Anatomic Restoration Technique of Continence Mechanism and Preservation of Puboprostatic Collar: A Novel Modification to Achieve Early Urinary Continence in Men Undergoing Robotic Prostatectomy

Objectives

The puboprostatic ligaments, puboperinealis muscle, and arcus tendineus are all recognized as important for continence in men and women. This complex of ligaments, muscles, and tendineus aponeurosis acts in unison to provide continence and can be disrupted during robotic prostatectomy. We propose that preservation of the puboprostatic collar during robotic surgery will help to restore early continence in men undergoing robotic prostatectomy.

Methods

We performed cadaveric studies in 10 fresh cadavers to devise strategies to leave intact the puboprostatic ligaments, muscular collar, and arcus tendineus supporting the continence mechanism. We developed reconstructive strategies to reconnect the ligaments to the urethrovesical anastomosis, reapproximated the muscles, and fixed the distal bladder to the arcus tendineus. These modifications were then attempted in 50 consecutive patients who underwent robotic prostatectomy for clinically localized prostate cancer. The patient-reported outcomes were then used to assess the efficacy of this procedure.

Results

The technique was reproducible, and the average additional time taken for the final reconstruction was only 2 to 5 minutes. The continence rate was 29% in the first week, 62% at 6 weeks, 88% at 12 weeks, and 95% in 16 weeks after catheter removal. No other differences were found in the operative, oncologic, or perioperative outcomes.

Conclusions

This modification helped in the early return of continence. It is unlikely that the long-term results will be any different, but shortening the recovery time will have psychological, financial, and health-related quality-of-life benefits for the patients.