Orgasm-associated urinary incontinence (climacturia) following radical prostatectomy: a review of pathophysiology and current treatment options

Systematic review on urinary continence rates after robot-assisted laparoscopic radical prostatectomy

OBJECTIVE

The objective was to investigate the current evidence and discern urinary continence rates post robot-assisted laparoscopic radical prostatectomy (RALP).

METHODS

A systematic review of the literature was carried out, searching the Embase, Scopus and PubMed databases between 1 January 2000 and 1 May 2020. The search terms "Robotic prostatectomy AND continence" were employed. Articles were selected in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Statistical analysis was performed using the programme R; cumulative analysis of percentage of men continent was calculated.

RESULTS

A total of 3101 abstracts and 50 full text articles were assessed, with 22 publications included (n = 2813 patients). There were 21 randomised controlled trials and one partly randomised controlled trial with four publications comparing RALP to other prostate cancer treatments. Thirteen studies explored different RALP techniques, and five studies examined vesicourethral anastomosis (VUA). There were statistically significant improvements in early urinary continence rates in three studies analysing reconstructive techniques (83% vs 60%, p = 0.04; 26.5% vs 15.4%, p = 0.016; 77% vs 44.1%, p ≤ 0.001). Long-term continence rates were not significantly improved across all studies assessing reconstruction. One study comparing RALP vs laparoscopic radical prostatectomy (LRP) demonstrated a statistically significant improvement in continence at 3 months (80% vs 73.3%, p < 0.001); 6 months (83.3% vs 81.4%, p < 0.001); 12 months (95% vs 83.3%, p < 0.001) and 24 months (96.7% vs 85%, p < 0.001). Early continence was less favourable for RALP when compared to brachytherapy (BT) patients at 3 months (86% vs 98.7%, p < 0.05) and 6 months (90.5% vs 98.7%, p < 0.05).

CONCLUSION

Early continence rates were improved across numerous techniques in RALP. These results were not translated into significantly improved long-term outcomes. Continence rates following RALP were favourable compared to LRP, similar to ORP and less favourable compared to BT. Our findings suggest that post-RALP continence can be further improved with alterations in robotic technique.

Evaluation of sexual function after robot-assisted radical prostatectomy: A farewell to IIEF questionnaire

Longevity with localized prostate cancer (PCa) has been achieved, and the contribution of robot-assisted radical prostatectomy (RARP) to cancer control is evident. The next step to investigate in the treatment of localized PCa is improvement of the quality of life (QOL) after RARP. Erectile dysfunction has been considered a major surgical complication, and patient satisfaction after RARP has not improved despite the development of nerve preservation and penile rehabilitation. To comprehensively understand sexual dysfunction after RARP, we must investigate other complications with regard to sexual health, including low sexual desire, disturbed orgasmic function (i.e., anejaculation, orgasm intensity, painful orgasm, and climacturia), shortening of penile length, penile curvature (Peyronie's disease) and unique psychological alterations after the diagnosis of PCa, which are neglected side effects after prostatectomy. In this context, routine evaluation of erectile function by the International Index of Erectile Function only is not sufficient to understand patients' difficulties. A questionnaire is just one way of enabling patients to evaluate their pre- and postoperative concerns; listening to patients face-to-face is warranted to detect symptoms. Understanding the relationship between symptoms and preserved nerve localization can ultimately provide an individualized nerve-sparing procedure and improve patient satisfaction after RARP. In combination with psychological counseling, including the partner and medical treatment, such as testosterone replacement, it is time to reconsider ways to improve sexual dysfunction after RARP.

Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel

BACKGROUND

Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships.

AIM

We convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients' and partners' sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship.

METHODS

The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995-2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment, according to the nomenclature of the American Urological Association (AUA). Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR).

OUTCOMES

Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel.

RESULTS

The guidelines account for patients' cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship.

CLINICAL IMPLICATIONS

The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer.

STRENGTHS & LIMITATIONS

The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries.

CONCLUSION

The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research. Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655-1669.