Intravesical prostatic protrusion as a predictor of early urinary continence recovery after laparoscopic radical prostatectomy

Recent Advances in Diagnosing and Treating Post-Prostatectomy Urinary Incontinence

Radical prostatectomy and radiotherapy are common first-line treatments for clinically localized prostate cancer. Despite advances in surgical technology and multidisciplinary management, post-prostatectomy urinary incontinence (PPI) remains a common clinical complication. The incidence and duration of PPI are highly heterogeneous, varying considerably between individuals. Post-prostatectomy urinary incontinence may result from a combination of factors, including patient characteristics, lower urinary tract function, and surgical procedures. Physicians often rely on detailed medical history, physical examinations, voiding diaries, pad tests, and questionnaires-based symptoms to identify critical factors and select appropriate treatment options. Post-prostatectomy urinary incontinence treatment can be divided into conservative treatment and surgical interventions, depending on the severity and type of incontinence. Pelvic floor muscle training and lifestyle interventions are commonly conservative strategies. When conservative treatment fails, surgery is frequently recommended, and the artificial urethral sphincter remains the "gold standard" surgical intervention for PPI. This review focuses on the diagnosis and treatment of PPI, based on the most recent clinical research and recommendations of guidelines, including epidemiology and risk factors, diagnostic methods, and treatment strategies, aimed at presenting a comprehensive overview of the latest advances in this field and assisting doctors in providing personalized treatment options for patients with PPI.

Analysis of the efficacy of Prostatic Artery Embolization in the treatment of Benign Prostatic Hyperplasia

OBJECTIVES

To investigate the safety and efficacy of prostatic artery embolization (PAE) in the treatment of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH), and to investigate predictors of clinical success of PAE.

METHODS

A retrospective analysis was used to collect 107 patients [median age 81.0 (73.0,85.0)] with BPH-related LUTS treated with PAE from September 2014 to February 2022 in a hospital. Repeated measurement ANOVA was used to compare the efficacy evaluation indicators at different times before and after PAE. Univariate and multivariate analyses were used to identify potential predictors of PAE clinical success and establish the optimal joint prediction model. The Receiver Operating Characteristic curves of the quantitative predictors and multivariate model prediction probability values significantly correlated with clinical success were plotted.

RESULTS

Of the 107 cases, 103 (96.3%) successfully underwent PAE. The International Prostate Symptom Score (IPSS) decreased from a baseline mean of 24.94 to 10.19 (P < 0.05) 3 months after PAE, and the mean IPSS at 6 months, 12 months and 24 months was 10.12, 11.30 and 11.86, respectively, which were statistically significant compared with baseline (P<0.05). Predictors of clinical success were greater prostate volume (> 65 ml, P = 0.018), adenomatous-dominant benign prostatic hyperplasia (AdBPH)(P = 0.030), indwelling catheterization due to urine retention (P = 0.028), and bilateral embolization (P = 0.018).

CONCLUSION

PAE was able to significantly improve BPH-related LUTS and the outcome indicators remained stable at long-term follow-up. Preoperative urinary retention catheters, AdBPH, larger prostate volume (> 65 ml) and bilateral embolization suggest better clinical efficacy.

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.

Quality of life after non-nerve-sparing, robot-assisted radical prostatectomy

OBJECTIVE

To evaluate quality of life (QOL) after non-nerve-sparing, robot-assisted radical prostatectomy (RARP) and factors associated with worsened QOL.

METHODS

Patients who underwent non-nerve-sparing RARP (n = 115) were enrolled. The Expanded Prostate Cancer Index Composite and 8-item Short Form Health Survey were used to evaluate QOL at baseline and postoperative 1, 3, 6, 12, and 24 months. Preoperative factors were evaluated by multivariate analysis for worsened QOL.

RESULTS

Postoperative 24-month urinary QOL worsened in 68 of 115 (59%) patients. In multivariate analysis, membranous urethral length ≥10.8 mm [odds ratio (OR): .26, 95% confidence interval (CI): .07-.96] and intravesical prostatic protrusion ≥12 mm (OR: .14, 95% CI .06-.35) were significantly associated with maintaining postoperative 24-month urinary QOL. Significantly more patients with intravesical prostatic protrusion ≥12 mm than < 12 mm had improved urinary QOL. At postoperative 24 months, 43 of 115 (38%) patients had worsened sexual QOL. In multivariate analysis, higher Sexual Health Inventory for Men score (OR: 8.39, 95% CI 2.28-30.9), sexual activity (OR: 6.94, 95% CI: 2.27-21.2), and intercourse activity (OR: 6.81, 95% CI: 1.64-28.3) preoperatively were significantly associated with worsened postoperative 24-month sexual QOL. More patients with high preoperative intercourse activity (12/23,53%) had significantly worsened (p = .009) QOL regarding sexual bother than those who had no preoperative intercourse activity (21/92, 23%).

CONCLUSION

After non-nerve-sparing RARP, patients with long membranous urethral length and/or intravesical prostatic protrusion maintain urinary QOL. Patients with high intercourse activity presented with impairment of sexual QOL after non-nerve-sparing RARP.

Inter-observer variability in male pelvic-floor MRI measurements that might predict post-prostatectomy incontinence

INTRODUCTION

Current studies are focusing on the relationship between anatomical variables in preoperative prostate MRI and the development of post-prostatectomy incontinence (PPI). Nevertheless, there is little evidence regarding the reliability of these measurements. The objective of this study was to analyze the concordance between urologists and radiologists for anatomical measurements that might be PPI predictors.

MATERIAL AND METHODS

Pelvic floor measurements with 3T-MRI were performed by two radiologists and two urologists independently and blindly. Interobserver agreement was determined using the intraclass correlation coefficient (ICC) and the Bland-Altman plot.

RESULTS

The concordance was good-acceptable for most measurements, except for the levator ani and puborectalis muscle thickness (some ICC values  < 0.20/p value > 0.05). The anatomical parameters with the highest degree of agreement were intravesical prostatic protrusion (IPP) and prostate volume (most of the ICC values > 0.60). The membranous urethral length (MUL) and the angle of the membranous urethra-prostate axis (aLUMP) presented ICC > 0.40. The obturator internus muscle thickness (OIT), urethral width and intraprostatic urethral length presented a fair-moderate degree of agreement (ICC > 0.20). Regarding the agreement between different specialists, the highest degree was obtained for the two radiologists and for urologist 1-radiologist 2 (moderate median agreement), while urologist 2 with each of the radiologists had a regular median agreement.

CONCLUSIONS

MUL, IPP, prostate volume, aLUMP, OIT, urethral width and prostatic length show acceptable inter-observer concordance and they would be reliable as possible predictors of PPI. Levator ani and puborectalis muscle thickness show bad agreement. Interobserver agreement might not be greatly influenced by previous professional experience.

Recognition of Postoperative Cystography Features by Artificial Intelligence to Predict Recovery from Postprostatectomy Urinary Incontinence: A Rapid and Easy Way to Predict Functional Outcome

Purpose: Post-operative cystography has been used to predict the recovery of postprostatectomy urinary incontinence (PPI) in patients with localized prostate cancer. This study aimed to validate the predictive value of cystography for PPI and utilize a deep learning model to identify favorable and unfavorable features. Methods: Medical records and cystography images of patients who underwent robotic-assisted radical prostatectomy for localized prostate cancer were retrospectively reviewed. Specific cystography features, including anastomosis leakage, a downward bladder neck (BN), and the bladder neck angle, were analyzed for the prediction of PPI recovery. Favorable and unfavorable patterns were categorized based on the three cystography features. The deep learning model used for transfer learning was ResNet 50 and weights were trained on ImageNet. We used 5-fold cross-validation to reduce bias. After each fold, we used a test set to confirm the model’s performance. Result: A total of 170 consecutive patients were included; 31.2% experienced immediate urinary continence after surgery, while 93.5% achieved a pad-free status and 6.5% were still incontinent in the 24 weeks after surgery. We divided patients into a fast recovery group (≤4 weeks) and a slow recovery group (>4 weeks). Compared with the slow recovery group, the fast recovery group had a significantly lower anastomosis leakage rate, less of a downward bladder neck, and a larger bladder neck angle. Test data used to evaluate the model’s performance demonstrated an average 5-fold accuracy, sensitivity, and specificity of 93.75%, 87.5%, and 100%, respectively. Conclusions: Postoperative cystography features can predict PPI recovery in patients with localized prostate cancer. A deep-learning model can facilitate the identification process. Further validation and exploration are required for the future development of artificial intelligence (AI) in this field.

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.

Preoperative predictive model of early urinary continence recovery after laparoscopic radical prostatectomy

PURPOSE

To develop and validate a predictive model include magnetic resonance imaging (MRI) parameters preoperatively which can assess the risk of incontinence after laparoscopic radical prostatectomy (LRP) accurately.

METHODS

We retrospectively reviewed and included 170 patients with prostate cancer who underwent LRP between July 2015 and June 2018 in our institution. All 170 patients were randomly resampled and divided into training set (n = 124) and verification set (n = 46) according to the ratio of 7:3. The Nomogram prediction model of the risk of incontinence after LRP was established through the training set and verified by the verification set. Baseline patient characteristics were obtained, including age, body mass index, and prostate volume. Perioperative characteristics such as pre-biopsy prostate specific antigen, biopsy Gleason score, clinical staging, and NVB sparing status were also collected. MRI parameters preoperatively including membranous urethral length (MUL), prostate apex depth ratio (PADR), and intravesical prostatic protrusion length (IPPL) were obtained. The C index and visual inspection of calibration curve were used to evaluate the discrimination and calibration of the model.

RESULTS

According to the urinary incontinence (UI) at 3 months postoperatively, the patients were divided into 104 cases (61.2%) in the group with no incontinence and 66 patients (38.8%) in the group with incontinence. Multivariate logistic regression analysis of training set showed that cT3a (OR = 0.427, 95% CI 0.142-1.281, P = 0.1288), MUL (OR = 0.237, 95% CI 0.102-0.551, P < 0.01), PADR (OR = 0.276, 95% CI 0.116-0.655, P < 0.01), and IPPL (OR = 0.073, 95% CI 0.030-0.179, P < 0.01) were independent predictors of urinary incontinence at 3 months postoperatively. The model showed good discrimination with an area under the receiver operating characteristic (ROC) curve of 0.880, with the sensitivity and specificity 0.800 and 0.816, respectively, and good calibration (Hosmer-Lemeshow test result of 5.57, P = 0.695). Decision curve analysis demonstrated that the model was clinically useful.

CONCLUSION

This study developed and validated a preoperative model in the form of a nomogram to predict the risk of UI after LRP at 3 months. MUL, PADR, and IPPL were significant independent predictive factors of the postoperative early urinary continence.

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.

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.

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.

Anatomical predictors of long-term urinary incontinence after robot-assisted laparoscopic prostatectomy: A systematic review

AIMS

There is scarce evidence of anatomical risk factors that might affect long-term post-prostatectomy incontinence (PPI) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). This systematic review aims to identify anatomical measurements in preoperative magnetic resonance imaging (MRI) that might be associated with increased risk of urinary incontinence (UI) 1 year after RALP.

METHODS

A comprehensive search on Pubmed and Scopus databases up to November 2020 was performed. Eight articles met the inclusion criteria and were finally selected.

RESULTS

The selected studies included 1146 patients. Seven articles focused on membranous urethral length (MUL); all of them related MUL to long-term PPI in univariate analysis and five of them in multivariate analysis. Four studies presented MUL difference to measure the magnitude of the effect. Average MUL (mm) was 15.9 (SD, 2.6), 16.1 (95% confidence interval [CI]: 13.9-18.9), 12.1 (95% CI 9.7-14.9) and 14.5 in continent patients and 13.9 (SD, 2.9), 10 (95% CI: 8.7-12.1), 10.3 (95% CI: 8.7-12.4) and 9.3 in incontinent patients, with statistically significant differences in all cases. Five studies presented the odds ratio as a result; although there was substantial heterogeneity in the methods used to obtain it, there was consistency in finding an inverse association between MUL and PPI. Other measurements including prostatic-urethral angle, membranous urethral thickness, intraprostatic urethral length and intravesical prostatic protrusion have been reported in few studies, and no association with long-term PPI was found. Levator ani muscle thickness was related to long-term PPI in one article.

CONCLUSION

Greater MUL on preoperative MRI is associated with lower risk of UI 1 year after RALP.

Impact of protruded median lobe on perioperative, urinary continence and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy

Background

To investigate the effect of protruded median lobe (PML) on the perioperative, oncological, and urinary continence (UC) outcomes among patients underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).

Methods

231 consecutive patients who had undergone RS-RARP were collected and analyzed. Patients were divided into three groups based on the PML degree: PML<5 mm (n=99); 5≤ PML <10 mm (n=91); PML ≥10 mm (n=41). The perioperative outcomes, short-term oncological, and UC outcomes were compared among the three groups. Those outcomes were also compared in patients with significant PML (>10 mm) who underwent the traditional or Retzius-sparing RARP.

Results

The median PML was significantly associated age (P<0.001) and prostate volume (P<0.001). Perioperative characteristics including console time, estimated blood loss (EBL), intraoperative transfusion rate, and complications were not statistically different among the three groups (P=0.647, 0.574, 0.231, 0.661, respectively). The rate of positive surgical margin (PSM) were not significantly different in the three groups (P=0.065). No significant difference regarding UC and biochemical recurrence (BCR) at 12-month follow-up was observed in the three groups (P>0.05). Comparison between the two approaches in men with significant PML showed better recovery of UC (HR =1.83, 95% CI: 1.117-3.01, log-rank P=0.002) and similar BCR (log-rank P=0.072) after RS-RARP.

Conclusions

RS-RARP is an oncologically and functionally equivalent approach for patients with PML. Compared with the traditional approach, RS-RARP offers benefits regarding UC for cases with significant PML.

Correlation between lumbar skeletal muscle size and urinary incontinence after radical prostatectomy

OBJECTIVES

Urinary incontinence is a major concern after radical prostatectomy because it can decrease quality of life. The aim of the present study was to explore the effect of preoperative skeletal muscle on urinary quality of life after robot-assisted radical prostatectomy.

METHODS

A total of 762 patients underwent robot-assisted radical prostatectomy. Longitudinal health-related quality of life was evaluated using the Expanded Prostate Cancer Index Composite instrument. The skeletal muscle area at the level of the third lumbar vertebra was assessed preoperatively by computed tomography and was standardized to height to obtain the skeletal muscle index. Reduced skeletal muscle size (RSMS) was defined as a skeletal muscle index ≤ 53 or ≤ 43 cm² /m² in patients with a body mass index (BMI) ≥25 or < 25, respectively.

RESULTS

A total of 301 patients were included in this study, of whom 91 were classified as having RSMS (30.2%). Non-RSMS patients exhibited better urinary function at 12 months (P = .012) and better urinary continence recovery at 2 weeks and 12 months (P = .033 and P = .014, respectively) after prostatectomy compared with RSMS patients. Univariate and multivariate analyses identified preoperative RSMS as a significant and independent predictor of urinary incontinence (odds ratio = 1.77, P = .028).

CONCLUSIONS

Patients with RSMS had a lower urinary quality of life compared with non-RSMS patients after robot-assisted radical prostatectomy, and RSMS, independent of age or BMI, was predictive of postoperative urinary incontinence.

Impact of Preoperative Magnetic Resonance Imaging Anatomic Features on Urinary Continence Recovery after Laparoscopic Radical Prostatectomy

PURPOSE

To evaluate the impact of preoperative magnetic resonance imaging anatomic features on urinary continence recovery after laparoscopic radical prostatectomy (LRP).

METHODS

We retrospectively analyzed 150 consecutive prostate cancer patients who underwent LRP between July 2015 and June 2018 in our institution. Patients reporting freedom from using safety pad (0 pads/day) were defined as urinary continent. We evaluated the association of urinary continence recovery after LRP and the perioperative variables, including age, prostatic volume (PV), intravesical prostatic protrusion length (IPPL), membranous urethral length (MUL), and neurovascular bundle (NVB) sparing status. Kaplan-Meier and log-rank tests were used to compare urinary continence rates between groups. Univariate and multivariate Cox proportional hazards regression analyses were used to identify independent predictors for urinary continence recovery.

RESULTS

60.6% (91/150), 83.3% (125/150), and 96.0% (144/150) of the patients experienced urinary continence recovery at 3, 6, and 12 months, respectively. There was significant difference in PV, IPPL, MUL, and NVB sparing between groups stratified by urinary continence status at 3, 6, and 12 months. Kaplan-Meier curves of urinary continence rates showed significant differences between groups stratified by PV (<50 mL vs. ≥50 mL, p < 0.001), IPPL (<5 mm vs. ≥5 mm, p < 0.001), MUL (≥15 mm vs. <15 mm, p < 0.001), and NVB sparing status (yes vs. no, p = 0.003), respectively. On univariate analysis, PV, IPPL, MUL, and NVB sparing were significantly associated with urinary continence recovery (all, p < 0.05). On multivariate analysis, only IPPL (HR = 0.94, p = 0.003) and MUL (HR = 1.10, p < 0.001) were independent predictors for urinary continence recovery.

CONCLUSION

Patients with larger IPPL and shorter MUL have higher chances of delayed recovery of urinary continence after LRP. IPPL and MUL were reliable morphometric parameters for predicting urinary continence.

Effect of Median Lobe Enlargement on Early Prostatic Artery Embolization Outcomes

PURPOSE

To evaluate outcomes after prostatic artery embolization (PAE) in patients with severe intravesical prostatic protrusion (IPP).

MATERIALS AND METHODS

This was a retrospective, single health system, 2-hospital study from April 2015 to December 2018 of 54 patients who underwent elective PAE procedures (age mean 67.5 years; standard deviation [SD] 8.5). The cohort had a mean ellipsoid prostate volume of 100.1 cm³ (SD 56.7), a mean baseline International Prostate Symptom Score (IPSS) of 18.7 (SD 8.2), a mean baseline quality of life (QOL) score of 4.1 (SD 1.4), and a median follow-up of 38 days (range 10-656 days). Outcomes including IPSS and QOL score reduction (where a lower QOL score indicates an improvement in QOL), and clinical success were compared between severe (≥10 mm) and nonsevere (<10 mm) IPP patients. A linear regression model was used to examine the impact of IPP on these outcomes.

RESULTS

No significant differences in patient characteristics were found between nonsevere (n = 17) and severe (n = 37) IPP patients. Both cohorts showed IPSS reduction (nonsevere 6.0, P = .0397; severe 8.2, P < .0001) and QOL score reduction (nonsevere 1.0, P = .102; severe 2.0, P < .0001). No significant differences in IPSS or QOL score reduction were found between the cohorts (P = .431 and P = .127). Linear regression found that baseline IPP was not a significant contributor to the outcomes (IPSS: R² = .5, P < .0001; IPP: P = .702; QOL: R² = .5, P = .0003; IPP: P = .108).

CONCLUSIONS

There were no significant differences in early outcomes in PAE between patients with severe and nonsevere IPP.

Preservation of continence in radical prostatectomy patients: a laparoscopic surgeon's perspective

Introduction

Preserving continence in patients who underwent radical prostatectomy is of utmost importance. Therefore, modification of surgical technique that would contribute to the regaining of continence with a shortest possible delay after the procedure and adequate evaluation of chances of continence recovery should be considered.

Material and methods

A PubMed database search was performed to review the current literature concerning the physiology and anatomy of sphincter mechanisms, perioperative risk factors, the effects of surgical techniques on post-prostatectomy continence and post-operative management.

Results

Modifications of surgical approach with an aim to minimize damage to the sphincter complex, maintenance of maximal urethral length to enable safe anastomosis, and the reconstruction of the urethral support system appears necessary. The patient should also be informed about the chances of regaining continence after surgery.

Conclusions

There is a need to develop a predictive model to stratify patients according to risk of incontinence and implement adequate action to minimize those risks including preoperative pelvic floor muscle training and/or surgical technique modification.

Clinical Considerations for Intravesical Prostatic Protrusion in the Evaluation and Management of Bladder Outlet Obstruction Secondary to Benign Prostatic Hyperplasia

Background

Intravesical prostatic protrusion (IPP) is a manifestation of benign prostatic hyperplasia marked by overgrowth of the prostatic median lobe into the bladder, producing bladder outlet obstruction and related storage and voiding symptoms.

Methods

A MEDLINE® database search of the current literature was guided using combination of "prostate" with the following terms: intravesical prostatic protrusion, bladder trabeculation, bladder outlet obstruction, lower urinary tract symptoms, alpha blockers, transrectal ultrasonography, and prostatectomy.

Results

Although IPP can be identified via a variety of imaging modalities, it is easily detected via transrectal ultrasonography (TRUS). Failing to detect IPP promptly by TRUS may result in refractory symptoms of benign prostatic hyperplasia, as the condition may not respond to typical α₁-adrenoceptor antagonist therapy. In addition, depending on grade, IPP can influence outcomes and complications of prostatectomies.

Conclusion

Upon report of lower urinary tract symptoms, initial performance of TRUS along with digital rectal examination prevents delay in the appropriate evaluation and management of prostatic diseases.

The association between the outcomes of extraperitoneal laparoscopic radical prostatectomy and the anthropometric measurements of the prostate by magnetic resonance imaging

Introduction and objective

To determine the association between the anthropometric measurements by magnetic resonance imaging (MRI) and perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP).

Materials and Methods

From 2008 to June 2016, 86 patients underwent preoperative MRI prior to undergoing ELRP for localized prostate cancer. We analyzed the associations between anthropometric measurements of MRI and the perioperative outcomes of patients who underwent ELRP.

Results

The mean patient age was 69.61±8.30 years. The medians of operating time and blood loss were 2.30 hours and 725.30ml, respectively. The total post-surgical complication rate was 1.16%. The median hospital stay was 6.50 days. The pathological stages for T2 and T3 were 45.74% and 34.04%, respectively. The rate as positive surgical margins (PSMs) was 18.09% (pT2 and pT3; 6.38% and 9.57%). The angles between pubic bone and prostate gland (angle 1&2), were significantly associated with operative time and hospital stay, respectively (p<0.05). There was no correlation between the pelvimetry and positive surgical margin.

Conclusions

The findings of the present study suggest that anthropometric measurements of the MRI are related to operative difficulties in ELRP. This study confirmed that MRI planning is the key to preventing complications in ELRP.

Typology of intravesical prostatic protrusions, or so-called median lobes, in middle-aged and older men

PURPOSE

Changes related to prostatic ageing include an increase of prostate volume and morphologic distortions of the prostatic edges in middle-aged and older men. These changes of the prostate exhibit a certain level of heterogeneity, which is clinically obvious for surgeons, radiologists, and anatomists, and which can be explained by the complex nature of the embryologic/anatomic development of the prostate. While the etiology of the median lobe has typically been attributed to a growth and protrusion of the prostatic area at the top of the utricle, we argue that this is not necessarily the case as intravesical protrusions of the prostate have also been observed laterally and anteriorly to the bladder neck, suggesting the involvement of other prostatic zones, thereby highlighting the need to refine the concept of the median lobe.

MATERIAL

The current study examined a large series of 478 prostate magnetic resonance imaging scans (MRIs). Intravesical prostatic protrusions were classified, based on their topography: anterior (A), posterolateral (P), and dual (D). Data were analyzed using MedCalc^®11.6.1.1.0 software. Pearson's correlations with coefficients (r) and P values were calculated for the patient's age, prostate volume, and IVPP size.

RESULTS

An intravesical prostatic protrusion was observed in 27% of cases, with type A occurring in 18% (3% isolated), type P in 96% (81% isolated), and type D in 15%.

CONCLUSION

The new insights regarding the variability in prostate anatomy will contribute to the improved management of prostate hypertrophy by radiologists and surgeons.

Clinical value of intravesical prostatic protrusion in the evaluation and management of prostatic and other lower urinary tract diseases

Intravesical prostatic protrusion (IPP) has emerged as a new prostatic morphometric parameter of significance to aid the clinicians in various aspects of managing the patients with some diseases of the lower urinary tract and the prostate. These include but may not be limited to its role in such conditions as: bladder outlet obstruction, trial without catheter, medical treatment effect, progression of lower urinary tract symptoms related to benign prostatic hypertrophy (LUTS/BPH), risk factor for bladder stone in BPH, overactive bladder, prostate carcinoma, and early urinary continence recovery after laparoscopic radical prostatectomy. In this review, I will try to summarize the different researchers' efforts on the potential practical application of this clinical tool. Technology is ever evolving to help us in the diagnosis and management of our patients. However, we as clinicians should contemplate their cost and possible suffering for the patient by wise and judicious utilization based on our clinical experience and tools. IPP seems to be one such promising clinical tool.

Intra-vesical Prostatic Protrusion (IPP) Can Be Reduced by Prostatic Artery Embolization

BACKGROUND

Prostate artery embolization (PAE) is a new approach to improve lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia. PAE results in global reduction of prostate volume (PV). There are no data available on the efficacy of PAE in reducing intra-vesical prostatic protrusion (IPP), an anatomic feature that is clinically related with bladder outlet obstruction and LUTS.

OBJECTIVE

To assess the results of PAE in patients with significant IPP due to median lobe hyperplasia and to compare the IPSS decrease and IPP change.

MATERIAL AND METHODS

Prospective analysis of 18 consecutive patients with significant IPP (>5 mm) related to median lobe hyperplasia undergoing PAE using 30-500-μm-calibrated trisacryl microspheres. We measured IPP on sagittal T2-weighted images before and 3 months after PAE. IPSS and clinical results were also evaluated at 3 months.

RESULTS

PAE resulted in significant IPP reduction (1.57 cm ± 0.55 before PAE and 1.30 cm ± 0.46 after PAE, p = 0.0005) (Fig. 1) with no complication. IPSS, quality of life (QoL), total prostate-specific antigen (PSA) level, and PV showed significant reduction after PAE, and maximum urinary flow rate (Q max) showed significant increase after PAE. No significant change of International Index of Erectile Function (IIEF) for clinical evaluation after PAE. A significant correlation was found between the IPP change and the IPSS change (r = 0.636, p = 0.0045).

CONCLUSION

Patients had significant IPP reduction as well as significant symptomatic improvement after PAE, and these improvements were positively correlated.