Urinary Incontinence and Sexual Function After the Introduction of NeuroSAFE in Radical Prostatectomy for Prostate Cancer

Intraoperative margin assessment during radical prostatectomy: is microscopy frozen in time or ready for digital defrost?

Intraoperative frozen section (IFS) is used with the intention to improve functional and oncological outcomes for patients undergoing radical prostatectomy (RP). High resource requirements of IFS techniques such as NeuroSAFE may preclude widespread adoption, even if there are benefits to patients. Recent advances in fresh-tissue microscopic digital imaging technologies may offer an attractive alternative, and there is a growing body of evidence regarding these technologies. In this narrative review, we discuss some of the familiar limitations of IFS and compare these to the attractive counterpoints of modern digital imaging technologies such as the speed and ease of image generation, the locality of equipment within (or near) the operating room, the ability to maintain tissue integrity, and digital transfer of images. Confocal laser microscopy (CLM) is the modality most frequently reported in the literature for margin assessment during RP. We discuss several imitations and obstacles to widespread dissemination of digital imaging technologies. Among these, we consider how the 'en-face' margin perspective will challenge urologists and pathologists to understand afresh the meaning of positive margin significance. As a part of this, discussions on how to describe, categorize, react to, and evaluate these technologies are needed to improve patient outcomes. Limitations of this review include its narrative structure and that the evidence base in this field is relatively immature but developing at pace.

Impact of frozen section on long-term outcomes in robot-assisted laparoscopic prostatectomy

OBJECTIVES

To compare 1-year functional and 5-year oncological outcomes of men undergoing robot-assisted laparoscopic prostatectomy (RALP) with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) with those in men undergoing RALP without NeuroSAFE (standard of care [SOC]).

SUBJECTS AND METHODS

Men undergoing RALP in our centre between 1 January 2009 and 30 June 2018 were enrolled from a prospectively maintained database. Patients were excluded if they had undergone preoperative therapy or postoperative adjuvant therapy or were enrolled in clinical trials. Patients were grouped based on use of NeuroSAFE. Follow-up was censored at 5 years. The primary outcome was difference in time to biochemical recurrence (BCR) on multivariable analysis, defined as prostate-specific antigen (PSA) >0.2 ng/L on two consecutive measurements. Secondary outcomes were difference in 1-year erectile dysfunction and incontinence.

RESULTS

In the enrolment period, 1199 consecutive men underwent RALP, of whom 1140 were eligible, including 317 with NeuroSAFE and 823 with SOC. The median PSA follow-up was 60 months in both groups. Rates of 5-year BCR were similar on Kaplan-Meier survival curve analysis (11% vs 11%; P = 0.9), as was time to BCR on multivariable Cox proportional hazards modelling (hazard ratio 1.2; P = 0.6). Compared with the SOC group at 1 year, the NeuroSAFE group had similar unadjusted rates of incontinence (5.1% vs 7.7%) and lower unadjusted impotence (57% vs 80%). On multivariable analysis, NeuroSAFE patients had equivalent risk of incontinence (odds ratio [OR] 0.59, 95% CI 0.17-1.6; P = 0.4) but significantly reduced risk of erectile dysfunction (OR 0.37, 95% CI 0.22-0.60; P < 0.001).

CONCLUSIONS

For men undergoing RALP, compared with SOC, NeuroSAFE patients had equivalent time to BCR and risk of 1-year incontinence, and significantly lower risk of 1-year erectile dysfunction.

Nerve-sparing radical prostatectomy using the neurovascular structure-adjacent frozen-section examination (NeuroSAFE): results after 20 years of experience

OBJECTIVES

To evaluate the long-term oncological outcomes and functional results of the neurovascular structure-adjacent frozen-section examination (NeuroSAFE) during nerve-sparing (NS) radical prostatectomy (RP).

MATERIALS AND METHODS

A 10-yr survival analysis on 11069 RPs performed with or without the NeuroSAFE, between January 2002 to June 2011 was carried out. In the NeuroSAFE cohort, the neurovascular structure-adjacent prostatic margins are removed and stained for cryo-sectioning during RP. In case of a PSM, partial or full removal of the neurovascular bundle was performed. The impact of NeuroSAFE on biochemical recurrence-free survival (BFS), salvage radiation therapy-free survival, metastasis-free survival, and prostate cancer-specific survival at 10 years was analyzed. 1-year (1-yr) erectile function (EF), 1-yr, and 2-yr continence rates were assessed in propensity score-based matched cohorts.

RESULTS

Median follow-up was 121 (IQR: 73, 156) months. No differences in BFS between NeuroSAFE and non-NeuroSAFE were recorded (10-yr BFS: NeuroSAFE vs non-Neurosafe, pT2: 81% vs 84%, p = 0.06; pT3a: 58% vs. 63%, p = 0.6; ≥pT3b: 22% vs. 27%, p = 0.99). No differences were found between the two groups in terms of sRFS (pT2: p = 0.1; pT3a: p = 0.4; ≥pT3b: p = 0.4) (Fig. 1B, Table 2), and MTS (pT2: p = 0.3; pT3a: p = 0.6; ≥pT3b: p = 0.9). The NeuroSAFE-navigated patients reported a better 1-yr EF than non-NeuroSAFE (68% vs. 58%, p = 0.02) and no differences in 1-yr and 2-yr continence rates (92.4% vs. 91.8%, and 93.4% vs. 93%, respectively). The main limitation is the retrospective study design.

CONCLUSIONS

While the NeuroSAFE approach did not show significant improvements in long-term oncologic or continence outcomes, it did provide an opportunity for a higher proportion of patients to improve postoperative functional results, possibly through increased nerve-sparing procedures.

Comparison of In-person Versus Online Comprehensive Pelvic Floor Rehabilitation Program Following Prostatectomy

OBJECTIVE

To compare continence outcomes in post-prostatectomy patients undergoing supervised in-person versus online pelvic floor muscle training and pelvic floor education (iPMFT vs oPFMT/PFE). Despite the proven benefit of in-person PFMT for urinary incontinence (UI) following prostatectomy, numerous barriers impede access. We developed a comprehensive online program to deliver oPFMT/PFE.

METHODS

We performed a retrospective review of patients receiving iPFMT versus oPFMT/PFE with minimum 12-month follow-up. Outcomes were assessed at 3 weeks, 3-, 6-, and 12 months following robotic-assisted laparoscopic prostatectomy using validated ICIQ-MLUTS and IIQ-7 questionnaires and additional items (daily pad use [PPD] and satisfaction). The primary study outcome was ICIQ-MLUTS SUI domain score (SDS). Secondary outcomes were PPD, PPD cure (0 PPD at 12 months), SUI cure (12-month SDS=baseline score), and QOL score (IIQ-7 Sum).

RESULTS

Analysis included 41 men. Though men enrolled in oPFMT/PFE demonstrated lower SUI domain scores than iPFMT at most time points (3wk P <.01, 3 mo P = .04, 6 mo P = .15, 12 mo P = .04), the rate of improvement from 3 weeks to other time points was similar between groups (P = NS at all time points). SDS Cure was no different for oPFMT/PFE (75%, 15/20) compared to iPFMT (60%, 12/20, P = .3). PPD and IIQ-7 were also similar at all time points and demonstrated a similar rate of decrease over time through 12 months.

CONCLUSION

Significant and similar improvements in UI and QOL are seen both in men completing iPFMT or oPFMT/PFE programs. Our novel online program provides another option to improve PFMT/PFE access in men undergoing RALP.

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.

Urinary incontinence rehabilitation of after radical prostatectomy: a systematic review and network meta-analysis

Purpose

The aim of this study is to provide treatment for patients with urinary incontinence at different periods after radical prostatectomy.

Methods

The PubMed, Embase, Cochrane, and Web of Science were searched for all literature on the effectiveness on urinary control after radical prostate cancer between the date of database creation and 15 November 2023 and performed a quality assessment. A network meta-analysis was performed using RevMan 5.3 and Stata 17.0 software and evaluated using the surface under the cumulative ranking curve.

Results

The results of the network meta-analysis showed that pelvic floor muscle therapy including biofeedback with professional therapist-guided treatment demonstrated better results at 1 month to 6 months; electrical stimulation, biofeedback, and professional therapist guidance may be more effective at 3 months of treatment; professional therapist-guided recovery may be less effective at 6 months of treatment; and combined therapy demonstrated better results at 1 year of treatment. During the course of treatment, biofeedback with professional therapist-guided treatment may have significant therapeutic effects in the short term after surgery, but, in the long term, the combination of multiple treatments (pelvic floor muscle training+ routine care + biofeedback + professional therapist-guided treatment + electrical nerve stimulation therapy) may address cases of urinary incontinence that remain unrecovered long after surgery.

Conclusion

In general, all treatment methods improve the different stages of functional recovery of the pelvic floor muscles. However, in the long term, there are no significant differences between the treatments. Given the cost-effectiveness, pelvic floor muscle training + routine care + biofeedback + professional therapist-guided treatment + electrical nerve stimulation therapy within 3 months and pelvic floor muscle + routine care after 3 months may be a more economical option to treat urinary incontinence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=331797, identifier CRD42022331797.

Impact of multiparametric magnetic resonance imaging targeted biopsy on functional outcomes in patients following robot-assisted laparoscopic radical prostatectomy

Introduction

Multiparametric magnetic resonance imaging guided prostate biopsy (mpMRI PBx) leads to a higher rate of successful nerve-sparing in robot-assisted laparoscopic prostatectomy (ns-RALP) for prostate cancer (PCa). This study aimed to evaluate the impact of mpMRI PBx compared to standard ultrasound-guided PBx on functional outcomes focusing on erectile function in patients following ns-RALP.

Material and methods

All RALPs performed between 01/2016 and 06/2021 were retrospectively stratified according to (attempted) ns vs. non ns RALPs and were then categorized based on the PBx technique (mpMRI PBx vs. standard PBx). We compared RALP outcomes such as pathological tumor stage, rates of secondary nerve resection (SNR) and positive surgical margin status (PSM). Furthermore, we explored the association between PBx-technique and patient-reported outcomes assessed 12 months after RALP using the prospectively collected 26-item Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire. Chi-square tests and logistic regression analysis were conducted.

Results

A total of 849 RALPs included 517 (61%) procedures with (attempted) ns. Among these, 37.5% were diagnosed via preoperative mpMRI PBx. Patients with a preoperative standard PBx had a 57% higher association of PSM (p = 0.030) compared to patients with mpMRI PBx and a 24% higher risk of erectile dysfunction (ED) 12 months post RALP (p = 0.025). When ns was attempted, we observed a significantly higher rate of SNR in patients who underwent a standard PBx compared to those who received a mpMRI PBx (50.8% vs. 26.7%, p < 0.001) prior RALP. In comparison, upgrading occurred more often in the standard PBx group (50% vs. 40% mpMRI PBx, p = 0.008).

Conclusion

The combination of mpMRI PBx for PCa diagnosis followed by ns-RALP resulted in significantly fewer cases of SNR, better oncological outcomes and reduced incidence of ED 1 year after surgery. This included fewer PSM and a lower rate of postoperative tumor upgrading.

Urinary continence in high-risk prostate cancer after robot-assisted radical prostatectomy

PURPOSE OF REVIEW

Urinary incontinence is common postoperative complication following robot-assisted radical prostatectomy (RARP) in patients with prostate cancer (PCa). Despite the increasing adoption of RARP in the treatment of high-risk PCa (HRPC), concerns persist regarding the adequacy of reported continence outcomes in this subgroup. This review aims to illuminate the state of continence recovery in HRPC patients post-RARP.

RECENT FINDINGS

Urinary continence (UC) recovery rates in HRPC was reported to be lower than the intermediate/low-risk counterparts from 6 to 24 months post-RARP. Predictive models showed that age, obesity, race, disease status, and surgical approaches represent predictors of continence recovery. Special techniques like NeuroSAFE technique and Retzius-Sparing approach also play a role in reducing incontinence also in the high-risk scenario.

SUMMARY

RARP for HRPC appears to be associated with worse continence compared with other risk groups. A multimodality approach for prediction and prevention of incontinence after RARP is vital. Further research into this area is necessary to enhance continence recovery outcomes in HRPC patients undergoing RARP.