Acute and chronic prostatitis discussion. Arnon Krongrad, MD, moderator.
A question for the good doctor.... do you remove the internal involuntary sphincter along with the prostate? If so why? I did a quick trawl on Google for this plus LRP, and it seems many LRPs also remove that part of the bladder as it is frequently damaged during the LRP surgery, mainly because it is difficult to determine where the bladder ends and the prostate actually starts. Is this correct? I also read stuff from some places that use techniques to determine the precise effective join of the bladder and prostate, and take real care to preserve the internal sphincter without damage, such that onward urinary issues are absolutely minimised. If these techniques exist then why do all surgeons not use them?
The external is a well developed muscle wrapping around the proximal urethra; it controls continence. The internal sphincter is really a long set of small fibers running from the ureters across the trigone and down through the bladder neck and into the prostate. The photo shows a surgically preserved blader neck, as seen during a laparoscopic prostatectomy, appearing as a pink, anular "fish mouth," the fibers of the internal sphincter run through this bladder neck structure. (more photos posted here).
The internal sphincter seems to have little, if any, role in continence. Consider that it is routinely compromised during transurethral prostatectomy (TURP), but patients are perfectly continent. We also see in patients having radical prostatectomy, many times in the setting of massive prostate enlargement, which compromises the bladder neck, or previous TURP, which also compromises the bladder neck, that internal sphincter preservation is not possible and patients are continent.
"Removing" the internal sphincter, which is to say to not preserve the bladder neck, is seen with all forms of radical prostatectomy, both open and minimally invasive, and is not a function of which gizmos are used. It's a function of patient anatomy and surgeon experience.
Sure, there are techniques to help identify the junction of the bladder and prostate. Experience matters. But again, it's not apparent that this has much of an effect on "urinary issues." It does accelerate urethro-vesical anastomosis and minimizes the likelihood of urinary leak. And as for why other surgeons may or may not use which technique, you'd have to ask them directly. At issue, again and again, is surgeon experience.
I had TURP in which the internal sphinchter has been knocked off. I am normally continent but there is urine leakage when flatus(gas) is released . Though continence can be maintained with external sphincter, it appears that the pelvic floor muscle has to be relaxed for allowing the gas to pass and simultaneously the external sphincter is also relaxed leading to leakage of urine. Is there anyway to train the muscles only to open for the gas to pass without opening the external sphincter?
Interesting question. I believe that the two are involuntarily linked but would want the opinion of someone expert in pelvic rehab and feedback. I've not heard of anyone separately training the external sphincter.
Thanks Dr. Krongrad. I will post if there is any progress
Dr. Do you recommend Kegel before and after surgery?
Not before. I do talk about them with my patients after surgery; many don't need them but for a handful they may help.