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2 0 0 9 B J U I N T E R N A T I O N A L | 1 0 4 , 2 7 4 2 8 1 | doi:10.1111/j.1464-410X.2009.08751.x

Surgery Illustrated Focus on Details

Anatomical reconstruction of the rhabdosphincter
after radical prostatectomy

Francesco Rocco and Bernardo Rocco*

Clinica Urologica I, Universit degli Studi di Milano, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina
Elena, and *Division of Urology, European Institute of Urology, Milan, Italy

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

INTRODUCTION

The widespread use of PSA has led to an
increasing incidence of prostate cancer with a
consistent downward stage migration [1],
making a surgical approach with curative
intents suitable in most cases. Retropubic
radical prostatectomy is the reference
standard for clinically localized prostate
cancer [2] and the surgical technique has
been rened over the years, in particular after
the anatomical and physiopathological
studies by Walsh and Donker [3]. Nevertheless,
despite consistent results in terms of
oncological outcomes [4], the procedure still
has signicant drawbacks, among which the
most signicant are erectile dysfunction and
urinary incontinence. According to the
European Association of Urology guidelines
[5], urinary incontinence persists after 1 year
in only 7.7% of patients; however, although
most patients eventually recover continence,
the period of incontinence is poorly tolerated

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urethra, 12 cm from the urethra itself,
adhering to the prostatic fascia and merging
into the posterior aspect of Denonvilliers
fascia (Fig. 1).
Axial sections of the sphincter show a
horseshoe or omega shape, with thick
anterolateral walls rich in muscle bres and a
thin and brous posterior portion.
The posterior aspect of the rhabdosphincter
is characterized by a reduced amount or
complete absence of muscular bres. It is
mainly constituted by connective tissue, and
it is contiguous with the posterior median
raphe.
The posterior wall is brous and xed and
constitutes the fulcrum of contraction of the
muscular anterolateral wall; the contraction
of the anterolateral wall towards the xed
posterior portion occludes the lumen of the
sphincter.
and the patients quality of life is
compromised [6].
Here we present our technical renement
of the original Walsh radical retropubic
prostatectomy aimed at obtaining a rapid
recovery of urinary continence [6].

ANATOMY AND PATHOPHYSIOLOGY

According to studies by Oelrich [7], Myers [8],
and Burnett and Mostwyn [9], the urethral
rhabdosphincter is a cylindrical structure
surrounding the urethra and extending
vertically from the perineal membrane to the
base of the bladder. The rhabdosphincter
inserts caudally into the central tendon of the
perineum and into the perineal fascia.
Cranially its muscle bres insert into the apex
and anterior face of the prostate gland to
merge with the bres of the detrusor muscle.
Posteriorly, the rhabdosphincter inserts into
the prostatic apex cranially and dorsally to the

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Figure 1a:

1, bladder; 2, seminal vesicles; 3,
Denonvilliers fascia; 4, prostate; 5, median
brous raphe; 6, rhabdosphincter; 7, central
tendon. The posterior median raphe with the
connected rhabdosphincter, prostate dorsal
aspect, and Denonvilliers fascia form a single
musculofascial plate extending from the
peritoneum of the pouch of Douglas to the
perineal membrane and the central tendon of
the perineum [6]. This musculofascial plate
has been described as a dynamic suspensory
system for the prostatomembranous urethra
[9].

Figure 1b

We hypothesized [6] that the section of the
musculofascial plate could be responsible for
a loss of the posterior cranial insertions of
the urethral sphincteric complex into the
prostatic apex and Denonvilliers fascia,
resulting in:
Loss of the relatively rigid posterior surface
against which the anterolateral walls contract
to close the urethra;
Shortening and retraction of the urethral
sphincteric complex;
Perineal prolapse and distal sliding of the
urethral sphincteric complex.
The technique we illustrate has the following
aims: (i) Restoring anterior urethral length,
suturing the urethra to the bladder and
including the puboprostatic ligaments
ventrally; (ii) rebuilding the posterior
musculofascial plate, suturing the posterior
median raphe to the residual Denonvilliers
fascia; (iii) placing the urethral sphincteric
complex in a correct position in the pelvis by
hanging the posterior median raphe joined
to Denonvilliers fascia to the bladder: sutures
are passed 12 cm cranially and dorsally to
the urethrovesical anastomosis obtaining
posterior elongation of the urethral
sphincteric complex and urethropexy.
a
b
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2
3
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Figure 2

The dorsal vein complex has already been
sutured and divided; the anterior wall of the
rhabdosphincter is incised; underneath, the
anterior wall of the urethra is visible.

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Figure 3

After the division of the urethra, the posterior
median brous raphe is identied and isolated
from the neurovascular bundles. After its
section, the prostatectomy is completed
according to the original Walsh technique.

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Figure 4

After prostate removal, the residual portion of
the Denonvilliers fascia is identied on the
rectal plane and joined to the median brous
raphe, identied as reported before passing
two stitches.
According to our previous denition, this
manoeuvre allows for reconstruction of the
posterior musculofascial plate, after the
withdrawal of one of its components
represented by the dorsal aspect of the
prostate.

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Figure 5

The reconstructed musculofascial plate is
then xed 12 cm dorsocephalad to the
bladder neck, to restore a cranial insertion of
the sphincter, using the same two stitches
used to join the Denonvilliers fascia and
the posterior wall of the rhabdosphincter.
This step is of the utmost importance to
create a new contraction fulcrum for the
rhabdosphincter.

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Figure 6

The nal appearance of the urethral
sphincteric complex after reconstruction of
the musculofascial plate and after it has been
joined close to the bladder neck. From this
side view it is easier to understand the
importance of attaching the musculofascial
plate to the bladder to x it in the right
anatomical position.
a
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SURGICAL TIPS AND COMMENTS

This technique was developed to achieve
earlier recovery of continence, rather than a
better overall continence. The key steps of the
technique are the reconstruction of the
posterior musculofascial plate and its xation
in a new anatomical position, to restore
urethral length and create an adequate
fulcrum of contraction.
The technique requires an accurate
preparation of the prostatic apex.
Neurovascular bundles can be easily identied
and isolated, and are not damaged by the
application of this technique. In a minimally
invasive setting, we report a further advantage
of the technique, consisting in the possibility
of making a tension-free anastomosis, as
the sutures of the musculofascial plate are
tightened before making the anastomosis
[10]. Furthermore, the reconstruction of the
musculofascial plate has been associated with
a reduced risk of anastomotic leakage [11].
There have been no specic complications
related to the technique in our experience, nor
have any been published to our knowledge.
In our series of 250 patients treated using
this technique, 62%, 74% and 82.5% were
continent at 3, 30 and 90 days after catheter
removal [10]. In a minimally invasive
laparoscopic series of 30 patients, 74%, 84%
and 92% were continent at 3, 30 and 90 days
[12].
This technique has been validated by
comparative studies of experienced operators
in minimally invasive settings: Nguyen

et al.


[13] reported signicant advantages with
posterior musculofascial plate reconstruction
in robotic and laparoscopic settings. Tewari

et al.

[14] found increasing evidence of early
recovery of continence combining the
interesting anterior reconstruction of
periprostatic tissue with our technique [15].
Coughlin

et al.

[16] recently reported their
interesting modication of our technique
with a double running suture, but Menon

et al.

[11] reported no signicant difference in
terms of early continence with musculofascial
plate reconstruction and double-layer
anastomosis. However, the technique
described in that study is only partly similar to
ours, as the nal xation of the urethral
sphincteric complex to the bladder was
completely omitted, losing one of the keys to
functional recovery.

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Surgery Illustrated focus on details.
Modied posterior reconstruction of the
rhabdosphincter: application to robotic-
assisted laparoscopic prostatectomy

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Int

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Correspondence: Bernardo Rocco, Division of
Urology, European Institute of Urology, Via
Ripamonti, 435, 20141 Milan, Italy.
e-mail: Bernardo.rocco@ieo.it