[Vesico-urethral and entero-urethral anastomosis: anatomo-surgical considerations and technical note]

Following radical prostatectomy or radical cystectomy with orthotopic ileal bladder (in male patients), the cervico-urethral or entero-urethral anastomosis are at high risk for urinary stress incontinence, due to the shortening of the urethral functional length as well as "unavoidable downward fall" of the perineum after sectioning of the anterior portion of the sacro-pubic ligaments. That descensus of the perineum, if uncorrected, might cause a functional extraabdominal positioning of the residual functional urethra; this feature is close similar to one of the most important pathogenetic factors of genuine stress incontinence in the female. In order to correct that perineal fall is advisable to perform the so-called "secondary sphincter" (after Rocca Rossetti, 1982) by suturing with the same stitches not only the anastomotic edges but the medial part of the levator ani (i.d. pubo-rectal muscles) and the retro-urethral striated musculature as well; this technique ensure a good intraabdominal position of the residual functional urethra and prevents dangerous tensions on the anastomosis. The Authors stress the importance of a delicate dissection of the prostatic apex with no or minimal manipulation of the membranous urethra avoiding to evaginate it from the surrounding pelvic floor, that could damage its vascular supply. Following the before mentioned criteria the Authors performed 17 radical prostatectomies and 7 ileal bladder after radical cystectomy with satisfactory results (4.1% of postoperative urinary incontinence).