CLINICS 2011;66(12):2007-2012 CLINICAL SCIENCE DOI:10.1590/S1807-59322011001200002 Influence of perineal prostatectomy on anal continence Na´ dia Ricci Guilger,I Jose´ Marcio Neves Jorge,I Renato Prado Costa,II Fernando Cesar Salla,II Magaly Gemio Teixeira,I Sergio Carlos Nahas,I Ivan CecconelloI I Faculdade de Medicina da Universidade de S a˜o Paulo, Digestive Surgery Division, Coloproctology Service of the Gastroenterology, S a˜o Paulo,SP/Brazil. II Hospital Amaral Carvalho, Section of Urology, Jau´ , SP/Brazil. OBJECTIVE: Perineal prostatectomy has been proposed as a less invasive and safe procedure, but the risk of anal incontinence has been studied. This study aimed to evaluate the effects of perineal access on anal continence mechanisms after perineal prostatectomy. METHODS: From August 2008 to May 2009, twenty three patients underwent perineal prostatectomy. These patients were evaluated before surgery and eight months postoperatively using the Cleveland Clinic Anal Incontinence Score, the Fecal Incontinence Quality of Life Score, and anorectal manometry. RESULTS: The mean age of the subjects was 65 (range, 54-72) years, and the mean prostate weight was 34.5 (range, 24-54) grams. Gleason scores ranged from 6-7, and the mean Cleveland Clinic Anal Incontinence Score (mean¡standard deviation) values were 0.9¡1.9 and 0.7¡1.2 (p.0.05) before and after surgery, respectively. The Fecal Incontinence Quality of Life Score did not change significantly after surgery. The mean values for anal manometric parameters before and after surgery were, respectively: Resting Pressures of 64¡23 mmHg and 65¡17 mmHg (p = 0.763), Maximum Squeezing Pressures of 130¡41 mmHg and 117¡40 mmHg (p = 0.259), High Pressure Zones of 3.0¡0.9 cm and 2.7¡0.8 cm (p = 0.398), Rectal Sensory Thresholds of 76¡25 ml and 71¡35 ml (p = 0.539), Maximum Tolerated Rectal Volumes of 157¡48 ml and 156¡56 ml (p = 0.836), and Sphincter Asymmetry Indexes 22.4¡9% and 14.4¡5% (p = 0.003). CONCLUSION: There was a significant decrease in the sphincter symmetry index after perineal prostatectomy. With the exception of the sphincter asymmetry index, perineal prostatectomy did not affect anal continence parameters. KEYWORDS: Anal incontinence; Anorectal manometry; Perineal prostatectomy; Prostate cancer. Guilger NR, Jorge JMN, Costa RP, Salla FC, Teixeira MG, Nahas SC, et al. Influence of perineal prostatectomy on anal continence. Clinics. 2011;66(12):2007-2012. Received for publication on May 19, 2011; First review completed on June 22, 2011; Accepted for publication on August 9, 2011 E-mail: coloproctologista@gmail.com Tel.: 55 11 2661-7561 INTRODUCTION Prostate cancer is the second most common cancer worldwide, the sixth leading cause of cancer death. Seventy-five percent of cases are diagnosed after 65 years of age, and its diagnosis is increasing due to the diffusion of screening policies.1-3 There are many surgical techniques to treat this disease. The balance between cost-effectiveness and adverse events occurring due to these different techniques is being studied in the literature. In this context, perineal prostatectomy is distinguished from other approaches; this technique is less invasive and is safe and effective without compromising oncologic principles.4 Copyright 2011 CLINICS – This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. No potential conflict of interest was reported. Perineal prostatectomy is less time consuming, results in less blood loss and a faster postoperative recovery time with a consequent reduction in hospital stay; thus, perineal prostatectomy is an effective surgical approach for the treatment of localized prostate cancer.2 However, concerns remain regarding the effects of this technique on the anal sphincter mechanism and the development of incontinence. The correlation between anal incontinence and perineal prostatectomy has been described by many authors based on clinical observations.5-7 However, the correlation between this surgical approach and postoperative anal incontinence is still controversial. The use of a more standardized evaluation of the symptoms of anal incon- tinence that can be examined using anorectal manometry parameters, including sphincter asymmetry, may provide a better assessment of the effects of perineal access on the posterior pelvic floor compartment.8 Anal incontinence is the inability to exert voluntarily control over the release of gas and stool. Anal continence is preserved by complex mechanisms that involve the volume and consistency of stool, rectal capacity and compliance, 2007