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\begin{document}

\title{The effect of vesicourethral anostomosis technique on functional results
in retropubic radical prostatectomy}



\author[1]{Fuat Kizilay}%
\author[2]{Serdar Kalemci}%
\author[2]{Adnan Simsir}%
\affil[1]{Affiliation not available}%
\affil[2]{Ege University Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Aim We aimed to compare the functional results of two different
vesicourethral anostomosis (VUA) techniques used in retropubic radical
prostatectomy (RRP). Methods A total of 476 patients including the first
group with 4 focal VUA at 12-, 3-, 6-, and 9-o'clock positions (n = 288)
and the second group with 6 focal VUA at 12-, 2-, 4-, 6-, 8- and
10-o'clock (n = 188) were included in the study. Perioperative data and
erectile function and continence status over a 12-month period were
compared. Results Demographic and perioperative data were similar
between the two groups. The proportion of patients with VUA stricture in
the first group was significantly higher than in the second group (5.1\%
vs 3.2\%, p = 0.017). The mean time to stricture development was also
shorter in the first group (48.9 vs 74.3 days, p = 0.002). In the second
group, the proportion of continent patients at the sixth and twelfth
months was higher than the first group (79.3\% vs 62.8\%, p
\textless{}0.001; 92.4\% vs 81.3\%, p = 0.032, respectively). There was
no significant difference between the two groups in terms of the
proportions of potent patients (p = 0.194 for 6 months and p = 0.351 for
12 months). Conclusions Better continence results can be obtained with
the six-focus VUA compared to the four-focus technique. The number of
anostomotic sutures in VUA can affect functional results and may be a
decisive factor for surgeons who focus on functional results as well as
oncological results.%
\end{abstract}%



\sloppy


\textbf{The effect of vesicourethral anostomosis technique on functional
results in retropubic radical prostatectomy}

\textbf{Aim}

We aimed to compare the functional results of two different
vesicourethral anostomosis (VUA) techniques used in retropubic radical
prostatectomy (RRP).

\textbf{Methods}

A total of 476 patients including the first group with 4 focal VUA at
12-, 3-, 6-, and 9-o'clock positions (n = 288) and the second group with
6 focal VUA at 12-, 2-, 4-, 6-, 8- and 10-o'clock (n = 188) were
included in the study. Perioperative data and erectile function and
continence status over a 12-month period were compared.

\textbf{Results}

Demographic and perioperative data were similar between the two groups.
The proportion of patients with VUA stricture in the first group was
significantly higher than in the second group (5.1\% vs 3.2\%, p =
0.017). The mean time to stricture development was also shorter in the
first group (48.9 vs 74.3 days, p = 0.002). In the second group, the
proportion of continent patients at the sixth and twelfth months was
higher than the first group (79.3\% vs 62.8\%, p \textless{}0.001;
92.4\% vs 81.3\%, p = 0.032, respectively). There was no significant
difference between the two groups in terms of the proportions of potent
patients (p = 0.194 for 6 months and p = 0.351 for 12 months).

\textbf{Conclusions}

Better continence results can be obtained with the six-focus VUA
compared to the four-focus technique. The number of anostomotic sutures
in VUA can affect functional results and may be a decisive factor for
surgeons who focus on functional results as well as oncological results.

\textbf{Key words:} prostate cancer, retropubic radical prostatectomy,
functional outcomes, vesicourethral anostomosis, incontinence.

\textbf{Introduction}

Prostate cancer (PCa), the most common cancer of men, accounts for
approximately one third of all cancers in
men.\textsuperscript{1}Although there are treatment options such as
high-intensity focused ultrasound, cryoablation and radiotherapy, the
vast majority of men undergo open retropubic radical prostatectomy
(RRP), which is the gold standard in the treatment of this
disease.\textsuperscript{2} With the developing technique and
technology, minimally invasive treatment methods have become popularized
in urological oncological surgery. Robotic radical prostatectomy, which
is one of these techniques, has revolutionized PCa surgical treatment
with the benefits it provides to surgeons. However, the high cost of the
robotic platform and the long learning curve of the laparoscopic
technique prevented them from spreading globally, and in most centers,
RRP is still the most performed technique.

In radical prostatectomy, it is of great importance to achieve optimal
functional results in addition to oncological control. Vesicourethral
anostomosis (VUA) technique affects significant complications such as
colllum sclerosis and incontinence affecting the course of surgery
results. Various modifications have been developed to optimize
anostomosis and avoid those complications. In the past, Walsh, who has
contributed greatly to the development of the RRP technique, proposed 6
focal sutures for VUA.\textsuperscript{3} Then, this technique was tried
to be modified and the results of studies dealing with suturing sites,
numbers and continuous suturing were
published.\textsuperscript{4-6}These techniques have been tried to be
performed in laparoscopic and robotic techniques besides open technique.
In addition to these modifications, a technique, in which a completely
sutureless anostomosis was made, appeared in the
literat\selectlanguage{ngerman}üre.\textsuperscript{7} Their common goal was to optimize the
functional results after VUA.

It is an undeniable fact that VUA technique affects important functional
results, especially anostomosis stricture. There is no consensus in the
literature on the optimal anostomosis technique and more studies are
needed to clarify this issue. In this study, we aimed to evaluate the
effect of two different VUA techniques that we frequently use in our
clinic on functional outcomes.

\textbf{Materials and Methods}

Patient selection and data collection

Five hundred thirty-five patients who underwent RRP between June 2015
and June 2019 were evaluated. Patients who had a history of pelvic
radiotherapy, urethral intervention, overactive bladder and / or
neurogenous bladder and who used drugs that could affect continence were
excluded from the study. The remaining 476 patients were included in the
study. Patients were divided into two groups according to the VUA
technique: patients who underwent four focal VUA (12-, 3-, 6-, and
9-o'clock positions) (group I) and patients who underwent six focal VUA
(12-, 2-, 4-, 6-, 8- and 10-o'clock positions) (group II). There were
288 patients in group I and 188 patients in group II. The flow chart of
the study is shown in \textbf{Figure 1} . All data were collected
retrospectively from the hospital database. Demographic, perioperative
and postoperative data and functional results of the two groups were
recorded and analyzed.

Evaluation criteria

Patients who were not using pads or using a single pad for protection
within 24 hours were considered as continent. Erectile function was
evaluated using the International Erectile Function Index (IIEF) and
patients with IIEF scores below 10 were considered to have erectile
dysfunction.\textsuperscript{8} Patients who were followed for at least
12 months after surgery were included in the study. Patients suffering
from urinary difficulty in the postoperative period were evaluated for
VUA stricture. In patients with suspected stricture in the uroflowmetry
test, a definitive diagnosis was made by performing urethroscopy.

Retropubic radical prostatectomy technique

The RRP was carried out in accordance with the technique described by
Walsh in 1988.\textsuperscript{9} Under general intratracheal
anesthesia, an 18 Fr Foley catheter was introduced and the skin,
subcutaneous, and muscles were cut through the suprapubic incision. Then
the endopelvic fascia was opened, the dorsal venous plexus was ligated
with 0 Vicryl suture and cut. The urethra was released, suspended and
cut. The prostate was released by sharp and blunt dissections from the
denonvilliers fascia. Bilateral ductus deferens were clamped and cut,
the right and left seminal vesicles were removed enblock with the
prostate. A 22 Fr Foley catheter was introduced. VUA was performed from
4 or 6 foci with 2/0 monocryl sutures. One
Jackson-pratt\textsuperscript{®} drain was inserted into the surgical
area, fasia was closed with 0 PDS suture, and skin with stapler,
respectively. In the four focus technique, sutures were placed at the
12-, 3-, 6-, and 9-o'clock positions. In the six focus technique,
sutures were placed at 12-, 2-, 4-, 6-, 8- and 10-o'clock positions. VUA
techniques with four and six focus are schematized in \textbf{Figure 2}
.

Outcome measures

The primary endpoint of the study was the evaluation of the relationship
between the vesicourethral anostomosis technique and elapsed time for
causing collum sclerosis, and the number of recurrences. Analysis of the
effect of the technique on erectile function and continence results was
the secondary endpoint.

Statistical analysis

While Student's t-test was used for the analysis of quantitative data,
chi-square test was used for the analysis of categorical data. P values
less than 0.05 were considered statistically significant. SPSS 23.0 for
Macintosh was used for all analyzes.

\textbf{Results}

The data of 476 patients whose information was obtained and who
underwent RRP were evaluated. The demographic data and basal PSA values
of the first group with four-focus VUA and the second group with
six-focus VUA were similar. The majority of the patients in both groups
consisted of patients with Gleason score 3 + 3 and 3 + 4. Prostate
volume and perioperative data were also similar between the two groups.
There was no significant difference between the T stage of the
prostatectomy specimens. Comparison of the demographic and perioperative
data of the groups is summarized in \textbf{Table 1} .

The proportion of patients with VUA stricture in the first group was
significantly higher than in the second group (5.1\% vs 3.2\%, p =
0.017). Also, the mean time to stricture development was shorter in the
first group (48.9 vs 74.3 days, p = 0.002). Although the continence
rates in the sixth month decreased in both groups compared to the
preoperative condition, the continence rate in the second group was
higher than the first group (79.3\% vs 62.8\%, p \textless{}0.001). At
12 months, improvement in continence status was observed in both groups,
but the second group had a higher rate of continence again (92.4\% vs
81.3\%, p = 0.032). Continence restoration curves for the two groups are
shown in \textbf{Figure 3} . The proportions of potent patients in the
two groups tended to decrease at 6 months, but improvement was seen at
12 months. In addition, there was no significant difference between the
two groups in terms of potent patient rates (p = 0.194 for the 6th month
and p = 0.351 for the 12th month). The restoration curves comparing the
potency rates of the two groups are schematized in \textbf{Figure 4} .
The comparison of the functional results of the two groups at 6 and 12
months is summarized in \textbf{Table 2} .

\textbf{Discussion}

In patients undergoing RRP for PCa, it is critical to provide optimal
functional results as well as oncological control. The most important of
these are results related to continence and erectile function. Although
these results have been tried to be optimized in recent years with the
robotic platform that enables large and three-dimensional images, the
open retropubic technique still continues to be performed at a
considerable rate in the world.\textsuperscript{10}

There is a consensus that the VUA technique is particularly important in
maintaining postoperative continence.\textsuperscript{11} In this study,
in which we analyzed the effect of these techniques on functional
results in patients who underwent two different VUA techniques in our
clinic, we revealed that although the continence results were better in
the 6-focal anostomosis group compared to the 4-focus group, it did not
have a significant effect on erectile function results. Our study
differs from previous studies by being the first to compare 4- and
6-focus VUA techniques head-to-head.

In a randomized controlled study in which the two techniques used in our
study were compared with the anostomosis technique performed with 2 U
sutures at 6 and 12 o'clock alignment, the number of sutures did not
affect the perioperative and postoperative parameters, but the VUA
duration was significantly shorter in patients operated with the
2-suture technique compared to the others \textsuperscript{5}. This
study is important as it is the first prospective study to focus on the
VUA technique during RRP. In our study, the duration of VUA was not
available, but the total operation times were similar between the two
groups. However, the conclusion, that the number of sutures did not
affect the continence results revealed in the previous study, was in
favor of the group in which the number of sutures was high in our study.
The factors that predispose to the development of VUA are not fully
understood. Anastomotic technique, previous endoscopic prostate surgery,
failure to obtain a watertight anastomosis resulting in urine
extravasation, excessive blood loss and excessive diathermy for
hemostasis of the bladder neck are the main
culprits.\textsuperscript{12} We hypothesize that the water-tight
anostomosis is more safely achieved in the six-focal anostomosis because
the suture line is denser and closer than the 4-focal technique, and
that better continence results are obtained as a result. As a result of
VUA performed with more frequent suturing, it is possible to expect that
foreign tissue penetrates the anostomosis line less and thus
mucosa-mucosa convergence is healthier. In a meta-analysis in which a
total of 9 studies including 1475 patients were evaluated, continuous
suturing and intermittent suturing were compared, and although
continuous suturing provided shorter catheterization time, anastomosis
time and a lower rate of extravasation, no significant difference was
found between continence rates and urethral stricture rates in the month
was 3, 6, and 12 and the duration of hospital stay between the two
techniques. It was underlined that the suture technique should be chosen
according to the surgeon's experience and technical
approach.\textsuperscript{13} In another retrospective analysis, the
results of sutureless anostomosis in patients undergoing open and
laparoscopic radical prostatectomy were evaluated. In this VUA
technique, which is designed completely without sutures, the catheter
balloon was inflated and traction was applied. The authors observed a
significant rate of stricture (13.6\%) while maintaining around 90\%
continence rates in patients.\textsuperscript{7} Although this rate
underlines the importance of sutured VUA, uncertainties remain as to
which VUA technique is superior. Although the general opinion in the
literature is that the number of sutures does not affect the risk of VUA
and continence outcomes, there is consensus that a water-tight
anostomosis is vital to prevent urine extravasation.\textsuperscript{14,
15}

During the operation, excessive blood loss and / or hematoma formation
may contribute to the development of VUA by negatively affecting tissue
healing by causing fibrosis and scar formation in the surrounding
tissue. The fact that the mean blood loss is similar in both groups
reveals that the effect of this factor is minimal in our patients. VUA
stricture development is an independent risk factor for the development
of postoperative incontinence.\textsuperscript{15} On the other hand,
prevention of anostomotic strictures is one of the most important
factors for continence recovery and also shortens the time required for
continence recovery.\textsuperscript{16} In our study, in the first
group with a higher stricture rate, the continence rates were found to
be lower in proportion to this outcome.

The application of oxidized cellulose sponges around the anastomotic
site can be used to block exudates and materials such as fluid or
cellular debris escaping from blood vessels. If urethral exudates
accumulate in the urethral cavity, it can lead to inflammation or even
infection of the urethra, jeopardizing healing.\textsuperscript{17} The
study using these materials provided slightly lower long-term
incontinence rates than ours.\textsuperscript{5} Cellulose sponges can
be effective agents in maintaining continence function. Some
modifications are recommended for use in VUA for optimum
postprostatectomic erectile function. One of these is that after
dissecting the anterior half of the urethra, four pre-placed sutures are
placed between 3 and 6 o'clock, and anostomotic sutures are placed on
the posterior half after the neurovascular bundle is separated from the
prostate apex.\textsuperscript{3, 18} Most of the patients in our group
consisted of patients with tumors limited to the prostate, and we
performed nerve-sparing prostatectomy in these patients. At the end of a
one-year follow-up, we achieved approximately 80\% of erectile function
restoration and we concluded that the two VUA techniques we used did not
have a significant effect on erectile functions. For the preservation of
erectile function, the application of neuroprotective surgery is more
important than the VUA technique according to the risk assessment on
patient basis.

In our study, we found that, contrary to the literature, the VUA
technique affected both stricture development time and stricture rate.
We did not evaluate the preoperative voiding functions of the patients
with objective questionnaires. Not knowing the patients' basal functions
can create confusion in comparing final functions, but preoperative
contience is not the only factor affecting this. Other reported risk
factors include patient age, disease stage, surgical technique,
surgeon's experience, and previous endoscopic prostate surgery, and
there was no significant difference in these factors between the
groups.\textsuperscript{18}

Our study has some important limitations. Since we do not know the
preoperative continence and erectile functions of the patients, we could
not analyze how much they changed according to basal levels in the
postoperative period. Surgery performed by different surgeons may cause
a surgeon selection bias, but this may be more consistent in that it is
a real-life picture of the situation in most reference centers.
Evaluating continence status with questions such as present / absent
instead of validated questionnaire forms might have overshadowed the
objective evaluation. On the other hand, in many studies in the
literature this function has been evaluated in this way. The main
strength of our study is that it is the first study to compare the
functional results of 4- and 6-focus VUA techniques, and obtaining
12-month restoration curves specific to the two functions appears to be
a valuable finding.

As a result, we found better continence results with 6-focus VUA than
with the 4-focus technique. There was no significant difference between
the two techniques in terms of other postoperative complications and
erectile function. Contrary to the general belief in the literature, the
number of anostomotic sutures in VUA may affect functional results and
may be decisive for surgeons who focus on functional results as well as
oncological results. Although the most important determining factor is
the surgeon's habits and experience, the 6-focus VUA technique we
schematized in our study can be preferred due to its easy application
and similar operation time with the other technique. More consistent
results can be expected with prospective, randomized, controlled studies
with a higher number of cases.

\textbf{References}

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. \emph{CA: a
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2. Sommers BD, Beard CJ, D'Amico AV, Kaplan I, Richie JP, Zeckhauser RJ.
Predictors of patient preferences and treatment choices for localized
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3. Walsh PC. Anatomic radical prostatectomy: evolution of the surgical
technique. \emph{J Urol} . Dec 1998;160(6 Pt 2):2418-24.
doi:10.1097/00005392-199812020-00010

4. Mazaris EM, Chatzidarellis E, Varkarakis IM, Dellis A, Deliveliotis
C. Reducing the number of sutures for vesicourethral anastomosis in
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5. Gallo L, Perdona S, Autorino R, et al. Vesicourethral anastomosis
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6. Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV.
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7. Simforoosh N, Javaherforooshzadeh A, Aminsharifi A, Tabibi A. Early
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experience. \emph{Urology journal} . Summer 2009;6(3):163-9.

8. Akkus E, Kadioglu A, Esen A, et al. Prevalence and correlates of
erectile dysfunction in Turkey: a population-based study. \emph{Eur
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9. Walsh PC. Nerve sparing radical prostatectomy for early stage
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11. Lee SW, Han DH, Lee KS, Jeon SS. Effect of Continuous
Urethro-Vesical Anastomosis Technique in Incontinence After Radical
Retropubic Prostatectomy, 1:1 Matching Study. \emph{International
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doi:10.5213/inj.2015.19.2.113

12. Besarani D, Amoroso P, Kirby R. Bladder neck contracture after
radical retropubic prostatectomy. \emph{BJU international} . Dec
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13. Kowalewski KF, Tapking C, Hetjens S, et al. Interrupted versus
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15. Licht MR, Klein EA, Tuason L, Levin H. Impact of bladder neck
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doi:10.1016/s0090-4295(94)80175-4

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\textbf{Figure legends}

\textbf{Figure 1. Flow-chart for the study population}

\textbf{Figure 2. Schematicization of anostomosis sutures and numbers in
vesicourethral anostomosis region. A) Four-focus anastomosis technique,
B) Six-focus anastomosis technique}

\textbf{Figure 3. Kaplan-Meyers curves for the continence restoration in
the studied patient groups (Group I: four focal vesicourethral
anostomosis anostomosis, Group II: six focal vesicourethral
anostomosis)}

\textbf{Figure 4. Kaplan-Meyers curves for the potency restoration in
the studied patient groups (Group I: four focal vesicourethral
anostomosis anostomosis, Group II: six focal vesicourethral
anostomosis)}

\textbf{Table 1. Comparison of demographic and peripoerative data of the
two groups}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Group I (four sutured anastomosis)\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
Group II (six sutured anastomosis)\strut
\end{minipage} & \begin{minipage}[b]{0.22\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Number of patients\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
288\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
188\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Age\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
56.8\selectlanguage{ngerman}±12.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
61.3\selectlanguage{ngerman}±16.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.562\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
BMI\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
22.4\selectlanguage{ngerman}±9.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
21.8\selectlanguage{ngerman}±8.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.408\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
PSA (ng/mL)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8.2\selectlanguage{ngerman}±1.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7.4\selectlanguage{ngerman}±0.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.255\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Gleason score 3+3 3+4 4+3 4+4 4+5\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
97 (33.7\%) 116 (40.3\%) 56 (19.4\%) 12 (4.2\%) 7 (2.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
60 (31.9\%) 78 (41.5\%) 33 (17.5\%) 9 (4.8\%) 8 (4.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.621\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Prostate volume (mL)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
42.2\selectlanguage{ngerman}±18.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
37.5\selectlanguage{ngerman}±14.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.112\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Operative time (min)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
112\selectlanguage{ngerman}±29\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
126\selectlanguage{ngerman}±33\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.398\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Estimated blood loss (ml)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
68\selectlanguage{ngerman}±16\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
74\selectlanguage{ngerman}±21\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.702\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Drainage amount (ml)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
42\selectlanguage{ngerman}±16\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
36\selectlanguage{ngerman}±12\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.081\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Length of hospitalization (day)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.3\selectlanguage{ngerman}±0.8\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.5\selectlanguage{ngerman}±0.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.206\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Blood transfusion (unit)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.6\selectlanguage{ngerman}±0.2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.8\selectlanguage{ngerman}±0.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.190\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Foley duration (day)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8.7\selectlanguage{ngerman}±1.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9.1\selectlanguage{ngerman}±1.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.836\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Pathologic stage T1 T2 T3\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
72 (25\%) 114 (39.6\%) 102 (35.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
48 (25.5\%) 96 (51.1\%) 44 (23.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.070\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Values are given as mean \selectlanguage{ngerman}± standard deviation or number (percent), PSA:
prostate-spesific antigen, BMI: body mass index

\textbf{Table 2. Comparison of functional results of two groups}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Group I (four sutured anastomosis) & Group II (six sutured
anastomosis) & P value\tabularnewline
\midrule
\endhead
VUA stricture & 15 (5.1\%) & 6 (3.2\%) & 0.017\tabularnewline
Time to stricture (day) & 48.9\selectlanguage{ngerman}±16.6 & 74.3\selectlanguage{ngerman}±21.2 & 0.002\tabularnewline
Continence rate at 6 month & 181 (62.8\%) & 149 (79.3\%) &
\textless{}0.001\tabularnewline
Continence rate at 12 month & 234 (81.3\%) & 174 (92.4\%) &
0.032\tabularnewline
Potency rate at 6 month & 206 (71.5\%) & 141 (74.8\%) &
0.194\tabularnewline
Potency rate at 12 month & 226 (78.6\%) & 153 (81.5\%) &
0.351\tabularnewline
\bottomrule
\end{longtable}

Values are given as mean \selectlanguage{ngerman}± standard deviation or number (percent), VUA:
vesicourethral anostomosis\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure1/figure1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure2/figure2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure3/figure3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure4/figure4}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

