Recovery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging

The predictors of short and long term urinary continence recovery after laparoscopic radical prostatectomy: a single cancer center report in China

PURPOSE

To evaluate the predictors for short and long term urinary continence (UC) recovery after laparoscopic radical prostatectomy (LRP) from clinical and oncological variables.

METHODS

We retrospectively collected data from 142 prostate cancer patients who underwent LRP between September 2014 and June 2021 at a tumor specialist diagnosis and treatment center in China. The rate of post-prostatectomy incontinence (PPI) was evaluated from immediate and at 3, 6 and 12 mo after LRP, and UC was defined as the use of no or one safety pad. Sixteen clinical and oncological variables were analyzed by univariate and multivariate regression analysis to determine whether they were associated with short (3 mo) or long term (12 mo) UC recovery after LRP.

RESULTS

After eliminating patients who were lost to follow-up, 129 patients were eventually included. The mean ± SD age was 68 ± 6.3 years. The UC rates of immediate, 3, 6 and 12 mo after the operation were 27.9%, 54.3%, 75.2% and 88.4%, respectively. Multivariate analyses revealed that membranous urethral length (MUL) was a protective predictor of UC after catheter extraction(P < 0.001), and at 3 mo (P < 0.001), 6 mo (P < 0.001) and 12 mo (P = 0.009) after surgery.

CONCLUSION

MUL is a significant independent factor that can contribute to short and long term UC recovery post-LRP, which may assist clinicians and their patients in counseling of treatment.

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.

Early recovery of urinary continence after robot-assisted radical prostatectomy is associated with membranous urethra and neurovascular bundle preservation

OBJECTIVES

We investigated the correlation between surgical outcomes and postoperative urinary continence recovery in robot-assisted radical prostatectomy (RARP).

METHODS

Patients who underwent RARP in our institution (n = 195) were included in this study. Preserved urethral length (PUL) was assessed during the procedure. Other outcomes of the surgical procedure were collected from operative records. Kaplan-Meier analysis with log-rank test was used to compare urinary continence recovery rate with the PUL, sparing of the neurovascular bundle (NVB), and other surgical procedures. Univariate and multivariate analyses were performed using Cox proportional hazards model, and p-values of <0.05 were considered significant.

RESULTS

Patients with a PUL ≥26 mm had 10.0%, 24.7%, 36.6%, and 89.0% continence recovery rates at 30, 60, 90, and 365 days after surgery, respectively, while patients with a PUL <26 mm had 0%, 17.8%, 26.1%, and 80.9% recovery rates, respectively. Kaplan-Meier curves showed significantly better postoperative urinary continence recovery at 30 days after RARP in patients with a PUL ≥26 mm than those with a PUL <26 mm (p = 0.0028) and in patients with NVB preservation than those with no NVB preservation (p = 0.014). Urinary continence recovery within 30, 60, and 90 days after surgery was 90.6% for patients with a PUL of ≥26 mm and NVB preservation, while only 82.3% for patients with a PUL of <26 mm or no NVB preservation.

CONCLUSION

Our results suggest that a PUL ≥26 mm and NVB preservation after RARP correlate with a significantly higher postoperative rate of recovery of urinary continence.

Predictors of Early Continence Recovery Following Radical Prostatectomy, Including Transperineal Ultrasound to Evaluate the Membranous Urethra Length (CHECK-MUL Study)

INTRODUCTION

To predict early continence recovery following radical prostatectomy (RP) using baseline demographic and clinical data, as well as dynamic transperineal ultrasound (TPUS) parameters of membranous urethral length (MUL).

PATIENTS AND METHODS

A retrospective CHECK-MUL (check of membranous urethral length) study was conducted. We evaluated 154 patients who underwent RP between August 2018 and April 2023. All patients underwent pre- and postoperative dynamic TPUS to measure MUL. Urinary continence was defined as the use of one safety pad or less 3 months post surgery. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess urinary incontinence (UI). We used logistic regression to assess the association between MUL and early continence recovery. A multivariable logistic regression model was then constructed for the prediction of early continence recovery based on the MUL.

RESULTS

The median MUL observed pre- and postoperatively in this study were similar (14.6 mm and 12.9 mm). In the univariable logistic regression analysis, the pre- and postoperative MUL measured by TPUS (odds ratio (OR): 1.12; 95%-CI: 1.02-1.79; p = 0.05 and OR: 1.01; 95%-CI: 1.02-1.12; p < 0.01) directions were independent predictors of early continence recovery 3 months post surgery. In addition, age (OR: 1.23; 95%-CI: 1.11-1.42; p = 0.03), BMI (OR: 1.44; 95%-CI: 1.18-2.92; p = 0.05), and bilateral nerve sparing (OR: 1.24; 95%-CI: 1.02-1.9; p = 0.05) were independent predictors of urinary continence in univariable logistic regression models. Preoperative MUL >15 mm (95% CI 1.28-1.33; p = 0.03) and postoperative MUL >14 mm (95% CI 1.2-1.16; p = 0.05) were significantly associated with early continence recovery at 3 months post surgery.

CONCLUSIONS

The likelihood of continence recovery increases with membranous urethral length and decreases with age, BMI, and lack of nerve sparing. Preoperative MUL >15 mm and postoperative MUL >14 mm were significantly associated with early continence recovery at 3 months post surgery.

Membranous urethral length measurement on preoperative MRI to predict incontinence after radical prostatectomy: a literature review towards a proposal for measurement standardization

OBJECTIVES

To investigate the membranous urethral length (MUL) measurement and its interobserver agreement, and propose literature-based recommendations to standardize MUL measurement for increasing interobserver agreement. MUL measurements based on prostate MRI scans, for urinary incontinence risk assessment before radical prostatectomy (RP), may influence treatment decision-making in men with localised prostate cancer. Before implementation in clinical practise, MRI-based MUL measurements need standardization to improve observer agreement.

METHODS

Online libraries were searched up to August 5, 2022, on MUL measurements. Two reviewers performed article selection and critical appraisal. Papers reporting on preoperative MUL measurements and urinary continence correlation were selected. Extracted information included measuring procedures, MRI sequences, population mean/median values, and observer agreement.

RESULTS

Fifty papers were included. Studies that specified the MRI sequence used T2-weighted images and used either coronal images (n = 13), sagittal images (n = 18), or both (n = 12) for MUL measurements. 'Prostatic apex' was the most common description of the proximal membranous urethra landmark and 'level/entry of the urethra into the penile bulb' was the most common description of the distal landmark. Population mean (median) MUL value range was 10.4-17.1 mm (7.3-17.3 mm), suggesting either population or measurement differences. Detailed measurement technique descriptions for reproducibility were lacking. Recommendations on MRI-based MUL measurement were formulated by using anatomical landmarks and detailed descriptions and illustrations.

CONCLUSIONS

In order to improve on measurement variability, a literature-based measuring method of the MUL was proposed, supported by several illustrative case studies, in an attempt to standardize MRI-based MUL measurements for appropriate urinary incontinence risk preoperatively.

CLINICAL RELEVANCE STATEMENT

Implementation of MUL measurements into clinical practise for personalized post-prostatectomy continence prediction is hampered by lack of standardization and suboptimal interobserver agreement. Our proposed standardized MUL measurement aims to facilitate standardization and to improve the interobserver agreement.

KEY POINTS

• Variable approaches for membranous urethral length measurement are being used, without detailed description and with substantial differences in length of the membranous urethra, hampering standardization. • Limited interobserver agreement for membranous urethral length measurement was observed in several studies, while preoperative incontinence risk assessment necessitates high interobserver agreement. • Literature-based recommendations are proposed to standardize MRI-based membranous urethral length measurement for increasing interobserver agreement and improving preoperative incontinence risk assessment, using anatomical landmarks on sagittal T2-weighted images.

Navigating Now and Next: Recent Advances and Future Horizons in Robotic Radical Prostatectomy

Robotic-assisted radical prostatectomy (RARP) has become the leading approach for radical prostatectomy driven by innovations aimed at improving functional and oncological outcomes. The initial advancement in this field was transperitoneal multiport robotics, which has since undergone numerous technical modifications. These enhancements include the development of extraperitoneal, transperineal, and transvesical approaches to radical prostatectomy, greatly facilitated by the advent of the Single Port (SP) robot. This review offers a comprehensive analysis of these evolving techniques and their impact on RARP. Additionally, we explore the transformative role of artificial intelligence (AI) in digitizing robotic prostatectomy. AI advancements, particularly in automated surgical video analysis using computer vision technology, are unprecedented in their scope. These developments hold the potential to revolutionize surgeon feedback and assessment and transform surgical documentation, and they could lay the groundwork for real-time AI decision support during surgical procedures in the future. Furthermore, we discuss future robotic platforms and their potential to further enhance the field of RARP. Overall, the field of minimally invasive radical prostatectomy for prostate cancer has been an incubator of innovation over the last two decades. This review focuses on some recent developments in robotic prostatectomy, provides an overview of the next frontier in AI innovation during prostate cancer surgery, and highlights novel robotic platforms that may play an increasing role in prostate cancer surgery in the future.

The Association Between Low Preoperative Serum Testosterone and Post-radical Prostatectomy Urinary Function

OBJECTIVE

To determine if hypogonadism leads to delayed urinary function recovery post-radical prostatectomy (RP) by studying the effect of preoperative factors including age, membranous urethral length, radiation therapy, and Body Mass Index on urinary continence in patients with or without hypogonadism.

MATERIALS AND METHODS

We identified 1209 patients treated by RP with both pretreatment T and post-treatment urinary outcome. We assessed whether there was an association between low preoperative T level (prenoon T ≤ 300 ng/dL) and continence (using ≤1 pad/d) at 6 and 12months post-RP. Patient-reported continence was used when available, otherwise, surgeon-assessed continence was used. Logistic regression models were used, adjusted for age at RP and nerve-sparing status.

RESULTS

Median age at RP was 61 (Intraquatile Range (IQR) 56, 66), 92% of patients had at least one nerve spared and 99% were continent at baseline. Continence in patients with low T was nonsignificantly lower at 6months (odds ratio 0.69, 95% confidence interval 0.44, 1.06; P = .10) and nonsignificantly higher at 12months (odds ratio 1.07, 95% confidence interval 0.71, 1.58; P = .8). Sensitivity analyses excluding patients with preoperative metastasis or treated with androgen deprivation therapy (ADT) and including testosterone as a continuous predictor were consistent with the primary analysis; similarly finding no evidence of an association.

CONCLUSION

Although we cannot rule out an effect on early continence, overall the evidence does not suggest that low serum testosterone adversely impacts urinary function recovery after RP. This finding can be used to counsel patients enrolled in neoadjuvant ADT trials or those patients undergoing RP who have had prior ADT, such as in the setting of oligometastatic disease.

An artificial intelligence method for predicting postoperative urinary incontinence based on multiple anatomic parameters of MRI

Background

Deep learning methods are increasingly applied in the medical field; however, their lack of interpretability remains a challenge. Captum is a tool that can be used to interpret neural network models by computing feature importance weights. Although Captum is an interpretable model, it is rarely used to study medical problems, and there is a scarcity of data regarding MRI anatomical measurements for patients with prostate cancer after undergoing Robotic-Assisted Radical Prostatectomy (RARP). Consequently, predictive models for continence that use multiple types of anatomical MRI measurements are limited.

Methods

We explored the energy efficiency of deep learning models for predicting continence by analyzing MRI measurements. We analyzed and compared various statistical models and provided reference examples for the clinical application of interpretable deep-learning models. Patients who underwent RARP at our institution between July 2019 and December 2020 were included in this study. A series of clinical MRI anatomical measurements from these patients was used to discover continence features, and their impact on continence was primarily evaluated using a series of statistical methods and computational models.

Results

Age and six other anatomical measurements were identified as the top seven features of continence by the proposed model UINet7 with an accuracy of 0.97, and the first four of these features were also found by primary statistical analysis.

Conclusions

This study fills the gaps in the in-depth investigation of continence features after RARP due to the limitations of clinical data and applicable models. We provide a pioneering example of the application of deep-learning models to clinical problems. The interpretability analysis of deep learning models has the potential for clinical applications.

Duration and Influencing Factors of Postoperative Urinary Incontinence after Robot-Assisted Radical Prostatectomy in a Japanese Community Hospital: A Single-Center Retrospective Cohort Study

OBJECTIVES

Post-operative urinary incontinence (PUI) after robotic-assisted radical prostatectomy (RARP) is an important complication; PUI occurs immediately after postoperative urethral catheter removal, and, although approximately 90% of patients improve within one year after surgery, it can significantly worsen their quality of life. However, information is lacking on its nature in community hospital settings, particularly in Asian countries. The purposes of this study were to investigate the time required to recover from PUI after RARP and to identify its associated factors in a Japanese community hospital.

METHODS

Data were extracted from the medical records of 214 men with prostate cancer who underwent RARP from 2019 to 2021. We then calculated the number of days elapsed from the surgery to the initial outpatient visit confirming PUI recovery among the patients. We estimated the PUI recovery rate using the Kaplan-Meier product limit method and evaluated associated factors using the multivariable Cox proportional hazards model.

RESULTS

The PUI recovery rates were 5.7%, 23.4%, 64.6%, and 93.3% at 30, 90, 180, and 365 days following RARP, respectively. After an adjustment, those with preoperative urinary incontinence experienced significantly slower PUI recovery than their counterparts, while those with bilateral nerve sparing experienced recovery significantly sooner than those with no nerve sparing.

CONCLUSION

Most PUI improved within one year, but a proportion of those experiencing recovery before 90 days was smaller than previously reported.

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.

"Urethral-Sparing" Robotic Radical Prostatectomy: Critical Appraisal of the Safety of the Technique Based on the Histologic Characteristics of the Prostatic Urethra

BACKGROUND

The prostatic urethra (PU) is conventionally resected during robot-assisted radical prostatectomy (RALP). Recent studies demonstrated the feasibility of the extended PU preservation (EPUP).

AIMS

To describe the histologic features of the PU.

METHODS

The PU was evaluated using cystoprostatectomy and RALP specimens. Cases of PU infiltration by prostate cancer or distortion by benign hyperplastic nodules were excluded. The thickness of the chorion and distance between the urothelium and prostate glands were measured. Prostate-specific antigen expression in the PU epithelium was evaluated with immunohistochemistry. Descriptive statistics were used.

RESULTS

Six specimens of PU were examined. Histologically, the following layers of the PU were observed: (1) urothelium with basal membrane, (2) chorion, and (3) prostatic peri-urethral fibromuscular tissue. The chorion measures between 0.2 and 0.4 mm. There is not a distinct urethral muscle layer, but rather muscular fibers that originate near the prostatic stroma and are distributed around the PU. This muscular tissue appears to be mainly represented in the basal and apical urethra, but not in the middle urethra. The mean distance between the chorion and prostatic glands is 1.74 mm, with significant differences between base of the prostate, middle urethral portion, and apex (2.5 vs. 1.49 vs. 1.23 mm, respectively). PSA-expressing cells are abundant in the PU epithelium, coexisting with urothelial cells.

CONCLUSIONS

The exiguity of thickness of the PU chorion, short distance from glandular tissue, and coexistence of PSA-expressing cells in the epithelium raise important concerns about the oncologic safety of EPUP.

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.

A standardized method to measure the membranous urethral length (MUL) on MRI of the prostate with high inter- and intra-observer agreement

OBJECTIVES

The membranous urethral length (MUL), defined as the length between the apex and penile base as measured on preoperative prostate magnetic resonance imaging (MRI), is an important predictor for urinary incontinence after radical prostatectomy. Literature on inter- and intra - observer agreement of MUL measurement is limited. We studied the inter- and intra-observer agreement between radiologists using a well-defined method to measure the MUL on the prostate MRI.

METHODS

Prostate cancer patients underwent a preoperative MRI and robot-assisted radical prostatectomy (RARP) at one high-volume RARP center. MUL measurement was based on well-defined landmarks on sagittal T2-weighted (anatomical) images. Three radiologists independently performed MUL measurements retrospectively in 106 patients blinded to themselves, to each other, and to clinical outcomes. The inter- and intra-observer agreement of MUL measurement between the radiologists were calculated, expressed as intra-class correlation coefficient (ICC).

RESULTS

The initial inter-observer agreement was ICC 0.63; 95% confidence interval (CI) 0.28-0.81. Radiologist 3 measured the MUL mean 3.9 mm (SD 3.3) longer than the other readers, interpreting the caudal point of the MUL (penile base) differently. After discussion on the correct anatomical definition, radiologist 3 re-assessed all scans, which resulted in a high inter-observer agreement (ICC 0.84; 95% CI 0.66-0.91). After a subsequent reading by radiologists 1 and 2, the intra-observer agreements were ICC 0.93; 95% CI 0.89-0.96, and ICC 0.98; 95% CI 0.97-0.98, respectively. Limitation is the monocenter design.

CONCLUSIONS

The MUL can be measured reliably with high agreement among radiologists.

KEY POINTS

• After discussion on the correct anatomical definition, the inter- and intra - observer agreements of membranous urethral length (MUL) measurement on magnetic resonance imaging (MRI) were high. • A reproducible method to measure the MUL can improve the clinical usefulness of prediction models for urinary continence after RARP which may benefit patient counselling.

Value of Different Magnetic Resonance Imaging-based Measurements of Anatomical Structures on Preoperative Prostate Imaging in Predicting Urinary Continence After Radical Prostatectomy in Men with Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Measurements of anatomical structures on preoperative prostate magnetic resonance imaging (MRI) are used in risk models for treatment decisions to predict urinary continence (UC) following radical prostatectomy (RP). However, the association between these parameters and UC is unclear.

OBJECTIVE

To systematically summarize the literature on prognostic preoperative prostate MRI measurements of (peri)prostatic structures in relation to time to recovery of postoperative UC in men with prostate cancer.

EVIDENCE ACQUISITION

Online libraries were searched up to August 27, 2021. Article selection and critical appraisal were performed by two reviewers. All papers reporting on preoperative MRI measurements with UC correlation in univariable or multivariable analyses were included.

EVIDENCE SYNTHESIS

In the 50 studies included (mostly retrospective), 57 MRI parameters were evaluated. The pooled analyses showed that greater membranous urethra length (MUL) was prognostic for regaining UC at 1 mo (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.10-1.21), 3 mo (OR 1.23, 95% CI 1.16-1.31), 6 mo (OR 1.16, 95% CI 1.08-1.25), and 12 mo (OR 1.19, 95% CI 1.10-1.29). Several other anatomical structures showed at least in one study a significant correlation with later return to UC: four prostate-related parameters (greater depth, apical protrusion, larger intravesical protrusion, small dorsal vascular complex), five urethra-related parameters (thicker wall, severe fibrosis, smaller volume, larger preoperative angle between the prostate axis and membranous urethra, shorter minimal residual MUL), and six musculoskeletal-related parameters (lower perfusion ratio, thinner levator ani muscle, larger inner or outer levator distance, shorter pelvic diaphragm length, and larger midpelvic area).

CONCLUSIONS

Greater MUL as measured on preoperative MRI was an independent prognostic factor for return to UC within 1 mo after RP and remained prognostic at 12 mo. Other anatomical structures may potentially be predictive, but these would need to be substantiated in prospective trials before being adopted in postoperative UC risk models for treatment decisions in men with prostate cancer.

PATIENT SUMMARY

We summarized study data on the relation between measurements of anatomical structures on preoperative magnetic resonance imaging scans and urinary continence after removal of the prostate. Greater length of one part of the urethra (membranous urethra) is associated with faster return to continence. Other anatomical structures have potential for predicting postoperative continence, but need further investigation.

The role of preoperative prostatic shape in the recovery of urinary continence after robotic radical prostatectomy: a single cohort analysis

BACKGROUND

To explore the role of preoperative MRI prostate shape in urinary incontinence after robot-assisted radical prostatectomy (RARP).

METHODS

Patients were stratified into four groups based on the mpMRI prostatic apex shape: Group A (prostatic apex overlapping the membranous urethra anteriorly and posteriorly), Group B and C (overlap of the prostatic apex of the anterior or posterior membranous urethra, respectively) and Group D (no overlap). Preoperative variables and intraoperative data were compared. Continence recovery was defined as no pad/day or 1 safety pad/day by an outpatient evaluation performed at 1, 3, 6, and 12 months after RARP.

RESULTS

One hundred patients underwent RARP were classified as belonging to Group A (n = 30), Group B (n = 16), Group C (n = 14), and Group D (n = 40). Group D showed a significantly more favorable urinary continence recovery after RARP respect to all the other shapes presenting any forms of overlapping (HR = 1.9, 95% CI 1.2-3.1, p = 0.007). The estimated HR remained substantially unchanged after adjusting by age, body mass index, CCI, prostate volume, and bladder neck sparing (HR = 1.9, 95% CI 1.1-3.2, p = 0.016). The continence recovery median time was 9 months for Group A + B + C (95% CI 5-11) and 4 months for Group D (95% CI 2-6) (p = 0.023).

CONCLUSION

Shape D showed a better continence recovery when compared to other shapes presenting any kind of overlapping of the prostatic apex over the membranous urethra.

Pre-prostatectomy membranous urethral length as a predictive factor of post prostatectomy incontinence requiring surgical intervention with an artificial urinary sphincter or a male sling

AIMS

To ascertain whether the membranous urethral length (MUL) is predictive of postprostatectomy incontinence (PPI) that requires surgery such as artificial urinary sphincter (AUS) or male sling (MS).

METHODS

Men who had undergone AUS or MS for PPI were identified from a prospectively maintained database and compared to a control group of men who were continent at 12 months after radical prostatectomy. MUL in sagittal and coronal planes, sphincter height and width were measured on prebiopsy T2-weighted MRI scans. Sphincter volume was estimated as an ellipsoid cylinder.

RESULTS

A total of 95 patients (64 AUS and 31 MS) were compared to 60 continent controls. There was no statistical difference in presenting PSA, prostate volume, and T-stage. The mean MUL in sagittal and coronal planes was 11.31 mm (SD: 2.6, range: 6-17 mm) and 11.43 mm (SD: 2.94, range: 5-17 mm) in patients who had AUS and MS, respectively; 15.23 mm (SD: 4.2, range: 8.25-25 mm) and 15.75 mm (SD: 4.1, range: 8-24 mm) in controls (p < 0.01). No men in the PPI surgery group had an MUL >17 mm compared to 35% (20/57 sagittal, 20/58 coronal) of controls. The odds ratio for requiring surgery for PPI was 13.4 for sagittal MUL <9 mm and 3.2 if the MUL <12 mm.

CONCLUSIONS

Patients who had surgery for PPI had a significantly shorter MUL and sphincter volume than continent controls. Men with an MUL >17 mm are unlikely to require surgery for PPI whereas an MUL <12 mm significantly increases the risk of requiring surgery for PPI. MUL should be considered when discussing treatment options for prostate cancer.

Preoperative Prostate MRI Predictors of Urinary Continence Following Radical Prostatectomy

Background Urinary continence after radical prostatectomy (RP) is an important determinant of patient quality of life. Anatomic measures at prostate MRI have been previously associated with continence outcomes, but their predictive ability and interrater agreement are unclear in comprehensive clinical models. Purpose To evaluate the predictive ability and interrater agreement of MRI-based anatomic measurements of post-RP continence when combined with clinical multivariable models. Materials and Methods In this retrospective cohort study, continence outcomes were evaluated in men who underwent RP from August 2015 to October 2019. Preoperative MRI-based anatomic measures were obtained retrospectively by four abdominal radiologists. Before participation, these radiologists completed measure-specific training. Logistic regression models were developed with clinical variables alone, MRI variables alone, and combined variables for predicting continence at 3, 6, and 12 months after RP; some patient data were missing at each time point. Interrater agreement of MRI variables was assessed by using intraclass correlation coefficients (ICCs). Results A total of 586 men were included (mean age ± standard deviation: 63 years ± 7). The proportion of patients with incontinence was 0.2% (one of 589) at baseline, 27% (145 of 529) at 3 months, 14% (63 of 465) at 6 months, and 9% (37 of 425) at 12 months. Longer coronal membranous urethra length (MUL) improved the odds of post-RP continence at all time points (odds ratio per 1 mm: 0.86 [95% CI: 0.80, 0.93], P < .001; 0.86 [95% CI: 0.78, 0.95], P = .003; and 0.79 [95% CI: 0.67, 0.91], P = .002, respectively) in models that incorporated both clinical and MRI predictors. No other MRI variables were predictive. Age and baseline urinary function score were the only other predictive clinical variables at every time point. Interrater agreement was moderate (ICC, 0.62) for MUL among readers with measure-specific prostate MRI training and poor among those without the training (ICC, 0.38). Conclusion Preoperative MRI-measured coronal membranous urethra length was an independent predictor of urinary continence after prostatectomy. © RSNA, 2022 Online supplemental material is available for this article.

Evaluation of image-based prognostic parameters of post-prostatectomy urinary incontinence: A literature review

Prostate cancer is the second most common male cancer, and radical prostatectomy is a highly effective treatment for intermediate and high-risk disease. However, post-prostatectomy urinary incontinence remains a major functional side-effect in patients undergoing radical prostatectomy. Despite recent improvements in preoperative imaging quality and surgical techniques, it remains challenging to predict or prevent occurrence of this complication. The aim of this research was to review the current published literature on pre- and postoperative imaging evaluation of the prostate and pelvic structures, to identify added value in the prediction of post-prostatectomy urinary incontinence. A computerized bibliographic search of the PubMed library was carried out to identify imaging-based articles evaluating the pelvic floor and surrounding structures pre- and/or postradical prostatectomy to predict post-prostatectomy urinary incontinence. A total of 32 articles were included. Of these, 29 papers assessed the importance of magnetic resonance imaging evaluation, with a total of 16 parameters evaluated. The most common parameters were intravesical protrusion, the membranous urethral length, prostatic volume and periurethral fibrosis. Preoperative membranous urethral length and its preservation after surgery showed the strongest correlation with urinary incontinence. Three studies evaluated ultrasound, with all carried out postoperatively. This technique benefits from a dynamic evaluation, and the results are promising for proximal urethral hypermobility and the degree of bladder neck funneling on the Valsalva maneuver. Several imaging studies evaluated the predictors of post-prostatectomy urinary incontinence, with preoperative membranous urethral length offering the most promise. However, the current literature is limited by the single-center nature of studies, and the heterogeneity in patient populations and methodologies used.

Racial Variation in Membranous Urethral Length and Postprostatectomy Urinary Function

Urinary incontinence remains a significant post-prostatectomy sequalae. While many patient and technical factors have been found to contribute to post-prostatectomy incontinence, the impact of anatomical differences by races has not been studied . Shorter preoperative membranous urethral length (MUL) on prostate MRI has been associated with higher risk of post-prostatectomy incontinence. We compared MUL in Asian and non-Asian men and their post-prostatectomy urinary function using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). We found that MUL was significantly shorter for Asian vs. non-Asian men (7.9mm, 95% confidence interval [CI] 7.5-8.3 vs. 10.9mm, 95%CI 10.2-11.7 - mean difference 3.0mm, 95%CI for mean difference 2.15-3.87; p<0.01) and that Asian men had significantly worse EPIC-CP urinary score ≥12 months post-prostatectomy (3.82; 95%CI 2.47-5.17 vs. 1.95; 95%CI 1.11-2.79 - mean difference: 1.87; 95% CI for mean difference is 0.32-3.42; p=0.022). Confirmatory studies are needed to explore racial differences in MUL and its effect on post-prostatectomy urinary incontinence.

The effects of bladder neck sparing with an additional anterior urethral fixation on postoperative continence after robot-assisted radical prostatectomy

OBJECTIVE:

Urinary incontinence remains one of the main problems affecting the quality of life after radical prostatectomy. Along with the improved understanding of the precise anatomy of the prostate, urethra and their surrounding structures, minimally invasive surgical techniques have been refined and described, aiming to improve functional outcomes without oncological compromise. This study aimed to investigate the impacts of anterior urethral fixation (AUF) and bladder neck sparing (BNS) on the early continence success after Robot-assisted Radical Prostatectomy (RALP).

METHODS:

This retrospective study included 120 patients who underwent RALP between January 2018 and June 2019. Patients were allocated to one of two groups; group 1 (n=60) underwent RALP with BNS, group 2 (n=60) underwent RALP with both AUF and BNS. The patient continence status was measured at baseline on day 7 and in the 1^st, 3^rd, and 6^th months postoperatively.

RESULTS:

Concerning Incontinence Impact Questionnaire-7 form, statistically significant better results in group 2 were recorded in all visits, but the last (month 6) (p=0.023). Following catheter removal, postmicturition symptoms, including incomplete emptying and post-micturition dribble rate, were significantly higher in group 1 after catheter removal and in the 1^st month (13.3% vs. 0 p=0.006). This difference was not recorded at the next visits (months 3 and 6).

CONCLUSION:

Our findings showed that the combination of AUF and BNS significantly increases early continence rates and decreases post-mictional symptoms after RALP without hampering oncologic outcomes.

Integrity of the Urethral Sphincter Complex, Nerve-sparing, and Long-term Continence Status after Robotic-assisted Radical Prostatectomy

BACKGROUND

The applicability of the sphincter complex integral theory to robotic-assisted radical prostatectomy (RARP) is unclear, with little known about the long-term effect of sphincter complex integrity on continence.

OBJECTIVE

To determine whether the preoperative anatomical and functional features of the sphincter complex and the degree of nerve-sparing affect long-term continence after RARP.

DESIGN, SETTING, AND PARTICIPANTS

Prospective study of 529 patients who underwent RARP at a single tertiary center.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Anatomical factors, including membranous urethral length (MUL) and pelvic diaphragm length (PDL), were assessed using sagittal views of preoperative magnetic resonance imaging. MUL was defined as the distance from the posterior prostate apex to the urethra level at the penile bulb, and PDL was defined as the length of the urethra that met the planes created by the pelvic floor muscles. Functional parameters including maximum urethral closure pressure (MUCP) and functional urethral length were evaluated using preoperative measurements of the urethral pressure profiles. The degree of nerve-sparing was stratified as bilateral, unilateral, or none. Continence (pad-free status) was assessed according to anatomical and functional factors and nerve-sparing. We used binary logistic regression to assess factors predicting continence return 12 mo after RARP.

RESULTS AND LIMITATIONS

Continence return rates 1, 3, 6, and 12 mo after RARP were 39.7%, 66.0%, 80.2%, and 87.0%, respectively. Continence return rates at 12 mo differed significantly in patients with MUL ≥11.7mm (91.9%) and <11.7mm (79.9%), PDL ≥9.9mm (96.7%) and <9.9mm (74.5%), and MUCP ≥66 cmH₂O (89.7%) and <66 cmH₂O (79.4%). The continence return rate was significantly higher in patients with bilateral (93.0%) than in patients with unilateral (78.1%) or no (76.7%) nerve-sparing. Multivariate analysis showed that PDL (odds ratio [OR]=2.187 per mm), MUCP (OR=1.037 per cmH₂O), and bilateral nerve-sparing (OR=3.671) were independently associated with continence return 12 mo after RALP.

CONCLUSIONS

The anatomical length and static pressure of the sphincter complex affected continence after RARP. Bilateral nerve-sparing was independently associated with long-term continence.

PATIENT SUMMARY

Predisposing length and static pressure of the urinary sphincter affect continence after robotic-assisted radical prostatectomy. Nerve bundle preservation during surgery enhances postoperative return of continence.

Postoperative membranous urethral length is the single most important surgical factor predicting recovery of postoperative urinary continence

PURPOSE

To analyze the potential surgical factors affecting postoperative urinary continence, including postoperative membranous urethral length (MUL), in an era where open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) coexist.

METHODS

Consecutive patients undergoing either ORP or RARP between April 2009 and June 2017 were included in this study. Pericatheter urethrography (PCU) was performed the day of catheter removal to confirm healing of the vesicourethral anastomosis and to measure PCU-MUL. Daily usage of incontinence pad was self-reported by the patient at each post-operative visit through a questionnaire. Univariate and multivariate analyses were performed to identify factors that influenced recovery of continence.

RESULTS

Of the 196 patients included, 121 and 75 patients received ORP and RARP, respectively. The cumulative full continence rates (0 pad/day) at 1 year in the ORP and RARP groups were 87% and 95%, respectively. In the univariate analysis, older age, high preoperative International Prostate Symptom Score (IPSS) irritative symptom domain, ORP, poorer NVB preservation, and shorter PCU-MUL were associated with delayed recovery of full continence. In the multivariate analysis, only older age, high preoperative IPSS irritative symptom domain, and shorter PCU-MUL remained as independent factors significantly associated with delayed recovery of full continence.

CONCLUSIONS

Our study highlights the importance of saving the MUL as long as possible in terms of continence recovery. This holds true for ORP even in the era of RARP and surgeons should not simply give up the prospect of early urinary continence in exchange for the patient's choice of ORP instead of RARP.

Deep learning using preoperative magnetic resonance imaging information to predict early recovery of urinary continence after robot-assisted radical prostatectomy

OBJECTIVES

To investigate whether a deep learning model from magnetic resonance imaging information is an accurate method to predict the risk of urinary incontinence after robot-assisted radical prostatectomy.

METHODS

This study included 400 patients with prostate cancer who underwent robot-assisted radical prostatectomy. Patients using 0 or 1 pad/day within 3 months after robot-assisted radical prostatectomy were categorized into the "good" group, whereas the other patients were categorized into the "bad" group. Magnetic resonance imaging DICOM data, and preoperative and intraoperative covariates were assessed. To evaluate the deep learning models from the testing dataset, their sensitivity, specificity and area under the receiver operating characteristic curve were analyzed. Gradient-weighted class activation mapping was used to visualize the regions of deep learning interest.

RESULTS

The combination of deep learning and naive Bayes algorithm using axial magnetic resonance imaging in addition to clinicopathological parameters had the highest performance, with an area under the receiver operating characteristic curve of 77.5% for predicting early recovery from post-prostatectomy urinary incontinence, whereas machine learning using clinicopathological parameters only achieved low performance, with an area under the receiver operating characteristic curve of 62.2%. The gradient-weighted class activation mapping methods showed that deep learning focused on pelvic skeletal muscles in patients in the good group, and on the perirectal and hip joint regions in patients in the bad group.

CONCLUSIONS

Our results suggest that deep learning using magnetic resonance imaging is useful for predicting the severity of urinary incontinence after robot-assisted radical prostatectomy. Deep learning algorithms might help in the choice of treatment strategy, especially for prostate cancer patients who wish to avoid prolonged urinary incontinence after robot-assisted radical prostatectomy.

How can we prevent postprostatectomy urinary incontinence by patient selection, and by preoperative, peroperative, and postoperative measures? International Consultation on Incontinence-Research Society 2018

AIMS

To review current prevention strategies for urinary incontinence among patients undergoing radical prostatectomy (RP).

METHODS

This is a consensus report of the proceedings of a research proposal from the annual International Consultation on Incontinence-Research Society (ICI-RS), 14 to 16 June 2018 (Bristol, UK): "How can we prevent postprostatectomy incontinence by patient selection, and by preoperative, peroperative, and postoperative measures?"

RESULTS

Several baseline parameters were proposed as predicting factors for postprostatectomy urinary incontinence (PPUI), including age, tumor stage, prostate volume, preoperative lower urinary tract symptoms, maximum urethral closure pressure, and previous transurethral resection of the prostate. More recently, magnetic resonance imaging has been used to measure the membranous urethral length and sphincter volume. Peroperative techniques include preservative and reconstructive approaches. Bladder neck preservation improved early (6 months), as well as long-term (>12 months) continence rates. Several prospective studies have reported earlier return of continence following preservation of puboprostatic ligaments, although no long-term data are available. Preservation of the urethral length yielded controversial outcomes. Concerning postoperative strategies, it is probably optimal to remove the catheter in a window between 4 and 7 days if clinically appropriate; however, more research in this regard is still required. Postoperative PFME (preoperative pelvic floor muscle exercise) appears to speed up the recovery of continence after RP.

CONCLUSIONS

Conservative strategies to prevent PPUI include proper patient selection and PFME. Peroperative techniques have largely shown benefit in the short term. Postoperative complications and timing of trial without catheter can influence continence status. Future research initiatives must assess peroperative and postoperative measures, with longer-term follow-up.

Anatomical robotic prostatectomy: technical factors to achieve superb continence and erectile function

Debate continues as to the superiority of robotic versus open radical prostatectomy for the surgical treatment of localized prostate cancer. Despite this controversy, retrospective data from high volume centres has demonstrated RARP is associated with improved pentafecta outcomes with lower transfusion rates, less incontinence, lower positive surgical margins and improved potency. Advocates of robotic assisted radical prostatectomy (RARP) believe an enhanced visual field, the precision afforded by robotic technology as well as lack of bleeding, sharp dissection and delicate tissue handling lead to improved outcomes. Prostate Cancer is the second most common cancer diagnosed in men, and as the number of post-surgical patients increases, the complications of urinary incontinence and erectile dysfunction not only have a significant negative impact on patients' quality of life, but have become an expanding part of clinical practice. This article outlines what are believed to be the most important strategies based on anatomical knowledge and technical expertise, that allow robotic prostatectomists to achieve superb outcomes in urinary and erectile function.

Locally advanced prostate cancer imaging findings and implications for treatment from the surgical perspective

The anatomy of the prostate is reviewed in the context of discussing the staging of prostate cancer and patterns of tumor spread. The utility of prostate magnetic resonance imaging along with new advancements in tumor staging are discussed specifically in locally advanced disease. What should be included in the radiology report carries a substantial weight to formulate the urologist's decision in regards to the selection of surgical candidates, preoperative planning and avoiding postoperative complications.

Feasibility and continence outcomes of extended prostatic urethral preservation during robot-assisted radical prostatectomy

BACKGROUND

The prostatic urethra is conventionally resected during robot-assisted radical prostatectomy (RARP). We describe the technical feasibility and urinary continence outcomes of extended prostatic urethral preservation (EPUP) during RARP.

METHODS

A single surgeon at a National Comprehensive Cancer Network institute performed 48 consecutive RARP operations using EPUP from March 2014 to March 2016, during which time 177 conventional non-EPUP RARP operations were performed by other surgeons. Prior to this period, the EPUP surgeon had performed 17 non-EPUP RARP operations over 15 months. Total intracorporeal urethral length (IUL) preserved during EPUP was measured intraoperatively. Associations of EPUP and IUL with continence recovery rates and/or times were tested in Fisher's exact and log rank univariate analyses and Cox logistic regression multivariable analyses.

RESULTS

Median IUL preserved during EPUP was 4.0 cm (range 2.5-6.0 cm), and urethral dissections typically spanned the prostatic apex to mid-gland or base. Seven-week continence rates were significantly higher with versus without EPUP. EPUP patient rates of using 0 or 0-1 pads per day immediately after catheter removal were 19% and 35%, respectively. These rates increased significantly (53% and 76%, respectively), as did the IUL preserved (median 5.0 cm), among more recent EPUP patients (n = 17), which suggested a learning curve. In multivariable analyses including all patients, an EPUP approach was an independent predictor of faster continence recovery. In multivariable analyses of the EPUP subset, a longer IUL preserved was independently associated with faster continence recovery. No EPUP patient had a urethral fossa positive margin, and apical positive margins were similarly infrequent among EPUP and non-EPUP patients.

CONCLUSIONS

EPUP is technically feasible during RARP and associated with faster continence recovery. Future investigation into the generalizability of these findings and the oncologic safety of EPUP is warranted.

The preoperative pad test as a predictor of urinary incontinence and quality of life after robot-assisted radical prostatectomy: a prospective, observational, clinical study

PURPOSE

To assess whether the preoperative 1-h pad test could predict postoperative urinary incontinence and quality of life after robot-assisted radical prostatectomy.

METHODS

A total of 329 patients who underwent robot-assisted radical prostatectomy between 2013 and 2016 were prospectively enrolled in this study. These patients were divided into the preoperative urinary continence group and the preoperative urinary incontinence group according to the 1-h pad test. The time to achieve urinary continence, lower urinary tract function evaluated by uroflowmetry and post-voided residual urine volume, and quality of life evaluated by King's Health Questionnaire and International Consultation on Incontinence Questionnaire-Short Form were compared between these two groups.

RESULTS

There were 190 patients (58%) in the preoperative urinary continence group (1-h pad test ≤ 2 g) and 139 patients (42%) in the preoperative urinary incontinence group (1-h pad test > 2 g). In the preoperative urinary continence/incontinence groups, 83%/76% of patients achieved continence within 12 months, respectively, and urinary incontinence remained significantly longer in the preoperative incontinence group than in the preoperative continence group (P  = 0.042). Although there were no significant differences in all quality of life items between the two groups before surgery, several items were significantly higher in the preoperative urinary continence group.

CONCLUSION

Achievement of urinary continence and improvement of urinary quality of life are delayed in patients with preoperative urinary incontinence assessed by the 1-h pad test. The preoperative 1-h pad test could be a useful predictor of prolonged urinary incontinence and poor quality of life after robot-assisted radical prostatectomy.

Improvement in early urinary continence recovery after robotic-assisted radical prostatectomy based on postoperative pelvic anatomic features: a retrospective review

Background

We investigated the impact of postoperative membranous urethral length and other anatomic characteristics of the pelvic floor shape as measured by magnetic resonance imaging on the improvement in continence following robotic-assisted radical prostatectomy.

Methods

We retrospectively reviewed data from 73 patients who underwent postoperative prostate magnetic resonance imaging following robotic-assisted radical prostatectomy between 2013 and 2018. Patient demographics; pre-, peri-, and post-operative parameters; and pelvic anatomic features on magnetic resonance imaging were reviewed. Patients who used no urinary incontinence pads or pads for protection were considered to have achieved complete continence.

Results

Urinary continence was restored in 27.4, 53.4, 68.5, and 84.9% of patients at 1, 3, 6, and 12 months after robotic-assisted radical prostatectomy, respectively. When patients were divided into early and late continence groups based on urinary continence at 3 months after robotic-assisted radical prostatectomy, no significantly different clinical characteristics or surgical outcomes were found. However, the mean membranous urethral length (18.5 mm for the early continence group vs. 16.9 mm for the late continence group), levator muscle width (7.1 vs. 6.5 mm, respectively), and bladder neck width on the trigone side (7.2 mm vs. 5.4 mm, respectively) were significantly different between groups (all p < 0.05). Multivariate logistic regression analysis showed that membranous urethral length (odds ratio, 1.227; 95% confidence interval, 1.011–1.489; p = 0.038) and bladder neck width (odds ratio, 1.585; 95% confidence interval, 1.050–2.393; p = 0.028) were associated with the period of early urinary continence.

Conclusions

Postoperative membranous urethral length and bladder neck width were significantly associated with early urinary continence recovery after robotic-assisted radical prostatectomy. It is highly recommended that surgeons focus on preserving the membranous urethral length and increasing the bladder neck width on the trigone side during surgery to achieve optimal continence outcomes after robotic-assisted radical prostatectomy.

Preoperative magnetic resonance imaging in predicting early continence recovery after robotic radical prostatectomy

INTRODUCTION AND AIMS

Urinary incontinence is a common complication after radical prostatectomy. The aim of our study was to describe the preoperative anatomical features using magnetic resonance imaging in order to predict early continence recovery after robotic radical prostatectomy.

MATERIAL AND METHODS

72 patients who underwent robotic radical prostatectomy were prospectively analysed. EPIC questionnaire (1, 6 and 12 mo) and first self-reported continence were used to assess functional outcomes. Membranous urethral length (MUL) and MUL-prostate axis angle (aMULP) were assessed preoperatively on T2 weighted sagittal images.

RESULTS

Continence rate was 67.2%, 92.6% and 95.2% at 1, 6 and 12 months, respectively. Early continence was achieved in patients with the lower aMULP. At 1 month, average aMULP in continent patients was 107.21° (IC 95% 90.3-124.6) vs. 118.5° (IC 95% 117.7-134) in incontinent ones (P=.014). At 6 month differences in aMULP among groups were found: 114.24° (IC 95% 104.6-123.9) in continents vs. 142° (IC 95% 126.5-157.6) in incontinents (P=0.015). At 12 month, continent group showed a significantly higher preoperative aMULP. aMULP was revealed as the only independent predictor of urinary continence at 6 mo in multivariate analysis, OR 0.007 (IC 95% 0.002-0.012), P=0.012.

CONCLUSIONS

Preoperative anatomical parameters assessment prior surgery can help to identified those patients will achieve early continence recovery and it supports therapeutic decisions making.

Anatomical, surgical and technical factors influencing continence after radical prostatectomy

Radical prostatectomy (RP) is the most frequent treatment with curative intent performed for prostate cancer to date. Different surgical approaches (perineal, transperitoneal, and extraperitoneal) and techniques (laparoscopic and robot assisted) have been described to increase the efficiency and potentially diminish the postoperative complications of this procedure. The aim of this narrative review is to investigate and define the factors that influence postprostatectomy urinary continence. We highlighted the anatomical landmarks and the modifications of surgical techniques aimed at improving the continence rates and thus, patient quality of life. After RP, the long-term continence rates range from 84% to 97%. In order to achieve good continence rates, a careful dissection along with meticulous anatomical reconstruction is required. To this end, a detailed knowledge of the periprostatic anatomy is mandatory.

The measurement of membranous urethral length using transperineal ultrasound prior to radical prostatectomy

OBJECTIVE

To compare preoperative membranous urethral length (MUL) measurements using magnetic resonance imaging (MRI) with two-dimensional transperineal ultrasound imaging (TPUS) in two supine positions on two separate days in men prior to radical prostatectomy.

MATERIALS AND METHODS

MUL was prospectively measured in 18 male volunteers using MRI and on two separate occasions in two different patient positions using TPUS; the patient supine with the knees extended (Supine) and supine with the knees flexed to 70 degrees (Supine KF). Agreement between TPUS and MRI measurements of MUL was assessed using Bland-Altman method comparison techniques and a two-way mixed-effects single measures intraclass correlation (ICC). Test-retest reliability was assessed using a two-way random effects single measures ICC.

RESULTS

The mean difference in MUL measurements between MRI and i) TPUS Supine was -0.8 mm (95% limits of agreement (LOA): -3.2, 1.7) and ii) TPUS Supine KF was -0.8mm (95% LOA: -3.5, 1.9). ICC indicated a point estimate of excellent agreement between MRI and TPUS Supine ICC 0.93 (95% CI: 0.76, 0.98) and TPUS Supine KF ICC 0.91 (95%CI 0.79, 0.97). There was excellent agreement between TPUS Supine and TPUS Supine KF (ICC 0.98, 95% CI: 0.96, 0.99) with a mean difference of 0.3mm (95% LOA: -1.2 to 1.3mm).

CONCLUSIONS

Preoperative MUL can be reliably measured using TPUS and demonstrates excellent agreement with MRI measurements of MUL. TPUS provides clinicians with an accessible non-invasive alternative to MRI for the measurement of MUL that can be used in outpatient urological settings and for patients where MRI is contraindicated.

Clinical significance of anatomical urethral length on stress urinary incontinence women

Objective

To evaluate the association between the length of the female urethra and urodynamic study (UDS) parameters in patients presenting with stress urinary incontinence (SUI).

Patients and methods

We retrospectively enrolled 391 women who underwent a transobturator adjustable tape sling implantation for the management of SUI between April 2009 and March 2016. All patients underwent a physical examination and UDS. Filling cystometry data that were evaluated included the Valsalva leak point pressure, and the cough leak point pressure. The maximal urethral closure pressure, the functional urethral length (FUL), and the length of the continence zone (LCZ) were measured using the urethral profile obtained from the UDS. The anatomical urethral length (AUL) was measured intraoperatively using a Foley catheter. We calculated the LCZ/FUL ratio to determine the anatomical continence length for this study.

Results

We noted that 299 patients completed the study. The mean AUL was 26.25±3.59 mm. The mean FUL and LCZ were 41.37±15.05 mm and 24.15±13.90 mm, respectively. The mean LCZ/FUL was 0.57±0.19. Using the Pearson correlation coefficient, we observed that the AUL showed a correlation with the FUL (0.168, P=0.034), the LCZ (0.212, P=0.007), the LCZ/FUL ratio (0.190, P=0.016), the Valsalva leak point pressure (0.223, P=0.005), the cough leak point pressure (0.215, P=0.006), and the maximal urethral closure pressure (0.178, P=0.043).

Conclusion

Our results show that the AUL in women is associated with UDS parameters relating to SUI.

Significant association between urethral length measured by magnetic resonance imaging and urinary continence recovery after robot-assisted radical prostatectomy

Introduction

To determine the clinical predictive factors affecting the recovery from postoperative urinary incontinence after robot-assisted radical prostatectomy (RARP).

Materials and methods

We consecutively analyzed 320 patients who underwent RARP between January 2012 and March 2015. The restoration of urinary continence was defined as follows: the use of no pads/no leakage of urine or the use of a safety pad. Preoperative covariates were statistically assessed by multivariate logistic regression analysis to investigate their predict factor to recovery of urinary incontinence. Therefore, in this study, we sought to identify predictors of early urinary continence status in a single-center retrospective study of consecutive patients who underwent RARP.

Results

Continence rates at 1, 3, 6, and 12 months after the catheter was removed were 44%, 71%, 83%, and 93%, respectively. Age, body mass index, and prostate volume had no significant association with urinary continence recovery. In contrast to this, longer preoperative membranous urethral length (MUL) was significantly associated with earlier postoperative continence recovery. Multivariate analysis demonstrated that longer preoperative MUL is significantly associated with continence recovery at 1 month (P = 0.0235).

Conclusion

Approximately 70% of patients achieved urinary continence within 3 months after RARP. Multivariate analysis showed that age, body mass index, and prostate volume had no significant association with urinary continence recovery. Preoperative MUL assessed by magnetic resonance imaging was an independent predictor of early recovery from urinary incontinence after RARP.

Prevalence analysis of urinary incontinence after radical prostatectomy and influential preoperative factors in a single institution

AIMS

To assess prevalence of urinary incontinence (UI) after radical prostatectomy (RP) and to analyze which preoperative characteristics of the patients have influence on UI.

METHODS

Between 2002 and 2012, 746 consecutive patients underwent RP for clinically localized prostate cancer. We defined UI according to International Continence Society (ICS) definition: "the complaint of any involuntary leakage of urine" after 12 months of recovery, international consultation on incontinence questionnaire (ICIQ-SF) and pads/day was collected too. Clinical features and magnetic resonance imaging measurements were assessed. A multivariable logistic regression model predicting incontinence were built-in after adjust by cofounding factors and bootstrapping.

RESULTS

About 172 (23%) of the patients were classified as incontinent according to the ICS definition. The mean value of the ICIQ-SF was 10.87 (±4). 17.8% of patients use at least one pad/day, 11.9% use more than one pad/day. The preoperative factors independently influential in UI are: age [OR: 1.055; CI 95% (1.006-1.107), p = .028], urethral wall thickness [OR: 5.03; CI 95% (1.11-22.8), p = .036], history of transurethral resection of the prostate [OR: 6.13; CI 95% (1.86-20.18), p = .003] and membranous urethral length [OR: 0.173; CI 95% (0.046-0.64), p = .009]. The predictive accuracy of the model is 78.7% and the area under the curve (AUC) value 71.7%.

CONCLUSIONS

Urinary incontinence after radical prostatectomy has different prevalence depending on the definition. Age, prior transurethral resection of the prostate (TURP), membranous urethral length (MUL) and urethral wall thickness (UWT) were risk factors.

Review of optimal techniques for robotic-assisted radical prostatectomy

PURPOSE OF REVIEW

Robotic-assisted radical prostatectomy has been rapidly adopted and is now the standard of care in the surgical management of prostate cancer. Since the initial description in 2001, the technique has evolved to optimize oncological functional outcomes. Herein, we review key techniques for the robotic-assisted radical prostatectomy.

RECENT FINDINGS

With the current influx of new technology such as focal therapy, stereotactic body radiation therapy and prostate-sparing treatments, there is greater emphasis on maximizing outcomes of robotic-assisted radical prostatectomy. The evidence-based techniques of optimizing oncological outcomes including the lymph node dissection and improving cancer control through minimizing positive surgical margins are reviewed. Improvements in functional recovery has also been seen with technical modifications such as nerve sparing, preservation of the urethral support structures and the bladder neck and the urethra-vesical reconstruction.

SUMMARY

Robotic prostatectomy has demonstrated adequate long-term oncologic success and satisfactory functional recovery. As technology and techniques in robotic-assisted surgery evolve, surgeons will continue to optimize techniques to maximize functional outcome recovery and cancer control. Further studies are actively being conducted to provide level one evidence in multiple aspects of the robotic-assisted radical prostatectomy.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Quantitative assessment of fascia preservation improves the prediction of membranous urethral length and inner levator distance on continence outcome after robot-assisted radical prostatectomy

AIMS

To determine whether preoperative prostate/pelvic anatomical structures and intraoperative fascia preservation (FP) predict continence recovery after robot-assisted radical prostatectomy (RARP).

METHODS

Between January 2012 and March 2016, 439 prostate cancer (PCa) patients with normal preoperative continence were retrospectively included. FP score was defined as the extent of FP from base to apex of the prostate, quantitatively assessed by the surgeon. Anatomical prostate structures were measured on endorectal preoperative Magnetic Resonance Imaging. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess urinary incontinence (UI). Cox analysis was used to determine predictive factors for early continence recovery. Finally a binary logistic regression analysis was performed to develop a risk calculator.

RESULTS

At a median follow up of 12.1 months 50.8% of men reported UI. In the Cox multivariate analysis longer membranous urethral length (MUL; P < 0.0001; OR 1.309; CI 1.211, 1.415) and shorter inner levator distance (ILD; P < 0.0001; OR 0.904; CI 0.85, 0.961) were predictors of earlier continence recovery. In the multivariate binary logistic regression analysis longer MUL (P < 0.0001; OR 1.565, CI 1.362, 1.798), shorter ILD (P < 0.0001; OR 0.819, CI 0.742, 0.904) and higher FP score (P = 0.024; OR 1.089, CI 1.011, 1.172) were independent predictors of continence outcome. The risk calculator predicted continence recovery between 1.3% and 99%.

CONCLUSIONS

Preoperative longer MUL and shorter ILD, but also intraoperative FP independently improve continence recovery after RARP. The risk calculator could be used to identify patients at high risk of UI.

Impact of preoperative and postoperative membranous urethral length measured by 3 Tesla magnetic resonance imaging on urinary continence recovery after robotic-assisted radical prostatectomy

INTRODUCTION

We sought to investigate the impact of preoperative and postoperative membranous urethral length (MUL) on urinary continence using 3 Tesla (3T) magnetic resonance imaging (MRI) after robotic-assisted radical prostatectomy (RARP).

METHODS

Between 2008 and 2013, 190 men with RARP underwent preoperative and postoperative MRI. Patients who received adjuvant radiotherapy or who were lost to followup were excluded, leaving 186 patients eligible for analysis. Preoperative MUL was estimated from the prostate apex to the penile bulb, while postoperative MUL was estimated from the bladder neck to penile bulb. Patients with no pads or protection were considered to have complete continence. Logistic regression analysis was used to identify predictors associated with urinary incontinence at six and 12 months.

RESULTS

Age was commonly associated with urinary incontinence at six and 12 months. In addition, diabetes mellitus (DM) was another factor associated with urinary incontinence at 12 months. When adjusting these variables, preoperative MUL ≤16 mm (95% confidence interval [CI] 1.01-1.14; p=0.022), postoperative MUL ≤14 mm (95% CI 1.16-9.80; p=0.025) and percent change of MUL >18% (95% CI 1.17-7.23; p=0.021) were significantly associated with urinary incontinence at six months. However, at 12 months, preoperative MUL ≤13.5 mm (95% CI 1.85-19.21; p=0.003) and postoperative MUL ≤13 mm (95% CI 1.24-13.84; p=0.021) had impacts on urinary incontinence, but not percent change of MUL.

CONCLUSIONS

Preoperative and postoperative MUL were significantly associated with urinary continence recovery after RARP. Therefore, efforts to preserve MUL are highly recommended during surgery for optimal continence outcomes after RARP.

A prognostic model for predicting urinary incontinence after robot-assisted radical prostatectomy

BACKGROUND

The aim of this study is to develop a novel prognostic model for estimating the risk of postoperative urinary incontinence (UI) after robot-assisted radical prostatectomy (RARP).

METHODS

Participants comprised 131 men who underwent RARP at our hospital from 2011 to 2013. Cox regression analyses were performed to evaluate associations between UI and preoperative factors including filling cystometry and pressure-flow study results and magnetic resonance imaging.

RESULTS

Logistic regression analyses revealed significant associations between membranous urethral length or levator thickness and UI at 3 and 6 months. Stratification produced high (membranous urethral length < 9.5 mm or levator thickness < 9.0 mm) and low (membranous urethral length ≥ 9.5 mm and levator thickness ≥ 9.0 mm) UI risk groups. These inter-group differences in UI rate were significant.

CONCLUSIONS

We developed a novel prognostic model based on preoperative patient data that can be used for patient counselling.

Monocyte Chemotactic Protein-1 (MCP-1) as a Predictor of Prolonged Urinary Incontinence After Radical Prostatectomy

Objectives:

To investigate monocyte chemotactic protein-1 (MCP-1) as a novel urinary biomarker to predict prolonged post prostatectomy incontinence.

Methods:

Men submitted urine samples prior to robotic radical prostatectomy. MCP-1 values were derived using an ELISA test. Pad usage at 7, 30, and 60 days were documented by patient post cards mailed when zero pads was reached. The primary outcome was defined as no incontinence pad usage at 30 days at prostatectomy.

Results:

After exclusions, 76 patients were included in analyses. Continence was reached by 29% (22/76), 56% (42/76), and (75/76) 98% at 7, 30, and 60 days, respectively. The average MCP-1 (p=0.258) was not different between the continent and incontinent groups. Highest quartile of MCP-1 (MCP > 166 pg/mL) and normalized MCP-1 (MCP-1/TV >0.53) noted a significant delay in continence at 30 days (p=0.050 and p=0.003). Only 26% (5/19) in the highest MCP1/TV quartile were continent, whereas 65% (37/57) of men in the 3 lower quartiles reached zero pad continence (p=0.003). In a logistic regression model the highest quartile of MCP1/TV had a significant chance of being incontinent at 30 days (OR 0.22; 95% CI 0.058-0.80; p=0.022).

Conclusion:

MCP-1/TV is a urinary biomarker that may predict prolonged urinary incontinence after radical prostatectomy.

Evaluation and Management of Postprostatectomy Incontinence: A Systematic Review of Current Literature

CONTEXT

Radical prostatectomy is the most common reason for male stress urinary incontinence. There is still uncertainty about its diagnostic and therapeutic management.

OBJECTIVE

To evaluate current evidence regarding the diagnosis and therapy of postprostatectomy incontinence (PPI).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in October 2015 using the Medline database.

EVIDENCE SYNTHESIS

Diagnosis and conservative treatment of PPI are currently mostly based on expert opinions. Pelvic floor muscle training is the noninvasive treatment of choice of PPI. For invasive management of moderate to severe PPI, the artificial urinary sphincter is still the treatment of choice, but an increasing number of adjustable and nonadjustable, noncompressive as well as compressive devices are used more frequently. However, no randomized controlled trial has yet investigated the outcome of one specific surgical treatment or compared the outcome of different surgical treatment options.

CONCLUSIONS

The level of evidence addressing the surgical management of PPI is still unsatisfactory. Further research is urgently needed.

PATIENT SUMMARY

Incontinence after the removal of the prostate (postprostatectomy incontinence) is the most common cause of male stress urinary incontinence. First-line therapy is physiotherapy and lifestyle changes. If no satisfactory improvement is obtained, various surgical treatment options are available. The most commonly used is the artificial urinary sphincter, but other treatment options like male slings are also available.