Sphincter lesions after radical prostatectomy-evaluation and classification

The aim of this study was to analyze the sphincteric/perisphincteric lesions and modifications in incontinent patients with iatrogenic damage to the external urethral sphincter after radical prostatectomy (RP).

We evaluated 169 patients with postprostatectomy urinary incontinence who were referred from 28 German hospitals from December 2004 to March 2009. Inclusion criteria were refractory grade III stress urinary incontinence and duration of incontinence of at least 12 months. Patients underwent clinical, ultrasonographic examination, urethrocystoscopy, and if technically possible, urethrocystomanometry. Sphincteric defects were classified and evaluated with regard to type and localization.

Mean duration of incontinence before evaluation was 44.8 (12-156) months. Distribution of the previous prostatectomy technique was 66.9% retropubic RP, 27.8% laparoscopic RP, 3.5% perineal RP, and 1.8% robot-assisted RP. A transection of the sphincter was seen in 65.1% (110/169) of cases, a sphincter penetration in 46.2% (78/169) of cases. A combination of both sphincter injuries was seen in 37% (63/169) of patients. In 87% (147/169) of the cases, the sphincter defect was localized to the lower circumference, and in 13% (22/169) of cases, to the upper circumference. A stricture of the vesicourethral anastomosis was found in 45% (76/169) of cases.

Direct iatrogenic damages to the urethral sphincter are a potential reason for postprostatectomy urinary incontinence. They seem to follow a particular local distribution pattern, indicating that apex preparation and building of the urethrovesical anastomosis show an increased risk for these sphincter injuries. Cystoscopic evaluation of the sphincteric region in incontinent patients after surgery may be a valuable tool for examination.