Since robot-assisted laparoscopic radical prostatectomy (RALP) was introduced to prostate cancer surgery, reconstructive procedures that were difficult to carry out in the laparoscopic and open radical prostatectomy era, such as posterior reconstruction (PR), have become easily accessible for surgeons to carry out.
In this study, the authors described their PR method consisting of a single-layer running suture from the detrusor muscle plate in the posterior aspect of the bladder neck to the musculo-fascial tissue beneath the urethra.1 Their important point is that the key to PR is anastomosis arising not from the Denonvilliers' fascia, but from the strong structure of detrusor muscle layer (posterior detrusor raphe). Their procedure without suturing the Denonvilliers' fascia is different from the PR reported in previous studies. Furthermore, the authors showed differences between the groups with and without PR. They also summarized and discussed various PR methods of previous studies in their comments.
Four or five more recent studies associated with PR have been reported. Sutherland et al. described a randomized trial comparing continence results in patients treated with RALP who underwent PR of the rhabdosphincter to those who did not.2 They found no difference in 3-month continence in 94 patients with and without PR. In contrast, Coelho et al. showed that PR improved early continence in a large non-randomized trial including 803 patients receiving RALP.3 Brien et al. also showed that PR led to an earlier return to baseline continence in 89 patients undergoing RALP in their prospective quality of life study.4 Anterior reconstruction after PR showed significant early continence recovery in two randomized trials. Koliakos et al. found a difference in the continence rate at 7 weeks after RALP using their anterior suspension (AS) anchored not to the pubic bone, but to the dorsal vein complex.5 Hurtes et al. carried out AS and PR in their randomized trial including 75 patients undergoing RALP, and showed differences in early continence recovery at 1 and 3 months.6
There have been various randomized and non-randomized reports examining the significance and effect of PR on continence that have used different PR procedures and different continent definitions. The significance of PR is still not totally understood in studies using RALP, because it might have other advantages for continence recovery; functional preservation of the sphincter and preserving urethra length. The significant advantages of PR for early continence recovery in case-controlled studies compared with simple clinical outcome could not be concluded.
Further research focusing on the anatomical and physiological effects is necessary to prove real effectiveness on continence after RALP with the PR procedure.