Radical prostatectomy with preservation of urinary continence.

PURPOSE: In an effort to improve postoperative urinary continence after radical retropubic prostatectomy, a new operation to preserve the bladder neck and a significant portion of the prostatic urethra has been developed. MATERIALS AND METHODS: The prostatic urethra is dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis. RESULTS: A total of 24 patients who underwent the new continence sparing radical retropubic prostatectomy was compared retrospectively to 80 who previously underwent a nerve sparing procedure. Total continence was noted immediately in 11 patients, within 9 days in 15 and within 7 weeks in 21 of 24 who underwent the new operation, compared to 1, 5 and 33, respectively, of 80 who underwent the standard operation. Microscopic positive margins were noted in 2 of 24 patients with the new continence sparing operation. Early results of cancer control were good. CONCLUSIONS: Early followup of this new technique of radical retropubic prostatectomy suggest that preservation of the continence mechanism at the level of the bladder neck and prostatic urethra results in significantly improved postoperative urinary continence without adversely affecting cancer control.

Pelvic recurrence of rectal cancer. Options for curative resection.

Pelvic recurrence is an ominous event after curative resection of rectal cancer and is rarely amenable to re-resection by conventional methods. A method to permit a composite resection of these using the abdominal sacral approach has been described previously. This report updates that experience with resection of pelvic recurrence of rectal cancer in 28 patients. Of these, 24 were done with curative intent, and four were done for palliation (mainly for infected or fungating tumor). All patients had extensive preoperative evaluation by clinical and radiologic tests, and most patients had a long free interval period of approximately 18 months, after their primary resection. Although 47 patients had exploratory surgery, only 29 had local disease amenable to resection and four had palliative resections. About half the patients had had an abdominoperineal resection, half had had an anterior resection, and one third had had previous efforts to resect the recurrence. All but one patient had been irradiated with 3000-11,000 cGy. All but two patients (of the 24 curative efforts) required a formal abdominosacral resection (through S1-2 in 12, S2-3 in 9, and S4-5 in 1). Over half the patients also required a bladder resection. There were three operative deaths (12%); one patient had a cardiac death immediately after operation and two were septic deaths at 35 and 60 days. The survivors generally had relief of sacral root pain and good motor function; most of those previously employed could return to work. The actuarial 5-year survival rate is 25% and median survival is 36 months. Long-term survival over 48 months was recorded in five of 21 surgical survivors (23.8%). Survival in a historic comparative group of 30 patients treated for local recurrence only (mainly by radiation) was 15 months median, and at 5 years the survival rate was 3% (p less than 0.001). In conclusion, selected patients with pelvic recurrence of rectal cancer may be retrieved by and returned to functional life with the composite abdominosacral resection.