Preservation of the neurovascular bundles is associated with improved time to continence after radical prostatectomy but not long-term continence rates: results of a systematic review and meta-analysis

Integrating clinical and image-based parameters for prediction of early post-prostatectomy incontinence recovery: simplified nomogram approach

PURPOSE

This study aimed to develop a novel model that combines both clinical and image-based parameters to predict early recovery of urinary incontinence after robotic-assisted radical prostatectomy (RARP) more easily and precisely.

MATERIALS AND METHODS

We retrospectively enrolled data from patients who underwent RARP performed by a single surgeon. Clinical parameters were collected through medical chart review. All patients received cystography one week after RARP to evaluate the anastomosis healing condition. All cystography images were analyzed by a single radiologist who was blinded to the clinical status of the patients. Multivariate analysis was performed to select significant predictors for early post-prostatectomy incontinence (PPI) recovery, defined as being pad-free within four weeks after surgery.

RESULTS

A total of 293 patients were enrolled in this study. Among them, 26.7% experienced immediate dryness after surgery, while 47.6% achieved being pad-free within one month. The overall continence rate was over 90% six months after surgery. In univariate analysis, factors associated with early PPI recovery were BMI, T stage, NVB preservation, surgical margin status, downward bladder neck, and bladder neck angle on cystography. BMI, NVB preservation, and downward bladder neck remained significant in multivariate analysis (p-values = 0.041, 0.027, and 0.023, respectively). A nomogram model was established based on these three predictors.

CONCLUSION

This is the first model to combine preoperative clinical factors, peri-surgical factors, and postoperative image-based factors to predict PPI recovery after RARP. This model can assist clinicians in taking optimal actions for PPI and also reduce patient anxiety.

[Effect of Precise Dissection and Reconstruction of the Prostate Apex and Bladder Neck in Radical Prostatectomy on Urinary Control Improvement]

Objective

To investigate the impact of the precise dissection and reconstruction of the prostate apex and bladder neck urethra during radical prostatectomy on the improvement in postoperative urinary control in patients with prostate cancer.

Methods

A retrospective study was conducted. A total of 131 prostate cancer patients who underwent robot-assisted radical prostatectomy at our institution between January 1, 2023 and December 31, 2023 were enrolled. The subjects were divided into two groups, with 64 in the experimental group and 67 in the control group. Patients in the experimental group underwent radical prostatectomy in a modified approach, while those in the control group underwent conventional radical prostatectomy. Propensity score matching was employed to match the two groups at a 1-to-1 ratio based on age, body mass index (BMI), preoperative prostate specific antigen (PSA), prostate volume, Prostate Imaging Reporting and Data System (PI-RADS) scores, biopsy Gleason score, and preoperative urinary control status. After matching, we compared the preoperative baseline data, surgical margin positivity rates, and urinary control status at 3 months post operation between the two groups. Urinary control was assessed before and after surgery using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) scale.

Results

A total of 56 pairs of patients were successfully matched between the experimental group and the control group through 1-to-1 propensity score matching. At 3 months after surgery, the median score for ICIQ-SF scale of the experimental group was 7.0 points, while that of the control group was 9.5 points, with the difference being statistical significant (P<0.05). There was no significant difference in the positive rate of incision margins between the experimental group and the control group. Multiple linear regression analysis showed that both the prostate volume and the Gleason score in the experimental group were positively correlated with the ICIQ-UI SF scores 3 months after surgery (P<0.05), while the age of patients in the control group was positively correlated with ICIQ-UI SF score 3 months after surgery (P<0.05).

Conclusion

Precise dissection and reconstruction of the prostate apex and bladder neck urethra during radical prostatectomy significantly improve the postoperative urinary control of patients at 3 months after surgery.

The Association between Specimen Neuromuscular Characteristics and Urinary Incontinence after Robotic-Assisted Radical Prostatectomy

Urinary incontinence after robotic-assisted radical prostatectomy (RARP) has been associated with older age, a longer operative time, a higher BMI, a short membranous urethral length and preoperative erectile function. The authors sought to assess the association between the neuromuscular characteristics and postoperative urinary incontinence.

METHODS

RARP specimens from 29 men who underwent bilateral nerve sparing were reanalyzed. Urinary incontinence was evaluated using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) at 6 weeks post surgery and last follow-up. Linear and logistic regression analyses were performed to assess neuromuscular characteristics and incontinence.

RESULTS

At the 1-year follow-up, 11 patients (38%) reported severe incontinence (>12 ICIQ-SF score). The median number of peripheral nerves observed at the base and apex in the specimens was 52 (IQR 13-139) and 59 (IQR: 28-129), respectively. Ganglia were present in 19 patients (65%) at the base and 12 patients (41%) at the apex. Additionally, the median proportional area of detrusor smooth muscle fibers at the base was 0.54 (IQR 0.31-1), while the median proportional area of striated muscle fibers at the apex was 0.13 (IQR 0.08-0.24). No statistically significant associations were found.

CONCLUSIONS

Histologic neuromuscular characteristics were not associated with postoperative urinary incontinence. Enhanced intraoperative evaluation and larger-scale studies may prove useful for the prediction of postprostatectomy incontinence.

Effect of a Modified Technique of Posterior Reconstruction by Iliopectineal Ligament Suspension During Robot-assisted Laparoscopic Radical Prostatectomy on Early Continence: A Randomised Controlled Trial

OBJECTIVE

To evaluate the effect of a modified technique of posterior reconstruction by iliopectineal ligament suspension during robot-assisted radical prostatectomy (RARP) on recovery of early continence.

METHODS

A prospective, single surgeon, single centre, randomised controlled trial was performed from August 2018 to March 2020 with 171 patients (92 control vs 79 experimental). The posterior reconstruction was done using a standard technique in the control group and was modified for the experimental group by incorporating not only the "Rocco" stitch between Denonvilliers' fascia and the rhabdosphincter but also the iliopectineal ligaments bilaterally to further improve posterior support with this suspensory 'hammock'. Both groups of patients were followed for a year with questionnaires and 24-hour pad tests.

RESULTS

Both groups were comparable in terms of baseline demographic, clinical, and pathological characteristics. With regards to recovery of urinary continence, no statistically significant differences were found for socially continent (0-1 pads per day) or fully continent (0 pads per day) rates at all time points examined (1, 3, 6, 12 months). Moreover, there were no statistically significant differences between the groups for presence of urinary symptoms, bowel symptoms, sexual function, and hormonal symptoms.

CONCLUSION

The modified technique of posterior reconstruction by iliopectineal ligament suspension is not associated with improved early continence as compared to the standard posterior reconstruction technique during RARP. Future studies may want to explore other variations of suspensory sutures that could strengthen posterior urethral support to achieve earlier recovery of continence.

Impact of postoperative sexual function on health-related quality of life after robot-assisted radical prostatectomy

Background

We investigated potential disparities in health-related quality of life, particularly concerning urinary function, between patients with preserved and those with impaired sexual function after robot-assisted radical prostatectomy (RARP).

Materials and methods

Between December 2012 and April 2020, 704 men underwent RARP in our hospital. This study included 155 patients with a preoperative 5-item International Index of Erectile Function (IIEF-5) of ≥12 points and an assessable IIEF-5 at 12 months postoperatively. Health-related quality of life was assessed using the 8-item Short-Form Health Survey and Expanded Prostate Cancer Index Composite (EPIC) preoperatively and at 3, 6, and 12 months postoperatively. A logistic regression analysis and Wilcoxon rank sum tests were performed.

Results

Patients were grouped according to the median IIEF-5 score 12 months after surgery: those with preserved sexual function (n = 71) and those with impaired sexual function (n = 84). The mental component summary of the 8-item Short-Form Health Survey was better in the group with preserved sexual function at 6 months postoperatively than in the group with impaired sexual function (p < 0.01). In the EPIC, the group with preserved sexual function performed better not only in the sexual domain but also in the urinary domain at all time points compared with the group with impaired sexual function (p < 0.01). In the comparison of the urinary subdomains of the EPIC, there were no significant differences in urinary function or incontinence, but there were significant differences in urinary distress and irritative/obstructive scores (p < 0.01).

Conclusions

Patients with preserved postoperative sexual function after RARP showed better urinary function than those with impaired sexual function. Hence, preserved sexual function is closely associated with urinary function.

Surgical management of post prostatectomy incontinence

Post prostatectomy incontinence (PPI) is a well-recognized and bothersome complication following radical prostatectomy. Conservative measures such as pelvic floor physical therapy, biofeedback, and medication are first line management of PPI. When first line therapies fail, patients are offered a variety of surgical procedures based on the degree of incontinence, prior radiation therapy, and comorbidities. Among the various surgical options, placement of an artificial urinary sphincter (AUS) is the gold standard for PPI. However, AUS placement has a high rate of re-operation and requires good manual dexterity. In cases of mild-moderate incontinence, especially in patients without prior radiation therapy, male slings and proACT are a less invasive option. Bulking therapy, although highly successful for female stress urinary incontinence (SUI), is not currently advised in the treatment of male SUI. Regardless of surgical approach used to treat PPI, providers should counsel patients regarding risks of re-operation and have an open an honest discussion regarding the degree of continence that can be restored following each procedure.

Membranous urethral length is the single independent predictor of urinary continence recovery at 12 months following Retzius-sparing robot-assisted radical prostatectomy

The influence of anatomical parameters on urinary continence (UC) after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) remains uncharted. Our objective was to evaluate their association with UC at 3, 6 and 12 months post-operatively. Data from patients who underwent RS-RARP were prospectively collected. Continence was defined as no pad use. Anatomic variables were measured on preoperative magnetic resonance imaging (MRI). Regression analyses were performed to identify predictors of UC at each time point. We included 158 patients with a median age of 60 years, most of whom had a localized tumor (≤ cT2). On multivariate analyses, at 3 months post-surgery, urinary incontinence (UI) rises with age, odds ratio (OR) 1.07 [95% confidence interval (CI) 1.004-1.142] and with prostate volume (PV), OR 1.029 (95% CI 1.006-1.052); it reduces with longer membranous urethral length (MUL), OR 0.875 (95% CI 0.780-0.983) and with higher membranous urethral volume (MUV), OR 0.299 (95% CI 0.121-0.737). At 6 months, UI rises with PV, OR 1.033 (95% CI 1.011-1.056) and decreases with MUV, OR 0.1504 (95% CI 0.050-0.444). Significantly, at 12 months post-surgery, the only predictor of UI is MUL, OR 0.830 (95% CI 0.706-0.975), establishing a threshold associated with a risk of UI of 5% (MUL > 15 mm) in opposition to a risk of 25% (MUL < 10 mm). This single institutional study requires external validation. To our knowledge, this is the first prospective cohort study supporting MUL as the single independent predictor of UC at 12 months post-surgery. By establishing MUL thresholds, we enable precise patient counseling.

Comparison of perioperative and functional outcomes of single-incision versus standard multi-incision robot-assisted laparoscopic radical prostatectomy: a prospective, controlled, nonrandomized trial

To compare perioperative and functional outcomes between improved (port-free) single-site robot-assisted laparoscopic radical prostatectomy (pf-ssRARP) and standard multi-port robot-assisted radical prostatectomy (MPRARP). A total of 372 consecutive patients underwent RARAP using the da Vinci Si® robotic surgical system. Group I (n = 210) included patients undergoing pf-ssRARP and Group II (n = 162) included patients undergoing MPRARP. Demographics and perioperative data including postoperative recovery outcomes were recorded and compared between the two groups. Overall mean operative time was significantly shorter with the pf-ssRARP compared to the MPRARP (p < 0.05). The length of hospitalization after the pf-ssRARP was shorter (p < 0.05). In Group I, the positive surgical margin rate was 15.2%; while in Group II, the positive margin rate was 33.3% (p < 0.05). The rate of instant urinary continence was significantly higher in Group I than in Group II (p < 0.05). The percentage of urinary continence was higher in the pf-ssRARP than in the MPRARP, at 6 months post-surgery (p < 0.05) and 9 months post-surgery (p < 0.05). There was no significant difference in the proportion of erectile function in the pf-ssRARP and MPRARP groups at the time of reaching the endpoint of this study (p > 0.05). The two groups were comparable in terms of total hospitalization costs (p < 0.05). The improved (port-free) single-site robot-assisted laparoscopic radical prostatectomy is a practical and easy technique to implement in clinical practice. Extraperitoneal implementation of the modified technique requires only a small incision, no special PORT, no additional auxiliary foramen creation, increased postoperative aesthetics and reduced hospitalization costs, and a high percentage of early postoperative urinary control recovery.

Improved early continence following laparoscopic radical prostatectomy: the urethral hammock technique

PURPOSE

To introduce and illustrate a novel urethral reconstruction technique-the 'urethral hammock-technique'-and to assess its impact on early postoperative continence following laparoscopic radical prostatectomy (LRP).

METHODS

119 patients who underwent LRP between January 2020 and May 2022 (hammock group: n = 43, control group: n = 76) were included in the study. The primary outcome was continence (zero pads or max. one security pad) at 1, 3, and 6 months following surgery. Secondary outcomes were operative time, complications, and histological findings. Univariate and multivariate regression analyses were performed to reveal predictors for continence. p values < 0.05 with a two-sided 95%-confidence interval were considered statistically significant.

RESULTS

Baseline characteristics were comparable among both groups. The number of patients achieving complete continence in both the hammock and control groups at various time intervals was: 4 weeks 37.2% (16/43) vs. 19.2% (14/73) (p = 0.047); 3 months 60.5% (26/43) vs. 37.3% (28/75) (p = 0.021) and 6 months 72.1% (31/43) vs. 60.3% (44/73) (p = 0.23), respectively. Adjusting for bladder neck preservation status and age, the hammock technique was a significant predictor for continence for the 4-week (OR 0.33, 95% CI 0.13-0.83, p = 0.019) and 3-month (OR 0.28, 95% CI 0.12-0.66, p = 0.004) interval but not for the 6-month interval (OR 0.64, 95% CI 0.27-1.5, p = 0.31). Operative time, complication rates, time till catheter extraction and histological findings were comparable between both groups (all p > 0.05).

CONCLUSIONS

The hammock technique is a simple and reproducible technique to improve early postoperative continence for at least 3 months following surgery. However, these promising results warrant confirmation through a randomized controlled trial.

Association between 3D membranous urethral parameters and urinary continence recovery after RARP

OBJECTIVES

To evaluate whether the urinary continence (UC) recovery after robotic-assisted radical prostatectomy (RARP) relates to the membranous urethral length (MUL) and the membranous urethral complex volume (MUV).

MATERIALS AND METHODS

120 patients who underwent RARP were enrolled according to the different times of UC recovery and examined using prostate magnetic resonance imaging (MRI) before surgery. The membranous urethral (MU) parameters were measured using the three-Dimensional (3D) model reconstructed by holographic technology, such as total MUV (tMUV), exposed MUV (eMUV), full MUL (fMUL) and exposed MUL (eMUL). Statistical software SPSS 26.0 was used to analyze the data and compare the MU parameters and baseline data in different groups.

RESULTS

Patients with larger tMUV (p = 0.038), eMUV (p = 0.003), longer fMUL (p = 0.025), eMUL (p = 0.044) had better UC after removal of the catheter, and eMUV (OR = 1.002, 95%CI = 1.001-1.004, p = 0.004) was a predictor; the patients with younger age (p = 0.021), lower VPSS score (p = 0.004) and larger eMUV (p = 0.012) and longer eMUL (p = 0.049) had better UC recovery one month after RARP while eMUV (OR = 1.002, 95% CI = 1.000-1.003, p = 0.008) and VPSS score (OR = 0.886, 95% CI = 0.806-0.973, p = 0.011) were independent risk factors; The patients with younger age (p = 0.018), larger tMUV (p = 0.029), eMUV (p = 0.016) had better UC recovery three months after RARP. eMUV (OR = 1.002, 95% CI = 1.000-1.004, p = 0.042) and age (OR = 0.904, 95% CI = 0.818-0.998, p = 0.046) were independent risk factors.

CONCLUSION

This clinical study shows that patients with larger MUV and longer MUL can return to UC earlier after surgery. Among that, eMUV is a better predictor.

Surgical approach affecting long-term urinary continence status after robot-assisted laparoscopic prostatectomy prospectively evaluated using self-reported functional status (Expanded Prostate Cancer Index Composite, EPIC-26)

Purpose

The aim of the study was to examine the influence of the surgical approach for robot-assisted laparoscopic prostatectomy (RALP) on long-term urinary continence status in the era of self-reported functional status measures using the Expanded Prostate Cancer Index Composite 26.

Materials and methods

This is a prospective evaluation of 232 patients undergoing RALP between September, 2019 and September, 2020. Urinary continence status and postoperative incontinence (pad usage) were evaluated 12 months after RALP using Expanded Prostate Cancer Index Composite 26 questionnaires. Patients were categorized according to their surgical approach and outcome into the following groups: successful nerve sparing (NS), primarily without nerve sparing (prim. NNS), and no nerve sparing by secondary resection (NNS by SR). The median levels of their questionnaire outcomes were evaluated and compared using the Wilcoxon rank sum test with continuity correction.

Results

Urinary continence status 12 months after RALP differed significantly between the NS and prim. NNS (p = 0.0071) and the NS and NNS by SR (p = 0.0076) groups. There was no significant difference between the prim. NNS and NNS by SR (p = 0.53) groups. Pad usage 12 months after RALP had no significant difference with regard to SR of the neurovascular bundle (p = 0.14).

Conclusions

Patient-reported outcomes of long-term urinary continence status seem to show no difference in postoperative continence, regardless of whether a non-nerve-sparing result was planned or reached through SR. Instead, preservation of neurovascular bundle seems to lead to better long-term continence rates.

Urinary Symptoms Change and Quality of Life After Robotic Radical Prostatectomy: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

To present the patient-reported quality of life (QoL) outcomes from a prospective, randomized controlled trial comparing the use of pelvic floor muscle training (PFMT) and duloxetine after robot-assisted radical prostatectomy (RARP).

METHODS

We identified 213 men with organ-confined disease having post-RARP urinary incontinence who were randomly assigned to received PFMT, duloxetine, combined PFMT-duloxetine and pelvic floor muscle home exercises. Urinary symptoms burden was measured by marked clinical important difference improvement (MCID) defined by using the International Prostate Symptom Score (IPSS) difference of - 8 points (ΔIPSS ≤-8). QoL was assessed according to Visual Analog Scale (VAS), King's Health Questionnaire (KQH), and International Index of Erectile Function (IIEF-5). Multivariable regression analyses aimed to predict MCID, burden of urinary symptoms (IPSS ≥8), and patients reporting to be satisfied (IPSS QoL ≤2) or comfortable (VAS ≤1) post-RARP.

RESULTS

Moderate to severe urinary symptoms decreased from 48% preoperatively to 40%, 34%, and 23% at 3, 6, and 12months post-RARP. After surgery, MCID improvement was observed in 19% of patients, and deterioration in 3.3%. Large prostate was the only factor associated to MCID (OR 1.03 [95%CI 1.01-1.05], P = .005). At 6months, patients reached the same degree of preoperative satisfaction. Neurovascular bundle preservation was the only predictor of being comfortable regarding urinary symptoms postoperatively (OR 12.8 [CI95% 1.47-111.7], P = .02 at 3months) and was also associated to higher median postoperative IIEF-5.

CONCLUSION

Despite urinary incontinence following RARP, patients with larger prostates experience a reduction of lower urinary tract symptoms within a year, which subsequently elevates QoL. Furthermore, nerve-sparing surgery augments erectile function and urinary outcomes, shaping postoperative QoL.

Is there any difference in urinary continence between bilateral and unilateral nerve sparing during radical prostatectomy? A systematic review and meta-analysis

CONTEXT

In men with prostate cancer, urinary incontinence is one of the most common long-term side effects of radical prostatectomy (RP). The recovery of urinary continence in patients is positively influenced by preserving the integrity of the neurovascular bundles (NVBs). However, it is still unclear if bilateral nerve sparing (BNS) is superior to unilateral nerve sparing (UNS) in terms of post-RP urinary continence. The aim of this study is to systematically compare the differences in post-RP urinary continence outcomes between BNS and UNS.

METHODS

The electronic databases of PubMed and Web of Science were comprehensively searched. The search period was up to May 31, 2023. English language articles comparing urinary continence outcomes of patients undergoing BNS and UNS radical prostatectomy were included. Meta-analyses were performed to calculate pooled relative risk (RR) estimates with 95% confidence intervals for urinary continence in BNS and UNS groups at selected follow-up intervals using a random-effects model. Sensitivity analyses were performed in prospective studies and robotic-assisted RP studies.

RESULTS

A meta-analysis was conducted using data from 26,961 participants in fifty-seven studies. A meta-analysis demonstrated that BNS improved the urinary continence rate compared to UNS at all selected follow-up points. RRs were 1.36 (1.14-1.63; p = 0.0007) at ≤ 1.5 months (mo), 1.28 (1.08-1.51; p = 0.005) at 3-4 mo, 1.12 (1.03-1.22; p = 0.01) at 6 mo, 1.08 (1.05-1.12; p < 0.00001) at 12 mo, and 1.07 (1.00-1.13; p = 0.03) at ≥ 24 mo, respectively. With the extension of the follow-up time, RRs decreased from 1.36 to 1.07, showing a gradual downward trend. Pooled estimates were largely heterogeneous. Similar findings were obtained through sensitivity analyses of prospective studies and robotic-assisted RP studies.

CONCLUSION

The findings of this meta-analysis demonstrate that BNS yields superior outcomes in terms of urinary continence compared to UNS, with these advantages being sustained for a minimum duration of 24 months. It may be due to the real effect of saving the nerves involved. Future high-quality studies are needed to confirm these findings.

Functional Impact of Neuro-Vascular Bundle Preservation in High Risk Prostate Cancer without Compromising Oncological Outcomes: A Propensity-Modelled Analysis

Nerve sparing (NS) is a surgical technique to optimize functional outcomes of radical prostatectomy (RP). However, it is not recommended in high risk (HR) cases because of the risk of a positive surgical margin that may increase the risk of cancer recurrence. In the last two decades there has been a change of perspective to the effect that in well-selected cases NS could be an oncologically safe option with better functional outcomes. Therefore, we aim to compare the functional outcomes and oncological safety of NS during RP in men with HR disease. A total of 1340 patients were included in this analysis, of which 12% (n = 158) underwent non-NSRP and 39% (n = 516) and 50% (n = 666) uni- and bilateral NSRP, respectively. We calculated a propensity score and used inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of Pca patients undergoing non-NSRP and those having uni- and bilateral NSRP, respectively. NS improved functional outcomes; after IPTW, only 3% of patients having non-NSRP reached complete erectile function recovery (without erectile aid) at 24 months, whereas 22% reached erectile function recovery (with erectile aid), while 87% were continent. Unilateral NS increased the probability of functional recovery in all outcomes (OR 1.1 or 1.2, respectively), bilateral NS slightly more so (OR 1.1 to 1.4). NSRP did not impact the risk of any recurrence (HR 0.99, 95%CI 0.73-1.34, p = 0.09), and there was no difference in survival for men who underwent NSRP (HR 0.65, 95%CI 0.39-1.08). There was no difference in cancer-specific survival (0.56, 95%CI 0.29-1.11). Our study found that NSRP significantly improved functional outcomes and can be safely performed in carefully selected patients with HR-PCa without compromising long term oncological outcomes.

Improved urinary continence recovery after robot-assisted radical prostatectomy with lateral pelvic fascia preservation

The novel technique of lateral pelvic fascia preservation (LPFP) in robot-assisted radical prostatectomy (RARP) has been reported to improve urinary continence recovery. We aimed to investigate surgical and oncological outcomes after RARP using the LPFP technique and compare them with conventional RARP. This study included patients who underwent RARP with and without the LPFP technique. Time to urinary continence recovery was compared between the LPFP and non-LPFP groups using univariate, multivariate, and propensity-score matched analysis. Perioperative and postoperative outcomes were compared between the two groups using univariate analysis. We included 139 patients who underwent RARP, 68 in the LPFP group and 71 in the non-LPFP group. The LPFP technique was associated with a shorter time to urinary continence recovery, a shorter operative time and lower estimated blood loss. Surgical and oncological outcomes, including complications, pathological T-stage, surgical margin status, and biochemical recurrence-free survival, were comparable between the two groups. This study demonstrated that the LPFP technique improves urinary continence recovery and operative times without compromising surgical and oncological outcomes. The use of this technique in patients with clinically localized prostate cancer is recommended.

Early and late urinary continence outcomes after unilateral and bilateral nerve-sparing robot-assisted radical prostatectomy: A retrospective multicentre cohort study in Japan (the MSUG94 group)

BACKGROUND

The impact of unilateral and bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (NS-RARP) procedures on continence and the time to continence recovery have not been established.

MATERIAL AND METHODS

We retrospectively reviewed a total of 2801 patients who underwent RARP in 9 institutions. Procedures were classified as NS or non-NS; NS procedures were further classified as unilateral or bilateral. The recovery of continence was analysed using propensity score matching method.

RESULTS

The pad-free rates at 12 months after surgery were higher in the NS group (95% confidence interval of odds ratio, 1.06-1.51). Pad-free rates at all time points within 12 months of surgery did not significantly differ between the unilateral and bilateral NS groups.

CONCLUSIONS

NS-RARP resulted in better urinary continence outcomes than non-NS-RARP in the first 12 months after surgery. Urinary recovery rates did not significantly differ between unilateral and bilateral NS-RARP.

Surgical techniques to preserve continence after robot-assisted radical prostatectomy

Radical prostatectomy significantly impacts the inherent anatomy of the male pelvis and the functional mechanisms of urinary continence. Incontinence has a considerable negative influence on the quality of life of patients, as well as their social and psychological wellbeing. Numerous surgical techniques have been demonstrated to support the preservation of continence during robot-assisted radical prostatectomy (RARP). In this in-depth analysis, we give a general summary of the surgical techniques used in RARP and their impact on incontinence rates.

A single-center retrospective comparative analysis of urinary continence in robotic prostatectomy with a combination of umbilical ligament preservation and Hood technique

OBJECTIVES

Data available on the effect of the recently developed Hood technique and its modified iterations in robot-assisted radical prostatectomy on postoperative urinary continence are insufficient. We evaluated the time to achieve urinary continence with the modified Hood technique compared with the standard or umbilical ligament preservation robot-assisted radical prostatectomy.

METHODS

This retrospective analysis examines patient records for those who underwent robot-assisted radical prostatectomy at the Jyoban Hospital of Tokiwa Foundation in Fukushima, Japan, from 2017 to 2021. The main outcome was to determine significant differences in the time taken to achieve urinary continence among the three procedure types. We employed the Kaplan-Meier survival analysis to estimate the time to achieve urinary continence in the three procedure types of robot-assisted radical prostatectomy. Additionally, we used a Cox regression hazard model to evaluate the association between the time to achieve urinary continence and the procedure types.

RESULTS

We considered 196 patients in this study. The estimated rates of achieving urinary continence at 6 months following standard, umbilical ligament preservation, and modified Hood technique robot-assisted radical prostatectomy were 77.6%, 89.5%, and 100%, respectively. The multivariable Cox hazard regression model showed that patients who underwent the modified Hood technique were significantly more likely to achieve urinary continence than those who underwent the standard robot-assisted radical prostatectomy.

CONCLUSIONS

The modified Hood technique achieved better urinary continence outcomes, with all patients with the procedure achieving urinary continence at 6 months. Further randomized controlled trials are required to validate this finding.

Robot-assisted radical prostatectomy following holmium laser enucleation of the prostate: perioperative, functional, and oncological outcomes

Robot-assisted radical prostatectomy with previous holmium laser enucleation of the prostate is challenging, and few studies have analyzed its perioperative, functional, and oncological outcomes. Here we retrospectively evaluated 298 robot-assisted radical prostatectomies, including 25 with and 273 without previous holmium laser enucleation of the prostate, performed in 2015-2022. Regarding perioperative outcomes, operative and console times were significantly longer in the previous holmium laser enucleation of the prostate group. In contrast, the estimated blood loss was similar between groups, and there were no transfusions or intraoperative complications. Multivariable Cox hazard regression analysis of the functional outcomes of postoperative urinary continence showed that body mass index, intraoperative bladder neck repair, and nerve sparing were independently associated factors, whereas a history of holmium laser enucleation of the prostate was not. Similarly, a history of holmium laser enucleation of the prostate was not associated with biochemical recurrence; however, positive surgical margins and seminal vesicle invasion were independent risk factors of biochemical recurrence. Our findings revealed that robot-assisted radical prostatectomy after holmium laser enucleation of the prostate was safe and raised no concerns of postoperative urinary incontinence or biochemical recurrence. Therefore, robot-assisted radical prostatectomy may be a treatment option for patients with prostate cancer after holmium laser enucleation of the prostate.

Impact of modified bladder neck suspension on early recovery of continence after robot-assisted radical prostatectomy (RARP)

The incontinence after RARP significantly decreases the quality of life in prostate cancer patients. A number of techniques have been introduced for the recovery of continence after RARP. Although, the mechanism of the continence recovery is still unclear. We aimed to evaluate the early recovery of continence after RARP by inducing early anterior adhesion and reducing the hypermobility of the urethra through the modified bladder neck suspension (BNS) procedure. From March 2018 to February 2020, a total of 227 consecutive patients who underwent RARP (by single surgeon) were included. Patients were divided into two groups based on operation procedure (Standard procedure vs BNS procedure). Demographics, perioperative variables, and pathologic outcome were analyzed. We assessed recovery of continence at 1, 3, 6 and 9 months after surgery. Postoperative recovery of continence defined as the use of no pad during 24 h. Multivariable logistic regression analyses were performed to evaluate independent predictors of the early recovery of continence at 1 month. We performed RARP with standard procedure (n = 106) or BNS procedure (n = 121). There was no statistical difference in perioperative variables between the two groups except anastomosis time (21.6 ± 12.9 vs 17.0 ± 7.6, p = 0.003). The pad free continence rate were 80.2% (standard group) and 91.3% (BNS group) at 9 month after RARP (p = 0.037). However, early continence rate (1mo) were significantly higher in the BNS group (12.3% vs 29.1%, p = 0.004). On multivariate logistic analyses, BNS procedure (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.03-7.45, p = 0.0426), age (OR 0.92, CI 0.86-0.98, p = 0.0154) were independent factor for early recovery of continence after RARP. The modified bladder neck suspension procedure showed significantly better outcomes than the standard procedure in terms of the early recovery of urinary continence.

Comparing pentafecta outcomes between nerve sparing and non nerve sparing robot-assisted radical prostatectomy in a propensity score-matched study

Pentafecta (continence, potency, cancer control, free surgical margins, and no complications) is an important outcome of prostatectomy. Our objective was to assess the pentafecta achievement between nerve-spring and non-nerve-sparing robot-assisted radical prostatectomy (RARP) in a large single-center cohort. The study included 1674 patients treated with RARP between August 2009 and November 2022 to assess the clinical outcomes. Cox regression analyses were performed to evaluate the prognostic significance of RARP for pentafecta achievement, and 1:1 propensity score matching (PSM) was performed between the nerve-sparing and non-nerve-sparing to test the validity of the results. Pentafecta definition included continence, which was defined as the use of zero pads; potency, which was defined as the ability to achieve and maintain satisfactory erections or ones firm enough for sexual activity and sexual intercourse. The biochemical recurrence rate was defined as two consecutive PSA levels > 0.2 ng/mL after RARP; 90-day Clavien-Dindo complications ≤ 3a; and a negative surgical pathologic margin. The median follow-up period was 61.3 months (IQR 6-159 months). A multivariate Cox regression analysis demonstrated that pentafecta achievement was significantly associated with nerve-sparing (NS) approach (1188 patients) (OR 4.16; 95% CI 2.51-6.9), p < 0.001), unilateral nerve preservation (983 patients) (OR 3.83; 95% CI 2.31-6.37, p < 0.001) and bilateral nerve preservation (205 patients) (OR 7.43; 95% CI 4.14-13.36, p < 0.001). After propensity matching, pentafecta achievement rates in the NS (476 patients) and non-NS (476 patients) groups were 72 (15.1%) and 19 (4%), respectively. (p < 0.001). NS in RARP offers a superior advantage in pentafecta achievement compared with non-NS RARP. This validation study provides the pentafecta outcome after RARP associated with nerve-sparing in clinical practice.

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

BACKGROUND

Nerve-sparing (NS) radical prostatectomy (RP) results in better functional outcomes. Intraoperative neurovascular structure-adjacent frozen section examination (NeuroSAFE) significantly increases the frequency of NS surgery. The effect of NeuroSAFE on postoperative erectile function (EF) and continence is not yet clear.

OBJECTIVE

To describe EF and continence outcomes for men undergoing RP with the NeuroSAFE technique.

DESIGN, SETTING, AND PARTICIPANTS

Between September 2018 and February 2021, 1034 men underwent robot-assisted RP. Data for patient-reported outcomes were collected via validated questionnaires.

INTERVENTION

NeuroSAFE technique for RP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Continence was assessed using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) or Expanded Prostate Cancer Index Composite short form (EPIC-26) and defined as use of 0-1 pads/d. EF was evaluated using EPIC-26 or the International Index of Erectile Function short form (IIEF-5), with data converted according to the Vertosick method and categorized. Descriptive statistics were used to asses and describe tumor characteristics and continence and EF outcomes.

RESULTS AND LIMITATIONS

Of the 1034 men who underwent RP after introduction of the NeuroSAFE technique, 63% and 60% completed a preoperative and at least one postoperative questionnaire on continence and EF, respectively. Of the men who underwent unilateral or bilateral NS surgery, use of 0-1 pads/d was reported by 93% after 1 yr and 96% after 2 yr; the corresponding rates for men who underwent non-NS surgery were 86% and 78%. Overall, use of 0-1 pads/d was reported by 92% of the men at 1 yr and by 94% at 2 yr after RP. Men in the NS group had a good or intermediate Vertosick score after RP more often than the non-NS group. Overall, 44% of the men had a good or intermediate Vertosick score at 1 and 2 yr after RP.

CONCLUSIONS

After introduction of the NeuroSAFE technique, the continence rate was 92% at 1 yr and 94% at 2 yr after RP. The NS group had a greater percentage of men with an intermediate or good Vertosick score and a higher continence rate after RP in comparison to the non-NS group.

PATIENT SUMMARY

Our study shows that after introduction of the NeuroSAFE technique during removal of the prostate, the continence rate among patients was 92% at 1 year and 94% at 2 years after surgery. Some 44% of the men had a good or intermediate score for erectile function 1 and 2 years after surgery.

Application of anatomic reconstruction technique for periurethral structure in robotic assisted laparoscopic radical prostatectomy

OBJECTIVE

To investigate the outcome of patients underwent anatomic periurethral reconstruction during robotic assisted laparoscopic radical prostatectomy (RARP).

MATERIALS AND METHODS

During August 2016 to May 2018, periurethral structure anatomic reconstruction was performed during RARP in 58 consecutive patients. The control group consists of another 50 patients had no reconstruction procedure during RARP. Perioperative data of these patients were collected retrospectively, including operation time, anastomosis time, intraoperative blood loss, duration of indwelling catheter, length of hospital stay, complications, postoperative pathology, and continence outcome at 1,3,6 and 12 months.

RESULTS

All cases were successfully performed without conversion to open or laparoscopic surgery. There were no major intraoperative or postoperative complications.The percentage of patients maintain continence in the reconstruction group versus non-reconstruction group: At 1 month 84.5% (49/58)versus 70.0% (35/50), at 3 months 89.7% (52/58)versus 78.0% (39/50), at 6 months 91.3% (53/58)versus 86.0% (43/50) and 1 year after surgery 100.0% (58/58)versus 96.0% (48/50). Reconstruction group showed better continence outcome in 1 and 3 months (P<0.05). There is no statistical differences in 6 month and 1 year.

CONCLUSION

Anatomic reconstruction of periurethral structure during RARP is safe and feasible with reduced duration of indwelling catheter and better continence outcome.

Predictors of Urinary Continence Recovery after Laparoscopic-Assisted Radical Prostatectomy: Is Surgical Urethral Length the Only Key Factor?

Several efforts in recent years have been made to predict urinary continence (UC) recovery after radical prostatectomy. The aim of our study was to investigate the impact of surgical urethral length preservation (SULP) on urinary continence after LARP (laparoscopic-assisted radical prostatectomy). We retrospectively queried our datasets from May 2021 to May 2022. After the application of exclusion criteria, a total of 100 patients who underwent LARP for prostate cancer at our institution were enrolled. Through a sterile ruler inserted by a 12 mm trocar, the length of the membranous urethra spared during LARP was assessed intra-operatively. The baseline and peri- and postoperative data of patients were collected, and UC was defined as 0 or 1 on a safety pad. The median SULP was 20.5 mm (IQR, 14.5-25), and the median intraoperative EBL were 150 mL (IQR, 100-200). The Kaplan-Meier curve showed a significant difference at 20 mm, which was used as the cut-off value for SULP (log-rank test, p < 0.001). Multivariate Cox proportional hazards models showed that SULP and EBL < 250 mL were associated with UC recovery (all p < 0.02). Surgical urethral length preservation seemed to improve early UC recovery after LARP. Further multicentric studies are needed to confirm our findings.

Anterior Sphincter-sparing Suturing of the Vesicourethral Anastomosis During Robotic-assisted Laparoscopic Radical Prostatectomy

Background

Continence is an important functional outcome after robotic-assisted laparoscopic radical prostatectomy (RARP), and modifications of the surgical technique may improve outcomes.

Objective

To illustrate a novel RARP technique and to describe the observed continence outcomes.

Design setting and participants

A retrospective study of men treated with RARP between 2017 and 2021 was conducted.

Surgical procedure

During RARP, periprostatic structures are preserved, the intraprostatic urethra is partially spared, and the anterior anastomosis stitches involve the plexus structures but not the anterior urethra.

Measurements

A descriptive analysis of the pathological, functional, and short-term oncological outcomes was performed.

Results and limitations

Of 640 men, 448 (70%) with at least 1 yr of follow-up and a median age of 66 yr were included. The median operative time was 270 min and the prostatic volume 52 ml. The transurethral catheter was removed after a median of 3 d, and leakage of urine in the first 24 h after catheter removal was observed in 66/448 patients (15%). Positive surgical margins were reported in 104/448 (23%). Prostate-specific antigen persistence after prostatectomy was observed in 26/448 (6%). During a median follow-up of 2 yr (interquartile range 1-3 yr), the biochemical recurrence after prostatectomy was observed in 19/448 patients (4%). One year after prostatectomy, 406/448 patients (91%) were continent and required no pad at all, while 42/448 (9%) required at least one pad per day.

Conclusions

Not stitching the anterior urethra is a novel technical modification and may improve continence outcomes.

Patient summary

We describe a novel way to stitch the bladder neck to the urethra after removal of the prostate using a surgical robotic system. Our technique appeared safe, with promising urinary continence results.

Erectile function, urinary continence and oncologic outcomes of neurovascular bundle sparing robot-assisted radical prostatectomy for high-risk prostate cancer: A systematic review and meta-analysis

Background

The nerve-sparing (NS) effect of robot-assisted radical prostatectomy (RARP) on patients with a high-risk prostate cancer remains unclear. The objective of this study was to compare the urinary continence, erectile function and oncology outcomes of the nerve-sparing and non-nerve-sparing (NNS) group during RARP surgeries.

Methods

We systematically searched databases including PubMed, Embase, Cochrane Library and Web of Science to identify relevant studies published in English up to December 2022. Newcastle-Ottawa Scale (NOS) was used as a quality evaluation tool to evaluate the quality of the literature parameters involved, including urinary continence, erectile function and oncologic outcomes, which were compared using the Stata 15.1 software (StataSE, USA).

Results

A total of 8 cohort studies involving 2499 patients were included. A meta-analysis of results showed that the NS group was beneficial to the recovery of urinary continence (RR 0.46, 95%CI 0.22, 0.96; p=0.045&lt;0.05) and erectile function (RR 0.32, 95%CI 0.16, 0.63; p=0.001&lt;0.05) 12 months after surgeries, which showed a better oncological outcome (RR 1.31, 95%CI 1.01, 1.69; p=0.01&lt;0.05).

Conclusions

The current study results indicate that intraoperative NS during RARP is beneficial to long-term postoperative functional recovery and tumor prognosis of patients with high-risk prostate cancers. Due to interstudy interferences, the results should be interpreted with caution.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022384647.

Prospective evaluation of an intraoperative urodynamic stress test predicting urinary incontinence after robot-assisted laparoscopic radical prostatectomy

Introduction

Multiple factors influence postprostatectomy incontinence (PPI). This study evaluates the association between an intraoperative urodynamic stress test (IST) with PPI.

Materials and Methods

This is an observational, single-center, prospective evaluation of 109 robot-assisted laparoscopic radical prostatectomies (RALPs) performed between July 2020 and March 2021. All patients underwent an intraoperative urodynamic stress test (IST) in which the bladder is filled up to an intravesical pressure of 40 cm H2O to evaluate whether the rhabdomyosphincter is capable of withstanding the pressure and ensure continence. Early PPI was evaluated using a standardized 1-h pad test performed the day after removal of the urinary catheter. The association of IST and PPI was evaluated using univariate and multivariable logistic regression models.

Results

Nearly 76.6% of the patients showed no urine loss during the IST ("sufficient" population group). There was no significant correlation between this group and PPI after catheter removal (P = 0.5). Subgroup analyses of the "sufficient" patient population showed a 3.1 higher risk of PPI when no nerve sparing was performed (95% confidence interval: 1.05-9.70, P = 0.045).

Conclusion

A sufficient IST, as a surrogate variable for a fully obtained rhabdomyosphincter, has no significant predictive value on its own but seems to be the optimal prerequisite for continence, since the data shows that the lack of neurovascular supply required for a functioning sphincter leads up to a 3.1 times higher risk for PPI.

Impact of human placental derivative allografts on functional and oncological outcomes after radical prostatectomy: a literature review

Post radical prostatectomy (RP) erectile dysfunction and incontinence impacts quality of life for patients. In an objective to hasten the recovery of these functional outcomes, human placental derived allografts laid on neurovascular bundles (NVB) have been investigated. These grafts include amniotic membranes (AM) chorionic membranes (CM) or umbilical cord (UC) allografts. A literature review performed using the MeSH terms "AMNION" OR "CHORION" OR "AMNIOTIC MEMBRANE" OR "UMBILICAL CORD" AND "PROSTATE CANCER" from no specified start date, to April 2022. 163 articles were retrieved, with 149 articles excluded. 14 articles were eligible and analysed. 5 articles were included in this review for an analysis on comparative outcomes. The average return to potency was statistically significant in the intervention groups. Positive surgical margin (PSM) rates showed a higher rate in the control groups. BCR was observed at a lower rate in the interventional group. This review reveals a benefit from human placental allograft's ability to hasten post RP functional recovery, without impacting oncological control.

The application of "S.I.S" technique improves long-term continence after robotic radical prostatectomy

AIMS

To propose a novel S.I.S technique during the robotic-assisted radical prostatectomy (RARP), encompassing pubourethral suspension, posterior wall intensification, and bladder neck stripping, and to present functional and oncological outcomes with a special focus on long-term continence.

METHODS

From January 1, 2018, to December 31, 2019, consecutive patients who underwent RARP were retrospectively investigated and separated into the S.I.S group and the conventional group. Preoperative patient characteristics, tumor status, and perioperative parameters were collected, followed by the assessment of self-reported status on continence, using an International Consultation on Incontinence Modular Questionnaire-urinary incontinence short form (ICIQ-UI-SF). Statistical comparisons were performed on variables between the two surgery groups, and multivariate logistic regression analysis was used to determine predictive factors for postoperative incontinence severity.

RESULTS

A total of 602 subjects were analyzed with a median follow-up of 24 months. There was no significant difference regarding baseline characteristics and perioperative parameters, except for a more advanced tumor stage in the S.I.S group. The application of the S.I.S technique did not jeopardize the positive surgical margin rate at the bladder neck or long-term tumor control. Notably, the patient-reported degree of incontinence was significantly reduced with the assistance of S.I.S technique, as evidenced by the diminished severe-to-very severe cases. On multivariate analysis, both preoperative body mass index and use of S.I.S modification were independent predictive factors for the long-term incontinence severity.

CONCLUSIONS

The application of S.I.S technique during RARP is feasible and superior compare with the conventional approach, with a significantly alleviated long-term incontinence severity, without compromising cancer control.

Contribution of Retzius-sparing robot-assisted radical prostatectomy to the mechanism of urinary continence as demonstrated by dynamic MRI

Retzius-sparing robot-assisted radical prostatectomy (RARP) has been reported to exhibit better postoperative urinary continence, but the reasons behind this are unknown. This study included 254 cases who underwent RARP and underwent postoperative dynamic MRI. We measured the urine loss ratio (ULR) immediately after postoperative urethral catheter removal and investigated its affecting factors and the mechanisms. Nerve-sparing (NS) techniques was performed in 175 (69%) unilateral and 34 (13%) bilateral cases, whereas Retzius-sparing in 58 (23%) cases. The median ULR early after indwelling catheter removal in all patients was 4.0%. The multivariate analysis was performed on factors that reduce ULR and found that the following factors were associated with ULR: younger age, NS and Retzius-sparing, which were significant. Additionally, dynamic MRI findings showed that membranous urethral length and the anterior rectal wall movement toward the pubic bone during abdominal pressure were significant factors. The movement observed on the dynamic MRI during abdominal pressure was thought to reflect an effective urethral sphincter closure mechanism. Long membranous urethral length and an effective urethral sphincter closure mechanism during abdominal pressure were considered effective for favorable urinary continence after RARP. NS and Retzius-sparing were clearly shown to have an additive effect in preventing urinary incontinence.

The NeuroSAFE frozen section technique during radical prostatectomy - Implementation and optimization of technical aspects in a routine pathology workflow

BACKGROUND AND AIMS

In prostate cancer patients, application of the NeuroSAFE frozen section technique during radical prostatectomy has been shown to increase the rate of nerve sparing surgery and to improve functional outcome for the patients. The aim of this study is to report on technical and organizational optimization opportunities of the procedure.

MATERIAL AND METHODS

All patients submitted to bilateral intraoperative frozen section from January 2018 until December 2020 (n = 452) were retrospectively analyzed and parameters such as turnaround time, staff situation in the laboratory and histologic properties of the tumors were assessed.

RESULTS

The median turnaround time per case was 40.3 ( ± 10.5) min. In 2020 the average time needed from accessioning to diagnosis was 38.1 min. Multivariate linear regression suggested that the number of technical assistants/cryotomes (46.1 min vs. 39.13 min; p < 0.001), the place of microscopic examination (43.0 min vs. 38.7 min; p < 0.001) and the presence of a positive margin (38.0 vs. 44.0 min; p < 0.001) were significant influential factors. The turnaround time was independent of the uropathological expertize of the consultant (39.84 min vs. 40.7 min; p = 0.09), the tumor grade (42.3 vs 39.8 min; p = 0.493) and the presence of extraprostatic extension (44.0 vs 39.8 min; p = 0.099).

CONCLUSION

The implementation of simple optimization measures in the workflow as well as structured training of all pathology staff involved in the examination leads to a significant increase in the efficiency of the examination while maintaining the same level of resources. The results could thus be a contribution to the broader application of the procedure.

Management of Urinary Incontinence Following Radical Prostatectomy: Challenges and Solutions

Urinary incontinence is a common and debilitating problem in patients undergoing radical prostatectomy. Current methods developed to treat urinary incontinence include conservative treatments, such as lifestyle education, pelvic muscle floor training, pharmacotherapy, and surgical treatments, such as bulking agents use, artificial urinary sphincter implants, retrourethral transobturator slings, and adjustable male sling system. Pelvic floor muscle exercise is the most common management to improve the strength of striated muscles of the pelvic floor to try to recover the sphincter weakness. Antimuscarinic drugs, phosphodiesterase inhibitors, duloxetine, and a-adrenergic drugs have been proposed as medical treatments for urinary incontinence after radical prostatectomy. Development of new surgical techniques, new surgical tools and materials, such as male slings, has provided an improvement of outcomes after UI surgery. Such improvement is still ongoing, and the uptake of new devices might lead to even better outcomes after UI surgery.

The development and assessment of a predicting nomogram for the recovery of immediate urinary continence following laparoscopic radical prostatectomy

Purpose

This study aimed to develop a nomogram to predict the recovery of immediate urinary continence in laparoscopic radical prostatectomy (LRP) patients.

Methods

A prediction model was developed based on a dataset of 154 LRP patients. Immediate urinary continence was defined as free from using pads within 7 days after the removal of the urinary catheter. The least absolute shrinkage and selection operator regression (LASSO) model was applied to screen the features. Multivariate logistic regression analysis was used to establish prediction model integrating the features selected from the LASSO regression analysis. Receiver operating curve (ROC), calibration and decision curve analysis (DCA) were used to assess the model's discrimination, calibration and clinical utility.

Results

The identified features of the prediction model included age, body mass index (BMI) and three pelvic anatomic parameters measured by MRI: membranous urethral length (MUL), intravesical prostatic protrusion length (IPPL) and puborectalis muscle width (PMW). The nomogram showed good discrimination with an are under the curve(AUC) of 0.914 (95% CI, 0.865-0.959, p < 0.001). Moreover, good calibration was showed in the model. Lastly, DCA showed that the nomogram was clinically useful.

Conclusion

The developed novel nomogram that can predict the possibility for post-prostatectomy patients to recover immediate urinary continence could be used as a counseling tool to explain urinary incontinence to patients after LRP.

Full functional-length urethral sphincter- and neurovascular bundle preservation improves long-term continence rates after robotic-assisted radical prostatectomy

The objective of the study was to test the impact of implementing standard full functional-length urethral sphincter (FFLU) and neurovascular bundle preservation (NVBP) with intraoperative frozen section technique (IFT) on long-term urinary continence in patients undergoing robotic-assisted radical prostatectomy (RARP). We relied on an institutional tertiary-care database to identify patients who underwent RARP between 01/2014 and 09/2019. Until 10/2017, FFLU was not performed and decision for NVBP was taken without IFT. From 11/2017, FFLU and IFT-guided NVBP was routinely performed in all patients undergoing RARP. Long-term continence (≥ 12 months) was defined as the usage of no or one safety- pad. Uni- and multivariable logistic regression models tested the correlation between surgical approach (standard vs FFLU + NVBP) and long-term continence. Covariates consisted of age, body mass index, prostate volume and extraprostatic extension of tumor. The study cohort consisted of 142 patients, with equally sized groups for standard vs FFLU + NVBP RARP (68 vs 74 patients). Routine FFLU + NVBP implementation resulted in a long-term continence rate of 91%, compared to 63% in standard RARP (p < 0.001). Following FFLU + NVBP RARP, 5% needed 1-2, 4% 3-5 pads/24 h and no patient (0%) suffered severe long-term incontinence (> 5 pads/24 h). No significant differences in patient or tumor characteristics were recorded between both groups. In multivariable logistic regression models, FFLU + NVBP was a robust predictor for continence (Odds ratio [OR]: 7.62; 95% CI 2.51-27.36; p < 0.001). Implementation of FFLU and NVBP in patients undergoing RARP results in improved long-term continence rates of 91%.

Validation of user-friendly models predicting extracapsular extension in prostate cancer patients

Objective

There are many models to predict extracapsular extension (ECE) in patients with prostate cancer. We aimed to externally validate several models in a Japanese cohort.

Methods

We included patients treated with robotic-assisted radical prostatectomy for prostate cancer. The risk of ECE was calculated for each patient in several models (prostate side-specific and non-side-specific). Model performance was assessed by calculating the receiver operating curve and the area under the curve (AUC), calibration plots, and decision curve analyses.

Results

We identified ECE in 117 (32.9%) of the 356 prostate lobes included. Patients with ECE had a statistically significant higher prostate-specific antigen level, percentage of positive digital rectal examination, percentage of hypoechoic nodes, percentage of magnetic resonance imaging nodes or ECE suggestion, percentage of biopsy positive cores, International Society of Urological Pathology grade group, and percentage of core involvement. Among the side-specific models, the Soeterik, Patel, Sayyid, Martini, and Steuber models presented AUC of 0.81, 0.78, 0.77, 0.75, and 0.73, respectively. Among the non-side-specific models, the memorial Sloan Kettering Cancer Center web calculator, the Roach formula, the Partin tables of 2016, 2013, and 2007 presented AUC of 0.74, 0.72, 0.64, 0.61, and 0.60, respectively. However, the 95% confidence interval for most of these models overlapped. The side-specific models presented adequate calibration. In the decision curve analyses, most models showed net benefit, but it overlapped among them.

Conclusion

Models predicting ECE were externally validated in Japanese men. The side-specific models predicted better than the non-side-specific models. The Soeterik and Patel models were the most accurate performing models.

Oncological and functional outcomes of high-risk and very high-risk prostate cancer patients after robot-assisted radical prostatectomy

PURPOSE

This study investigated the oncological and functional outcomes of robot-assisted radical prostatectomy (RaRP) in high-risk and very high-risk prostate cancer patients.

MATERIALS AND METHODS

One hundred localized prostate cancer patients receiving RaRP from August 2015 to December 2020 were retrospectively enrolled. According to NCCN risk classification, patients were classified into two groups, below high-risk group, and high-risk/very high-risk group, to analyze continence outcome within postoperative year one and biochemical recurrence-free survival.

RESULTS

The mean age of the cohort was 69.7 ± 7.4 years with a median follow-up of 26.4 (range 3.3-71.3) months. Among them, 53%, and 47% patients were below high-risk group, and high-risk/very high-risk group, respectively. The median biochemical recurrence-free survival of the entire cohort was 53.1 months. The high-risk/very high-risk group without adjuvant treatment had significantly worse biochemical recurrence-free survival than the high-risk/very high-risk group with adjuvant treatment (19.6 vs. 60.5 months, p = 0.029). Rates of postoperative stress urinary incontinence at 1 week, 1 month, and 12 months were 50.7%, 43.7%, and 8.5%, respectively. High-risk/very high-risk patients had significantly higher rates of stress urinary incontinence at postoperative week 1 (75.8% vs. 28.9%) and month 1 (63.6% vs. 26.3%) than the below high-risk group (both p < 0.01). Rates of stress urinary incontinence after RaRP did not differ between two groups from postoperative 3 months to 12 months. The factor of high-risk / very high-risk group was a predictor of immediate but not for long-term postoperative stress urinary incontinence.

CONCLUSIONS

High-risk and very high-risk prostate cancer patients receiving a combination of RaRP and adjuvant treatment had comparable biochemical recurrence-free survival to below high-risk prostate cancer patients. The high-risk/very high-risk factor impeded early but not long-term postoperative recovery of continence. RaRP can be considered a safe and feasible option for high-risk and very high-risk prostate cancer patients.

Sustainable functional urethral reconstruction improves early urinary continence after robot-assisted radical prostatectomy: a randomised controlled trial

OBJECTIVE

To evaluate the impact of sustainable functional urethral reconstruction (SFUR) on early recovery of urinary continence (UC) after robot-assisted radical prostatectomy.

PATIENTS AND METHODS

Overall, 96 patients with primary prostate cancer were randomised into the SFUR or standard group (n = 48 each). The primary outcome was the 1-month UC recovery. Secondary outcomes included short-term (≤3 months) UC recovery, urinary function, micturition-related bother, perioperative complications, and oncological outcomes. Kaplan-Meier curves and Cox proportional hazard models were used to assess the 3-month UC recovery. Generalised estimating equations were used to compare postoperative urinary function and micturition-related bother.

RESULTS

The 1-month UC recovery rates, median 24-h pad weights, and median operative time in the SFUR and standard groups were 73% and 49% (P = 0.017), 0 and 47 g (P = 0.001), and 125 and 103 min (P = 0.025), respectively. The UC recovery rates in the SFUR vs standard groups were 53% vs 23% at 1 week (P = 0.003), 53% vs 32% at 2 weeks (P = 0.038), and 93% vs 77% at 3 months (P = 0.025). The median time to UC recovery in the SFUR and standard groups was 5 and 34 days, respectively (log-rank P = 0.006); multivariable Cox regression supported this result (hazard ratio 1.73, 95% confidence interval 1.08-2.79, P = 0.024). Similar results were observed when UC was defined as 0 pads/day. Urinary function (P = 0.2) and micturition-related bother (P = 0.8) were similar at all follow-up intervals. The perioperative complication rates, positive surgical margin rates, and 1-year biochemical recurrence-free survival were comparable between both groups (all P > 0.05).

CONCLUSION

SFUR resulted in earlier UC recovery without compromising postoperative urinary function. Long-term validation and multicentre studies are required to confirm the results of this novel technique.

Prostate-specific antigen level, biopsy grade group, and tumor-capsular contact length on magnetic resonance imaging are independently associated with an extraprostatic extension

OBJECTIVE

To define the clinicopathological and radiological factors independently associated with the existence of an extraprostatic extension in radical prostatectomy specimens.

METHODS

A total of 202 patients who underwent robotic prostatectomy following biparametric magnetic resonance imaging were assessed. We evaluated the clinicopathological and magnetic resonance imaging variables. We performed receiver-operating characteristic curve analyses to identify factors associated with extraprostatic extension. We engaged in multivariate analysis to identify factors independently associated with such extension.

RESULTS

Extraprostatic extensions were apparent in the final prostatectomy specimens of 62 patients (31%). The areas under the curves of the prostate-specific antigen level, the biopsy grade group, and the tumor-capsular contact length on magnetic resonance imaging were 0.76, 0.71, and 0.70, respectively, in receiver-operating characteristic analysis when used to predict extraprostatic extension; thus, higher than the areas under the curves of the other variables (0.61-0.68). The prostate-specific antigen level (odds ratio 1.090, p = 0.004), the biopsy grade group (odds ratios 2.678 and 6.358, p = 0.017 and p < 0.001 for grade group 3-4 and 5), and the tumor-capsular contact length (odds ratio 1.079, p = 0.001) were independently associated with extraprostatic extension. When the three factors were combined, the area under the receiver-operator characteristic curve increased to 0.79.

CONCLUSIONS

The prostate-specific antigen level, the biopsy grade group, and the tumor-capsular contact length on magnetic resonance imaging were independently associated with extracapsular extension.

Minimal residual membranous urethral length and membranous urethral length predict poor recovery from incontinence after robot-assisted radical prostatectomy and after open radical prostatectomy

OBJECTIVES

To investigate how much minimal residual membranous urethral length (mRUL) and maximal urethral length (MUL) measured on MRI preoperatively affect postoperative urinary incontinence (PUI) and recovery in robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP).

METHODS

The subjects were 190 and 110 patients undergoing RARP and ORP, respectively, in our institution. Patients underwent preoperative MRI for prostate cancer evaluation and completed the quality of life questionnaire of the Expanded Prostate Cancer Index Composite instrument before and 1, 3, 6, and 12 months after surgery. The parameters of mRUL and MUL were measured on MRI and analyzed along with other parameters including age, body mass index, and nerve sparing.

RESULTS

The median mRUL and MUL were 7.81 and 14.27 mm in the RARP group and 7.15 and 13.57 mm in the ORP group, respectively. Recovery rates from PUI were similar in the two groups. Multivariate analyses showed that mRUL was a predictor of baseline continence, whereas shorter MUL was a predictor of poor recovery from PUI. Patients with both shorter mRUL and MUL had significantly worse recoveries from PUI after RARP and ORP than patients with longer mRUL and MUL.

CONCLUSIONS

Minimal residual membranous urethral length contributes to urethral function as basal urinary continence, whereas MUL represents the potential of recovery from PUI in RARP and ORP. The MUL measured by preoperative MRI can predict poor recovery from PUI after radical prostatectomy and combined evaluation of MUL and mRUL support to anticipate poor recovery of PUI.

Understanding long-term continence rates after robot-assisted laparoscopic prostatectomy - one-year follow-up on "Cognitive ability as a non-modifiable risk factor for post-prostatectomy urinary incontinence"

Purpose

To evaluate long-term continence rates (12 months) in patients after robot-assisted laparoscopic prostatectomy (RALP) in relation to their cognitive ability (CoAb), which proved to be a predictor for early post-prostatectomy incontinence.

Material & Methods

This is the 12-month follow-up evaluation of our previously published observational single-center, prospective evaluation of 84 patients who underwent RALP as treatment of their localized prostate cancer between 07/2020 and 03/2021. Post-prostatectomy incontinence (PPI) was measured by asking patients about their 24 h pad usage, whereby 0 pads were considered continent and ≥1 pad was considered incontinent. CoAb was evaluated by performing the Mini-Mental State Examination prior to surgery. Possible predictors for PPI were evaluated using univariate and multivariable logistic regression models.

Results

Multivariable logistic regression analyses identified early incontinence status and nerve sparing (NS) as independent predictors for PPI after 12 months, resulting in a 5.69 times higher risk for PPI when the loss of urine was between 10 and 50 ml during the early performed pad test (one day after catheter removal) compared to 0-1 ml loss of urine [95% confidence interval (CI): 1.33-28.30, p = 0.024] and a 6.77 times higher risk for PPI, respectively, when only unilateral NS was performed compared to bilateral NS (95% CI: 1.79-30.89, p = 0.007). CoAb lost its predictive value for long-term PPI (p = 0.44).

Conclusion

The results of this study suggest that PPI is a dynamic, rather than a static condition with a dynamically changing pathophysiology within the first 12 months after RALP. Coping methods and therapies should adapt to this circumstance.

Significance of postoperative membranous urethral length and position of vesicourethral anastomosis for short-term continence recovery following robot-assisted laparoscopic radical prostatectomy

BACKGROUND

We assess whether short-term recovery of urinary incontinence following robot-assisted laparoscopic radical prostatectomy (RARP) is associated with postoperative membranous urethral length (MUL) and position of vesico-urethral anastomosis (PVUA).

METHODS

Clinical variables including PVUA and pre-and postoperative MUL were evaluated in 251 patients who underwent RARP from August 2019 to February 2021. Continence recovery was defined as no pad or one security liner per day assessed by patient interview at least 6 months follow-up. Univariate and multivariate logistic regression analyses were used to assess variables associated with continence recovery at 3 months after the operation.

RESULTS

Continence recovery rates at 3 and 6 months were 75% and 84%, respectively. Lower BMI (< 25 kg/m2) (p = 0.040), longer preoperative MUL (≥ 9.5 mm) (p = 0.013), longer postoperative MUL (≥ 9 mm) (p < 0.001), higher PVUA (< 14.5 mm) (p = 0.019) and shorter operating time (< 170 min) (p = 0.013) were significantly associated with continence recovery at 3 months in univariate analysis. Multivariate analysis revealed that postoperative MUL (OR 3.75, 95% CI 1.90-7.40, p < 0.001) and higher PVUA (OR 2.02, 95% CI 1.07-3.82, p = 0.032) were independent factors for continence recovery. Patients were divided into 3 groups based on the multivariate analysis, with urinary continence recovery rates found to have increased in turn with rates of 43.7% versus 68.2% versus 85.0% (p < 0.001) at 3 months.

CONCLUSIONS

PVUA and postoperative MUL were significant factors for short-term continence recovery. Preservation of urethral length might contribute to continence recovery after RARP.

A Matched-Pair Analysis after Robotic and Retropubic Radical Prostatectomy: A New Definition of Continence and the Impact of Different Surgical Techniques

Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.

Impact of nerve sparing in robot-assisted radical prostatectomy on the risk of positive surgical margin and biochemical recurrence

OBJECTIVES

Nerve sparing may increase positive surgical margin rate during radical prostatectomy. Our objective was to analyze the positive surgical margin rate and location as well as its impact on biochemical recurrence according to nerve sparing procedure in robot-assisted radical prostatectomy.

METHODS

We included 814 patients treated with robot-assisted radical prostatectomy between 2009 and 2021, and evaluated the impact of nerve sparing on positive surgical margin and biochemical recurrence using logistic regression and Cox models.

RESULTS

Unilateral nerve sparing and bilateral nerve sparing were performed in 152 (18.6%) cases and 118 (14.5%) cases, respectively. On multivariable analysis, in addition to nerve sparing, bilateral nerve sparing, but not unilateral nerve sparing was associated with an increased risk of positive surgical margin compared with non-nerve sparing. Positive surgical margin at any location increased the risk of biochemical recurrence. During unilateral nerve sparing, positive surgical margin in nerve sparing side, but not in non-nerve sparing side was associated with increased risk of biochemical recurrence on multivariate analysis.

CONCLUSIONS

Taken together, surgeons need to notice an increased risk of biochemical recurrence associated with positive surgical margin when performing nerve sparing in robot-assisted radical prostatectomy, and then need to choose the patients suitable for nerve sparing.

Impact of Pelvic Anatomical Changes Caused by Radical Prostatectomy

Simple Summary

After radical prostatectomy, the pelvic anatomy is altered such that the postoperative structure differs from the preoperative one, resulting in a variety of complications. In this review, the complications and mechanisms of pelvic anatomical changes associated with radical prostatectomy, as well as countermeasures, are outlined. An analysis of the anatomical mechanisms that cause complications after radical prostatectomy using imaging and other modalities is in progress. In addition, many surgical techniques that ensure the prevention of postoperative complications have been reported, and their usefulness has been evaluated. The preservation of as much periprostatic tissue and periprostatic structures as possible may lead to favorable postoperative functions, as long as the cancer condition permits.

Abstract

During radical prostatectomy, the prostate is removed along with the seminal vesicles, and the urinary tract is reconstructed by dropping the bladder onto the pelvic floor and suturing the bladder and urethra together. This process causes damage to the pelvic floor and postoperative complications due to the anatomical changes in the pelvic floor caused by the vesicourethral anastomosis. Urinary incontinence and erectile dysfunction are major complications that impair patients’ quality of life after radical prostatectomy. In addition, the shortening of the penis and the increased prevalence of inguinal hernia have been reported. Since these postoperative complications subsequently affect patients’ quality of life, their reduction is a matter of great interest, and procedural innovations such as nerve-sparing techniques, Retzius space preservation, and inguinal hernia prophylaxis have been developed. It is clear that nerve sparing is useful for preserving the erectile function, and nerve sparing, urethral length preservation, and Retzius sparing are useful for urinary continence. The evaluation of pre- and postoperative imaging to observe changes in pelvic anatomy is also beginning to clarify why these techniques are useful. Changes in pelvic anatomy after radical prostatectomy are inevitable and, therefore, postoperative complications cannot be completely eliminated; however, preserving as much of the tissue and structure around the prostate as possible, to the extent that prostate cancer control is not compromised, may help reduce the prevalence of postoperative complications.

The Effectiveness of Pelvic Floor Muscle Training in Men after Radical Prostatectomy Measured with the Insert Test

A commonly used physiotherapeutic method for the treatment of urinary incontinence (UI) after radical prostatectomy (RP) is pelvic floor muscle training (PFMT). The aim of this study was to evaluate the effectiveness of PFMT by enhanced biofeedback using the 1h pad-weighing test. The following factors were taken into consideration in the analysis of PFMT effectiveness: the relevance of the patients’ age, time from RP, BMI, mental health, functional state, and depression. A total of 60 post-RP patients who underwent 10-week PFMT were studied. They were divided into groups: A (n = 20) and B (n = 20) (random division, time from RP: 2−6 weeks) and group C (time from RP > 6 weeks). Group B had enhanced training using EMG biofeedback. UI improved in all groups: A, p = 0.0000; B, p = 0.0000; and C, p = 0.0001. After the completion of PFMT, complete control over miction was achieved by 60% of the patients in group A, 85% in group B, and 45% in group C. There was no correlation between the results of PFMT efficacy and patients’ age, BMI, time from RP, mental health, functional state, and depression. PFMT is highly effective in UI treatment. The enhancement of PFMT by EMG biofeedback seems to increase the effectiveness of the therapy.

Myosteatosis as a novel predictor of urinary incontinence after robot-assisted radical prostatectomy

OBJECTIVES

To evaluate the impact of sarcopenia and myosteatosis on urinary incontinence after prostatectomy.

METHODS

We retrospectively reviewed consecutive patients who underwent robot-assisted radical prostatectomy without nerve sparing between December 2012 and March 2019. Psoas muscle index and average total psoas density, which were measured on preoperative computed tomography images at level L3, were used to evaluate sarcopenia and myosteatosis, respectively. In addition, several magnetic resonance imaging variables associated with pelvic muscles, the urethra and the prostate were measured. Urinary continence was defined as non-use or use of just one incontinence pad per day. Logistic regression analyses aimed to identify the predictors of urinary incontinence 3 and 12 months after surgery.

RESULTS

Overall, 121 patients were included in the analysis. The incidence rates of urinary incontinence 3 and 12 months after surgery were 42% (51/121 cases) and 16% (19/121 cases), respectively. Logistic multivariable analysis showed that low average total psoas density was the only significant independent predictor of urinary incontinence 3 months after surgery (P < 0.01), and low obturator internus muscle thickness (P = 0.01), short membranous urethral length (P = 0.01) and low average total psoas density (P < 0.01) were significant independent predictors of urinary incontinence 12 months after surgery. By contrast, psoas muscle index was not statistically associated with urinary incontinence after surgery.

CONCLUSIONS

Myosteatosis (low average total psoas density) could be a novel predictor of urinary incontinence after robot-assisted radical prostatectomy.

Cryopreserved placental tissue allograft accelerates time to continence following robot-assisted radical prostatectomy

Intra-operatively placed cryopreserved placental tissue allograft (CPTA) has shown promise in expediting the recovery urinary continence (UC) following robot-assisted radical prostatectomy (RARP). In this retrospective review of a prospectively maintained single-surgeon, single-institution RARP database, we compare three groups of patients: historical controls (C; N = 183 men) that received no allograft versus two different CPTA products (total CPTA N = 162 [A1 N = 81; A2 N = 81]). The CPTA product was intra-operatively placed as an onlay over the area of the neurovascular bundles during RARP. CPTA cases had significantly faster median time to UC (A1 = 1.4 months; A2 = 1.45 months) versus controls (1.64 months), p = 0.01. On multivariable analysis, use of A1 (HR 1.55, 95% CI [1.14-2.09], p = 0.005) and use of A2 (HR 1.53, CI [1.11-2.11], p = 0.01) were significantly associated with quicker return of UC. Older age (HR 0.97, CI [0.96-0.99], p = 0.001) and non-organ-confined clinical stage (HR 0.51, CI [0.26-1.0] p = 0.05), were significantly associated with slower return of UC. In a propensity score-matched analysis of 77 CPTA patients with sufficient follow-up versus controls, there was significantly less biochemical recurrence (BCR; p = 0.01). Our study indicates that CPTA use appears to accelerate time to UC in age- and performance status-matched men undergoing RARP without increased risk of BCR.

Selection of patients for nerve sparing surgery in robot‐assisted radical prostatectomy

Context

Robot‐assisted radical prostatectomy (RARP) has become the standard surgical procedure for localized prostate‐cancer (PCa). Nerve‐sparing surgery (NSS) during RARP has been associated with improved erectile function and continence rates after surgery. However, it remains unclear what are the most appropriate indications for NSS.

Objective

The objective of this study is to systematically review the available parameters for selection of patients for NSS. The weight of different clinical variables, multiparametric magnetic‐resonance‐imaging (mpMRI) findings, and the impact of multiparametric‐nomograms in the decision‐making process on (side‐specific) NSS were assessed.

Evidence acquisition

This systematic review searched relevant databases and included studies performed from January 2000 until December 2020 and recruited a total of 15 840 PCa patients. Studies were assessed that defined criteria for (side‐specific) NSS and associated them with oncological safety and/or functional outcomes. Risk of bias assessment was performed.

Evidence synthesis

Nineteen articles were eligible for full‐text review. NSS is primarily recommended in men with adequate erectile function, and with low‐risk of extracapsular extension (ECE) on the side‐of NSS. Separate clinical and radiological variables have low accuracy for predicting ECE, whereas nomograms optimize the risk‐stratification and decision‐making process to perform or to refrain from NSS when oncological safety (organ‐confined disease, PSM rates) and functional outcomes (erectile function and continence rates) were assessed.

Conclusions

Consensus exists that patients who are at high risk of ECE should refrain from NSS. Several multiparametric preoperative nomograms were developed to predict ECE with increased accuracy compared with single clinical, pathological, or radiological variables, but controversy exists on risk thresholds and decision rules on a conservative versus a less‐conservative surgical approach. An individual clinical judgment on the possibilities of NSS set against the risks of ECE is warranted.

Patient summary

NSS is aimed at sparing the nerves responsible for erection. NSS may lead to unfavorable tumor control if the risk of capsule penetration is high. Nomograms predicting extraprostatic tumor‐growth are probably most helpful.

Short-term efficacy and mechanism of electrical pudendal nerve stimulation versus pelvic floor muscle training plus transanal electrical stimulation in treating post-radical prostatectomy urinary incontinence

OBJECTIVE

To assess the short-term efficacy of electrical pudendal nerve stimulation (EPNS) versus pelvic floor muscle training (PFMT) plus transanal electrical stimulation (TES) for the early treatment of post-radical prostatectomy urinary incontinence (PRPUI) and explore its mechanism of action.

SUBJECTS AND METHODS

A parallel designed randomized controlled trial was conducted at a research institute and a university hospital. Ninety-six PRPUI patients were allocated to EPNS group (64 cases) and PFMT+TES group (32 cases) and treated by EPNS and biofeedback-assisted PFMT plus TES, 3 times a week for 8 weeks, respectively. Outcome measurements were improvement rate, scores of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and the number of used diapers.

RESULTS

After 24 treatments, the efficacy rate of 68.7% in EPNS group was significantly higher than that of 34.4% in PFMT+TES group (P=0.005). The ICIQ-UI SF score, and urine leakage amount score, diaper score, symptom and quality of life improved significantly in both groups and showed Therapy x Treatment interaction, and the above scores in EPNS group were significantly lower than these in PFMT+TES group. Perineal ultrasonographic recordings showed that PFM movement amplitude during EPNS (≥1- <3 mm) was similar to that during PFMT, however, PFM movement EMG amplitude was significantly higher during EPNS than during PFMT (P<0.001).

CONCLUSIONS

EPNS is more effective than PFMT+TES in short-term (8 weeks) treatments of early urinary incontinence after radical prostatectomy. Its mechanism of action is that EPNS can excite the pudendal nerve and simulate PFMT.

To sling or not to sling? Impact of intraoperative sling procedures during radical prostatectomy on postoperative continence outcomes: A systematic review and meta‐analysis

Purpose

This systematic review and meta‐analysis investigates the efficacy of intraoperative sling procedures in reducing postprostatectomy urinary incontinence compared to having no slings.

Methods

A comprehensive search of PubMed, Medline, Embase, and the Cochrane library from inception to November 2020 was performed. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized studies and Newcastle‐Ottawa Scale for nonrandomized studies. The GRADE approach was used for critical appraisal of evidences and meta‐analyses were conducted using random‐effects models.

Results

Ten studies were included (n = 1,447). Quality of evidence ranged from moderate to very low. Sling procedure was generally favorable for short‐term continence outcomes, although discrepancies exist due to variability in continence definition. Sling procedure resulted in reduced urinary pad weight at 1 month postoperatively (MD: 21.55; 95%CI: 12.58 to 30.52). Patient‐reported questionnaires were also favorable for the sling group for up to 3 months (IPSS; (MD: 1.44; 95%CI: 0.14 to 2.74), ICIQ‐SF; (MD: 2.25; 95%CI: 1.26 to 3.24), EPIC‐U; (MD: 5.30; 95%CI: 1.12 to 9.39)) postoperatively. Sling procedure improved the number of continent patients at 1 month with continence definition of zero pad use/day (RR:1.41; 95%CI: 1.10 to 1.83) but not with the definition of ≤ 1pad/day. Similarly, it reduced the time to continence with the ≤ 1 pad/day definition (MD: 0.5; 95%CI: 0.1 to 0.9) but not with the zero pad/day definition.

Conclusion

The current literature suggests that intraoperative sling procedures during radical prostatectomy may promote early return of continence compared to having no sling, however, there are no long‐term differences.