Incontinence and vesical neck strictures following radical retropubic prostatectomy

Management of the Devastated Bladder Outlet after Prostate CANCER Treatment

PURPOSE OF REVIEW

Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion.

RECENT FINDINGS

The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.

Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life

Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1-8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients' quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.

Patient- and Tumour-related Prognostic Factors for Urinary Incontinence After Radical Prostatectomy for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

While urinary incontinence (UI) commonly occurs after radical prostatectomy (RP), it is unclear what factors increase the risk of UI development.

OBJECTIVE

To perform a systematic review of patient- and tumour-related prognostic factors for post-RP UI. The primary outcome was UI within 3 mo after RP. Secondary outcomes included UI at 3-12 mo and ≥12 mo after RP.

EVIDENCE ACQUISITION

Databases including Medline, EMBASE, and CENTRAL were searched between January 1990 and May 2020. All studies reporting patient- and tumour-related prognostic factors in univariable or multivariable analyses were included. Surgical factors were excluded. Risk of bias (RoB) and confounding assessments were performed using the Quality In Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were performed for all prognostic factor, where possible.

EVIDENCE SYNTHESIS

A total of 119 studies (5 randomised controlled trials, 24 prospective, 88 retrospective, and 2 case-control studies) with 131 379 patients were included. RoB was high for study participation and confounding; moderate to high for statistical analysis, study attrition, and prognostic factor measurement; and low for outcome measurements. Significant prognostic factors for postoperative UI within 3 mo after RP were age (odds ratio [OR] per yearly increase 1.04, 95% confidence interval [CI] 1.03-1.05), membranous urethral length (MUL; OR per 1-mm increase 0.81, 95% CI 0.74-0.88), prostate volume (PV; OR per 1-ml increase 1.005, 95% CI 1.000-1.011), and Charlson comorbidity index (CCI; OR 1.28, 95% CI 1.09-1.50).

CONCLUSIONS

Increasing age, shorter MUL, greater PV, and higher CCI are independent prognostic factors for UI within 3 mo after RP, with all except CCI remaining prognostic at 3-12 mo.

PATIENT SUMMARY

We reviewed the literature to identify patient and disease factors associated with urinary incontinence after surgery for prostate cancer. We found increasing age, larger prostate volume, shorter length of a section of the urethra (membranous urethra), and lower fitness were associated with worse urinary incontinence for the first 3 mo after surgery, with all except lower fitness remaining predictive at 3-12 mo.

A prospective study of erectile dysfunction in men after pelvic surgical procedures and its association with non-modifiable risk factors

Objective

A pelvic surgery can cause erectile dysfunction. The purpose of this study was to evaluate erectile function at various times after pelvic surgery in male patients; to search the non-modifiable risk factors associated with the presence and intensity of sexuality in these patients. This prospective study used the erectile dysfunction IIEF scale.

Results

The study population comprised of 106 male patients who had undergone minor pelvic surgery at least 9 months before and during the 2010–2016 period in the 4th Surgical Clinic. A control group of healthy males (N = 106) who underwent no pelvic surgery matched for age was also used for reference values. The main age of the participants was 66.16 ± 13.07 years old. A history of colectomy was present in 36.8%, 18.9% had undergone sigmoidectomy, and 33% inguinal hernia repair. The percentage of severe erectile function increased from 38.7% before surgery to 48.1% (25% increase) after surgery, at the end of the follow-up period (p < 0.05). In the multivariate analysis model, age emerged as an independent predictor of erectile function (p < 0.001). Age was the most important determinant of the IIEF score, which was aggravated by 25% from the first to the last assessment of patients.

Anatomy and techniques in posterior urethroplasty

Given its complex anatomy, injury to the posterior urethra may result in a number of reconstructive challenges. With the appropriate operative planning and experience, surgical repair can be very successful. This review discusses the applicable techniques for the perineal approach to posterior urethral stenosis, including bulbomembranous anastomosis for pelvic fracture urethral injury and repair of vesicourethral anastomotic stenosis (VUAS) following prostate surgery. The advanced techniques reviewed include an adaptation allowing a bulbar artery sparing approach to posterior urethroplasty and an intrasphincteric urethroplasty procedure which may allow continence preservation in patients with membranous urethral stenosis.

An update on best practice in the diagnosis and management of post-prostatectomy anastomotic strictures

Postprostatectomy vesicourethral anastomotic stenosis (VUAS) remains a challenging problem for both patient and urologist. Improved surgical techniques and perioperative identification and treatment of risk factors has led to a decline over the last several decades. High-level evidence to guide management is lacking, primarily relying on small retrospective studies and expert opinion. Endourologic therapies, including dilation and transurethral incision or resection with or without adjunct injection of scar modulators is considered first-line management. Recalcitrant VUAS requires surgical reconstruction of the vesicourethral anastomosis, and in poor surgical candidates, a chronic indwelling catheter or urinary diversion may be the only option. This review provides an update in the diagnosis and management of postprostatectomy VUAS.

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.

Is Risk of Artificial Urethral Sphincter Cuff Erosion Higher in Patients with Penile Prosthesis?

INTRODUCTION

Frequently encountered morbidities after prostatectomy include stress urinary incontinence and erectile dysfunction. Patients with severe disease may undergo placement of both a penile prosthesis (PP) and an artificial urethral sphincter (AUS).

AIM

We hypothesized that concomitant PP may promote AUS cuff erosion by impaired corporal blood flow and/or direct pressure on the cuff. The aim of this study was to compare the rate of AUS cuff erosion in patients with and without a PP.

METHODS

We reviewed 366 AUS operations at our tertiary center between 2007 and 2015 with a mean follow-up of 41 months (range 6-104). Included in the analysis were first-time AUS cuff erosions. Patients with recurrent erosions, AUS revisions, and iatrogenic erosions were excluded. In a separate analysis, we analyzed AUS explantations for all causes. Cohorts were compared by demographic information, preoperative characteristics, and rates of erosion and explantation.

MAIN OUTCOME MEASURES

Erosion confirmed by cystourethroscopy and explantation of the AUS for all causes.

RESULTS

Among 366 AUS surgeries at a mean follow-up of 41 months, there were 248 (67.8%) AUS alone cases compared to 118 (32.2%) AUS and PP cases (AUS/PP). Sixty-two patients met exclusion criteria for first-time cuff erosion. Among 304 evaluable AUS patients, we found a significantly higher rate of erosion in the AUS/PP group (11/95, 11.6%) compared to the AUS alone group (9/209, 4.3%, P = .037). When examining explantations for all causes in the entire cohort (n = 366), we observed a significantly higher rate of device removal, (20/118, 17%) in the AUS/PP group compared to the AUS group (23/248, 9.2%, P = .044).

CONCLUSION

AUS/PP patients appear to have a higher risk of AUS cuff erosion and explantation compared to men with AUS alone.

Urethral Strictures and Stenoses Caused by Prostate Therapy

The number of patients with prostate cancer and benign prostatic hyperplasia is on the rise. As a result, the volume of prostate treatment and treatment-related complications is also increasing. Urethral strictures and stenoses are relatively common complications that require individualized management based on the length and location of the obstruction, and the patient's overall health, and goals of care. In general, less invasive options such as dilation and urethrotomy are preferred as first-line therapy, followed by more invasive substitution, flap, and anastomotic urethroplasty.

Current Status of Salvage Cryoablation for Prostate Cancer following Radiation Failure

The role of salvage cryoablation of the prostate for patients with clinically localized prostate cancer that have failed radiotherapy to the prostate is reviewed with reference to alternatives including salvage radical prostatectomy and brachytherapy. The diagnosis and work-up of local recurrence/persistence of cancer in the prostate are reviewed and the patient selection criteria for salvage cryoablation is discussed. Technical aspects of the cryoablation procedure along with the outcome in terms of cancer control and treatment-related complications are detailed. The five-year biochemical disease-free rate is approximately 40%. The complication rate is acceptable. Salvage cryoablation definitely has a role in the management of localized prostate cancer treatment failure following radiotherapy, especially in older patients and those with some comorbidities.

Bladder neck contracture

Bladder neck contracture (BNC) is a well-described complication of the surgical treatment of benign and malignant prostate conditions. Nevertheless, etiologies of BNC development are highly dependent on the primary treatment modality undertaken with BNC also occurring after pelvic radiation. The treatment options for BNC can range from simple, office-based dilation procedures to more invasive, complex abdomino-perineal reconstructive surgery. Although numerous strategies have been described, a patient-specific approach is usually necessary in the management of these complex patients. In this review, we highlight various therapeutic maneuvers described for the management of BNC and further delineate a tailored approach utilized at our institution in these complicated patients.

Adjunctive maneuvers to treat urethral stricture: a review of the world literature

The development of urethral stricture (US) or bladder neck contracture is a relatively uncommon but well described condition observed primarily in men. Despite familiarity with US disease, management remains challenging for urologists. Risk factors for the development of USs or bladder neck contracture include primary treatment modality, tobacco smoking, coronary artery disease and poorly controlled diabetes mellitus. Numerous treatment options exist for this condition that vary in procedural complexity, including intermittent self catheterization (CIC), serial urethral dilation, endoscopic techniques and open reconstructive repairs. Repetitive procedures for this condition may carry increased failure rates and morbidities. For the treatment of refractory or recalcitrant bladder neck contracture, newer intralesional anti-proliferative, anti-scar agents have been used in combination with transurethral bladder neck incisions to augment outcome and long-term effect. The primary focus of this systematic review of the published literature is to streamline and summarize various and newer therapeutic modalities available to manage patients with US or bladder neck contracture.

SIU/ICUD Consultation on Urethral Strictures: Posterior urethral stenosis after treatment of prostate cancer

Posterior urethral stenosis can result from radical prostatectomy in approximately 5%-10% of patients (range 1.4%-29%). Similarly, 4%-9% of men after brachytherapy and 1%-13% after external beam radiotherapy will develop stenosis. The rate will be greater after combination therapy and can exceed 40% after salvage radical prostatectomy. Although postradical prostatectomy stenoses mostly develop within 2 years, postradiotherapy stenoses take longer to appear. Many result in storage and voiding symptoms and can be associated with incontinence. The evaluation consists of a workup similar to that for lower urinary tract symptoms, with additional testing to rule out recurrent or persistent prostate cancer. Treatment is usually initiated with an endoscopic approach commonly involving dilation, visual urethrotomy with or without laser treatment, and, possibly, UroLume stent placement. Open surgical urethroplasty has been reported, as well as urinary diversion for recalcitrant stenosis. A proposed algorithm illustrating a graded approach has been provided.

Standardized approach for the treatment of refractory bladder neck contractures

Bladder neck contracture is a relatively uncommon but well-described complication after the surgical treatment of prostate cancer. Although numerous treatments have been described as an initial management strategy for patients with this condition, the management of refractory cases remains highly variable. This article evaluates various therapeutic maneuvers used for the treatment of refractory bladder neck contracture and further describes the preliminary results of an endoscopic balloon dilation with concomitant deep traunsurethral incision procedure. Short- and long-term management algorithms for patients with recurrent bladder neck contractures are reviewed.

Overactive bladder syndrome: an underestimated long-term problem after treatment of patients with localized prostate cancer?

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? In this study we observed courses of micturition symptoms and differentiated degrees of symptoms for each point in time while also considering the impact of bothersomeness. Our data show that not only significantly more patients who have undergone BT suffer from OAB than those who have undergone RP, but also that those affected show significantly higher values for severity of OAB symptoms throughout the whole observation period of 36 months. Our data analysis further shows that variability of OAB symptoms as well as fluctuation of severity of OAB symptoms vary to a significantly higher degree after BT than after RP. Looking only at mean figures at a given point in time clearly underestimates the underlying problem. This fact is not reflected in the literature.

OBJECTIVE

• To look at individual courses of postoperative micturition symptoms, especially urgency, in patients treated either with radical prostatectomy (RP) or with brachytherapy (BT).

PATIENTS AND METHODS

• In a prospective longitudinal study we investigated individual changes in micturition symptoms before treatment, and 6, 12, 24 and 36 months after treatment. • All patients received the European Organization for the Research and Treatment of Cancer quality-of-life questionnaire, QLQ-C30, and the International Continence Society male questionnaire at each assessment. • We looked at long-term results as well as changes in time using repeated measures analysis of variance. We further analysed fluctuation of symptoms using sum of changes.

RESULTS

• Of the 389 patients treated consecutively in our clinic over the last few years, 99 patients with a mean (sd) age of 65 (6.3) years had completed all five questionnaires and thus were further analysed. Of these, 66 (66.7%) were treated with RP and 33 (33.3%) with BT. • With the exception of age, no significant difference was found between the treatment groups either in physical functioning or in prevalence and severity of overactive bladder (OAB) symptoms. • Adjusted for age and pretreatment symptoms in analysis of covariance, we found that there were statistically more symptoms of OAB 36 months after BT compared with those patients treated with RP (P < 0.025). Whereas 30% of patients complained about severe symptoms of urgency after BT, only 11% did so after RP. • Changes of severity of OAB symptoms over the course of time (P < 0.007) using analysis of repeated measures as well as variability of OAB symptoms (P < 0.033) using the two-sided Wilcoxon t-test were significantly higher in patients treated with BT than in patients treated with RP.

CONCLUSIONS

• Independently of age and physical functioning, BT is significantly associated with higher rates of long-term urgency symptoms, even after 3 years. • Repeated measurements show that OAB symptoms are highly fluctuating and that in patients treated with BT, severity of symptoms as well as variability of symptoms was significantly higher than in those patients treated with RP. • Persistent OAB seems to be an underestimated problem after treatment for localized prostate cancer, especially in patients treated with BT.

Trends in the care of radical prostatectomy in the United States from 2003 to 2006

OBJECTIVE

• o determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy.

PATIENTS AND METHODS

• We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employer-based administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach.

RESULTS

• Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P = 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P = 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P = 0.049), miscellaneous surgical complications (3.6 to 2.3%, P = 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, (P < 0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P = 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P = 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P < 0.001), blood transfusions (1.5 vs 8.9%, P < 0.001) and anastomotic strictures (6.3 vs 12.8%, P < 0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P < 0.001) during the study period.

CONCLUSION

• The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control.

Single center comparison of anastomotic strictures after radical perineal and radical retropubic prostatectomy

OBJECTIVES

To analyze the incidence and management of anastomotic strictures (ASs) after radical perineal prostatectomy (RPP) and retropubic prostatectomy (RRP) and to identify possible predisposing factors.

METHODS

Between 1997 and 2007, we performed 866 RPP and 2052 RRP for localized prostate cancer. Median follow-up was 52 months (12-136). We analyzed preoperative serum prostate-specific antigen, prostate size, clinical and pathologic tumor stage, neoadjuvant hormone deprivation, previous transurethral resection of the prostate, transfusion requirement, anastomotic insufficiency, and acute urinary retention (AUR) and its subsequent management to identify possible predisposing factors for AS formation.

RESULTS

The rate of AS after RPP and RRP was 3.8% (33/863) and 5.5% (113/2048), respectively (P = .067). In multivariate analysis, RRP was a statistically significant risk factor for AS (P = .0002). On survival analysis, the incidence of AS was lower for RPP as compared with RRP at median follow-up (P = .0229). Primary response to endoscopic AS incision or resection was 94% (31/33) and 72.6% (82/113) after RPP and RRP, respectively. On multivariate logistic regression analysis biopsy Gleason score, previous transurethral resection of the prostate, prostate volume, pathologic tumor stage and grade, transfusion requirement, AUR, and surgical technique were independent risk factors for the development of AS. An AS developed in 45.4% (20/44) and 10.9% (5/46) of the postoperative AUR cases treated with a suprapubic cystostomy tube and a transurethral Foley catheter, respectively (P <.05).

CONCLUSIONS

ASs occur more frequently after RRP in comparison with RPP. Primary endoscopic AS incision or resection are both highly successful. Treating postoperative AUR with a suprapubic cystostomy poses a high risk for AS formation and should be avoided.

Late toxicity after postprostatectomy salvage radiation therapy

PURPOSE

To evaluate late toxicity in patients who received salvage external beam radiotherapy (EBRT) for a detectable prostate-specific antigen (PSA) level after radical prostatectomy (RP).

METHODS

A cohort of 308 consecutive patients underwent salvage EBRT from July 1987 through June 2003 for a detectable PSA level after RP. All were treated with high-energy photons (6-20 MV) to a median dose of 64.8 Gy (range: 54.0-72.4 Gy) in 1.8- to 2.0-Gy fractions.

RESULTS

Median follow-up from the completion of EBRT was 60 months (range: 1 day-174 months). Late toxicity occurring more than 90 days after EBRT completion was identified in 41 patients (13%). Twelve patients (3.9%) had grade 2 urethral strictures and were treated with urethral dilation, 3 patients had grade 3 cystitis, and 1 had a grade 4 rectal complication. These numbers correspond to an estimated 0.7% (95% confidence interval, 0.0-1.6%) of patients experiencing a grade 3 or 4 complication by 5 years after the start of EBRT.

CONCLUSIONS

Salvage EBRT for a detectable PSA level after RP is the only curative treatment in this setting. This treatment can be administered in a manner that results in a low likelihood of late complications.

Laparoscopic radical prostatectomy: A European virus

The evolution of prostate cancer treatment has now incorporated the principles of minimally invasive surgery. Laparoscopic radical prostatectomy, just like a virus, infected first Europe and three years ago the United States. This European virus has nowadays a potentially widespread application. Oncological efficacy and ability to preserve and improve continence and potency are the factors that will ultimately determine the role of laparoscopic radical prostatectomy and thus the future of this virus infection. This article reviews the current published experience with minimally invasive prostatectomy and provides comparisons to published data on radical retropubic prostatectomy to increase awareness about viability. Some prospective and retrospective non-randomized comparative studies of the two approaches are also included in the present review. The current practice patterns regarding urological laparoscopic surgery and the tendency of the urologic community in Europe and in the United States to establish minimally invasive radical prostatectomy in more urological departments are described.

The role of vacuum erection devices in penile rehabilitation after radical prostatectomy

Even nerve-sparing radical prostatectomy damages the cavernous nerves and leads to temporary erectile dysfunction (ED) in men recovering from prostate cancer surgery. Historically, patients recovering from prostate cancer surgery have been advised that the return of erectile function (EF) can take from 6 to 18 months, or even longer. Unfortunately, the return of sexual function in these patients remains variable, but is generally thought to be dependent on the individual patient's pre-surgery EF, as well as the degree of cavernous nerve disruption during prostate removal. Recently, there has been a growing movement to proactively treat patients postoperatively for presumed nerve damage to stimulate nerve recovery and possibly reduce the degree of irreversible damage. This would reduce the on-demand therapy these patients would require, and hopefully remove the requirement for an implantable prosthesis. The underlying hypothesis is that the artificial induction of erections shortly after surgery facilitates tissue oxygenation, reducing cavernosal fibrosis in the absence of nocturnal erections, potentially increasing the likelihood of preserving EF. Vacuum erection devices (VED), because of their ability to draw blood into the penis regardless of nerve disturbance, have become the centerpiece of penile rehabilitation protocols. This review will discuss the pathophysiology of radical prostatectomy induced ED and the rationale for rehabilitation. It will then discuss current protocols, including those involving the VED.

Management of complications of prostate cancer treatment

Prostate cancer is the most commonly diagnosed noncutaneous cancer in men in the United States. Treatment of men with prostate cancer commonly involves surgical, radiation, or hormone therapy. Most men with prostate cancer live for many years after diagnosis and may never suffer morbidity or mortality attributable to prostate cancer. The short-term and long-term adverse consequences of therapy are, therefore, of great importance. Adverse effects of radical prostatectomy include immediate postoperative complications and long-term urinary and sexual complications. External beam or interstitial radiation therapy in men with localized prostate cancer may lead to urinary, gastrointestinal, and sexual complications. Improvements in surgical and radiation techniques have reduced the incidence of many of these complications. Hormone treatment typically consists of androgen deprivation therapy, and consequences of such therapy may include vasomotor flushing, anemia, and bone density loss. Numerous clinical trials have studied the role of bone antiresorptive therapy for prevention of bone density loss and fractures. Other long-term consequences of androgen deprivation therapy may include adverse body composition changes and increased risk of insulin resistance, diabetes, and cardiovascular disease. Ongoing and planned clinical trials will continue to address strategies to prevent treatment-related side effects and improve quality of life for men with prostate cancer.

[Study of urinary continence after radical prostatectomy. Comparison between laparoscopic and retropubic prostatectomy based on a series of 251 cases]

INTRODUCTION

The objective of this study was to compare the results in terms of continence and quality of life between retropubic radical prostatectomy and laparoscopic radical prostatectomy, performed according to the same principle of retrograde dissection from the apex.

MATERIAL AND METHOD

The series was composed of 120 patients undergoing retropubic radical prostatectomy and 131 patients undergoing laparoscopic radical prostatectomy performed in the Limoges hospital, urology and andrology department, between January 2002 and September 2005. Continence was evaluated by anonymous self-administered questionnaire sent to the patient's home. Pain was evaluated by visual analogue scale and narcotic consumption. Predictive factors of continence were analysed.

RESULTS

The two groups were comparable in terms of pathological stage, Gleason score and age. The laparoscopy group comprised more patients with a history of transurethral resection of the prostate and more obese patients. No significant difference was observed between laparoscopy and laparotomy for degree of continence (71% versus 76%; p>0.05), time to return of continence (13 weeks versus nine weeks; p>0.05) and rate of mild (14% versus 13%), moderate (7% versus 6%) and severe (7% versus 5%) urinary incontinence. The anastomosis secondary stenosis rate was also identical in the two groups. Age was found to be a predictive factor for continence, especially for the mean time to return periods of continence. The patient's weight, prostate weight and TNM stage were not predictive factors for incontinence. The incontinence rate was 40% for salvage prostatectomies after radiotherapy. The mean duration of bladder catheterization was 6.9 days in the laparoscopy group and 7.2 days in the laparotomy group. Narcotic consumption was significantly lower in the laparoscopy group (21 mg versus 36 mg; p<0.05).

CONCLUSION

Laparoscopic radical prostatectomy appears to give the same results in terms of continence as retropubic radical prostatectomy. However, these procedures were the first laparoscopic prostatectomies performed in the department, suggesting that, with greater experience, the results of laparoscopy could become superior to those of laparotomy. The laparoscopic technique also appeared to provide better patient comfort by decreasing postoperative pain.

Utilization and outcomes of minimally invasive radical prostatectomy

PURPOSE

Demand for minimally invasive radical prostatectomy (MIRP) to treat prostate cancer is increasing; however, outcomes remain unclear. We assessed utilization, complications, lengths of stay, and salvage therapy rates for MIRP versus open radical prostatectomy assessed whether MIRP surgeon volume is associated with better outcomes.

METHODS

We identified 2,702 men undergoing MIRP and open radical prostatectomy during 2003 to 2005 from a national 5% sample of Medicare beneficiaries. We assessed the association between surgical approach and outcomes, adjusting for surgeon volume, age, race, comorbidity, and geographic region.

RESULTS

MIRP utilization increased from 12.2% in 2003 to 31.4% in 2005. Men undergoing MIRP versus open radical prostatectomy had fewer perioperative complications (29.8% v 36.4%; P = .002) and shorter lengths of stay (1.4 v 4.4 days; P < .001); however, they were more likely to receive salvage therapy (27.8% v 9.1%, P < .001). In adjusted analyses, MIRP versus open radical prostatectomy was associated with fewer perioperative complications (odds ratio [OR], 0.73; 95% CI, 0.60 to 0.90), shorter lengths of stay (parameter estimate, -2.99; 95% CI, -3.45 to -2.53) but more anastomotic strictures (OR, 1.40; 95% CI, 1.04 to 1.87) and higher rates of salvage therapy (OR, 3.67; 95% CI, 2.81 to 4.81). Patients of high-volume MIRP experienced fewer anastomotic strictures (OR, 0.93; 95% CI, 0.87 to 0.99) and less salvage therapy (OR, 0.92; 95% CI, 0.88 to 0.98).

CONCLUSION

Men undergoing MIRP versus open radical prostatectomy have lower risk for perioperative complications and shorter lengths of stay, but are at higher risk for salvage therapy and anastomotic strictures. However, risk for these unfavorable outcomes decreases with increasing MIRP surgical volume.

A randomized clinical trial of suspension technique for improving early recovery of urinary continence after radical retropubic prostatectomy

OBJECTIVE

To evaluate, in a prospective, single-blind, randomized trial, the safety and efficacy of a suspension technique for improving early recovery of continence after radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

We randomly assigned 60 men with clinically localized prostate cancer to RRP; 30 were treated with the suspension technique and the remaining 30 were not. All patients had RRP by the same surgeon followed by early catheter removal on the third day after RRP. The primary outcome measures were the interval to recovery of continence, and the positive margin rates. The continence status was evaluated by a third party using validated questionnaires at baseline before RRP and at 4 and 7 days, and 2 weeks, 1, 3, 6 and 12 months after RRP.

RESULTS

The suspension technique resulted in significantly greater continence rates at 1, 3 and 6 months after RRP of 53% vs 20%, 73% vs 47% and 100% vs 83%. Kaplan-Meier curves also showed that patients in the suspension group had a significantly earlier recovery of continence than in the no-suspension group; the median (95% confidence interval) interval for recovery was 31 (12-74) days in the suspension group and 90 (65-150) days in the no-suspension group (log rank test, P = 0.002). The groups had no significant differences in their histological status.

CONCLUSIONS

The suspension technique had a significant effect on the earlier recovery of urinary continence within 6 months after RRP, without compromising the oncological outcome of RRP.

The impact of urinary drainage on the development of anastomotic stricture after radical retropubic prostatectomy

OBJECTIVES

Anastomotic stricture (AS) is a well-described complication of radical retropubic prostatectomy (RRP) despite all the refinements in surgical technique. We aimed to define and discuss the role of postoperative urinary drainage on AS development.

PATIENTS AND METHODS

A total of 136 patients with localized prostate carcinoma underwent RRP. In all patients, urethral catheter was removed 3 weeks after RRP without a cystogram. We documented duration of drainage (<3 days, n=86; 3-5 days, n=36; and >5 days, n=14), volume of drainage (<300 ml, n=78; 300-500 ml, n=27; and >500 ml, n=31), and mean volume of drainage per day (<100 ml, n=85 and >100 ml, n=51), continence status, and clinical and histopathological characteristics of patients as risk factors related with AS.

RESULTS

AS was diagnosed in 28.6% of patients. The rate was found to be 35.9%, 41%, and 23.1%, consistent with duration, and 38.4%, 15.4%, and 46.2% according to volume of drainage, respectively (P=0.0001). AS occurred in 43.6% and 56.4% of patients concerning mean volume of drainage per day, respectively (P=0.007). Analysis showed that AS was significantly associated with duration (>3 days), total volume (>500 ml), and the mean volume (>100 ml) of urinary drainage among the variables. The rates of urinary incontinence were 30.7% in patients with AS and 6.2% in patients without AS.

CONCLUSIONS

Time and the amount of urinary drainage were significantly associated with stricture formation following RRP that might be caused by partial disruption of the anastomosis.

Urinary incontinence after radical prostatectomy: can men at risk be identified preoperatively?

BACKGROUND

Incontinence after radical prostatectomy for early stage prostate cancer can significantly affect quality of life. Identification of risk factors preoperatively would enable clinicians to counsel men and their partners about the risk of incontinence following surgery. We conducted a population-based study to identify subjective and objective preoperative factors, other than PSA and Gleason score, that may predict urinary incontinence following radical prostatectomy.

METHODS

Men booked for radical prostatectomy at 2 sites in Alberta were enrolled prospectively. Assessment was completed 2 weeks prior to surgery and included the International Prostate Symptom Score (IPSS) with a single quality-of-life (QOL) question, 24-hour pad test, and bladder diary. These parameters were repeated at 3 and 12 months postoperatively. A model predicting incontinence was developed using stepwise multivariable logistic regression analysis. Incontinence was defined as more than 8 g of urine loss on 24-hour pad test.

RESULTS

A total of 245 patients from 2 centers were enrolled; 228 (93%) completed data collection up to 12 months postsurgery. At the baseline preoperative assessment, 4% (10/228) of subjects had > or = 8 g of urine loss on 24-hour pad test, although these and all other subjects described complete continence. At 3 months postop, 43% had > or = 8 g on 24-hour pad testing (our definition of incontinence) (median 31 g, range 8.3-1654 g, SD 219.12); at 12 months, 15% had more than 8 g of urine loss on pad test (median 21.0 g, range 8.1-3380 g, SD 578.0). For all subjects, mean IPSS and the single QOL scores at baseline (7.4 and 1.5) did not change significantly at 3 months (7.2 and 2.5), but both were lower than or equal to baseline at 12 months (5.4 and 1.5). The IPSS was predictive of incontinence at 3 months, but not at 12 months. Bladder diary did not correlate with IPSS. Risk factors affecting continence at 12 months were preoperative urine loss > or = 8 g, previous transurethral resection of prostate (TURP), and age greater than 65 years.

CONCLUSION

Our results support previous research on risk factors for incontinence after radical prostatectomy and add to the current data by having presurgery (baseline) measures. Interestingly, a small percentage of men (4%) who reported complete continence were incontinent preoperatively, based on our definition of > or = 8 g weight gain on 24-hour pad test. Identified preoperative risk factors affecting continence were increasing age, baseline incontinence, and previous TURP. Mean IPSS was lower at 12 months than at baseline, suggesting that even mildly symptomatic men will improve after surgery. Men reported that regular contact with the continence research nurse provided a much-appreciated source of informed support as they recovered.

Early penile rehabilitation following radical prostatectomy: Cleveland clinic experience

Erectile dysfunction is one of the most important quality of life issues following radical prostatectomy. The potency rates reported following nerve-sparing technique varies between 40 and 86%, and the time period required for complete recovery of erectile function varies from 6 to 24 months. The literature evidence suggests that lack of natural erections during this period of time produces cavernosal hypoxia. Prolonged periods of cavernosal hypoxia induce fibrosis, which later increases the incidence of venous leak. Recently, there is a growing interest among the physicians to interrupt these events by preventing cavernosal hypoxia during the period of neuropraxia. Initial studies using intracavernosal injection appears to be beneficial. In this article, we reviewed the pathophysiology of cavernosal hypoxia following radical prostatectomy with currently available evidence for the interventions to promote the nerve recovery and regeneration.

[Radical prostatectomy: open, laparoscopic and robotic. Looking for a new gold standard?]

INTRODUCTION

It is well known that radical prostatectomy (RP) is an excellent option in localized prostatic cancer especially from oncological control point of view. The efforts, during last decades, of the urological community in this field have been addressed in trying to improve functional outcomes (urinary and sexual morbidity) after the procedure. From the beginning of this century, three managements (open, robotic and laparoscopic) have been coexisting trying to get and prove the best results. The objective of this review has been to make the most exhaustive, rigorous and objective updating with the functional and oncological outcomes from the three (RP) techniques.

MATERIAL AND METHODS

We have centered the comparison in four sections: perioperative, oncological outcomes, functional results and economic costs. With this purpose a systematic search was made in the following registers: PubMed, OVID, EMBASE and Cochrane Library, with the following terms: Retropubic RP. open RP, laparoscopic RP, robotic RP, Sexual function, urinary incontinence, quality of life, economic costs. At author's criteria, a total of 73 references were selected, that were individually analyzed.

RESULTS

Whatever the technique is, the mortality related to the procedure is extremely low, with little postoperative pain and minimum analgesic requirements. The oncological results are similar, measured in surgical margin terms: Open RP (14-20%), Laparoscopic RP (7.4-21.9%) and robotic RP (5.7-17.3%). Concerning functional results (sexual function and urinary continence), it is difficult to establish comparisons due to the multitude of existing byas (non randomized studies, different methods and measurement scales, different definitions, etc.) In the uni-insitutional studies, results seem to be equivalent.

CONCLUSIONS

Laparoscopic and robotic RP series are still pending of mature outcomes, related to long term biochemical control and functional results. It seems that with these managements, blood loss and transfusion needs are minor compared to open surgery. Robotic technology adds very interesting advantages that could have an important role in homogenize the minimally invasive management, but are still pending of validation at medium and long term.

Management of the complications of radical prostatectomy

Over the past several years, the morbidity associated with radical prostatectomy has improved due to advances in surgical technique, better understanding of male pelvic anatomy, and improved perioperative care. Despite these advances, patients are still at risk for several complications both intraoperatively and in the postoperative course. These risks include significant blood loss, rectal injury, ureteral injury, thromboembolic events, urinary incontinence, impotence, and a perioperative death rate of less than 1%. These risks should be reviewed and discussed before treating the patient with prostate cancer.

Oncological and functional results of open, robot-assisted and laparoscopic radical prostatectomy: does surgical approach and surgical experience matter?

The treatment of prostate cancer has undergone a fundamental change in the last decade. New surgical and nonsurgical minimal invasive methods have evolved. As the methodology of the different treatments is commonly known to urologists, this article focuses on oncological and functional outcome of open retropubic (ORP), trans- or extraperitoneal endoscopical (LRP), and robot-assisted radical prostatectomy (RALP), based on personal experience and review of the literature. A MEDLINE search was performed to review the literature on LRP and RALP between 1982 and 2007 with special emphasis on oncological and functional results, technical considerations, comparison of LRP and RALP to ORP, laparoscopic training, historical aspects, and cost-efficiency of the techniques. Based on diligent training and proctoring programs, a continuous dissemination of laparoscopic techniques takes place. There is a trend towards the extraperitoneal access in most of the minimal invasive programs at least in the European community. Mid-term outcomes of LRP and short-term outcomes of RALP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower transfusion rates, shorter convalescence, and better cosmetics. In contrast to RALP, LRP reaches cost-equivalence with open surgery in selected centers. LRP and RALP reproduce the short-term results of open surgery while providing the advantages of a minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow, but the discussion about the longer learning curve for laparoscopy handling remains. The future will show if European centers adopt the use of robots comparable to the United States.

Vesicourethral Anastomosis During Radical Retropubic Prostatectomy: Does the Number of Sutures Matter?

OBJECTIVES

To prospectively evaluate the outcome of radical retropubic prostatectomy using three different techniques of vesicourethral anastomosis (VUA), with a different number of sutures used during this surgical step.

METHODS

Three groups of patients who had undergone nerve-sparing radical retropubic prostatectomy were compared. Overall, 90 patients with localized prostate cancer were recruited. The patients were randomly assigned to undergo one of three different VUA techniques. The anastomotic sutures consisted of four or six monocryl 2-0 stitches. The "two-suture" anastomosis in group 1 was performed by passing two U-shaped horizontal stitches at the 6-o'clock and 12-o'clock positions. The following intraoperative and perioperative parameters were considered for the comparative analysis: time to perform VUA, blood loss, hospitalization, and time to drain removal.

RESULTS

A statistically significant difference was found in terms of the mean time to anastomosis between groups 1 and 2 (3.61 +/- 1.14 versus 16.6 +/- 4.04, P <0.0001) and between groups 1 and 3 (3.61 +/- 1.14 versus 23.45 +/- 5.4, P <0.0001). No significant differences could be detected for blood loss, time to drain removal, or hospitalization. No significant difference was detected in terms of functional outcome (stricture rate, erectile function, and continence).

CONCLUSIONS

The number of stitches used for VUA during radical retropubic prostatectomy did not influence the perioperative and postoperative parameters. The time to VUA was considerably lower using our "two-suture" technique.

Open Versus Laparoscopic Radical Prostatectomy: A Prospective Comparison of Postoperative Urinary Incontinence Rates

PURPOSE

We compared the 12-month postoperative urinary incontinence rates of open radical retropubic and laparoscopic radical prostatectomy.

MATERIALS AND METHODS

This prospective study included all men with clinically localized prostate cancer scheduled for radical prostatectomy (open retropubic or laparoscopic) at the University of Alberta between October 1999 and July 2002. Preoperative evaluation included a 24-hour pad test, fluid volume voiding diary and International Prostate Symptom Score questionnaire. Postoperative evaluation included a 24-hour pad test at 3 and 12 months, as well as a voiding diary and International Prostate Symptom Score questionnaire at 3, 6, 9 and 12 months.

RESULTS

A total of 239 patients met the eligibility criteria and consented to participate (172 open radical retropubic prostatectomy, 67 laparoscopic radical prostatectomy). Of the patients 87% (148) treated with open radical retropubic prostatectomy and 88% (57) of those treated with laparoscopic radical prostatectomy completed 12-month followup (p = 0.50). According to 24-hour pad testing 13% of those treated with open radical retropubic prostatectomy and 17% of those treated with laparoscopic radical prostatectomy remained incontinent at 1 year (p = 0.26). There was no difference in 24-hour pad weight, urinary symptom score and urinary quality of life at 1 year between the open and laparoscopic groups overall, or when stratified according to 12-month continence status. The majority of subjects in both groups described mild symptoms and a general satisfaction with urinary quality of life.

CONCLUSIONS

Based on objective and subjective measures, there were no differences in urinary functional outcomes 1 year after open radical retropubic prostatectomy or laparoscopic radical prostatectomy. Urinary incontinence was found to affect a similar proportion of patients who underwent open (13%) and laparoscopic (17%) radical prostatectomy 12 months postoperatively.

Radical prostatectomy with preservation of urinary continence: pathology and long-term results

PURPOSE

A continence sparing radical retropubic prostatectomy is described and evaluated. Results are compared with those of patients who underwent a standard anatomical radical retropubic prostatectomy previously by the same surgeon.

MATERIALS AND METHODS

A total of 275 consecutive patients underwent a continence sparing radical prostatectomy by a single surgeon (DLG) between 1996 and 2003. The technique is described in detail.

RESULTS

Total continence (no pad or device) was found immediately upon catheter removal in 36% of patients, within 14 days in 69% and within 7 weeks in 78%, compared to 1%, 6% and 41% of 80 patients who underwent the standard operation. Median time to total continence was 1 day for the new group versus 63 days for the standard surgery group. Positive margins were found in 6.9% of the new group versus 11% of the first 80 patients. Of the former patients 80% have a prostate specific antigen of less than 0.2 ng/ml at an average followup of 12.5 years. With the new procedure 90% of patients have a prostate specific antigen of less than 0.2 ng/ml with an average followup of 5.2 years. There was no operative mortality or unusual complication. The typical patient was discharged home 1 to 3 days postoperatively.

CONCLUSIONS

Preservation of the continence mechanism at the level of the bladder neck and proximal prostatic urethra results in earlier return of continence without adversely affecting cancer control. It is a relatively simple way to improve surgical results.

Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up

OBJECTIVES

To investigate the incidence of urinary incontinence and its development over time, to compare the effects of alternative definitions on the incontinence rate and to explore risk factors for incontinence after radical retropubic prostatectomy (RRP) for clinically localized prostate cancer.

PATIENTS AND METHODS

Urinary continence was assessed using a questionnaire administered by a third party in 1144 consecutive patients after undergoing RRP at our department from January 1986 to December 2001. Overall, 985 men (86%) were suitable for evaluation (mean age 64.5 years, mean follow-up 95.5 months). We compared the effects of three definitions on the actuarial rate of continence: (1) no or occasional pad use; (2) 0 or 1 pads used daily, but for occasional dribbling only; (3) 0-1 pads daily. The time to recovery of continence was defined as the date on which the patient met the continence definitions. The impact of incontinence on health-related quality of life (HRQoL) was also evaluated. Univariate and multivariate analyses were used to identify predictors of incontinence, using data gathered prospectively.

RESULTS

At the last follow-up at 24 months after RRP, 83%, 92.3% and 93.4% of men achieved continence according to definitions 1, 2 and 3, respectively. The difference in time to recovering continence was significant for definition 1 compared to the others (P < 0.001). Most men using 1 pad/day complained of occasional dribbling only (89.3%), considered themselves continent (98%) and their HRQoL was not as seriously affected as those requiring > or = 2 pads/day. Men continent (by definition 3) at 2 years had an actuarial probability of preserving continence of 72.2% at the last follow-up. On multivariate analysis the age at surgery (P = 0.009), anastomotic stricture and follow-up interval (both P < 0.001) were independent prognostic factors. Bilateral neurovascular bundle resection was another independent predictive factor (P = 0.03) in the subset of the last 560 men with available data on surgical technique. The reduction in the incidence of incontinence over time was as high as 86%.

CONCLUSIONS

Continence improves progressively until 2 years from RRP but some patients can become incontinent later. The criterion of pad use discriminates well between men with a limited reduction in their QoL (no or one pad used) and those with a markedly affected QoL (> or =2 pads/day). It could be clinically valid to consider users of 1 pad/day as continent. Age, bilateral neurovascular bundle resection and anastomotic stricture are significant risk factors for incontinence. There was a marked trend for the incidence of incontinence and anastomotic stricture to decrease with time.