Prospective predictors of urinary continence after anatomical radical retropubic prostatectomy: a multivariate analysis

Precise Prediction of Long-Term Urinary Incontinence after Robot-Assisted Laparoscopic Radical Prostatectomy by Readily Accessible "Everyday" Diagnostics during Post-Surgical Hospitalization

Aim and Objectives: We aimed to test the predictive value of readily accessible and easily performed post-surgical "bedside tests" on their validity of long-term urinary incontinence (UI) (≥12 months) in patients following robot-assisted laparoscopic radical prostatectomy (RALP). Material and Methods: Patients undergoing RALP between July 2020 and March 2021 were prospectively included and subdivided into two groups based on their pad usage after 12 months (0 vs. ≥1 pad). After catheter removal, patients performed a 1 h pad test, documented the need for pad change in a micturition protocol and received post-voiding residual urine volume ultrasound. Univariate and multivariable analyses were used to demonstrate the predictive value of easily accessible tests applied after catheter removal for UI following RALP. Results: Of 109 patients, 47 (43%) had to use at least one pad (vs. 62 (57%) zero pads) after 12 months. Univariate testing showed a significant difference in urine loss between both groups evaluated by the 1 h pad test performed within 24 h after catheter removal (70% < 10 mL, vs. 30% ≥ 10 mL, p = 0.004) and in the need for pad change within the first 24 h after catheter removal (14% dry pads vs. 86% wet pads, p = 0.003). In multivariable analyses, the combination of both tests (synoptical incontinence score) could be confirmed as an independent predictor for UI after 12 months (p = 0.011). Conclusions: Readily accessible "everyday" diagnostics (pad test/change of pads after catheter removal) following RALP seem to be associated with a higher rate of long-term UI. This finding is crucial since patients with a potentially higher need for patient education and counselling can be identified using these readily accessible tests. This could lead to a higher patient satisfaction and improved outcomes.

Simple and reliable predictive factor for early recovery of urinary continence after non-nerve-sparing robot-assisted laparoscopic radical prostatectomy

Post-prostatectomy urinary incontinence is one of the greatest concerns for both patients and urologists. The aim of this study is to elucidate simple and reliable factors contributing to early recovery of urinary continence (UC) and to develop a prediction model for early continence recovery after robot-assisted laparoscopic non-nerve-sparing radical prostatectomy (non-NS RARP). A retrospective analysis of 212 consecutive patients who underwent non-NS RARP by a single surgeon was carried out. Early recovery of urinary continence was defined as using no pads or one security pad per day within 1 month. Preoperative membranous urethral length (MUL) was measured on MRI, and the urinary continence at the standing position (UCSP) after removal of the catheter was examined during cystourethrography 6 days after surgery. Multivariable analysis was performed to detect predictive and postoperative factors associated with early recovery of urinary continence. The early continence recovery rate was 56.1%. Multivariable analysis revealed that MUL ≥ 13 mm, UCSP, and age ≤ 67 were the independent factors for early continence recovery. Early recovery rates were 97.1% for good risk, 76.3% for intermediate risk, and 28.4% for poor risk when divided into three risk groups by the sum score of three independent factors. Preoperative MUL, UCSP, and age are independent predictors of early recovery of UC in non-NS RARP, and our simple prediction model with the combination of the three factors could be a useful tool in clinical practice.

Cognitive Ability as a Non-modifiable Risk Factor for Post-prostatectomy Urinary Incontinence: A Double-Blinded, Prospective, Single-Center Trial

Introduction: Urinary incontinence (UI) is a wide-spread and feared side-effect of conventional or even robot-assisted laparoscopic prostatectomy (RALP) due to its high impact on patients' quality of life (QoL). Non-modifiable risk factors for UI have already been identified - on surgical and patient side. Yet, to our knowledge, focus thus far has not been placed on functional aspects regarding general cognitive ability. Materials and Methods: This is an observational single-center, prospective, double-blinded evaluation of 109 RALPs performed between 07/2020 and 03/2021. All patients underwent a Mini Mental State Examination (MMSE) prior to surgery to evaluate their cognitive ability. Early post-prostatectomy incontinence (PPI) was evaluated using a standardized 1 h pad test performed 24 h after removal of the urinary catheter. The association between MMSE results and PPI were evaluated using univariate and multivariate logistic regression models. Results: Multivariate logistic regression analyses identified MMSE results and nerve sparing (NS) as independent predictors for PPI in patients with an intermediate MMSE result (25-27 points) having a 3.17 times higher risk of PPI when compared to patients with a good MMSE result (≥28) (95% Confidence Interval (CI): 1.22-9.06, p = 0.023), while patients without NS had a 3.53 times higher risk of PPI when compared to patients with NS (95% CI: 1.54-11.09, p = 0.006). Conclusion: A lower cognitive ability should be treated as a non-modifiable risk-factor for early PPI. In the future it could find its place as a clinical screening tool to identify patients who require more attention especially in the pre-, but also in the postoperative phase.

Subsphincteric Anastomosis During Laparoscopic Robot-Assisted Radical Prostatectomy and Its Positive Impact on Continence Recovery

Introduction: To assess the interest of a new sphincter preserving anastomosis technique for continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP).

Materials and Methods: We performed a monocentric single-operator study on 187 consecutive RALP. Patients were divided into two groups: Group 1 (standard anastomosis, until December 2017) and Group 2 (subsphincteric anastomosis [SSA], since January 2018). The SSA consisted in respecting the sphincteric sleeve during the anastomosis suturing only the internal layer of the urethra with the bladder and thereby avoiding the loss of sphincteric length induced by the suture. Pre-, intra-, and postoperative data were prospectively collected and compared. Criteria of continence were as follows: no pad use and complete absence of leakage at catheter removal at 1 month and 1 year.

Results: The two groups were comparable in terms of prostate-specific antigen, gland volume, and Gleason score. In Group 2 (SSA), we observed a complete continence recovery in 75.6% at catheter removal (p = 0.0000035), in 82.9% at 1 month (p = 0.000092), and in 97.5% at 1 year (p = 0.028), independently of bladder neck preservation (p = 0.388). There was also a significant difference between the two groups concerning urinary reeducation requirement (p = 0.0006), pad use, and urinary quality of life (p = 0.0000002). No anastomosis complication was reported.

Conclusions: The SSA significantly improved the rates of immediate, early, and 1-year continence recovery after RALP. These results need further study among larger numbers of patients.

The effect of surgery report cards on improving radical prostatectomy quality: the SuRep study protocol

Background

The goal of radical prostatectomy is to achieve the optimal balance between complete cancer removal and preserving a patient’s urinary and sexual function. Performing a wider excision of peri-prostatic tissue helps achieve negative surgical margins, but can compromise urinary and sexual function. Alternatively, sparing peri-prostatic tissue to maintain functional outcomes may result in an increased risk of cancer recurrence. The objective of this study is to determine the effect of providing surgeons with detailed information about their patient outcomes through a surgical report card.

Methods

We propose a prospective cohort quasi-experimental study. The intervention is the provision of feedback to prostate cancer surgeons via surgical report cards. These report cards will be distributed every 3 months by email and will present surgeons with detailed information, including urinary function, erectile function, and surgical margin outcomes of their patients compared to patients treated by other de-identified surgeons in the study. For the first 12 months of the study, pre-operative, 6-month, and 12-month patient data will be collected but there will be no report cards distributed to surgeons. This will form the pre-feedback cohort. After the pre-feedback cohort has completed accrual, surgeons will receive quarterly report cards. Patients treated after the provision of report cards will comprise the post-feedback cohort. The primary comparison will be post-operative function of the pre-feedback cohort vs. post-feedback cohort. The secondary comparison will be the proportion of patients with positive surgical margins in the two cohorts. Outcomes will be stratified or case-mix adjusted, as appropriate. Assuming a baseline potency of 20% and a baseline continence of 70%, 292 patients will be required for 80% power at an alpha of 5% to detect a 10% improvement in functional outcomes. Assuming 30% of patients may be lost to follow-up, a minimum sample size of 210 patients is required in the pre-feedback cohort and 210 patients in the post-feedback cohort.

Discussion

The findings from this study will have an immediate impact on surgeon self-evaluation and we hypothesize surgical report cards will result in improved overall outcomes of men treated with radical prostatectomy.

Electronic supplementary material

The online version of this article (10.1186/s12894-018-0403-y) contains supplementary material, which is available to authorized users.

Predictors of short-term and long-term incontinence after robot-assisted radical prostatectomy

Purpose

To determine retrospectively the prognostic factors for urinary incontinence following robot-assisted radical prostatectomy (RARP).

Methods

Altogether, 180 patients with localized prostate cancer underwent RARP (same surgeon). Preoperative physical status, disease characteristics, laboratory findings, and surgical technique were recorded and the patients checked 1, 6, 12, and 24 months after RARP regarding their contribution to predicting post-prostatectomy urinary incontinence (PPI).

Results

Overall, 114 (63.3%) patients had PPI 1 month after RARP and 19 patients (16.0%) at 24 months. Univariate analysis showed that age was a significant factor for predicting PPI at 1 month. PPI predictors at 24 months were age, body mass index, preoperative serum albumin level, previous transurethral resection of the prostate, total operative time, and bladder neck sparing. Multivariate analysis indicated that age and total operative time were significant predictors.

Conclusion

Older age and longer operative time were highly relevant to short- and long-term PPI occurrence after RARP.

The association between nerve sparing and a positive surgical margin during radical prostatectomy

PURPOSE

A positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would increase rates of pT2 positive margins.

METHODS

We evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostate-specific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model.

RESULTS

Of 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP. Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] = 1.52, 95% CI: 0.97-2.39) after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated increase in risk of positive margin after adjustment for other variables (RR = 0.96, 95% CI: 0.80-1.16). Prostate incision into tumor (pT2R1) was significantly more likely in patients treated with robotic surgery (RR = 1.76, 95% CI: 1.25-2.48) than in those with open surgery. There was no difference between laparoscopic and open RP (RR = 0.86, 95% CI: 0.65-1.12).

CONCLUSIONS

Bilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease during RP.

The surgical procedure is the most important factor affecting continence recovery after laparoscopic radical prostatectomy

Purpose

We analyzed factors associated with early recovery of continence after laparoscopic radical prostatectomy.

Materials and Methods

Among 467 patients treated with laparoscopic radical prostatectomy for localized prostate cancer between 2007 and 2012, 249 patients who underwent a preoperative urodynamic study were enrolled. The patients' age, prostate volume, preoperative serum prostate-specific antigen (PSA), Gleason score, pathologic stage, and preoperative urodynamic parameters were recorded. The preoperative membranous and prostatic urethral length on magnetic resonance image, nerve sparing technique, and type of surgical procedure (extrafascial and intrafascial) were analyzed. Patients were considered to have early recovery of continence when they needed no pad in 3 months or less after surgery.

Results

Ninety-two patients were in the early recovery group and 157 were in the late recovery group. The membranous urethral lengths were 12.06±2.56 and 11.81±2.87 mm, and prostatic urethral lengths were 36.39±6.15 and 37.45±7.55 mm in each group, respectively. The membranous-posterior urethral length ratios were 0.25±0.06 and 0.24±0.06, and prostatic-posterior urethral length ratios were 0.75±0.06 and 0.76±0.06, respectively. In and of themselves, the membranous and prostatic urethral lengths were not associated with recovery duration however, the membranous-total and prostatic-total urethral length ratios were related (p=0.024 and 0.024, respectively). None of the urodynamic parameters correlated with continence recovery time. In the multivariate analysis, the type of surgical procedure (odds ratio [OR], 7.032; 95% confidence interval [CI], 2.660 to 18.590; p<0.001) and membranous urethral length (OR, 0.845; 95% CI, 0.766 to 0.931; p=0.001) were significantly related to early recovery of continence.

Conclusions

The current intrafascial surgical procedure is the most important factor affecting early recovery of continence after laparoscopic radical prostatectomy.

Prostate cancer magnetic resonance imaging (MRI): multidisciplinary standpoint

Prostate cancer is the most common cancer diagnosed in men and a leading cause of death. Accurate assessment is a prerequisite for optimal clinical management and therapy selection of prostate cancer. There are several parameters and nomograms to differentiate between patients with clinically insignificant disease and patients in need of treatment. Magnetic resonance imaging (MRI) is a technique which provides more detailed anatomical images due to high spatial resolution, superior contrast resolution, and multiplanar capability. State-of-the-art MRI techniques, such as diffusion weighted imaging (DWI), MR spectroscopic imaging (MRSI), dynamic contrast enhanced MRI (DCE-MRI), improve interpretation of prostate cancer imaging. In this article, we review the major role of MRI in the advanced management of prostate cancer to noninvasively improve tumor staging, biologic potential, treatment planning, therapy response, local recurrence, and to guide target biopsy for clinical suspected cancer with previous negative biopsy. Finally, future challenges and opportunities in prostate cancer management in the area of functional MRI are discussed as well.

Prostate cancer imaging: what the urologist wants to know

No consensus exists at present regarding the use of imaging for the evaluation of prostate cancer. Ultrasonography is mainly used for biopsy guidance and magnetic resonance imaging is the mainstay in evaluating the extent of local tumor. Computed tomography and radionuclide bone scanning are mainly reserved for assessment of advanced disease. Positron emission tomography is gaining acceptance in the evaluation of treatment response and recurrence. The combination of anatomic, functional, and metabolic imaging modalities has promise to improve treatment. This article reviews current imaging techniques and touches on the evolving technologies being used for detection and follow-up of prostate cancer.

[Study of urinary continence after radical prostatectomy. Comparison between laparoscopic and retropubic prostatectomy based on a series of 251 cases]

INTRODUCTION

The objective of this study was to compare the results in terms of continence and quality of life between retropubic radical prostatectomy and laparoscopic radical prostatectomy, performed according to the same principle of retrograde dissection from the apex.

MATERIAL AND METHOD

The series was composed of 120 patients undergoing retropubic radical prostatectomy and 131 patients undergoing laparoscopic radical prostatectomy performed in the Limoges hospital, urology and andrology department, between January 2002 and September 2005. Continence was evaluated by anonymous self-administered questionnaire sent to the patient's home. Pain was evaluated by visual analogue scale and narcotic consumption. Predictive factors of continence were analysed.

RESULTS

The two groups were comparable in terms of pathological stage, Gleason score and age. The laparoscopy group comprised more patients with a history of transurethral resection of the prostate and more obese patients. No significant difference was observed between laparoscopy and laparotomy for degree of continence (71% versus 76%; p>0.05), time to return of continence (13 weeks versus nine weeks; p>0.05) and rate of mild (14% versus 13%), moderate (7% versus 6%) and severe (7% versus 5%) urinary incontinence. The anastomosis secondary stenosis rate was also identical in the two groups. Age was found to be a predictive factor for continence, especially for the mean time to return periods of continence. The patient's weight, prostate weight and TNM stage were not predictive factors for incontinence. The incontinence rate was 40% for salvage prostatectomies after radiotherapy. The mean duration of bladder catheterization was 6.9 days in the laparoscopy group and 7.2 days in the laparotomy group. Narcotic consumption was significantly lower in the laparoscopy group (21 mg versus 36 mg; p<0.05).

CONCLUSION

Laparoscopic radical prostatectomy appears to give the same results in terms of continence as retropubic radical prostatectomy. However, these procedures were the first laparoscopic prostatectomies performed in the department, suggesting that, with greater experience, the results of laparoscopy could become superior to those of laparotomy. The laparoscopic technique also appeared to provide better patient comfort by decreasing postoperative pain.

Impact of urethral stump length on continence and positive surgical margins in robot-assisted laparoscopic prostatectomy

INTRODUCTION

We previously reported the benefit of meticulous apical dissection in reducing positive surgical margins (SM+) at the apex. Herein we assess whether a more aggressive urethral transection will reduce positive margins and whether reduced urethral length affects return to continence.

TECHNICAL CONSIDERATIONS

All data were collected prospectively. A positive surgical margin was defined by the presence of cancer cells with ink on them. Continence, defined as no pads, was assessed with validated Expanded Prostate Cancer Instrument Composite questionnaires. Evaluation of 200 consecutive cases (group 1) revealed that 75% of surgical margins occurred at the apex. Concomitantly we assessed visual cues for urethral length, which demonstrated that even patients with very short urethral stumps requiring perineal pressure during anastomosis had equivalent times to continence as those with long, accessible stumps. We altered the point of transection, distally, to include 3 to 6 mm more of striated external urethral sphincter. The SM+ rate and time to continence for the ensuing 200 cases (group 2) were tracked. The overall SM+ and apical SM+ rates were significantly reduced (SM+ 17.6% versus 7.5%, P = 0.003; and apical SM+ 13% versus 5.5%, P = 0.01). Kaplan-Meier times to continence curves were not significantly different.

CONCLUSIONS

A more aggressive apical resection resulted in marked reduction in overall SM+ rates without measurable change in time to continence or overall continence.

Relationship between the integrity of the pelvic floor muscles and early recovery of continence after radical prostatectomy

PURPOSE

We investigated how the preoperatively estimated integrity of pelvic floor muscles related to the recovery of continence after radical prostatectomy.

MATERIALS AND METHODS

A total of 94 patients underwent magnetic resonance image of the prostate and urodynamic studies before undergoing radical prostatectomy and evaluation of voiding symptoms before, and 3 and 6 months after surgery. Incontinence was defined as any unwanted urine leakage. On the magnetic resonance image the thickness of the levator ani and pelvic diaphragm, and prostate volume were measured to correlate with continence status.

RESULTS

Incontinence was noted in 41.5% and 15.9% of the patients at 3 and 6 months, respectively. Recovery of continence 3 months after RP was related to the thickness of the pelvic diaphragm on sagittal imaging (p=0.017), the ratio of the levator ani on the axial image to prostate volume (p=0.047), functional urethral length (p=0.007) and incontinence before surgery (p=0.009). Recovery at 6 months was related to neurovascular bundle sparing (p=0.013) and marginally to the pelvic diaphragm on sagittal imaging (p=0.059). On multivariate analysis the pelvic diaphragm on sagittal imaging (HR 2.455, 95% CI 0.894-6.739, p=0.008) and the ratio of the levator ani on the axial image to prostate volume (HR 1.886, 95% CI 0.952-3.736, p=0.011) significantly predicted continence at 3 months, while at 6 months only the pelvic diaphragm on sagittal imaging showed a significant relationship (p=0.024).

CONCLUSIONS

Pelvic diaphragm thickness and the ratio of levator ani thickness to prostate volume are independent factors predictive of post-prostatectomy incontinence. Patients with better developed pelvic floor muscles, especially in relation to the size of the prostate, can be expected to achieve earlier recovery of continence after radical prostatectomy.