Longterm complications

Bladder neck contracture (BNC)

Stricture or contracture formation at the vesicourethral anastomosis after RRP has been reported in as many as 17.5% of patients36 in published single institution series. In a study of the Medicare claims, 19.5% of patients identified to have had RRP by claim underwent one or more procedures for bladder neck obstruction or stricture after RRP.37 This contrasts with other studies reporting lower rates of postoperative BNC after RRP.38-40 Several studies have reported risk factors for the development of postoperative BNC, including previous prostate procedures or transurethral resections, excessive intraoperative blood loss, postoperative urinary extravasation and asymptomatic bacteriuria.39,41,42 In contrast, other studies found no relationship between development of BNC and previous transurethral resection of the prostate (TURP), or pathologic features including cancer volume, positive surgical margins, lymph node or seminal vesicle involvement.36'42 Patient comorbidities have also been implicated as risk factors for the development of BNC after RRP, including cigarette smoking, coronary artery disease, diabetes mellitus and hypertension, suggesting a microvascular component to the development of BNC. In all series, the majority of patients were treated with one or more transurethral dilations or incisions without requiring major reconstruction, which did not appear to impair continence. Thus, while the reported rate of BNC varies widely in the literature, the subsequent treatment and impact on patient quality of life appears to be minimal.

Incontinence

Urinary incontinence is one of the dreaded and most feared complications of RRP, and one that causes significant bother to patients.43 The rate of urinary incontinence varies widely in published series. As shown in Table 24.2, the published rates vary depending on how incontinence is measured, either from the surgeon's interview with the patient, a written survey from the institution or a population-based survey. Thus, obtaining an accurate measure of postoperative urinary incontinence remains difficult.

Eastham et al. looked at risk factors for urinary incontinence after RRP.44 This study examined the Baylor database from 1983 to 1994, overlapping a procedural change in RRP in 1990 in which meticulous care was taken to avoid traction on the urethra with minimal suture bites taken through the urethral stump, and to stomatize the bladder neck hiatus completely prior to performing the vesicourethral anastomosis. In a multivariate analysis, where incontinence is defined as leakage with moderate activity, the most important independent predictors of postoperative continence were younger age, improved modification of operative technique, preservation of both neurovascular bundles and the absence of postoperative BNC. With the modification of their operative technique, the time until regaining continence was significantly decreased from 5.6 months to 1.5 months, with a concomitant increase in overall continence from 82% to 95%.44

Impotence

Examination of postoperative impotence after RRP is difficult for several reasons. Objective measure of potency, both before and after treatment, is difficult to assess. The definition of potency also varies widely in reported series, without a consensus definition. Definitions include the degree of tumescence

Table 24.2. Incontinence after radical retropubic prostatectomy. Adapted from Eastham and Scardino (2000).1

Series

Number of Patients

Incontinence (%)

Definition of incontinence

Interview by treating physician at center of excellence

Steiner etal. (1 991 )106

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