Urinary incontinence is potentially the most debilitating complication of radical prostatectomy. The risk of urinary incontinence is not small and is variable among surgeons. It has been shown that the incidence of postoperative incontinence depends on the urologist's experience, patient's age (increased frequency after 70 years), and whether the operative technique includes minimal distal incision of the endopelvic fascia, preservation of the bladder neck, bilateral nerve-sparing surgery, or preservation of the PPL [7
]. In the American Urological Association guidelines, the reported risk of urinary incontinence ranges from 3 to 74% for radical prostatectomy [9
]. Continence mechanisms involve many structures, including the PPL, Denonvilliers' fascia, levator muscle, endopelvic fascia, and internal and external sphincters. Ventrally, the proximal prostate is covered by muscle fibers originating from the outer longitudinal bladder muscle and extending over the gland. These fibers constitute a detrusor apron [10
The pubovesical/PPLs (PV/PPLs) are paired fibrous bands originating from visceral endopelvic fascia. They insert on the distal third of the posterior surface of the pubic bone adjacent and anterior to the urethral sphincter [11
]. The visceral component of the endopelvic fascia covers the pelvic organs including the prostate, bladder, and rectum, and it is fused with the anterior fibromuscular stroma of the prostate at the upper ventral aspect of the gland [12
]. Along the pelvic sidewall at the lateral aspect of the prostate and bladder, the parietal and the visceral components of the endopelvic fascia are fused. As a fascial condensation, this fusion is often recognizable as a whitish line and is named the fascial tendinous arch of the pelvis. It stretches from the PV/PPLs to the ischial spine. During surgery, access to the lateral prostate may be gained by incision of the endopelvic fascia either medial or lateral to this fusion [10
]. The PV/PPLs stabilize the prostate, urethra, and bladder to the pubic bone and are considered an important part of the "suspensory system" of the continence mechanism [15
]. Some authors have suggested that preservation of these ligaments during radical prostatectomy may improve early recovery of urinary continence, but no definitive evidence has yet been established [17
]. Preservation of the PV/PPLs is facilitated by using the perineal and laparoscopic approach, whereas during open retropubic prostatectomy, the PV/PPLs are more difficult to preserve [20
]. Some authors have suggested that avoiding incision of the endopelvic fascia during radical prostatectomy, often combined with an intrafascial nerve-sparing procedure, might improve early recovery of urinary continence as well as improve postoperative erectile function, but definitive evidence has yet to be established [12
]. The parietal endopelvic fascia includes fascia of the levator ani muscle. The incision of this fascia immediately lateral to the fascial tendinous arch incises the levator ani fascia (LAF) and leaves the muscle fibers of the levator ani bare and the LAF adherent to the prostate [10
]. An incision of the visceral endopelvic fascia medial to the fascial tendinous arch results in a dissection plane that leaves the levator ani muscle covered with its fascia without exposure of its fibers [12
]. The result is a prostate covered only by prostatic fascia (PF), when present, and not by a layer of LAF [12
]. This fascia is not a discrete single-layered structure stretching over the lateral surface of the prostate. Laparoscopic surgery may offer an improved identification of these structures, resulting in less damage to the structures around the prostate. We could also identify these structures during the operation, which is related to recovery of postoperative urinary continence.
In addition, others have showed that continence rates correlate with differences in the mean functional urethral length and the existing differences in the maximal urethral closure pressure postprostatectomy [11
]. Poore et al. [17
] reported an earlier return of continence with a PPL-sparing technique versus a nonsparing technique, but the final outcomes were equivalent. Other authors also advocate the latter technique and have reported encouraging results [11
]. We believe that during mobilization of the prostate and especially during apical dissection, the intactness of the urethral supporting structures are of paramount importance because this avoids shear stress to the urethra as well as possible denervation. In our study, we observed an earlier return to continence in patients who underwent intrafascial nsELRP compared with previous conventional nerve-sparing LRP. Complete continence was achieved by 70.0% of patients who underwent nsELRP at 6 weeks after surgery and by 83.9% at 3 months after surgery. In the control group, however, 55.2% of patients achieved complete continence at 6 weeks after surgery and 75.0% at 3 months after surgery.
Reconstruction methods such as periurethral suspension stitch, bladder neck reconstruction, and posterior reconstruction have also been shown to provide improved early continence recovery, but the results are still controversial [24
]. Therefore, we focused on the preservation of normal structures rather than performing reconstruction after destruction of these structures.
Studies have reported that older age may be the only increasing risk factor for postprostatectomy incontinence [26
], but in our study, increased prostate volume and Gleason score were related with post-prostatectomy incontinence in the older aged group (age over 65 years). We speculate that large prostate volume and old age may be related to preoperative bladder and external urethral sphincter dysfunction leading to interference with postprostatectomy recovery of continence. A preoperative urodynamic study may be helpful in proving the relationship between prostate volume and old age with postoperative incontinence.
Anatomical studies [27
] have illustrated the prostatic neuroanatomy in detail, detecting additional neural tissues to the nerve bundles on the anterior midpart and posterior surface of the prostate. Costello et al. [29
] recently showed that most of the NVB descends posteriorly to the seminal vesicle. The nerves pass anteriorly and converge at the midprostatic level, and when they approach the apex, they diverge again. The anterior and posterior nerves of the NVB are separated by 3 cm at the level of the base of the prostate. At this anatomic site, the cavernosal nerves are not easily distinguished from the surrounding tissues and care should be taken during urethra-vesical anastomosis. Walsh [30
] proposed that the NVB is enclosed within the two layers of the lateral pelvic fascia composed of the lateral layer of the levator fascia and the medial layer of the PF. Kiyoshima et al. [14
] proved that the NVB was located on the posterolateral region of the prostate in 48% of their patients. In the remaining patients (52%), the NVB was widely distributed on the entire lateral aspect of the prostate without any specific localization. Thus, the authors proposed performing wide dissection of the lateral aspect of the prostate during radical prostatectomy to preserve the NVB. Therefore, meticulous dissection and disuse of electro-cauterization at the lateral and apex sides of the prostate are required to preserve the NVB by intrafascial nsELRP.
Anastasiadis et al. [1
] reported potency rates of 30% and 41% at 12 months after LRP (n=230) and open retropubic prostatectomy (n=70), respectively. After preservation of one or both NVBs, the potency rates increased from 37 to 44% with the retropubic approach and from 46 to 53% with LRP, respectively. Patients younger than 60 years who underwent bilateral NVB preservation were reported to be potent in 72% and 81% of cases, respectively. Graefen et al. [20
] reported rates of erections of 96.5%, 90.7%, and 84.3% and rates of intercourse of 69.0%, 52.8%, and 37.3% at 12 months after bilateral RRP in men <55 years, 55 to 65 years, and >65 years, respectively. In our study, the patients were generally old aged and were not sexually active; thus, we could not obtain potency recovery data. However, 19 patients (38.0%) reported subjective signs of potency recovery (morning erection or erection sensation) at 6 weeks after surgery, and at 3 months after surgery, the percentage was increased to 54.8% of patients.
The oncologic data of 1,000 LRPs at the Montsouris Institute revealed positive surgical margin rates of 6.9% for pT2a and 34% for pT3b tumors [2
]. In our study, the overall positive surgical margin rate was 34.0%. We consider this high positive margin rate as a "learning curve." In fact, from 30 cases, positive surgical margin rates decreased compared with the first 30 cases (51.7% vs. 9.5%). Most positive margins were seen at the apex of the prostate.