Conservative management of urinary incontinence following robot-assisted radical prostatectomy

Patients experience with the use of a penile clamp in post-prostatectomy incontinence - a prospective pilot study

OBJECTIVES

The aim of this study was to assess the efficacy of a penile clamp in managing urinary incontinence (UI) and its impact on perceived quality of life (QoL) amongst post-prostatectomy patients.

MATERIAL AND METHODS

A prospective pilot study was conducted including patients with post-prostatectomy UI treated with a penile clamp. Inclusion criteria consisted of UI after radical prostatectomy, good hand function, full cognitive function and a minimum penile length of 3 cm and a circumference of 5 cm. An appropriately sized penile clamp was selected during the first visit, and patients were given instructions on how to use it. The first follow-up was a scheduled phone call 1 week after the initial visit. Formal evaluations were performed prior to use of the penile clamp and again after 3 months of usage. These consisted of weighing pads during the daytime with evaluation of leakage, International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), incontinence-QoL (I-QoL) and a questionnaire specific for the penile clamp.

RESULTS

There were 22 patients included, and two were excluded due to reduced hand function and surgery before the study endpoint. The results showed a significant median reduction of urinary leakage of 57% at rest and 58% during physical activity. One complication was observed, as one patient developed a pinching ulcer, after extensive usage. ICIQ-SF showed an increase of 6% for the included patients (n = 20). Ten patients were satisfied with the clamp, and 15 would recommend the clamp to others.

CONCLUSION

The penile clamp shows promising results in reducing leakage with minimal risks of complications. It can be used as a treatment for patients awaiting surgery. However, patient selection is important regarding hand function, cognitive function and the penile anatomy.

Barriers and facilitators of the implementation of the application of pelvic floor muscle training in patients with prostate cancer: a scoping review

Background

Patients with prostate cancer (PCa) benefit significantly from pelvic floor exercises, but recent results indicate that these exercises have not been fully promoted in clinical settings. This scoping review aimed to identify the facilitators of and barriers to pelvic floor muscle training (PFMT) in PCa survivors.

Methods

A scoping review was conducted in November 2022. Relevant studies were identified from CINAHL, Embase, PubMed, PsycINFO, and Web of Science databases from their inception to 20 November 2022. Data were analyzed and extracted by two formally trained researchers.

Results

A total of 53 studies were included, most of which were randomized controlled trials. The Tailored Implementation for Chronic Diseases (TICD) model framework was used to identify the contents of seven barriers and promotion areas, as well as a series of sub-domains. The most common barriers to implementing pelvic floor muscle training (PFMT) included the following: the lack of a common scheme in guidelines and the measurement of common standardized outcomes, inadequate self-monitoring or feedback from healthcare professionals to improve PFMT compliance, poor patient compliance, and a lack of implementation equipment and financial support. Good treatment effects and easy operation were the facilitators of PFMT.

Conclusion

The implementation of PFMT faces several challenges and opportunities that should be understood thoroughly before implementation. In terms of guidelines and clinical practice, more work is needed, and the possibility of PFMT implementation in various hospitals and community health centers or clinics should be considered.

Effects of Web-Based and Mobile Self-Care Support in Addition to Standard Care in Patients After Radical Prostatectomy: Randomized Controlled Trial

BACKGROUND

Prostate cancer is a common form of cancer that is often treated with radical prostatectomy, which can leave patients with urinary incontinence and sexual dysfunction. Self-care (pelvic floor muscle exercises and physical activity) is recommended to reduce the side effects. As more and more men are living in the aftermath of treatment, effective rehabilitation support is warranted. Digital self-care support has the potential to improve patient outcomes, but it has rarely been evaluated longitudinally in randomized controlled trials. Therefore, we developed and evaluated the effects of digital self-care support (electronic Patient Activation in Treatment at Home [ePATH]) on prostate-specific symptoms.

OBJECTIVE

This study aimed to investigate the effects of web-based and mobile self-care support on urinary continence, sexual function, and self-care, compared with standard care, at 1, 3, 6, and 12 months after radical prostatectomy.

METHODS

A multicenter randomized controlled trial with 2 study arms was conducted, with the longitudinal effects of additional digital self-care support (ePATH) compared with those of standard care alone. ePATH was designed based on the self-determination theory to strengthen patients' activation in self-care through nurse-assisted individualized modules. Men planned for radical prostatectomy at 3 county hospitals in southern Sweden were included offline and randomly assigned to the intervention or control group. The effects of ePATH were evaluated for 1 year after surgery using self-assessed questionnaires. Linear mixed models and ordinal regression analyses were performed.

RESULTS

This study included 170 men (85 in each group) from January 2018 to December 2019. The participants in the intervention and control groups did not differ in their demographic characteristics. In the intervention group, 64% (53/83) of the participants used ePATH, but the use declined over time. The linear mixed model showed no substantial differences between the groups in urinary continence (β=-5.60; P=.09; 95% CI -12.15 to -0.96) or sexual function (β=-.12; P=.97; 95% CI -7.05 to -6.81). Participants in the intervention and control groups did not differ in physical activity (odds ratio 1.16, 95% CI 0.71-1.89; P=.57) or pelvic floor muscle exercises (odds ratio 1.51, 95% CI 0.86-2.66; P=.15).

CONCLUSIONS

ePATH did not affect postoperative side effects or self-care but reflected how this support may work in typical clinical conditions. To complement standard rehabilitation, digital self-care support must be adapted to the context and individual preferences for use and effect.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN18055968; https://www.isrctn.com/ISRCTN18055968.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11625.

MRI/real-time ultrasound image fusion guided high-intensity focused ultrasound: a prospective comparative and functional analysis of different ablative techniques

BACKGROUND

The aim of this paper was to compare safety and functional outcomes of total, hemi and focal ablation by the latest focal high-intensity focused ultrasound (HIFU) device.

METHODS

This is a prospective study including patients with low to intermediate-risk PCa treated with HIFU by Focal One^® device from 11/2018 to 3/2020. Before the treatment all patients underwent mp-magnetic resonance imaging (MRI) and subsequent MRI/transrectal ultrasound (TRUS) fusion and standard biopsy. Patients were stratified according to the type of ablation: total, hemi- or focal ablation. Functional data (IPSS, Quality of Life [QoL], IIEF-5, maximum flow [Qmax] and post void residual [PVR] at flowmetry) were assessed preoperatively and at 1, 3, 6 and 12 months after treatment. Moreover, the urinary symptoms reported by patients at IPSS questionnaire were divided in "irritative" and "obstructive" and compared.

RESULTS

One hundred patients were enrolled. Median prostate volume and lesion diameter were 46 (IQR 25-75) mL and 10 (IQR 6-13) mm. 15, 50 and 35 patients underwent total, hemi- and focal ablation, respectively. No differences were found between them except for operative time (lower in the focal group, P<0.01). Significant lower incidence of irritative symptoms was identified in the focal group compared to the others (P<0.05 at 1 and 3 months of follow-up). No differences were found among the baseline status and the postoperative assessment in terms of obstructive IPSS items, IIEF-5, QoL, Qmax and PVR (all P value>0.05).

CONCLUSIONS

Our study suggests that patients' specific HIFU tailoring with the MRI/real-time TRUS Guidance by Focal One^® device is able to minimize the side effects of treatment.

Urologic latency time during uroflow stop test with electromyography: an incontinence detector in rehabilitation after robotic radical prostatectomy

BACKGROUND

Stress urinary incontinence (UI) is the most common presentation following robot-assisted radical prostatectomy (RARP), but a postoperative non-invasive and objective test is still lacking. To assess pelvic floor integrity after RARP, we recently proposed Uroflow Stop Test (UST) with surface electromyography (EMG).

AIM

Here we provide two new clinical parameters: the neurologic latency time (NLT) and the urologic latency time (ULT) derived from UST-EMG Test. Principal outcome was to evaluate their variation during one year follow-up and ULT ability to predict post-RARP UI.

DESIGN

Observational and longitudinal study.

SETTING

Interdivisional Urology Clinic (Perugia-Terni, Italy).

POPULATION

Patients with prostate cancer treated with a full nerve-sparing RARP who underwent postoperative pelvic floor muscles training (PFMT): a diurnal functional home program and a weekly hospital program with the use of biofeedback, between 1 and 3 months postoperatively.

METHODS

All patients consecutively performed a UST-EMG test at one, three, six, and twelve months after surgery. At each follow-up visit we collected NLT values, ULT values, 5-item 26-Expanded Prostate Cancer Index (EPIC), Incontinence Developed on Incontinence Questionnaire (ICIQ-UI) Short Form and International Prostate Symptom Score (IPSS). We analysed statistically significant differences in NLT and ULT between continent and incontinent patients and we evaluate the diagnostic ability of 1-month post-surgery ULT value to diagnose the presence of postoperative UI.

RESULTS

Sixty patients were enrolled. The mean time to PFMT was 31.08 (range: 30-35) days. Overall IPSS, NLT and ULT had similar trends: progressive decrease until the six months after surgery (1-month vs. 3 months vs. 6 months, P<0.05) to plateau thereafter. When considering the two group of patients, IPSS and NLT were significantly higher in the incontinent group only one month after surgery, while ULT became similar between the two groups at 6 months after surgery. The best cut-off of 1-month ULT values that maximized the Youden function at 12-months resulted 3.13 second.

CONCLUSIONS

NLT and ULT may respectively account for the nerve and the urethral closure system integrity post-RARP. In the first month after RARP, both NLT and ULT differs between incontinent vs. continent patients. NLT become similar between two group after one month, confirming the recovery from neuropraxia, but ULT remains statistically significant different until 3 months postoperatively. The value of 1-month ULT resulted a valid tool to predict incontinence status at 12 months.

CLINICAL REHABILITATION IMPACT

ULT and NLT may be also useful tools to monitor the continence progressive recovery after RARP and they may help rehabilitation specialists to evaluate the ongoing results during postoperative follow-up.

Mucosal coaptation technique for early urinary continence after robot-assisted radical prostatectomy: a comparative exploratory study

Introduction

Urinary incontinence is a troublesome complication following radical prostatectomy. Various robot-assisted radical prostatectomy (RARP). We describe our technique (Santosh-PGI) of urethral and urinary bladder mucosa coaptation for early continence following RARP.

Material and methods

We performed a prospective comparative study of patients planned for RARP between July 2018 and December 2019 at our centre. A total of 40 patients were enrolled in the study protocol. Following prostatectomy, patients were alternatively assigned into two groups. In one group, urethral and urinary bladder coaptation sutures were placed in a purse string manner using 3-0 Monocryl sutures and none in the another group. All patients underwent standard end to end vesico-urethral anastomosis as described by Van Velthoven. The urinary catheter was removed on day 10 after surgery. All patients were evaluated on day 1, 30 and 90 after catheter removal.

Results

The two groups, each with 20 patients, were comparable in terms of age, clinical staging and D’Amico risk classification. The operative time, blood loss and surgical margin positivity were comparable. Following catheter removal, 75% of patients in Group A (Mucosal coaptation) and 50% in Group B (Standard technique) were continent (p = 0.264). At 30 and 90 days, 90% and 95% in Group A and 60% and 80% in Group B reported continence respectively (p-0.078). Four patients in group B reported bothersome incontinence at 90 days follow-up.

Conclusions

Urethral and urinary bladder mucosal coaptation is a simple innovative technique for early continence following RARP.

Systematic review comparing Anterior vs Retzius-sparing robotic assisted radical prostatectomy: can the approach really make a difference?

INTRODUCTION

Retzius-Sparing Robotic Assisted Radical Prostatectomy (RS-RARP) is a novel surgical approach to radical prostatectomy. Its pioneers have suggested an improved recovery of urinary continence, while maintaining adequate cancer control. Aim of this systematic review is to explore available data on RS-RALP and compare functional, oncologic and perioperative results of RS-RARP compared to anterior RARP.

EVIDENCE ACQUISITION

A search following PRISMA guidelines was performed including the combination of the following words: retzius AND sparing AND radical AND prostatectomy. 93 articles were identified and 13 were included in the systematic review, including 3 randomized controlled trials (RCT), 4 prospective studies and 6 retrospective studies.

EVIDENCE SYNTHESIS

All available randomized trials confirmed an improved immediate continence for RS-RARP, with rates ranging 51-71%, compared to 21-48% for anterior RARP. However, this advantage was progressively lost with no significant difference found after 6 months. Moreover, a prospective study found no discrepancy in terms of quality of life across the two techniques. Erectile function was difficult to compare, as patients had different baseline erectile function across studies and rate of neurovascular preservation was not comparable. Surgical approach remains controversial regarding positive margin rate, although related to the surgeon's experience and clinical stage. Biochemical recurrence-free survival appears similar between the two approaches.

CONCLUSIONS

RS-RARP improves early urinary continence recovery compared to anterior RARP, with this advantage being lost after 3 to 6 months. Erectile function and quality of life were however comparable between the two techniques. The results concerning the rate of positive margins remained controversial. Future studies with longer follow-up are needed to better assess oncologic outcomes.

Robot-assisted radical prostatectomy versus standard laparoscopic radical prostatectomy: an evidence-based analysis of comparative outcomes

PURPOSE

To provide a systematic analysis of the comparative outcomes of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer based on the best currently available evidence.

METHODS

An independent systematic review of the literature was performed up to February 2021, using MEDLINE^®, EMBASE^®, and Web of Science^® databases. Preferred reporting items for systematic review and meta-analysis (PRISMA) recommendations were followed to design search strategies, selection criteria, and evidence reports. The quality of the included studies was determined using the Newcastle-Ottawa scale for non-randomized controlled trials. Demographics and clinical characteristics, surgical, pathological, and functional outcomes were collected.

RESULTS

Twenty-six studies were identified. Only 16 "high-quality" (RCTs and Newcastle-Ottawa scale 8-9) studies were included in the meta-analysis. Among the 13,752 patients included, 6135 (44.6%) and 7617 (55.4%) were RARP and LRP, respectively. There was no difference between groups in terms of demographics and clinical characteristics. Overall and major complication (Clavien-Dindo ≥ III) rates were similar in LRP than RARP group. The biochemical recurrence (BCR) rate at 12months was significantly lower for RARP (OR: 0.52; 95% CI 0.43-0.63; p < 0.00001). RARP reported lower urinary incontinence rate at 12months (OR: 0.38; 95% CI 0.18-0.8; p = 0.01). The erectile function recovery rate at 12months was higher for RARP (OR: 2.16; 95% CI 1.23-3.78; p = 0.007).

CONCLUSION

Current evidence shows that RARP offers favorable outcomes compared with LRP, including higher potency and continence rates, and less likelihood of BCR. An assessment of longer-term outcomes is lacking, and higher cost remains a concern of robotic versus laparoscopic prostate cancer surgery.

Bioethical implications of robotic surgery in urology: a narrative review

BACKGROUND

Robotic technologies are being increasingly implemented in healthcare, including urology, holding promises for improving medicine worldwide. However, these new approaches raise ethical concerns for professionals, patients, researchers and institutions that need to be addressed. The aim of this review is to investigate the existing literature related to bioethical issues associated with robotic surgery in urology, in order to identify current challenges and make preliminary suggestions to ensure an ethical implementation of these technologies.

METHODS

We performed a narrative review of the pertaining literature through a systematic search of two databases (PubMed and Web of Science) in August 2020.

RESULTS

Our search yielded 76 articles for full-text evaluation and 48 articles were included in the narrative review. Several bioethical issues were identified and can be categorized into five main subjects: 1) robotic surgery accessibility; 2) safety; 3) gender gap; 4) costs and 5) learning curve. 1) Robotic surgery is expensive, and in some health systems may lead to inequality in healthcare access. In more affluent countries the national distribution of several robotic platforms may influence the centralization of robotic surgery, therefore potentially affecting oncological and functional outcomes in low-volume centers. 2) There is a considerable gap between surgical skills and patients' perception of competence, leading to ethical consequences on modern healthcare. Published incidence of adverse events during robotic surgery in large series is between 2% and 15%, which does not significantly differ amongst open or laparoscopic approaches. 3) No data about gap differences in accessibility to robotic platforms were retrieved from our search. 4) Robotic platforms are expensive but a key reason why hospitals are willing to absorb the high upfront costs is patient demand. It is possible to achieve cost-equivalence between open and robotic prostatectomy if the volume of centers is higher than 10 cases per week. 5) A validated, structured curriculum and accreditation has been created for robotic surgery. This allows acquisition and development of basic and complex robotic skills focusing on patient safety and short learning curve.

CONCLUSIONS

Tech-medicine is rapidly moving forward. Robotic approach to urology seems to be accessible in more affluent countries, safe, economically sustainable, and easy to learn with an appropriate learning curve for both sex. It is mandatory to keep maintaining a critical rational approach with constant control of the available evidence regarding efficacy, efficiency and safety.