A randomized, double-blind, solifenacin succinate versus placebo control, phase 4, multicenter study evaluating urinary continence after robotic assisted radical prostatectomy

Efficacy and safety evaluation of imidafenacin administered twice daily for continency recovery following radical prostatectomy in prostate cancer patients: Prospective open-label case-controlled randomized trial

PURPOSE

This study aims to prospectively analyze the effects of anticholinergic therapy using imidafenacin on detrusor overactivity occurring after robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

Patients were followed-up at outpatient visits 2-4 weeks post-surgery (visit 2) to confirm the presence of urinary incontinence. Those confirmed with urinary incontinence were randomly assigned in a 1:1 ratio to the anticholinergic medication group (imidafenacin 0.1 mg twice daily) or the control group. Patients were followed-up at 1, 3, and 6 months post-surgery for observational assessments, including the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS).

RESULTS

A total of 49 patients (25 in the treatment group and 24 in the control group) were randomized for the study. There were no differences observed between the groups in terms of age, comorbidities, prostate size, or pathological staging. According to the IPSS questionnaire results, there was no statistically significant difference between the medication and control groups (p=0.161). However, when comparing storage and voiding symptoms separately, there was a statistically significant improvement in storage symptom scores (p=0.012). OABSS also revealed statistically significant improvement in symptoms from 3 months post-surgery (p=0.005), which persisted until 6 months post-surgery (IPSS storage: p=0.023, OABSS: p=0.013).

CONCLUSIONS

In the case of urinary incontinence that occurs after RARP, even if the function of the intrinsic sphincter is sufficiently preserved, if urinary incontinence persists due to changes in the bladder, pharmacological therapy using imidafenacin can be beneficial in managing urinary incontinence.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Systematic review registration

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

Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults

BACKGROUND

Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006.

OBJECTIVES

To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.

Vesicoprostatic muscle reconstruction: a step further for immediate and early urinary continence

OBJECTIVES

The vesicoprostatic muscle (VPM) is a longitudinal smooth muscle that originates from the trigone of the bladder or the opening of the ureter and is involved in urination as part of the detrusor apron. We explored the effect of VPM reconstruction on immediate and early recovery of urinary continence in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP).

PATIENTS AND METHODS

A total of 523 patients with localized prostate cancer were enrolled from June 2018 to June 2020. All patients were diagnosed in our department based on magnetic resonance imaging and pathological findings on prostate biopsy. After 1:1 propensity score matching, 105 patient pairs were matched. The study was approved by our institutional review board and all surgeries were performed by three experienced high-volume surgeons. Demographic data, total operation time, pathological outcomes, the urinary continence rates of the two groups at different times after RALP, and factors influencing postoperative urinary continence after RALP were recorded. Student's t test was used to compare continuous variables and the Pearson χ² test to compare categorical variables. Logistic regression analysis was used to identify factors affecting immediate and early postoperative urinary control.

RESULTS

VPM reconstruction promoted immediate and early recovery of urinary continence (immediate continence, 66.67 vs. 40.00%, P = 0.000; 3-month continence, 80.95 vs. 64.76%, P = 0.008).

CONCLUSIONS

VPM reconstruction improved immediate and early urinary continence in patients who underwent RALP.

Latest Evidence on Post-Prostatectomy Urinary Incontinence

A radical prostatectomy is frequently used as the first-line treatment for men with prostate cancer. Persistent urinary incontinence after surgery is one of the most severe adverse events. We report the results of a comprehensive literature search focused on post-prostatectomy urinary incontinence (PPI), performed by a panel of experts on non-neurogenic lower urinary tract symptoms. The data on the prevalence and timing of PPI are very heterogeneous. The etiology of PPI can be multifactorial and mainly dependent on patient characteristics, lower urinary tract function or surgical issues. The medical history with a physical examination, the use of validated questionnaires with a voiding diary and pad tests are determinants in identifying the contributing factors and choosing the right treatment. Lifestyle intervention and urinary containment are the most frequently used strategies for the conservative management of PPI, while antimuscarinics, beta-3 agonists and duloxetine (off-label) are drugs indicated to manage PPI with a concomitant overactive bladder. Surgical therapies for the management of post-prostatectomy SUI include non-adjustable trans-obturator slings in men with mild-to-moderate incontinence and an artificial urinary sphincter in men with moderate-to-severe incontinence.

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.

How to Prevent and Manage Post-Prostatectomy Incontinence: A Review

PURPOSE

To provide an overview of the currently available evidence relating to the prevention and management strategies of urinary incontinence (UI) after radical prostatectomy (RP).

MATERIALS AND METHODS

A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning post-RP UI. The search strategy included these words: urinary continence; urinary continence recovery; urinary incontinence; radical prostatectomy; and prostate cancer.

RESULTS

Post-RP UI still represents a challenging issue for both urologic patients and clinicians. A complete preoperative assessment of the risk factors associated with post-RP UI aids both in counseling those patients with a higher estimated likelihood of postoperative UI and in identifying those who would probably benefit from preventive strategies in the preoperative and in the intraoperative settings. Over the last decades different surgical strategies based on either the "preservation" or the "reconstruction" of the anatomical elements responsible for urinary continence (UC) led to an overall improvement of postoperative functional outcomes. Finally, several therapeutic strategies should be evaluated for the postoperative UI management. Artificial urinary sphincter implantation represents the gold standard for treatment, notwithstanding its wide adoption is limited due to high costs and significant risk of surgical revision. In this context, male sling positioning seems the most promising strategy, in particular in mild and moderate post-RP UI.

CONCLUSIONS

To enhance the likelihood of obtaining an optimal UC recovery after RP, it is here strongly suggested to intervene throughout the overall clinical management process thus including the pre-, intra- and postoperative settings.

Impact of surgically maximized versus native membranous urethral length on 30-day and long-term pad-free continence after robot-assisted radical prostatectomy

BACKGROUND

Pelvic multiparametric magnetic resonance imaging (mpMRI)-determined membranous urethral length (MUL) and its surgical maximization have been reported to impact early- and long-term pad-free urinary continence after robot-assisted radical prostatectomy (RARP).

OBJECTIVE

The objective of this study was to present evidence (data and video) of important effects on post-RARP continence recovery from both innate mpMRI-assessed and surgical preservation of MUL.

DESIGN SETTING AND PARTICIPANTS

Of 605 men undergoing RARP, 580 with complete follow-up were included: Group 1, prior (N = 355), and Group 2, subsequent (N = 225) to technique change of MUL maximization. Effect of innate, mpMRI-assessed MUL on postoperative continence was assessed.

SURGICAL PROCEDURE

Before technique change, the dorsal venous complex was stapled before transection of the membranous urethra. After the change, the final step of extirpation was transection of the dorsal venous complex and periurethral attachments, thus facilitating surgical maximization of MUL.

MEASUREMENTS

Primary and secondary outcomes for technique change and mpMRI-assessed MUL were both patient-reported 30-day and 1-year pad-free continence after RARP, respectively.

RESULTS

Preoperative prostate-specific antigen, age, and disease aggressiveness were significantly higher in Group 2. After technique change and surgical maximization of MUL, 30-day and 1-year pad-free continence were both significantly improved (p < 0.05). In multivariate analysis, maximization of MUL significantly increased the likelihood of both early- and long-term continence recovery. For men undergoing MUL preservation, mpMRI-assessed MUL>1.4 cm also independently predicted higher 30-day (odds ratio: 4.85, 95% confidence interval: 1.24-18.9) and 1-year continence recovery (odds ratio: 11.26, 95% confidence interval: 1.07-118).

CONCLUSIONS

Prostatic rotation and circumferential release of apical attachments and maximization of MUL improves continence after RARP. Separately, innate MUL>1.4 cm independently increased 30-day and 1-year continence recovery.

PATIENT SUMMARY

Surgeon efforts to maximize MUL during radical prostatectomy are highly encouraged, as maximally preserved MUL likely improves post-RARP continence recovery. In addition, individual patients' mpMRI-assessed MUL (approximately >1.4 cm) independently limits continence recovery.

Conservative management of urinary incontinence following robot-assisted radical prostatectomy

INTRODUCTION

Robotic assisted radical prostatectomy (RARP) is getting more and more popular becoming the most common radical prostatectomy technique. Unfortunately, a not negligible proportion of patients in whom RARP is performed experience urinary incontinence. We aimed to systematically review the current literature evidence on urinary incontinence conservative treatment after RARP.

EDIDENCE AQUISITION

A systematic literature review search using PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines have been adopted. Population consisted of patients with urinary incontinence after RARP (P), conservative intervention was considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of continence and quality of life (O).

EVIDEDENCE SYNTHESIS

Six studies were included. Four of them investigated the use of pelvic floor muscle training (PFMT). PFMT improved pelvic muscle strength. Continence recovery was faster when guided PFMT was adopted. Moreover, two studies tested the effect of solifenacin on urinary incontinence. One of them, a randomized clinical trial, failed to show shorter time to continence in solifenacin group compared to placebo.

CONCLUSIONS

The use of pads is associated with a detrimental effect on quality of life thus active treatments for UI post-RARP are warranted. PFMT has the main advantage to shorten the time for recovery. The use of solifenacin seems to not offer striking advantages in UI following RARP. Future studies should focus on testing the efficacy of these treatments when used after robotic vs. open radical prostatectomy.

Management of Overactive Bladder Symptoms After Radical Prostatectomy

PURPOSE OF REVIEW

Post-prostatectomy overactive bladder (OAB) is a common and challenging condition to manage. The aim of the present report was to review the recent evidences regarding OAB symptoms that develop in men after prostatectomy and how to manage them.

RECENT FINDINGS

The prevalence of OAB after radical prostatectomy may range from 15.2 to 37.8%. Recent studies have highlighted the role of the urethrogenic mechanism (facilitation of the urethrovesical reflex due to stress urinary incontinence (SUI)) in the genesis of post-prostatectomy OAB in a significant proportion of patients. Several other pathophysiological factors such as iatrogenic decentralization of the bladder, defunctionalized bladder due to severe SUI, detrusor underactivity, or bladder outlet obstruction might be involved. The evaluation should aim to identify the underlying mechanism to tailor the treatment, which could range from SUI surgery, to fixing a urethral stricture, improving bladder emptying or using the conventional spectrum of OAB therapies. There is a paucity of data for OAB therapies specific to post-prostatectomy patients, with the exception of solifenacin, tolterodine, and botulinum toxin. There is currently no data on how preoperative management or surgical technique may prevent post-prostatectomy OAB.

Long-Term Continence Outcomes in Men Undergoing Radical Prostatectomy: A Prospective 15-Year Longitudinal Study

PURPOSE

We examined the time dependent rates of urinary continence following open retropubic radical prostatectomy.

MATERIALS AND METHODS

A total of 1,995 men treated with radical prostatectomy were enrolled in a prospective longitudinal outcomes study. The UCLA-PCI-UFS (UCLA-Prostate Cancer Index-Urinary Function Index) was administered at baseline, and 3, 6, 12, 24, 96, 120 and 180 months after open retropubic radical prostatectomy. Urinary continence was defined by 1 pad or less in 24 hours. Two multiple regression models were constructed to evaluate the association of time since open retropubic radical prostatectomy with the UCLA-PCI-UFI score and urinary continence.

RESULTS

The decrease in urinary continence rates between baseline and 15 years (99.6% vs 87.2%, p <0.001), and 2 and 15 years (95.3% vs 87.2%, p = 0.021) were statistically significant. Urinary continence rates were consistently higher in the younger group at all time points.

CONCLUSIONS

A significant decrease in urinary continence rates was observed between baseline and 2 years, and between 2 and 15 years in the entire cohort. Urinary continence rates in age matched men in the general population who were followed longitudinally for 15 years were comparable to those in our study population. This suggests that while open retropubic radical prostatectomy causes primarily sphincteric urinary incontinence, it may be protective for subsequent benign prostatic hyperplasia mediated urinary incontinence.

Literature review of factors affecting continence after radical prostatectomy

Radical prostatectomy (RP) is the most common cause of stress urinary incontinence (UI) in men. Several anatomic structures affect or may affect urinary continence - urethral sphincter, levator ani muscle, puboprostatic ligaments, bladder neck, endopelvic fascia, neurovascular bundle - and understanding of the anatomy of pelvic floor and urethra is crucial for satisfactory functional outcome of the procedure. Surgical techniques implemented to improve continence rates include nerve-sparing procedure, bladder neck preservation/plication, urethral length preservation, musculofascial reconstruction, puboprostatic ligaments preservation or seminal vesicle preservation. Perioperative (preoperative and postoperative) pelvic floor muscle training (PFMT) aims to shorten the duration of postoperative UI and thus, improve early continence rates postoperatively. In the review, complex information regarding anatomical, intra- and perioperative factors affecting urinary continence after RP is provided, including description of important anatomical structures, possible implications for surgical technique and evaluation of different PFMT strategies in perioperative period.

Comprehensive approach for post-prostatectomy incontinence in the era of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) has enabled steady and stable surgical procedures due to both meticulous maneuvers and magnified, clear, 3-dimensional vision. Therefore, better surgical outcomes have been expected with RARP than with other surgical modalities. However, even in the RARP era, post-prostatectomy incontinence has a relatively high incidence as a bothersome complication. To overcome post-prostatectomy incontinence, it goes without saying that meticulous surgical procedures and creative surgical procedures, i.e., "Preservation", "Reconstruction", and "Reinforcement" of the anatomical structures of the pelvis, are most important. In addition, medication and appropriate pad usage might sometimes be helpful for patients with post-prostatectomy incontinence. However, patients who have 1) BMI > 26 kg/m², 2) prostate volume > 70 mL, 3) eGFR < 60 mL/min, or a 4) Charlson comorbidity index > 2 have a tendency to develop post-prostatectomy incontinence despite undergoing the same surgical procedures. It is important for patients who have a high risk for post-prostatectomy incontinence to be given information about delayed recovery of post-prostatectomy incontinence. Thus, not only the surgical procedures, but also a comprehensive approach, as mentioned above, are important for post-prostatectomy incontinence.

Efficacy of solifenacin in the prevention of short-term complications after laparoscopic radical prostatectomy

Objective

To evaluate the efficacy of solifenacin in the prevention of short-term complications after laparoscopic radical prostatectomy (LRP).

Methods

This randomized placebo-controlled study enrolled patients with histologically proven prostate cancer who underwent LRP. The patients were randomized to receive either solifenacin (5 mg once daily; study group) or placebo (control group) for the 15-day period beginning on the first day after surgery. The mean duration of detrusor overactivity (DO), the frequency of DO, the duration of macroscopic haematuria, and the days before catheter removal were recorded. The International Continence Society Short Form Male questionnaire, bladder neck stenosis episodes, and maximum urinary flow rate were evaluated at 1 month after surgery. The side-effects after using solifenacin were also recorded.

Results

A total of 120 patients were randomly assigned to the study group (n = 62) or the control group (n = 58). There were significantly lower rates of DO episodes during the daytime and night-time, haematuria and transient incontinence in the study group compared with the control group.

Conclusion

Solifenacin was a well-tolerated and effective treatment for the prevention of complications after LRP, with the main advantage compared with placebo being the decreased frequency of DO episodes during the daytime and night-time.

Recovery of urinary continence after radical prostatectomy

INTRODUCTION

In the era of minimally-invasive surgery, urinary incontinence (UI) after radical prostatectomy (RP) still represents a troublesome issue for a considerable rate of patients. Factors associated with the risk of post-RP UI, need to be carefully assessed throughout the overall clinical management process thus including the pre-operative, intra-operative and post-operative setting.

AREAS COVERED

This review analyses current published evidences regarding clinical and surgical aspects associated with urinary continence (UC) recovery after RP. A careful evaluation of patient's clinical characteristics should be carried out before surgery in order to properly counsel the patients regarding the risk of UI. In the last two decades, the advent of robotic surgery has led to an overall improvement of functional outcomes after RP, thanks to the development of different surgical strategies based on either the 'preservation' or the 'reconstruction' of the anatomical elements responsible for urinary continence. Finally, several therapeutic strategies including either a conservative approach, or pharmacological and surgical treatments, should be carefully considered for the post-operative management of UI. Expert commentary: A comprehensive pre-operative patient's clinical assessment, along with a proper and well-conducted surgical procedure and an effective post-operative care management are essential element to achieve a high probability of UC recovery.

Effect of preoperative urodynamic detrusor overactivity on post-prostatectomy incontinence: a systematic review and meta-analysis

PURPOSE

To investigate whether preoperative urodynamic detrusor overactivity (DO) contributes to post-prostatectomy incontinence (PPI).

METHODS

We systematically searched the online PubMed, Embase, and Cochrane Library databases spanning the period of January 1989 to December 2014.

RESULTS

A total of nine articles met the eligibility criteria for this systematic review. The eligible studies included a total of 457 patients with a median number of 58 patients per study (range 17-92). Of the nine studies, five conducted open retropubic radical prostatectomy (RRP), two performed robot-assisted laparoscopic prostatectomy (RALP), and two others utilized multiple modalities. PPI was more likely to occur in patients with preoperative DO [pooled odds ratio (OR) 2.30; 95 % confidence interval (CI) 1.39-3.82; studies 9; participants 419], as compared to patients who were DO negative. Sensitivity analysis using the subgroups of RRP (OR 2.32; 95 % CI 1.11-4.85), RALP (OR 3.41; 95 % CI 1.55-7.47), DO defined as any amplitude of involuntary contraction (OR 2.32; 95 % CI 1.11-4.85), no postoperative intervention (OR 2.32; 95 % CI 1.11-4.85), and outcome evaluation after 6 months (OR 2.32; 95 % CI 1.11-4.85) demonstrated consistent results. Although some comparisons showed inter-study heterogeneity, there was no clear evidence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis results suggest that preoperative DO is another possible underlying mechanism for PPI.