Predictors of Early Continence after Robot-assisted Radical Prostatectomy

Oncologic and Functional Outcomes of Salvage Robot-Assisted Radical Prostatectomy: Report of the First 10 Cases

BACKGROUND

Salvage robot-assisted radical prostatectomy (sRARP) after PSA failure in patients who underwent initial radiotherapy or focal therapy has rarely been reported in Japan. We aimed to report the oncologic and functional outcomes of the first 10 cases of sRARP.

METHODS

Ten patients underwent sRARP after failing to respond to initial radiotherapy or focal therapy. Initial definitive treatment included volumetric modulated arc therapy, intensity-modulated radio therapy, stereotactic body radiotherapy, heavy-ion radiotherapy, low-dose-rate brachytherapy, and high-intensity focused ultrasound. We retrospectively investigated 10 cases on oncologic and functional outcomes of sRARP.

RESULTS

The median PSA level at sRARP, amount of blood loss, and console time were 2.17 ng/mL, 100 mL, and 136 min, respectively. Positive surgical margins were found in half of the cases. Median follow-up was 1.1 years. There were no 30-day major complications. No patients had erections after sRARP. Urinary continence and biochemical recurrence (BCR) rate were 40% and 30% at 1 year after sRARP, respectively.

CONCLUSIONS

Salvage RARP may be a feasible option after PSA failure in patients who underwent radiotherapy or focal therapy as initial treatment, showing acceptable BCR rate.

Variations in predictors for urinary continence recovery at different time periods following robot-assisted radical prostatectomy

INTRODUCTION

Urinary dysfunctions are common sequelae following prostatectomy. This study aimed to discover factors that can predict urinary continence recovery at various time periods after robot-assisted laparoscopic radical prostatectomy (RARP).

METHODS

This was a retrospective analysis of data of 419 consecutive patients. Only patients followed up for ≥1 year were enrolled. An answer of "zero pad per day" in the Expanded Prostate Cancer Index Composite urinary assessment (question 5) denoted continence. Possible predictors of urinary continence recovery were evaluated at 3, 3-6, and 6-12 months after the operation.

RESULTS

Continence rates at 3, 6, and 12 months after RARP were 12.9%, 21.2%, and 40.2%, respectively. The proportions of patients using 0-1 pad were 54.2%, 75.7%, and 83.1% at 3, 6, and 12 months after RARP, respectively. Multivariable regression analysis revealed that a membranous urethral length (MUL) ≥11 mm was significantly associated with urinary continence recovery both within 3 months (odds ratio: 0.367, P = .003) and 3-6 months (odds ratio: 0.354, P = .001) after RARP. The analysis also revealed that, in patients with urinary continence at 6 months, a large prostate volume (odds ratio: 1.973, P = .044) and a high body mass index (odds ratio: 2.874, P = .027) were negative predictors of urinary continence recovery within 6-12 months.

CONCLUSION

A longer MUL was linked to urinary continence recovery within 6 months following RARP, whereas a large prostate volume and a high body mass index were adverse predictors of urinary continence recovery beyond 6 months.

Preservation of pelvic floor muscles contributes to early continence recovery after robot-assisted radical prostatectomy

PURPOSE

Postoperative recovery of urinary continence has a great impact on quality of life for patients undergoing robot-assisted radical prostatectomy (RARP). A variety of surgical techniques including reconstruction of the periurethral structure have been introduced, and yet there are no effective methods that promote early urinary continence recovery after surgery. We hypothesized that the preservation of pelvic floor muscle structure could be responsible for early recovery of urinary continence after surgery.

METHODS

A total of 94 consecutive patients who underwent RARP at our hospital were enrolled in this study. Operative video records were reviewed and the severity of pelvic floor muscle injury was classified according to the scoring system that we devised in this study. Briefly, damage of pelvic floor muscles was classified into 4 categories; intact, fascial injury, unilateral muscle injury, and bilateral muscle injury. The volume of urinary incontinence was measured for 2 days after removal of the urethral catheter, and the incontinence ratio (amount of incontinence/total volume of urine per day) was calculated. Predictive factors for immediate incontinence after catheter removal were identified by multivariate regression analysis.

RESULTS

The severity of puboperineal muscle injury was significantly associated with the early incontinence ratio after catheter removal (p < 0.001). Age at surgery and severity of puboperineal muscle injury were independent predictors for early incontinence after catheter removal.

CONCLUSION

Preservation of the pelvic floor muscle, particularly the puboperineal muscle is an important factor for early continence recovery after RARP.

The association between the parameters of uroflowmetry and lower urinary tract symptoms in prostate cancer patients after robot-assisted radical prostatectomy

OBJECTIVE

To investigate changes in uroflowmetry parameters in men undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer.

MATERIALS AND METHODS

Four hundred and twenty-eight patients received uroflowmetry testing before and after RARP from November 2011 to December 2018. Clinicopathological data, including age, initial prostate-specific antigen (PSA), prostate volume, clinical stage, body mass index (BMI), uroflowmetry parameters, and core lower urinary tract symptom scores (CLSS) were retrospectively obtained from clinical records. Changes in uroflowmetry parameters were analyzed for statistical predictors and effects on post-operative outcomes.

RESULTS

A significant increase in maximum flow rate (MFR) and decreases in voided volume (VV) and post-void residual urine (PVR) were seen. In multivariate analysis, age was a negative predictor of MFR increase, while prostate volume was a positive predictor of PVR decrease and MFR increase. VV decrease led to worse incontinence symptoms, while PVR decrease and MFR increase led to improvement in voiding symptoms such as slow stream and straining. Continence recovery curves showed that VV decrease were associated with a delay in continence recovery.

CONCLUSIONS

Significant changes were seen in uroflowmetry results after RARP, each parameter directly related to urinary symptoms. In particular, VV decrease was associated with a worsening of incontinence symptoms and continence recovery.

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.

Clinical significance and risk factors of International Society of Urological Pathology (ISUP) grade upgrading in prostate cancer patients undergoing robot-assisted radical prostatectomy

BACKGROUND

The objective of this study is to investigate the clinical significance and risk factors of upgrading in the International Society of Urological Pathology (ISUP) Grade Group System in men undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer.

METHODS

A total of 583 patients diagnosed with prostate cancer by systematic biopsy were treated with RARP without neoadjuvant therapy from November 2011 to December 2018. Clinicopathological data were obtained from our clinical records. ISUP grade upgrading (IGU) was defined as 'ISUP grade in prostatectomy specimen determined to be higher than that in the biopsy specimen'. Clinicopathological factors, including age, PSA, prostate volume at biopsy (PV), PSA density, clinical stage, body mass index (BMI), interval from biopsy to prostatectomy, maximum percentage of cancer involvement per core (%CI), total number of biopsy cores, percentage of cancer positive biopsy cores (%PC), and sampling density were analyzed to detect potential risk factors of IGU. Biochemical recurrence (BCR) rates were calculated to analyze the effect of IGU on cancer prognosis.

RESULTS

In univariate analysis, BMI was a positive predictor of IGU, while %CI, %PC, and sampling density were negative predictors of IGU. BMI and %PC were statistically significant predictors of IGU in multivariate analysis. For cases diagnosed as ISUP grade group 2 or higher at biopsy, there was a significant difference in BCR rates between cases with and without IGU.

CONCLUSIONS

The results from our cohort showed that elements of both high-grade cancer risk (such as BMI) and sampling efficiency (such as %PC) contribute to IGU. Excluding cases diagnosed as ISUP grade group 1 at biopsy, BCR-free rates were significantly worse in cases with IGU, highlighting the need for more accurate pathological diagnosis at biopsy.