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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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Schepens MH, van Hooff ML, van der Galiën O, Ziedses des Plantes CM, Somford DM, van Leeuwen PJ, Busstra MB, Repping S, Wouters MW, van Limbeek J. Does Centralization of Radical Prostatectomy Reduce the Incidence of Postoperative Urinary Incontinence? EUR UROL SUPPL 2023; 58:47-54. [PMID: 38152486 PMCID: PMC10751543 DOI: 10.1016/j.euros.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 12/29/2023] Open
Abstract
Background On the basis of previous analyses of the incidence of urinary incontinence (UI) after radical prostatectomy (RP), the hospital RP volume threshold in the Netherlands was gradually increased from 20 per year in 2017, to 50 in 2018 and 100 from 2019 onwards. Objective To evaluate the impact of hospital RP volumes on the incidence and risk of UI after RP (RP-UI). Design setting and participants Patients who underwent RP during 2016-2020 were identified in the claims database of the largest health insurance company in the Netherlands. Incontinence was defined as an insurance claim for ≥1 pads/d. Outcome measurements and statistical analysis The relationship between hospital RP volume (HV) and RP-UI was assessed via multivariable analysis adjusted for age, comorbidity, postoperative radiotherapy, and lymph node dissection. Results and limitations RP-UI incidence nationwide and by RP volume category did not decrease significantly during the study period, and 5-yr RP-UI rates varied greatly among hospitals (19-85%). However, low-volume hospitals (≤120 RPs/yr) had a higher percentage of patients with RP-UI and higher variation in comparison to high-volume hospitals (>120 RPs/yr). In comparison to hospitals with low RP volumes throughout the study period, the risk of RP-UI was 29% lower in hospitals shifting from the low-volume to the high-volume category (>120 RPs/yr) and 52% lower in hospitals with a high RP volume throughout the study period (>120 RPs/yr for 5 yr). Conclusions A focus on increasing hospital RP volumes alone does not seem to be sufficient to reduce the incidence of RP-UI, at least in the short term. Measurement of outcomes, preferably per surgeon, and the introduction of quality assurance programs are recommended. Patient summary In the Netherlands, centralization of surgery to remove the prostate (RP) because of cancer has not yet improved the occurrence of urinary incontinence (UI) after surgery. Hospitals performing more than 120 RP operations per year had better UI outcomes. However, there was a big difference in UI outcomes between hospitals.
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Affiliation(s)
- Maike H.J. Schepens
- Department of Biomedical Data Sciences, Leiden UMC, Leiden, The Netherlands
- Healthcare Strategy and Innovation, Cirka BV, Zeist, The Netherlands
| | - Miranda L. van Hooff
- Department of Orthopedic Surgery, Radboud UMC, Nijmegen, The Netherlands
- Department of Research, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Onno van der Galiën
- Department of Strategy and Innovation, Zilveren Kruis Health Insurance, Zeist, The Netherlands
| | | | - Diederik M. Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
- Prosper Prostate Cancer Clinics, Nijmegen/Eindhoven, The Netherlands
| | - Pim J. van Leeuwen
- Department of Urology, Netherlands Cancer Institute, Netherlands Prostate Cancer Network, Amsterdam, The Netherlands
| | - Martijn B. Busstra
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sjoerd Repping
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Michel W.J.M. Wouters
- Department of Biomedical Data Sciences, Leiden UMC, Leiden, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jacques van Limbeek
- Department of Medical Advice, Zilveren Kruis Health Insurance, Zeist, The Netherlands
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Zhang F, Chu H, Hao Y, Yang B, Yan Y, Zhang Y, Liu C, Ma L, Huang Y. Preoperative predictive model of early urinary continence recovery after laparoscopic radical prostatectomy. World J Urol 2023; 41:59-65. [PMID: 36484818 DOI: 10.1007/s00345-022-04198-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To develop and validate a predictive model include magnetic resonance imaging (MRI) parameters preoperatively which can assess the risk of incontinence after laparoscopic radical prostatectomy (LRP) accurately. METHODS We retrospectively reviewed and included 170 patients with prostate cancer who underwent LRP between July 2015 and June 2018 in our institution. All 170 patients were randomly resampled and divided into training set (n = 124) and verification set (n = 46) according to the ratio of 7:3. The Nomogram prediction model of the risk of incontinence after LRP was established through the training set and verified by the verification set. Baseline patient characteristics were obtained, including age, body mass index, and prostate volume. Perioperative characteristics such as pre-biopsy prostate specific antigen, biopsy Gleason score, clinical staging, and NVB sparing status were also collected. MRI parameters preoperatively including membranous urethral length (MUL), prostate apex depth ratio (PADR), and intravesical prostatic protrusion length (IPPL) were obtained. The C index and visual inspection of calibration curve were used to evaluate the discrimination and calibration of the model. RESULTS According to the urinary incontinence (UI) at 3 months postoperatively, the patients were divided into 104 cases (61.2%) in the group with no incontinence and 66 patients (38.8%) in the group with incontinence. Multivariate logistic regression analysis of training set showed that cT3a (OR = 0.427, 95% CI 0.142-1.281, P = 0.1288), MUL (OR = 0.237, 95% CI 0.102-0.551, P < 0.01), PADR (OR = 0.276, 95% CI 0.116-0.655, P < 0.01), and IPPL (OR = 0.073, 95% CI 0.030-0.179, P < 0.01) were independent predictors of urinary incontinence at 3 months postoperatively. The model showed good discrimination with an area under the receiver operating characteristic (ROC) curve of 0.880, with the sensitivity and specificity 0.800 and 0.816, respectively, and good calibration (Hosmer-Lemeshow test result of 5.57, P = 0.695). Decision curve analysis demonstrated that the model was clinically useful. CONCLUSION This study developed and validated a preoperative model in the form of a nomogram to predict the risk of UI after LRP at 3 months. MUL, PADR, and IPPL were significant independent predictive factors of the postoperative early urinary continence.
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Affiliation(s)
- Fan Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Hongling Chu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yichang Hao
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Bin Yang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Ye Yan
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yu Zhang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
| | - Yi Huang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
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Veerman H, Hagens MJ, Hoeks CM, van der Poel HG, van Leeuwen PJ, Vis AN, Heijmink SWTJP, Schoots IG, de Haan MC, Boellaard TN. A standardized method to measure the membranous urethral length (MUL) on MRI of the prostate with high inter- and intra-observer agreement. Eur Radiol 2022; 33:3295-3302. [PMID: 36512044 DOI: 10.1007/s00330-022-09320-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/03/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The membranous urethral length (MUL), defined as the length between the apex and penile base as measured on preoperative prostate magnetic resonance imaging (MRI), is an important predictor for urinary incontinence after radical prostatectomy. Literature on inter- and intra - observer agreement of MUL measurement is limited. We studied the inter- and intra-observer agreement between radiologists using a well-defined method to measure the MUL on the prostate MRI. METHODS Prostate cancer patients underwent a preoperative MRI and robot-assisted radical prostatectomy (RARP) at one high-volume RARP center. MUL measurement was based on well-defined landmarks on sagittal T2-weighted (anatomical) images. Three radiologists independently performed MUL measurements retrospectively in 106 patients blinded to themselves, to each other, and to clinical outcomes. The inter- and intra-observer agreement of MUL measurement between the radiologists were calculated, expressed as intra-class correlation coefficient (ICC). RESULTS The initial inter-observer agreement was ICC 0.63; 95% confidence interval (CI) 0.28-0.81. Radiologist 3 measured the MUL mean 3.9 mm (SD 3.3) longer than the other readers, interpreting the caudal point of the MUL (penile base) differently. After discussion on the correct anatomical definition, radiologist 3 re-assessed all scans, which resulted in a high inter-observer agreement (ICC 0.84; 95% CI 0.66-0.91). After a subsequent reading by radiologists 1 and 2, the intra-observer agreements were ICC 0.93; 95% CI 0.89-0.96, and ICC 0.98; 95% CI 0.97-0.98, respectively. Limitation is the monocenter design. CONCLUSIONS The MUL can be measured reliably with high agreement among radiologists. KEY POINTS • After discussion on the correct anatomical definition, the inter- and intra - observer agreements of membranous urethral length (MUL) measurement on magnetic resonance imaging (MRI) were high. • A reproducible method to measure the MUL can improve the clinical usefulness of prediction models for urinary continence after RARP which may benefit patient counselling.
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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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张 帆, 陈 曲, 郝 一, 颜 野, 刘 承, 黄 毅, 马 潞. [Relationship between recovery of urinary continence after laparoscopic radical prostatectomy and preoperative/postoperative membranous urethral length]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54:299-303. [PMID: 35435196 PMCID: PMC9069035 DOI: 10.19723/j.issn.1671-167x.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the relationship between recovery of urinary continence after laparoscopic radical prostatectomy (LRP) and preoperative/postoperative membranous urethral length (MUL) on magnetic resonance imaging. METHODS We retrospectively analyzed 69 patients with pathologic confirmed prostate carcinoma who underwent laparoscopic radical prostatectomy. Preoperative MUL was defined as the distance from the apex of prostate to the level of the urethra at penile bulb on the coronal image. Postoperative MUL was defined as the distance from the bladder neck to the level of the urethra at the penile bulb on the coronal image. MUL-retained rate was defined as the percentage of postoperative MUL to preoperative MUL. All patients received extraperitoneal LRP. Patients reported freedom from using safety pad (0 pad/d) were defined as urinary continence. Multivariate Logistic regression analyses were used to identify independent predictors of early continence recovery after LRP. Kaplan-Meier analyses and log-rank test were used to compare time to continence recovery between the groups. RESULTS For all the 69 patients, the average age was (71.4±8.6) years. The prostate specific antigen before biopsy was (23.40±30.31) μg/L, and the mean preoperative prostatic volume by magnetic resonance imaging was (39.48±22.73) mL. The mean preoperative MUL was (13.0±3.3) mm, the mean postoperative MUL was (12.3±3.4) mm, and the mean MUL-retained rate was 93.9%±6.2%. The continence rate for all the patients after LRP was 57.9% and 97.1% in three months and one year, respectively. The patients achieving early continence recovery had significant smaller prostatic volume (P=0.028), longer preoperative MUL and postoperative MUL (P < 0.001). Multivariate Logistic regression analyses revealed postoperative MUL (P < 0.001) were predictors of continence recovery after LRP. Kaplan-Meier analyses and Log-rank test revealed that preoperative MUL (≥14 mm vs. < 14 mm, P < 0.001) and postoperative MUL (≥13 mm vs. < 13 mm, P < 0.001), MUL-retained rate (< 94% vs. ≥94%, P < 0.001) were all significantly associated with continence recovery. CONCLUSION Post-operative MUL was independently predictors of early continence recovery after LRP. Preoperative MUL, postoperative MUL and MUL retained rate were significantly associated with recovery of urinary continence.
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Affiliation(s)
- 帆 张
- />北京大学第三医院泌尿外科,北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 曲 陈
- />北京大学第三医院泌尿外科,北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 一昌 郝
- />北京大学第三医院泌尿外科,北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 野 颜
- />北京大学第三医院泌尿外科,北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 承 刘
- />北京大学第三医院泌尿外科,北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 毅 黄
- />北京大学第三医院泌尿外科,北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - 潞林 马
- />北京大学第三医院泌尿外科,北京 100191Department of Urology, Peking University Third Hospital, Beijing 100191, China
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Oza P, Walker NF, Rottenberg G, MacAskill F, Malde S, Taylor C, Sahai A. Pre-prostatectomy membranous urethral length as a predictive factor of post prostatectomy incontinence requiring surgical intervention with an artificial urinary sphincter or a male sling. Neurourol Urodyn 2022; 41:973-979. [PMID: 35266177 PMCID: PMC9313820 DOI: 10.1002/nau.24904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/30/2021] [Accepted: 01/15/2022] [Indexed: 11/10/2022]
Abstract
AIMS To ascertain whether the membranous urethral length (MUL) is predictive of postprostatectomy incontinence (PPI) that requires surgery such as artificial urinary sphincter (AUS) or male sling (MS). METHODS Men who had undergone AUS or MS for PPI were identified from a prospectively maintained database and compared to a control group of men who were continent at 12 months after radical prostatectomy. MUL in sagittal and coronal planes, sphincter height and width were measured on prebiopsy T2-weighted MRI scans. Sphincter volume was estimated as an ellipsoid cylinder. RESULTS A total of 95 patients (64 AUS and 31 MS) were compared to 60 continent controls. There was no statistical difference in presenting PSA, prostate volume, and T-stage. The mean MUL in sagittal and coronal planes was 11.31 mm (SD: 2.6, range: 6-17 mm) and 11.43 mm (SD: 2.94, range: 5-17 mm) in patients who had AUS and MS, respectively; 15.23 mm (SD: 4.2, range: 8.25-25 mm) and 15.75 mm (SD: 4.1, range: 8-24 mm) in controls (p < 0.01). No men in the PPI surgery group had an MUL >17 mm compared to 35% (20/57 sagittal, 20/58 coronal) of controls. The odds ratio for requiring surgery for PPI was 13.4 for sagittal MUL <9 mm and 3.2 if the MUL <12 mm. CONCLUSIONS Patients who had surgery for PPI had a significantly shorter MUL and sphincter volume than continent controls. Men with an MUL >17 mm are unlikely to require surgery for PPI whereas an MUL <12 mm significantly increases the risk of requiring surgery for PPI. MUL should be considered when discussing treatment options for prostate cancer.
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Affiliation(s)
- Priyanka Oza
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK,Faculty of Life Sciences & MedicineKing's College LondonLondonUK
| | | | - Giles Rottenberg
- Department of RadiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Findlay MacAskill
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Sachin Malde
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Claire Taylor
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Arun Sahai
- Department of Urology, Guy's HospitalGuy's and St Thomas' NHS Foundation TrustLondonUK,Faculty of Life Sciences & MedicineKing's College LondonLondonUK
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Urethral Sphincter Length but Not Prostatic Apex Shape in Preoperative MRI Is Associated with Mid-Term Continence Rates after Radical Prostatectomy. Diagnostics (Basel) 2022; 12:diagnostics12030701. [PMID: 35328254 PMCID: PMC8947169 DOI: 10.3390/diagnostics12030701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/01/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background: To test the impact of urethral sphincter length (USL) and anatomic variants of prostatic apex (Lee-type classification) in preoperative multiparametric magnet resonance imaging (mpMRI) on mid-term continence in prostate cancer patients treated with radical prostatectomy (RP). Methods: We relied on an institutional tertiary-care database to identify patients who underwent RP between 03/2018 and 12/2019 with preoperative mpMRI and data available on mid-term (>6 months post-surgery) urinary continence, defined as usage 0/1 (-safety) pad/24 h. Univariable and multivariable logistic regression models were fitted to test for predictor status of USL and prostatic apex variants, defined in mpMRI measurements. Results: Of 68 eligible patients, rate of mid-term urinary continence was 81% (n = 55). Median coronal (15.1 vs. 12.5 mm) and sagittal (15.4 vs. 11.1 mm) USL were longer in patients reporting urinary continence in mid-term follow-up (both p < 0.01). No difference was recorded for prostatic apex variants distribution (Lee-type) between continent vs. incontinent patients (p = 0.4). In separate multivariable logistic regression models, coronal (odds ratio (OR): 1.35) and sagittal (OR: 1.67) USL, but not Lee-type, were independent predictors for mid-term continence. Conclusion: USL, but not apex anatomy, in preoperative mpMRI was associated with higher rates of urinary continence at mid-term follow-up.
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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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10
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Colarieti A, Thiruchelvam N, Barrett T. Evaluation of image-based prognostic parameters of post-prostatectomy urinary incontinence: A literature review. Int J Urol 2021; 28:890-897. [PMID: 34101272 DOI: 10.1111/iju.14609] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/04/2021] [Indexed: 12/18/2022]
Abstract
Prostate cancer is the second most common male cancer, and radical prostatectomy is a highly effective treatment for intermediate and high-risk disease. However, post-prostatectomy urinary incontinence remains a major functional side-effect in patients undergoing radical prostatectomy. Despite recent improvements in preoperative imaging quality and surgical techniques, it remains challenging to predict or prevent occurrence of this complication. The aim of this research was to review the current published literature on pre- and postoperative imaging evaluation of the prostate and pelvic structures, to identify added value in the prediction of post-prostatectomy urinary incontinence. A computerized bibliographic search of the PubMed library was carried out to identify imaging-based articles evaluating the pelvic floor and surrounding structures pre- and/or postradical prostatectomy to predict post-prostatectomy urinary incontinence. A total of 32 articles were included. Of these, 29 papers assessed the importance of magnetic resonance imaging evaluation, with a total of 16 parameters evaluated. The most common parameters were intravesical protrusion, the membranous urethral length, prostatic volume and periurethral fibrosis. Preoperative membranous urethral length and its preservation after surgery showed the strongest correlation with urinary incontinence. Three studies evaluated ultrasound, with all carried out postoperatively. This technique benefits from a dynamic evaluation, and the results are promising for proximal urethral hypermobility and the degree of bladder neck funneling on the Valsalva maneuver. Several imaging studies evaluated the predictors of post-prostatectomy urinary incontinence, with preoperative membranous urethral length offering the most promise. However, the current literature is limited by the single-center nature of studies, and the heterogeneity in patient populations and methodologies used.
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Affiliation(s)
- Anna Colarieti
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Nikesh Thiruchelvam
- Department of, Urology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Tristan Barrett
- Department of, Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,CamPARI Clinic, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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11
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Lardas M, Grivas N, Debray TPA, Zattoni F, Berridge C, Cumberbatch M, Van den Broeck T, Briers E, De Santis M, Farolfi A, Fossati N, Gandaglia G, Gillessen S, O'Hanlon S, Henry A, Liew M, Mason M, Moris L, Oprea-Lager D, Ploussard G, Rouviere O, Schoots IG, van der Kwast T, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Grummet JP, Tilki D, van den Bergh RCN, Lam TB, Cornford P, Mottet N. Patient- and Tumour-related Prognostic Factors for Urinary Incontinence After Radical Prostatectomy for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus 2021; 8:674-689. [PMID: 33967010 DOI: 10.1016/j.euf.2021.04.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/23/2021] [Indexed: 12/22/2022]
Abstract
CONTEXT While urinary incontinence (UI) commonly occurs after radical prostatectomy (RP), it is unclear what factors increase the risk of UI development. OBJECTIVE To perform a systematic review of patient- and tumour-related prognostic factors for post-RP UI. The primary outcome was UI within 3 mo after RP. Secondary outcomes included UI at 3-12 mo and ≥12 mo after RP. EVIDENCE ACQUISITION Databases including Medline, EMBASE, and CENTRAL were searched between January 1990 and May 2020. All studies reporting patient- and tumour-related prognostic factors in univariable or multivariable analyses were included. Surgical factors were excluded. Risk of bias (RoB) and confounding assessments were performed using the Quality In Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were performed for all prognostic factor, where possible. EVIDENCE SYNTHESIS A total of 119 studies (5 randomised controlled trials, 24 prospective, 88 retrospective, and 2 case-control studies) with 131 379 patients were included. RoB was high for study participation and confounding; moderate to high for statistical analysis, study attrition, and prognostic factor measurement; and low for outcome measurements. Significant prognostic factors for postoperative UI within 3 mo after RP were age (odds ratio [OR] per yearly increase 1.04, 95% confidence interval [CI] 1.03-1.05), membranous urethral length (MUL; OR per 1-mm increase 0.81, 95% CI 0.74-0.88), prostate volume (PV; OR per 1-ml increase 1.005, 95% CI 1.000-1.011), and Charlson comorbidity index (CCI; OR 1.28, 95% CI 1.09-1.50). CONCLUSIONS Increasing age, shorter MUL, greater PV, and higher CCI are independent prognostic factors for UI within 3 mo after RP, with all except CCI remaining prognostic at 3-12 mo. PATIENT SUMMARY We reviewed the literature to identify patient and disease factors associated with urinary incontinence after surgery for prostate cancer. We found increasing age, larger prostate volume, shorter length of a section of the urethra (membranous urethra), and lower fitness were associated with worse urinary incontinence for the first 3 mo after surgery, with all except lower fitness remaining predictive at 3-12 mo.
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Affiliation(s)
- Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece.
| | - Nikos Grivas
- Department of Urology, University General Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fabio Zattoni
- Urology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | | | | | | | | | - Maria De Santis
- Department of Urology, Charité Universitätsmedizin Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Andrea Farolfi
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - Nicola Fossati
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | - Ann Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Malcolm Mason
- Division of Cancer & Genetics, Cardiff University School of Medicine, Velindre Cancer Centre, Cardiff, UK
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | | | - Olivier Rouviere
- Department of Urinary and Vascular Imaging, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, University Medical Center, Utrecht Cancer Center, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, and Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Thomas B Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Philip Cornford
- Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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12
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Muñoz-Calahorro C, García-Sánchez C, Barrero-Candau R, García-Ramos JB, Rodríguez-Pérez AJ, Medina-López RA. Anatomical predictors of long-term urinary incontinence after robot-assisted laparoscopic prostatectomy: A systematic review. Neurourol Urodyn 2021; 40:1089-1097. [PMID: 33851426 DOI: 10.1002/nau.24652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023]
Abstract
AIMS There is scarce evidence of anatomical risk factors that might affect long-term post-prostatectomy incontinence (PPI) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). This systematic review aims to identify anatomical measurements in preoperative magnetic resonance imaging (MRI) that might be associated with increased risk of urinary incontinence (UI) 1 year after RALP. METHODS A comprehensive search on Pubmed and Scopus databases up to November 2020 was performed. Eight articles met the inclusion criteria and were finally selected. RESULTS The selected studies included 1146 patients. Seven articles focused on membranous urethral length (MUL); all of them related MUL to long-term PPI in univariate analysis and five of them in multivariate analysis. Four studies presented MUL difference to measure the magnitude of the effect. Average MUL (mm) was 15.9 (SD, 2.6), 16.1 (95% confidence interval [CI]: 13.9-18.9), 12.1 (95% CI 9.7-14.9) and 14.5 in continent patients and 13.9 (SD, 2.9), 10 (95% CI: 8.7-12.1), 10.3 (95% CI: 8.7-12.4) and 9.3 in incontinent patients, with statistically significant differences in all cases. Five studies presented the odds ratio as a result; although there was substantial heterogeneity in the methods used to obtain it, there was consistency in finding an inverse association between MUL and PPI. Other measurements including prostatic-urethral angle, membranous urethral thickness, intraprostatic urethral length and intravesical prostatic protrusion have been reported in few studies, and no association with long-term PPI was found. Levator ani muscle thickness was related to long-term PPI in one article. CONCLUSION Greater MUL on preoperative MRI is associated with lower risk of UI 1 year after RALP.
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13
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Ueki H, Takahashi K, Yasufuku T, Yuen K, Yamashita M. Is the membranous urethral length related to postoperative urinary incontinence after holmium laser enucleation of the prostate? Int J Urol 2020; 27:893-898. [DOI: 10.1111/iju.14322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/15/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Hideto Ueki
- Department of Urology Shinko Memorial Hospital Kobe Hyogo Japan
| | | | | | - Keiji Yuen
- Department of Urology Shinko Memorial Hospital Kobe Hyogo Japan
| | - Masuo Yamashita
- Department of Urology Shinko Memorial Hospital Kobe Hyogo Japan
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