Rectus urethromyoplasty of radical prostatectomy anastomosis decreases postoperative incontinence and anastomotic stricture; technique and preliminary results

Purpose: To investigate the effect of rectus urethromyoplasty on vesicourethral anastomosis healing during radical retropubic prostatectomy (RRP) and in an animal model. Materials and Methods: Three groups of 10 female rats were studied. After complete urethral transection, group A animals underwent a primary urethral anastomosis, while rectus urethromyoplasty was used to reinforce the anastomosis of the animals in group B. Group C animals served as controls. All animals underwent urodynamic evaluation one month postoperatively, then were sacrificed for histological analysis. In 3 clinical subjects at the time of RRP, a 2-3 cm × 6-8 cm. strip of rectus muscle was isolated with its blood supply intact, emanating from an inferior epigastric artery pedicle. This muscular band was used to encircle the vesico-urethral anastomosis, suspending it slightly but without tension, and securing it to the pubic symphysis. Results: The micturition pattern, bladder capacity, and leak point pressure of the 3 groups of animals were not significantly different. Histological examination of the rectus sling revealed viable muscle with histofibroblast, collagen, and blood vessel ingrowth from the vascular rectus muscle into the urethra. Three successful clinical rectus urethromyoplasty cases were performed with over 12 months of follow-up. Conclusions: Reinforcement of the vesico-urethral anastomosis using rectus urethromyoplasty at the time of radical prostatectomy may improve continence by increasing urethral support and mucosal coaptation. This technique may decrease the incidence of stricture formation by augmenting blood supply available for healing of the anastomosis. Rectus urethromyoplasty may be especially beneficial to patients with an increased risk of requiring adjuvant radiation therapy post-prostatectomy.