that these were our firstatients with PMPR, demonstrating the simplicity of therocedure and virtual lack of a learning curve. Second,ur group’s experience with LRP and robotic prostatec-omy is vast; therefore, the increased surgeon experienceikely played no role in the difference in continence ratesetween the 2 groups in our retrospective study.Several possible explanations could account for the

arlier return of continence after PMPR. Using intraop-rative transrectal ultrasonography, we noted a reproduc-ble increase in the length of the external urethralphincter of 2 mm after PMPR compared with the lengthefore reconstruction. Essentially, the sphincter wasoted to shorten an average of 3.6 mm after prostatexcision, and PMPR restored a considerable amount ofhis length. This was likely a result of the re-establish-ent of a more cranial position of the perineal body with

he PMPR sutures. An additional theoretical advantagef re-establishing a stable and more cranial position ofhe perineal body is to provide a steady posterior supportor the horseshoe-shaped sphincter and thus a more ef-ective closing mechanism. It is unlikely that PMPRrovides any element of anatomic obstruction. We per-ormed retrograde urethral pressure measurements beforend after reconstruction, with essentially no differencesn the leak point pressures. In addition to the use ofMPR, ultimate urinary continence depends on severalther factors, such as patient age, bladder function, pros-ate size, urethral length, and neurovascular bundle pres-rvation.

A recent prospective randomized study reported notatistically significant difference in continence resultsetween vesicourethral anastomosis with or without theirwn PMPR technique.6 One concern with that study ishat the investigators only performed the first layer of the-layer PMPR that Rocco et al.3,4 described, used theame stitch for posterior reconstruction as for the vesi-ourethral anastomosis, and then performed an anterioreconstruction of the puboprostatic ligament to theubovesical collar. This technique differs in several fun-amental respects from the PMPR technique of Rocco etl.3,4 The results of Menon et al.6 suggest that meticulousttention to the reconstruction, as described by Rocco etl.,3,4 in 2 distinct layers posteriorly and separate from the

esicourethral anastomosis is pivotal for optimization of

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arly continence return. The investigators, however, didote an additional benefit of a lower anastomotic leakate with posterior reconstruction.6

This brings us to the question of whether we shoulderform total reconstruction of the vesicourethral junc-ion as described by Tewari et al.,7 or whether PMPRlone is functionally comparable and possibly more on-ologically sound. A review of the total reconstructionechnique (an approach to affect normal anatomy mini-ally) involves 6 different steps beyond PMPR. It was

eveloped as an evolution of steps, which additivelyncrease the continence rate (0-1 pad/d) at 6 weeksostoperatively, from 35% with no maneuvers to 83%ith total reconstruction. One technique that the inves-

igators continued to perform is preservation of the pubo-rostatic ligaments and arcus tendineus, with the even-ual reattachment of these structures to the bladder neckt the culmination of the procedure.

Several reports have compared continence rates, withr without sparing of the puboprostatic ligaments. Stol-enburg et al.,8 among others, have reported an improvedarly return of continence with the technique. In con-rast, other groups, such as Deliveliotis et al.,9 demon-trated no benefit from puboprostatic ligament sparing forrinary continence. Furthermore, Katz et al.10 reportedn improvement in margin rates since refraining from theractice of sparing the puboprostatic ligaments. The con-ern is anterior tumors, which certainly are a real entity,nd the question is whether it is necessary to dissect inlose proximity to the prostate anteriorly when PMPRight account for most, if not all, of the functional

enefit of total reconstruction. When the true effect ofnterior maneuvers for an earlier return of continence isn question, the greater oncologic risk might not beorthwhile. Thus, as is admittedly described in the Com-ent section of the total reconstruction study, a trial ofMPR alone compared with the 7 steps of total recon-truction would be most helpful.

In conclusion, PMPR is a highly effective and safeechnique for the early return of urinary continence, afterobotic or any form of radical prostatectomy. As thisechnique is popularized, quality-of-life assessments mayurther detail its true benefit. Regarding the addition ofre-existing continence-preserving techniques to PMPR,uch as has been proposed by the total reconstructiononcept, the jury is still out. Adding extra steps, whichight have questionable benefit for continence and

ould arguably jeopardize the oncologic outcome, re-uires strong evidence before being widely adopted. Untilhen, for the sake of simplicity and safety, and likelyacrificing minimal, if any, effectiveness, PMPR shoulde performed alone.

eferences1. Touijer K, Eastham JA, Secin FP, et al. Comprehensive prospective

comparative analysis of outcomes between open and laparoscopicradical prostatectomy conducted in 2003-2005. J Urol. 2008;179:

1811-1817.

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2. Guillonneau B. Editorial comment. Eur Urol. 2006;49:111-112.3. Rocco F, Carmignani L, Acquati P, et al. Early continence recovery

after open radical prostatectomy with restoration of the posterioraspect of the rhabdosphincter. Eur Urol. 2007;52:376-383.

4. Rocco B, Gregori A, Stener S, et al. Posterior reconstruction of therhabdosphincter allows a rapid recovery of continence after trans-peritoneal videolaparoscopic radical prostatectomy. Eur Urol. 2007;51:996-1003.

5. Nguyen MM, Kamoi K, Stein RJ, et al. Early continence out-comes of posterior musculofascial plate reconstruction duringrobotic and laparoscopic prostatectomy. BJU Int. 2008;101:1135-1139.

6. Menon M, Muhletaler F, Campos M, et al. Assessment of earlycontinence after reconstruction of the periprostatic tissues in pa-

tients undergoing computer assisted (robotic) prostatectomy: re-

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sults of a 2 group parallel randomized controlled trial. J Urol.2008;180:1018-1023.

7. Tewari A, Jhaveri J, Rao S, et al. Total reconstruction of thevesico-urethral junction. BJU Int. 2008;101:871-877.

8. Stolzenburg JU, Liatsikos EN, Rabenalt R, et al. Nerve sparingendoscopic extraperitoneal radical prostatectomy—effect of pubo-prostatic ligament preservation on early continence and positivemargins. Eur Urol. 2006;49:103-111.

9. Deliveliotis C, Protogerou V, Alargof E, et al. Radical prostatectomy:bladder neck preservation and puboprostatic ligament sparing-effectson continence and positive margins. Urology. 2002;60:855-858.

0. Katz R, Salomon L, Hoznek A, et al. Positive surgical margins inlaparoscopic radical prostatectomy: the impact of apical dissection,bladder neck remodeling and nerve preservation. J Urol. 2003;169:

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