Our initial study showed significantly faster rates of complete urinary continence in men undergoing MULP alone or in combination with posterior urethral reconstruction and anterior bladder suspension (MULP + PRAS), than PRAS alone (median time to complete continence 4 weeks, 3 weeks, and 22.5 weeks, respectively). Our initial study reported a mean of 14.4 mm urethral length preservation with the technique.
Since the publication of our initial study we anecdotally began to query our high volume patient population undergoing RALP on reasons for dissatisfaction after surgery. We noticed that in addition to time to full continence and erectile function, the factor most indicative of patient satisfaction after surgery was perceived length of penis. Radical prostatectomy is a known cause of penile shortening. Causes are multifactorial, including tethering of membranous urethra to pubis, traction injury causing progressive ischemia and periurethral scarring and penile tethering, and erectile dysfunction leading to penile fibrosis.2 With this in mind, we sought to determine whether maximizing membranous urethral length would contribute to preservation of stretched flaccid penile length (SFPL).
The study is descriptive in nature. In other words, we chose to defer a control group as we routinely perform MULP in all our patients. Unlike nerve sparing, which is oftentimes not feasible due to extraprostatic extension of disease, the technique of MULP can be reliably performed regardless of variation in prostate anatomy and tumor biology. Our results showed that combination of MULP with preoperative multiparametric MRI (mpMRI) preserve SFPL, with no change in the postoperative SFPL recorded among 27 subjects (77.1%), 5 patients (14.3%) with 0.5 cm shortening, and 3 (8.6%) with 1 cm shortening. In addition to MULP and mpMRI being predictors of SFPL preservation, we found that BMI and pathologic stage were also independent predictors.
Our findings merit eager discussion. While numerous adjunctive procedures, mainly involving penile rehabilitation and traction therapy, have been described in the literature, our study is the first to show that operative technique can have significant effect on measured penile length post RALP. This represents a great tool in the arsenal of the surgeon as it enables us to control one variable that can contribute to perceived loss of penile length and subsequent patient satisfaction. Many of the other ascribed factors contributing to loss of penile length are outside the control of the surgeon and rely more on each individual patient’s capacity of wound healing. Another finding of note from this study was the role preoperative mpMRI might play in contributing to the surgeon’s mental map while performing RALP and dictating how he or she navigates the extent of MULP and truly optimizing those outcomes. The finding of increased penile length loss with higher stage may not intuitively make sense. However, on closer inspection, our results suggest that patients with more aggressive disease, with extraprostatic extension or seminal vesicle invasion, are simply more likely to undergo aggressive apical dissection with resultant loss of membranous urethral length. However, this finding is mitigated, more significantly at higher stages, by the presence of preoperative mpMRI, which again serves as a roadmap for the urologist prior to embarking on surgery.
Takeaways from our work: mpMRI should be a standard part of the preoperative workup of a patient presenting for RALP, particularly in those with higher local stage disease, and MULP should be the technique of choice to both optimize urinary continence outcomes as well as penile length outcomes.
Written by:
- Shirin Razdan, MD, Icahn School of Medicine at Mount Sinai, New York, NY
- Sanjay Razdan, MD, MCh, FRCS (Glasg), International Robotic Institute for Prostate Cancer, Larkin Health System, Miami, FL
- Hamada A, Razdan S, Etafy MH, Fagin R, Razdan S. Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique. J Endourol. 2014;28(8):930-938. doi:10.1089/end.2013.0794
- Gontero P, Galzerano M, Bartoletti R, et al. New insights into the pathogenesis of penile shortening after radical prostatectomy and the role of postoperative sexual function. J Urol. 2007;178(2):602-607. doi:10.1016/j.juro.2007.03.119