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Boellaard TN, van Dijk-de Haan MC, Heijmink SWTPJ, Tillier CN, Veerman H, Mertens LS, van der Poel HG, van Leeuwen PJ, Schoots IG. Membranous urethral length measurement on preoperative MRI to predict incontinence after radical prostatectomy: a literature review towards a proposal for measurement standardization. Eur Radiol 2024; 34:2621-2640. [PMID: 37737870 PMCID: PMC10957670 DOI: 10.1007/s00330-023-10180-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/29/2023] [Accepted: 07/07/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES To investigate the membranous urethral length (MUL) measurement and its interobserver agreement, and propose literature-based recommendations to standardize MUL measurement for increasing interobserver agreement. MUL measurements based on prostate MRI scans, for urinary incontinence risk assessment before radical prostatectomy (RP), may influence treatment decision-making in men with localised prostate cancer. Before implementation in clinical practise, MRI-based MUL measurements need standardization to improve observer agreement. METHODS Online libraries were searched up to August 5, 2022, on MUL measurements. Two reviewers performed article selection and critical appraisal. Papers reporting on preoperative MUL measurements and urinary continence correlation were selected. Extracted information included measuring procedures, MRI sequences, population mean/median values, and observer agreement. RESULTS Fifty papers were included. Studies that specified the MRI sequence used T2-weighted images and used either coronal images (n = 13), sagittal images (n = 18), or both (n = 12) for MUL measurements. 'Prostatic apex' was the most common description of the proximal membranous urethra landmark and 'level/entry of the urethra into the penile bulb' was the most common description of the distal landmark. Population mean (median) MUL value range was 10.4-17.1 mm (7.3-17.3 mm), suggesting either population or measurement differences. Detailed measurement technique descriptions for reproducibility were lacking. Recommendations on MRI-based MUL measurement were formulated by using anatomical landmarks and detailed descriptions and illustrations. CONCLUSIONS In order to improve on measurement variability, a literature-based measuring method of the MUL was proposed, supported by several illustrative case studies, in an attempt to standardize MRI-based MUL measurements for appropriate urinary incontinence risk preoperatively. CLINICAL RELEVANCE STATEMENT Implementation of MUL measurements into clinical practise for personalized post-prostatectomy continence prediction is hampered by lack of standardization and suboptimal interobserver agreement. Our proposed standardized MUL measurement aims to facilitate standardization and to improve the interobserver agreement. KEY POINTS • Variable approaches for membranous urethral length measurement are being used, without detailed description and with substantial differences in length of the membranous urethra, hampering standardization. • Limited interobserver agreement for membranous urethral length measurement was observed in several studies, while preoperative incontinence risk assessment necessitates high interobserver agreement. • Literature-based recommendations are proposed to standardize MRI-based membranous urethral length measurement for increasing interobserver agreement and improving preoperative incontinence risk assessment, using anatomical landmarks on sagittal T2-weighted images.
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Affiliation(s)
- Thierry N Boellaard
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | | | - Stijn W T P J Heijmink
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Corinne N Tillier
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Hans Veerman
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Laura S Mertens
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Urology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Ivo G Schoots
- Department of Radiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands.
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Zhang H, Ning Z, Jia G, Zhang G, Wang J, Liu H, Tao B, Wang C. Modified hood technique for single-port robot-assisted radical prostatectomy contributes to early recovery of continence. Front Surg 2023; 10:1132303. [PMID: 37206347 PMCID: PMC10189123 DOI: 10.3389/fsurg.2023.1132303] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/19/2023] [Indexed: 05/21/2023] Open
Abstract
Background and purpose Urinary incontinence is one of the common side effects of robot-assisted radical prostatectomy (RARP). Here, we described the modified Hood technique for single-port RARP (sp-RARP) and assessed the interest of this new technique for early continence recovery. Methods We retrospectively reviewed 24 patients who underwent sp-RARP modified hood technique from June 2021 to December 2021. The pre-and intraoperative variables, postoperative functional and oncological outcomes of patients were collected and analyzed. The continence rates were estimated at 0 day, 1 week, 4 weeks, 3 months and 12 months after catheter removal. Continence was defined as wearing no pad over a 24 h period. Results Mean time of operation and estimated blood loss were 183 min and 170 ml, respectively. The postoperative continence rates at 0 day, 1 week, 4 weeks, 3 months and 12 months after catheter removal were 41.7%, 54.2%, 75.0%, 91.7% and 95.8%, respectively. There were two patients who detected positive surgical margins and no patients observed complications requiring further treatment. Conclusion The modified hood technique is a safe and feasible method that provides better outcomes in terms of early return of continence, without increasing estimated blood loss and compromising oncologic outcomes.
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Affiliation(s)
- Haoxun Zhang
- Department of Urology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zikuan Ning
- Department of Urology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guang Jia
- Department of Urology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guoling Zhang
- Department of Urology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiuliang Wang
- Department of Operating Room, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hua Liu
- Department of Urology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | | | - Chunyang Wang
- Department of Urology, First Affiliated Hospital of Harbin Medical University, Harbin, China
- Correspondence: Chunyang Wang
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van Dijk-de Haan MC, Boellaard TN, Tissier R, Heijmink SWTPJ, van Leeuwen PJ, van der Poel HG, Schoots IG. Value of Different Magnetic Resonance Imaging-based Measurements of Anatomical Structures on Preoperative Prostate Imaging in Predicting Urinary Continence After Radical Prostatectomy in Men with Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus 2022; 8:1211-1225. [PMID: 35181284 DOI: 10.1016/j.euf.2022.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/18/2021] [Accepted: 01/28/2022] [Indexed: 12/16/2022]
Abstract
CONTEXT Measurements of anatomical structures on preoperative prostate magnetic resonance imaging (MRI) are used in risk models for treatment decisions to predict urinary continence (UC) following radical prostatectomy (RP). However, the association between these parameters and UC is unclear. OBJECTIVE To systematically summarize the literature on prognostic preoperative prostate MRI measurements of (peri)prostatic structures in relation to time to recovery of postoperative UC in men with prostate cancer. EVIDENCE ACQUISITION Online libraries were searched up to August 27, 2021. Article selection and critical appraisal were performed by two reviewers. All papers reporting on preoperative MRI measurements with UC correlation in univariable or multivariable analyses were included. EVIDENCE SYNTHESIS In the 50 studies included (mostly retrospective), 57 MRI parameters were evaluated. The pooled analyses showed that greater membranous urethra length (MUL) was prognostic for regaining UC at 1 mo (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.10-1.21), 3 mo (OR 1.23, 95% CI 1.16-1.31), 6 mo (OR 1.16, 95% CI 1.08-1.25), and 12 mo (OR 1.19, 95% CI 1.10-1.29). Several other anatomical structures showed at least in one study a significant correlation with later return to UC: four prostate-related parameters (greater depth, apical protrusion, larger intravesical protrusion, small dorsal vascular complex), five urethra-related parameters (thicker wall, severe fibrosis, smaller volume, larger preoperative angle between the prostate axis and membranous urethra, shorter minimal residual MUL), and six musculoskeletal-related parameters (lower perfusion ratio, thinner levator ani muscle, larger inner or outer levator distance, shorter pelvic diaphragm length, and larger midpelvic area). CONCLUSIONS Greater MUL as measured on preoperative MRI was an independent prognostic factor for return to UC within 1 mo after RP and remained prognostic at 12 mo. Other anatomical structures may potentially be predictive, but these would need to be substantiated in prospective trials before being adopted in postoperative UC risk models for treatment decisions in men with prostate cancer. PATIENT SUMMARY We summarized study data on the relation between measurements of anatomical structures on preoperative magnetic resonance imaging scans and urinary continence after removal of the prostate. Greater length of one part of the urethra (membranous urethra) is associated with faster return to continence. Other anatomical structures have potential for predicting postoperative continence, but need further investigation.
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Affiliation(s)
| | - Thierry N Boellaard
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Renaud Tissier
- Biostatistics Unit, Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Pim J van Leeuwen
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ivo G Schoots
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Radiology & Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Lamberg H, Shankar PR, Singh K, Caoili EM, George AK, Hackett C, Johnson A, Davenport MS. Preoperative Prostate MRI Predictors of Urinary Continence Following Radical Prostatectomy. Radiology 2022; 303:99-109. [PMID: 35040671 PMCID: PMC8962824 DOI: 10.1148/radiol.210500] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Urinary continence after radical prostatectomy (RP) is an important determinant of patient quality of life. Anatomic measures at prostate MRI have been previously associated with continence outcomes, but their predictive ability and interrater agreement are unclear in comprehensive clinical models. Purpose To evaluate the predictive ability and interrater agreement of MRI-based anatomic measurements of post-RP continence when combined with clinical multivariable models. Materials and Methods In this retrospective cohort study, continence outcomes were evaluated in men who underwent RP from August 2015 to October 2019. Preoperative MRI-based anatomic measures were obtained retrospectively by four abdominal radiologists. Before participation, these radiologists completed measure-specific training. Logistic regression models were developed with clinical variables alone, MRI variables alone, and combined variables for predicting continence at 3, 6, and 12 months after RP; some patient data were missing at each time point. Interrater agreement of MRI variables was assessed by using intraclass correlation coefficients (ICCs). Results A total of 586 men were included (mean age ± standard deviation: 63 years ± 7). The proportion of patients with incontinence was 0.2% (one of 589) at baseline, 27% (145 of 529) at 3 months, 14% (63 of 465) at 6 months, and 9% (37 of 425) at 12 months. Longer coronal membranous urethra length (MUL) improved the odds of post-RP continence at all time points (odds ratio per 1 mm: 0.86 [95% CI: 0.80, 0.93], P < .001; 0.86 [95% CI: 0.78, 0.95], P = .003; and 0.79 [95% CI: 0.67, 0.91], P = .002, respectively) in models that incorporated both clinical and MRI predictors. No other MRI variables were predictive. Age and baseline urinary function score were the only other predictive clinical variables at every time point. Interrater agreement was moderate (ICC, 0.62) for MUL among readers with measure-specific prostate MRI training and poor among those without the training (ICC, 0.38). Conclusion Preoperative MRI-measured coronal membranous urethra length was an independent predictor of urinary continence after prostatectomy. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
- Hannah Lamberg
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
| | - Prasad R. Shankar
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
| | - Karandeep Singh
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
| | - Elaine M. Caoili
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
| | - Arvin K. George
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
| | - Caitlin Hackett
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
| | - Anna Johnson
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
| | - Matthew S. Davenport
- From the Department of Radiology (H.L., P.R.S., E.M.C., C.H., M.S.D.), Michigan Radiology Quality Collaborative (P.R.S., M.S.D.), and Department of Urology (K.S., A.K.G., A.J., M.S.D.), University of Michigan, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5030; and Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich (K.S.)
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Mungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI. Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis. Eur Urol 2016; 71:368-378. [PMID: 27394644 DOI: 10.1016/j.eururo.2016.06.023] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/20/2016] [Indexed: 12/29/2022]
Abstract
CONTEXT Membranous urethral length (MUL) measured prior to radical prostatectomy (RP) has been identified as a factor that is associated with the recovery of continence following surgery. OBJECTIVE To undertake a systematic review and meta-analysis of all studies reporting the effect of MUL on the recovery of continence following RP. EVIDENCE ACQUISITION A comprehensive search of PubMed, EMBASE, and Scopus databases up to September 2015 was performed. Thirteen studies comprising one randomized controlled trial and 12 cohort studies were selected for inclusion. EVIDENCE SYNTHESIS Four studies (1738 patients) that reported hazard ratio results. Every extra millimeter (mm) of MUL was associated with a faster return to continence (hazard ratio: 1.05; 95% confidence interval [CI]: 1.02-1.08, p<0.001). Eleven studies (6993 patients) reported the OR (OR) for the return to continence at one or more postoperative time points. MUL had a significant positive effect on continence recovery at 3 mo (OR: 1.08, 95% CI: 1.03-1.14, p=0.004), 6 mo (OR: 1.12, 95% CI: 1.09-1.15, p<0.0001). and 12 mo (OR: 1.12, 95% CI: 1.03-1.22, p=0.006) following surgery. After adjusting for repeated measurements over time and studies with overlapping data, all OR data combined indicated that every extra millimeter of MUL was associated with significantly greater odds for return to continence (OR: 1.09, 95% CI: 1.05-1.15, p<0.001). CONCLUSIONS A greater preoperative MUL is significantly and positively associated with a return to continence in men following RP. Magnetic resonance imaging measurement of MUL is recommended prior to RP. PATIENT SUMMARY We examined the effect that the length of a section of the urethra (called the membranous urethra) had on the recovery of continence after radical prostatectomy surgery. Our results indicate that measuring the length of the membranous urethra via magnetic resonance imaging before surgery may be useful to predict a longer period of urinary incontinence after surgery, or to explain a delay in achieving continence after surgery.
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Affiliation(s)
- Sean F Mungovan
- Westmead Private Physiotherapy Services, Westmead Private Hospital Sydney, Australia; The Clinical Research Institute, Sydney, Australia; Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.
| | - Jaspreet S Sandhu
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Centre, NY, USA
| | - Oguz Akin
- Department of Radiology, Memorial Sloan-Kettering Cancer Centre, NY, USA
| | - Neil A Smart
- The Clinical Research Institute, Sydney, Australia; School of Science & Technology, University of New England, Armidale, Australia
| | - Petra L Graham
- Department of Statistics, Macquarie University, Australia
| | - Manish I Patel
- Department of Urology, Westmead Hospital, Sydney, Australia; Discipline of Surgery, Sydney Medical School, The University of Sydney, Australia
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