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

Membranous urethral length is the single independent predictor of urinary continence recovery at 12 months following Retzius-sparing robot-assisted radical prostatectomy

The influence of anatomical parameters on urinary continence (UC) after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) remains uncharted. Our objective was to evaluate their association with UC at 3, 6 and 12 months post-operatively. Data from patients who underwent RS-RARP were prospectively collected. Continence was defined as no pad use. Anatomic variables were measured on preoperative magnetic resonance imaging (MRI). Regression analyses were performed to identify predictors of UC at each time point. We included 158 patients with a median age of 60 years, most of whom had a localized tumor (≤ cT2). On multivariate analyses, at 3 months post-surgery, urinary incontinence (UI) rises with age, odds ratio (OR) 1.07 [95% confidence interval (CI) 1.004-1.142] and with prostate volume (PV), OR 1.029 (95% CI 1.006-1.052); it reduces with longer membranous urethral length (MUL), OR 0.875 (95% CI 0.780-0.983) and with higher membranous urethral volume (MUV), OR 0.299 (95% CI 0.121-0.737). At 6 months, UI rises with PV, OR 1.033 (95% CI 1.011-1.056) and decreases with MUV, OR 0.1504 (95% CI 0.050-0.444). Significantly, at 12 months post-surgery, the only predictor of UI is MUL, OR 0.830 (95% CI 0.706-0.975), establishing a threshold associated with a risk of UI of 5% (MUL > 15 mm) in opposition to a risk of 25% (MUL < 10 mm). This single institutional study requires external validation. To our knowledge, this is the first prospective cohort study supporting MUL as the single independent predictor of UC at 12 months post-surgery. By establishing MUL thresholds, we enable precise patient counseling.

Role of puboperinealis and rectourethralis muscles as a urethral support system to maintain urinary continence after robot-assisted radical prostatectomy

The present study investigated the role of a urethral support system to maintain urinary continence after robot-assisted radical prostatectomy (RARP), with a focus on pelvic floor muscles, such as the puboperinealis muscle (PPM) and rectourethralis muscle (RUM). Finally, 323 patients who underwent RARP were analyzed in this study. All patients performed a one-hour pad test 1, 3, 6, 9, and 12 months after RARP to assess urinary incontinence and MRI before and 9 months after RARP to evaluate the pelvic anatomical structure. The preoperative cross-sectional area of PPM (2.21 ± 0.69 cm2) was significantly reduced by 19% after RARP (1.79 ± 0.60 cm2; p < 0.01). Positive correlations were observed between the amount of urinary leakage according to the 1-h pad test 1, 3, 6, 9, and 12 months after RARP and the change in the cross-sectional area of PPM by RARP (p < 0.01, < 0.001, < 0.001, < 0.001, and < 0.001, respectively). A positive correlation was also noted between the amount of urinary leakage 6 and 12 months after RARP and the preoperative RUM diameter (p < 0.05). The amount of urinary leakage 1, 3, 6, 9, and 12 months after RARP negatively correlated with the change in the antero-posterior diameter of the membranous urethra (MU diameter) from the static to dynamic phases during the Valsalva maneuver by cine MRI. Furthermore, the change in the MU diameter negatively correlated with the change in the cross-sectional area of PPM (p < 0.05). PPM and RUM play significant roles as a supportive mechanism to maintain urinary continence by functioning as a urethral support.

Predictors of Long-Term Urinary Incontinence After Robot-Assisted Laparoscopic Prostatectomy

Introduction

Urinary incontinence is a major complication after radical prostatectomy. We analyzed the predictors of urinary incontinence after robot-assisted radical prostatectomy.

Material and Methods

One hundred twenty-one patients, whose urinary continence status was evaluable at 3 months, 6 months, and 12 months after robot-assisted radical prostatectomy, were included from October 2016 to September 2021. Data were retrospectively collected from electronic medical records. The continence status was evaluated by interviewing the patients about the number of urinary pads used per day. We compared the patients' age, body mass index, prostate volume, membranous urethral length on preoperative magnetic resonance imaging, surgeon experience, and pathological findings between patients with and without regained continence at 12 months after robot-assisted radical prostatectomy.

Results

The urinary continence rates were 30%, 57.8% and 79.3% at 3 months, 6 months, and 12 months, respectively, after robot-assisted radical prostatectomy. Twelve months after robot-assisted radical prostatectomy, 96 patients had regained continence and did not require urinary pads, whereas 25 patients had persistent urinary incontinence and required urinary pads. Membranous urethral length and surgeon experience were significantly different between patients with and without regained continence at 12 months after robot-assisted radical prostatectomy (P=0.05). However, no significant differences existed in age, body mass index, prostate volume, and pathological findings between patients with and without regained continence at 12 months after robot-assisted radical prostatectomy.

Conclusion

Membranous urethral length and surgeon experience are predictors of urinary incontinence after robot-assisted radical prostatectomy. Measuring the membranous urethral length is recommended before performing the operation.

Update on Adjustable Trans-Obturator Male System (ATOMS) for Male Incontinence after Prostate Cancer Surgery

(1) Background: The adjustable trans-obturator male system (ATOMS) is a surgical device developed to treat post-prostatectomy incontinence (PPI) after prostate cancer treatment. We review the current literature on this anti-incontinence device with the intention of assessing the effectiveness, safety and duration of the silicone-covered scrotal port (SSP) ATOMS, the only generation of the device that is currently available. (2) Material and Methods: Non-systematic literature review is performed. Forty-eight full-text articles are assessed for eligibility. Case reports, expert opinions or commentaries without specific data reported (n = 6), studies with patients who underwent intervention before 2014 (IP or SP ATOMS; n = 10), and studies with incontinence after transurethral resection of the prostate (TUR-P; n = 2) are excluded for analysis. Thirty studies with SSP ATOMS are included in a qualitative synthesis that incorporates systematic reviews (n = 3), articles partially overlapping with other previously published studies (e.g., follow-up or series updates; n = 9), and studies focusing on specific populations (n = 8). Only articles revealing outcomes of SSP ATOMS were included in the quantitative synthesis of results (n = 10). (3) Results: the pooled data of 1515 patients from the 10 studies with SSP ATOMS confirmed very satisfactory results with this device after adjustment: dry rate: 63-82%, improved rate: 85-100%, complication rate: 7-33%, device infection rate: 2.7-6.2% and explant rate: 0-19%. The durability of the device is reassuring, with 89% of devices in place 5 years after implantation. (4) Conclusion: Despite the absence of randomized controlled studies, the literature findings confirm results of SSP ATOMS appear equivalent to those of artificial urinary sphincters (AUSs) in terms of continence, satisfaction and complications, but with a lower rate of revision in the long-term. A prospective study identified that patients with daily pad test results <900 mL and a Male Stress Incontinence Grading Scale (MSIGS) of not 4 (i.e., early and persistent stream or urine loss) are the best candidates. Future studies centered on the elder population at higher risk of impaired cognitive ability and in patients including radiation as prostate cancer treatment are needed.

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.

The relationship between pre- and postprostatectomy measures of pelvic floor muscle function and development of early incontinence after surgery

AIMS

The aim of this study is to investigate (i) whether pelvic floor muscle (PFM) shortening can be enhanced by provision of training focused on striated urethral sphincter (SUS) with feedback before prostatectomy, (ii) whether PFM shortening during voluntary efforts and coughing before and after prostatectomy differs between men who do and do not report symptoms of urinary incontinence 1 month after prostatectomy, and (iii) the relationship between severity of incontinence after prostatectomy and features of pelvic floor function (muscle shortening) and urethral length before and after prostatectomy.

METHODS

Sixty men referred for preoperative PFM training before radical prostatectomy participated. The International Continence Society Male Short Form questionnaire was used to quantify continence status. Transperineal ultrasound (US) imaging was used to record pelvic displacements related to activation of striated urethral sphincter, bulbocavernosus (BC) and puborectalis muscles during cough, "natural" voluntary contraction following pamphlet instruction, and trained voluntary contraction after formal physiotherapist instruction including US feedback.

RESULTS

Pelvic floor displacements following training differed between continent and incontinent men; continent participants demonstrated increased SUS shortening after training (compared with "natural"), but no difference was observed between trained and "natural" contractions for incontinent participants. Motion at ano-rectal junction during cough was reduced following surgery, but voluntary and involuntary activation of SUS or BC was not consistently affected by surgery.

CONCLUSIONS

Participants' capacity to improve function of the SUS with training appears related to postprostatectomy continence outcome.