Development and validation of nomograms to predict the recovery of urinary continence after radical prostatectomy: comparisons between immediate, early, and late continence

Predicting incontinence and erectile function after prostate cancer surgery: International validation of models

BACKGROUND

Our objective is to externally validate the most accurate, published tools predicting urinary incontinence and erectile dysfunction following prostatectomy. Several models have been developed to predict the risks of adverse events, though most have not been externally validated.

METHODS

Data were obtained from the Prostate Cancer Outcomes Registry of Australia and New Zealand (PCOR-ANZ). Self-reported urinary incontinence and erectile dysfunction were measured using EPIC-26 at 12 months after radical prostatectomy. Four predictive models were selected for external validation, being the top performing models from a systematic literature review. Two models related to urinary incontinence (Matsushita and Jeong) and two related to sexual function (Alemozaffar and Novara), were examined. Model discrimination was assessed by the Area Under the Received Operator Curve (AUC) and calibration was assessed.

RESULTS

We constructed a cohort of 590 patients resident in either New Zealand or South Australia who had received a radical prostatectomy 2007-2019. The average age at diagnosis was 65 years, with most men having few comorbidities (97.1 % Charlson comorbidity index 0) and treated with robotic surgery (93.6 %). In our external validation cohort, the Almozaffar model demonstrated the highest discrimination when predicting erectile dysfunction (AUC 0.73, 95%CI 0.67-0.78). The highest discrimination achieved by a model predicting urinary incontinence was developed by Jeong (AUC 0.69, 95%CI 0.61-0.76).

CONCLUSIONS

Models predicting erectile dysfunction performed well in external validation and may be suitable for clinical use. Models predicting post-prostatectomy urinary incontinence did not perform as well on validation.

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.

Radiologic feature of complications after artificial urinary sphincter implantation following total prostatectomy

Incontinence following total prostatectomy for prostate cancer significantly impairs patient's quality of life. In severe cases, implantation of an artificial urinary sphincter (AUS) has shown favorable outcomes, enhancing continence by constricting the bulbous urethra. The AUS system consists of a pressure-maintaining balloon, control pump serving as the operational switch, cuff that constricts the urethra, and tubes and connectors that link these components, maintaining a continuous circuit through an internal pressure medium. Most instances of AUS dysfunction are attributed to circuit leaks leading to a reduction in internal pressure, which is identifiable on imaging by fluid accumulation around the circuit, balloon collapse, control pump deformation, and air within the circuit. When the AUS circuit is uncompromised, dysfunction may arise from issues such as the inability to compress the pump due to pain or displacement outside the scrotum or urinary tract obstruction caused by bladder hemorrhage/hematoma. Imaging plays a pivotal role in the evaluation of urinary tract injuries, hematomas/seromas, and infections associated with AUS placement or replacement. Understanding the function of AUS and its appearance on CT imaging is essential for accurately assessing AUS dysfunction and post-implantation complications, guiding clinical decision-making and improving patient care outcomes.

Membranous urethral length measurement on preoperative MRI to predict incontinence after radical prostatectomy: a literature review towards a proposal for measurement standardization

OBJECTIVES

To investigate the membranous urethral length (MUL) measurement and its interobserver agreement, and propose literature-based recommendations to standardize MUL measurement for increasing interobserver agreement. MUL measurements based on prostate MRI scans, for urinary incontinence risk assessment before radical prostatectomy (RP), may influence treatment decision-making in men with localised prostate cancer. Before implementation in clinical practise, MRI-based MUL measurements need standardization to improve observer agreement.

METHODS

Online libraries were searched up to August 5, 2022, on MUL measurements. Two reviewers performed article selection and critical appraisal. Papers reporting on preoperative MUL measurements and urinary continence correlation were selected. Extracted information included measuring procedures, MRI sequences, population mean/median values, and observer agreement.

RESULTS

Fifty papers were included. Studies that specified the MRI sequence used T2-weighted images and used either coronal images (n = 13), sagittal images (n = 18), or both (n = 12) for MUL measurements. 'Prostatic apex' was the most common description of the proximal membranous urethra landmark and 'level/entry of the urethra into the penile bulb' was the most common description of the distal landmark. Population mean (median) MUL value range was 10.4-17.1 mm (7.3-17.3 mm), suggesting either population or measurement differences. Detailed measurement technique descriptions for reproducibility were lacking. Recommendations on MRI-based MUL measurement were formulated by using anatomical landmarks and detailed descriptions and illustrations.

CONCLUSIONS

In order to improve on measurement variability, a literature-based measuring method of the MUL was proposed, supported by several illustrative case studies, in an attempt to standardize MRI-based MUL measurements for appropriate urinary incontinence risk preoperatively.

CLINICAL RELEVANCE STATEMENT

Implementation of MUL measurements into clinical practise for personalized post-prostatectomy continence prediction is hampered by lack of standardization and suboptimal interobserver agreement. Our proposed standardized MUL measurement aims to facilitate standardization and to improve the interobserver agreement.

KEY POINTS

• Variable approaches for membranous urethral length measurement are being used, without detailed description and with substantial differences in length of the membranous urethra, hampering standardization. • Limited interobserver agreement for membranous urethral length measurement was observed in several studies, while preoperative incontinence risk assessment necessitates high interobserver agreement. • Literature-based recommendations are proposed to standardize MRI-based membranous urethral length measurement for increasing interobserver agreement and improving preoperative incontinence risk assessment, using anatomical landmarks on sagittal T2-weighted images.

The Association Between Low Preoperative Serum Testosterone and Post-radical Prostatectomy Urinary Function

OBJECTIVE

To determine if hypogonadism leads to delayed urinary function recovery post-radical prostatectomy (RP) by studying the effect of preoperative factors including age, membranous urethral length, radiation therapy, and Body Mass Index on urinary continence in patients with or without hypogonadism.

MATERIALS AND METHODS

We identified 1209 patients treated by RP with both pretreatment T and post-treatment urinary outcome. We assessed whether there was an association between low preoperative T level (prenoon T ≤ 300 ng/dL) and continence (using ≤1 pad/d) at 6 and 12months post-RP. Patient-reported continence was used when available, otherwise, surgeon-assessed continence was used. Logistic regression models were used, adjusted for age at RP and nerve-sparing status.

RESULTS

Median age at RP was 61 (Intraquatile Range (IQR) 56, 66), 92% of patients had at least one nerve spared and 99% were continent at baseline. Continence in patients with low T was nonsignificantly lower at 6months (odds ratio 0.69, 95% confidence interval 0.44, 1.06; P = .10) and nonsignificantly higher at 12months (odds ratio 1.07, 95% confidence interval 0.71, 1.58; P = .8). Sensitivity analyses excluding patients with preoperative metastasis or treated with androgen deprivation therapy (ADT) and including testosterone as a continuous predictor were consistent with the primary analysis; similarly finding no evidence of an association.

CONCLUSION

Although we cannot rule out an effect on early continence, overall the evidence does not suggest that low serum testosterone adversely impacts urinary function recovery after RP. This finding can be used to counsel patients enrolled in neoadjuvant ADT trials or those patients undergoing RP who have had prior ADT, such as in the setting of oligometastatic disease.

The significance of transrectal ultrasound and urologist_dually guided pelvic floor muscle exercise in improving urinary continence after radical prostatectomy

BACKGROUND

To determine whether transrectal ultrasound and urologist_dually guided pelvic floor muscle exercise is associated with immediate, early and long-term urinary continence after radical prostatectomy.

MATERIALS AND METHODS

Data from 114 patients with localized prostate cancer (PC) who underwent RP at Henan Cancer Hospital from November 2018 to April 2021 were included in the retrospective study. Of the 114 patients, 50 patients in the observation group underwent transrectal ultrasound and urologist_dually guided PFME, and 64 patients in the control group underwent verbally_guided PFME. Contractile function of the external urinary sphincter was in the observation group was evaluated. The immediate, early and long-term urinary continence rates were assessed in both groups, and the factors affecting urinary continence were analyzed.

RESULTS

The urinary continence rate at 2 weeks and 1, 3, 6 and 12 months in the observation group after RP was significantly higher than that in the control group (52.0% vs. 29.7%, 70.0% vs. 39.1%, 82% vs. 57.8, 88% vs. 70.3%, 98.0 vs. 84.4%, p < 0.05). The contractile function of the external urinary sphincter was obviously correlated with urinary continence at multiple visits after RP, except for the 12-month visit. Transrectal ultrasound and urologist-dually guided PFME was verified to be an independent positive factor for urinary continence at 2 weeks and 1, 3, 6 and 12 months using logistic regression analysis. However, TURP was a negative factor for postoperative urinary continence at different times.

CONCLUSIONS

Transrectal ultrasound and urologist_dually guided PFME had a significant role in improving immediate, early and long-term urinary continence after RP and acted as an independent prognostic factor.

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.

A Matched-Pair Analysis after Robotic and Retropubic Radical Prostatectomy: A New Definition of Continence and the Impact of Different Surgical Techniques

Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.

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.

The key role of levator ani thickness for early urinary continence recovery in patients undergoing robot-assisted radical prostatectomy: A multi-institutional study

BACKGROUND

Urinary continence (UC) recovery dramatically affects quality of life after robot-assisted radical prostatectomy (RARP). Membranous urethral length (MUL) has been the most studied anatomical variable associated with UC recovery.

OBJECTIVE

To investigate whether levator ani thickness (LAT), assessed with multi-parametric magnetic resonance imaging (mpMRI), correlates with UC recovery after RARP.

DESIGN, SETTING, AND PARTICIPANTS

The study included 209 patients treated with RARP by expert surgeons with extensive robotic experience from 2017 to 2019. All patients had complete, clinical, mpMRI, pathological, and postoperative data including pelvic floor muscle training (PFMT) protocols.

INTERVENTION

After a radiologist-specific training, two urologists independently examined the files, blinded to clinical and pathological findings as well as to postoperative continence status.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

On mpMRI, LAT, bladder neck (BN) shape, MUL, and apex overlapping (AO) were measured. UC recovery was defined as use of 0 or 1 safety pad at follow-up. Multivariable models were used to assess the association between variables and UC recovery.

RESULTS AND LIMITATIONS

Overall, 173 (82.8%) patients were continent after a median follow-up of 23 months (interquartile range [IQR]: 17-28). Of these, 98 (46.9%) recovered within 3 months after surgery, 42 (20.1%) from 3 to 6 months, and 33 (15.8%) from 6 months onwards. A significant higher rate of patients with LAT > 10 mm (88.1 vs.75.8%; p = 0.03) experienced UC recovery, compared to those with LAT < 10 mm. This difference was observed in the first 3 months after surgery. At multivariable analysis, LAT (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02-1.37; p = 0.02), Preoperative ICIQ score (OR: 0.91, 95% CI: 0.82-0.98, p = 0.03) and PFMT (OR: 1.98, 95% CI: 1.01-3.93; p = 0.04) independently predict higher UC recovery within 3 months, after accounting for age, BMI, preoperative PSA, D'Amico risk group, MUL, BN shape and AO.

CONCLUSIONS

LAT greater than 1 cm was associated with greater UC recovery. Specifically, LAT greater than 1 cm seems to be associated with higher UC rate at 3 months after RARP, compared to those with LAT < 1 cm.

PATIENT SUMMARY

Magnetic resonance features can help in predicting the risk of incontinence after robot-assisted radical prostatectomy and should be taken into account when counseling patients before surgery.

Prediction of Incontinence after Robot-Assisted Radical Prostatectomy: Development and Validation of a 24-Month Incontinence Nomogram

Simple Summary

Many men fear urinary leakage after radical surgery for prostate cancer and may even choose against operation for unrealistic fears of leakage. Many urologists are unaware of their own results, and some urologists who collect their results do so in different ways. We collected urinary leakage data from 680 men in a uniform and simple way at 6, 12, and 24 months after operation: no pads, 1–2 pads, or ≥3 pads required daily. We used many patient characteristics to identify the key factors that predict recovery of urinary control after operation: age, race, height and weight, and preoperative erectile function. Easy-to-use nomograms were constructed that should be tested by other urologists to make sure they perform equally well in their patients. Nomograms like these allow men and the urologists counseling them to share patient-specific information about the timeline for, and the chance of, recovery of urinary control after operation.

Abstract

Incontinence after robot-assisted radical prostatectomy (RARP) is feared by most patients with prostate cancer. Many risk factors for incontinence after RARP are known, but a paucity of data integrates them. Prospectively acquired data from 680 men who underwent RARP January 2008–December 2015 and met inclusion/exclusion criteria were queried retrospectively and then divided into model development (80%) and validation (20%) cohorts. The UCLA-PCI-Short Form-v2 Urinary Function questionnaire was used to categorize perfect continence (0 pads), social continence (1–2 pads), or incontinence (≥3 pads). The observed incontinence rates were 26% at 6 months, 7% at 12 months, and 3% at 24 months. Logistic regression was used for model development, with variables identified using a backward selection process. Variables found predictive included age, race, body mass index, and preoperative erectile function. Internal validation and calibration were performed using standard bootstrap methodology. Calibration plots and receiver operating curves were used to evaluate model performance. The initial model had 6-, 12-, and 24-month areas under the curves (AUCs) of 0.64, 0.66, and 0.80, respectively. The recalibrated model had 6-, 12-, and 24-month AUCs of 0.52, 0.52, and 0.76, respectively. The final model was superior to any single clinical variable for predicting the risk of incontinence after RARP.

Development of New Comorbidities in Patients Awaiting Urinary Incontinence Surgery Following Radical Prostatectomy

OBJECTIVE

To examine the incidence and factors associated with the development of new comorbidities in men undergoing anti-incontinence surgery after prostate cancer (PCa) surgery. Post-prostatectomy incontinence (PPI) may deter men from engaging in physical activities and increase the risk of developing comorbidities after prostatectomy.

METHODS

Patients undergoing surgery for PPI from 2006 to 2019 were identified. A retrospective review was performed to document patient characteristics noted at the time of PCa surgery and compare these with parameters recorded at the time of anti-incontinence surgery.

RESULTS

A total of 229 patients were included. Mean age was 68.8 years at time of incontinence surgery. Median duration of incontinence was 3.5 ± 4.6 years. There was a significant increase in CCI comorbidities between PCa surgery and PPI surgery (2.7 ± 1.5 vs 4.1 ± 1.9, P < .0001). Almost half of patients (45.2%) developed a new comorbidity while awaiting incontinence surgery including an increase in the incidence of diabetes (21.9% vs 12.7%; p<0.0001), hypertension (56.2% vs 36.7%; P < .0001), coronary artery disease (14.6% vs 8.9%; P = .008) and arrhythmia (11.0% vs 3.8%; P = .008). On multivariable analysis, duration of incontinence was significantly associated with development of new comorbidities (O.R. 1.2, P = .01) while age (P = .20) and incontinence severity (P = 1.0) were not. There was no change in weight (P = .34), obesity (P = 1.0) or BMI (P = .18) between PCa surgery and PPI surgery.

CONCLUSION

Patients with PPI appear at risk of developing new comorbidities while awaiting anti-incontinence surgery. Strategies which expedite return of continence for example, early surgical intervention, may facilitate resumption of physical activity and minimize the risk of future comorbidity.

Patient reported outcome measures concerning urinary incontinence after robot assisted radical prostatectomy: development and validation of an online prediction model using clinical parameters, lower urinary tract symptoms and surgical experience

The prediction of post-prostatectomy incontinence (PPI) after robot-assisted radical prostatectomy (RARP) depends on multiple clinical, anatomical and surgical factors. There are only few risk formulas, tables or nomograms predicting PPI that may assist clinicians and their patients in adequate risk counseling on postoperative side-effects. Prospective data collection of 1814 patients who underwent RARP between 2009 and 2017 was done. Pre-operative parameters were age, body mass index (BMI), prostate volume, the American Society of Anesthesiologists (ASA) score, severity of Lower Urinary Tract Symptoms (LUTS), type of planned nerve-sparing surgery and surgical experience. The continence status was reported using Patient Reported Outcome Measurements (PROMs) using the validated pad-use questionnaire EPIC26. Continence was defined as either the use of zero pads or one safety pad. Multivariable logistic regression analysis was performed to identify predictors of PPI within one year after RARP. An online prediction tool was developed and validated. The median follow-up was 36 months (range 12-108). The response rate was high at 85.2%. A total of 85% (1537/1814) of patients was continent on follow-up. One-year continence rate was 80.1% (95% CI 78.3-81.9%) (1453/1814) and increased to 87.4% (95% CI 85.4-89.4%) after 5 years. On multivariable analysis, severity of LUTS (OR = 0.56 p = 0.004), higher age (OR = 0.73 p = 0.049), extend of nerve-sparing surgery (OR = 0.60 p = 0.001) and surgeon experience (OR = 1.48 p = 0.025) were significant independent predictors for PPI. The online prediction model performed well in predicting continence status with poor discrimination and good calibration. An intuitive online tool was developed to predict PPI after RARP that may assist clinicians and their patients in counseling of treatment.

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.

Development and validation of a nomogram for predicting early stress urinary incontinence following endoscopic enucleation of the prostate

PURPOSE

To develop and validate a predictive nomogram for early stress urinary incontinence (SUI) after endoscopic enucleation of the prostate (EEP) in patients with benign prostatic hyperplasia (BPH).

METHODS

The records of 458 patients who underwent plasmakinetic- or diode-based EEP at our center from March 2016 to December 2019 were reviewed. Among these, 326 and 132 cases were randomly assigned to the training and validation set, respectively. A predictive nomogram was constructed based on multivariate logistic regression analysis. Receiver operating characteristic (ROC) analysis and calibration curves were employed to evaluate its performance.

RESULTS

65 years ≤ age < 70 years, 75 years ≤ age, 25 kg/m² ≤ BMI < 30 kg/m², 30 kg/m² ≤ BMI, 5 years ≤ LUTS duration, and 75 ml ≤ prostate volume were finally selected as independent predictors of early SUI into the multivariate logistics regression model. It was visualized as a concise nomogram with satisfactory discrimination and accuracy in both training and validation sets.

CONCLUSIONS

A concise nomogram was developed and validated as a useful clinical tool for predicting early SUI post-EEP.

Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy

Radical prostatectomy directly affects urinary continence dynamics with incontinence being a major factor in patients’ quality of life, social and psychological status. In order to help maintain continence after robot-assisted radical prostatectomy (RARP), a number of surgical techniques have been described. In the present narrative review, we summarize the surgical techniques that have been applied during RARP and their effects on incontinence rates and time to continence recovery.

Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy

Radical prostatectomy directly affects urinary continence dynamics with incontinence being a major factor in patients' quality of life, social and psychological status. In order to help maintain continence after robot-assisted radical prostatectomy (RARP), a number of surgical techniques have been described. In the present narrative review, we summarize the surgical techniques that have been applied during RARP and their effects on incontinence rates and time to continence recovery.

A novel tool to predict functional outcomes after robot-assisted radical prostatectomy and the value of additional surgery for incontinence

OBJECTIVES

To develop and validate a model to predict 12-month continence status after robot-assisted radical prostatectomy (RARP) from preoperative and 3-month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option.

PATIENTS AND METHODS

Data on 9421 patients in 25 Belgian centres were prospectively collected (2009-2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) at 12-months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3-month postoperative characteristics and 12-month continence status. This association was visualised using nomograms and an online tool.

RESULTS

At 12 months, the mean (sd) score of the ICIQ-UI-SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORCT QLQ-C30)/quality of life (QoL) score (Est. -0.011, se 0.003), higher preoperative ICIQ-UI-SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12-month ICIQ-UI-SF score. For the 3-month model, higher preoperative ICIQ-UI-SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3-month EORCT QLQ-C30/QoL score (Est. -0.010, se 0.002) and higher 3-month ICIQ-UI-SF score (Est. 0.562, se 0.009) were associated with a higher 12-month ICIQ-UI-SF score.

CONCLUSIONS

Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.

Patient reported outcome measures concerning urinary incontinence after robot assisted radical prostatectomy: development and validation of an online prediction model using clinical parameters, lower urinary tract symptoms and surgical experience

The prediction of post-prostatectomy incontinence (PPI) after robot-assisted radical prostatectomy (RARP) depends on multiple clinical, anatomical and surgical factors. There are only few risk formulas, tables or nomograms predicting PPI that may assist clinicians and their patients in adequate risk counseling on postoperative side-effects. Prospective data collection of 1814 patients who underwent RARP between 2009 and 2017 was done. Pre-operative parameters were age, body mass index (BMI), prostate volume, the American Society of Anesthesiologists (ASA) score, severity of Lower Urinary Tract Symptoms (LUTS), type of planned nerve-sparing surgery and surgical experience. The continence status was reported using Patient Reported Outcome Measurements (PROMs) using the validated pad-use questionnaire EPIC26. Continence was defined as either the use of zero pads or one safety pad. Multivariable logistic regression analysis was performed to identify predictors of PPI within one year after RARP. An online prediction tool was developed and validated. The median follow-up was 36 months (range 12–108). The response rate was high at 85.2%. A total of 85% (1537/1814) of patients was continent on follow-up. One-year continence rate was 80.1% (95% CI 78.3–81.9%) (1453/1814) and increased to 87.4% (95% CI 85.4–89.4%) after 5 years. On multivariable analysis, severity of LUTS (OR = 0.56 p = 0.004), higher age (OR = 0.73 p = 0.049), extend of nerve-sparing surgery (OR = 0.60 p = 0.001) and surgeon experience (OR = 1.48 p = 0.025) were significant independent predictors for PPI. The online prediction model performed well in predicting continence status with poor discrimination and good calibration. An intuitive online tool was developed to predict PPI after RARP that may assist clinicians and their patients in counseling of treatment.

Deep learning using preoperative magnetic resonance imaging information to predict early recovery of urinary continence after robot-assisted radical prostatectomy

OBJECTIVES

To investigate whether a deep learning model from magnetic resonance imaging information is an accurate method to predict the risk of urinary incontinence after robot-assisted radical prostatectomy.

METHODS

This study included 400 patients with prostate cancer who underwent robot-assisted radical prostatectomy. Patients using 0 or 1 pad/day within 3 months after robot-assisted radical prostatectomy were categorized into the "good" group, whereas the other patients were categorized into the "bad" group. Magnetic resonance imaging DICOM data, and preoperative and intraoperative covariates were assessed. To evaluate the deep learning models from the testing dataset, their sensitivity, specificity and area under the receiver operating characteristic curve were analyzed. Gradient-weighted class activation mapping was used to visualize the regions of deep learning interest.

RESULTS

The combination of deep learning and naive Bayes algorithm using axial magnetic resonance imaging in addition to clinicopathological parameters had the highest performance, with an area under the receiver operating characteristic curve of 77.5% for predicting early recovery from post-prostatectomy urinary incontinence, whereas machine learning using clinicopathological parameters only achieved low performance, with an area under the receiver operating characteristic curve of 62.2%. The gradient-weighted class activation mapping methods showed that deep learning focused on pelvic skeletal muscles in patients in the good group, and on the perirectal and hip joint regions in patients in the bad group.

CONCLUSIONS

Our results suggest that deep learning using magnetic resonance imaging is useful for predicting the severity of urinary incontinence after robot-assisted radical prostatectomy. Deep learning algorithms might help in the choice of treatment strategy, especially for prostate cancer patients who wish to avoid prolonged urinary incontinence after robot-assisted radical prostatectomy.

Applying nomograms based on the surveillance, epidemiology and end results database to predict long-term overall survival and cancer-specific survival in patients with oropharyngeal squamous cell carcinomas: A case-control research

Few models regarding to the individualized prognosis assessment of oropharyngeal squamous cell carcinoma (OPSCC) patients were documented. The purpose of this study was to establish nomogram model to predict the long-term overall survival (OS) and cancer-specific survival (CSS) of OPSCC patients. The detailed clinical data for the 10,980 OPSCC patients were collected from the surveillance, epidemiology and end results (SEER) database. Furthermore, we applied a popular and reasonable random split-sample method to divide the total 10,980 patients into 2 groups, including 9881 (90%) patients in the modeling cohort and 1099 (10%) patients in the external validation cohort. Among the modeling cohort, 3084 (31.2%) patients were deceased at the last follow-up date. Of those patients, 2188 (22.1%) patients died due to OPSCC. In addition, 896 (9.1%) patients died due to other causes. The median follow-up period was 45 months (1-119 months). We developed 2 nomograms to predict 5- and 8- year OS and CSS using Cox Proportional Hazards model. The nomograms' accuracy was evaluated through the concordance index (C-index) and calibration curves by internal and external validation. The C-indexes of internal validation on the 5- and 8-year OS and CSS were 0.742 and 0.765, respectively. Moreover, the C-indexes of external validation were 0.740 and 0.759, accordingly. Based on a retrospective cohort from the SEER database, we succeeded in constructing 2 nomograms to predict long-term OS and CSS for OPSCC patients, which provides reference for surgeons to develop a treatment plan and individual prognostic evaluations.

Effect of Reconstructive Techniques on Continence in Robot-Assisted Laparoscopic Prostatectomy: Novel Combination of Long Urethral Stump and Anterior Suspension Suture

Objective

To investigate the effects of the novel combination of a long urethral stump and anterior suspension suture in patients who underwent Robot-Assisted Laparoscopic Prostatectomy (RALP) for localized prostate cancer.

Materials and Methods

Of the 40 participating patients, 20 did not undergo any reconstructive technique, whereas the remaining 20 patients underwent reconstructive technique that included the combination of long urethral stump and anterior suspension suture. Body mass index (BMI) (kg/m²), age, preoperative prostate-specific antigen (PSA) levels, prostate volume, Gleason score, D'Amico risk class, clinical stage, operation type and the application of either perioperative or postoperative reconstructive techniques, and the duration of catheterization were the parameters investigated. Continence rate was measured in the 3^rd, 6^th, and 12^th month after the removal of the catheter. Both techniques were compared statistically.

Results

The control and reconstructive groups each comprised 20 patients. Between the groups, no statistically significant differences were observed in age, BMI, American Society of Anesthesiologists class, risk group, prostate weight, perioperative PSA, duration of surgery, duration of hospitalization, surgical margins, and the total amount of bleeding (p>0.05). Continence rate was significantly higher in the reconstructive group in the 3^rd and 6^th months compared with the control group (p<0.05).

Conclusion

The combination of anterior suspension suture and long urethral stump contributed to early improvement in the continence rates.

Total anatomical reconstruction during robot-assisted radical prostatectomy: focus on urinary continence recovery and related complications after 1000 procedures

OBJECTIVES

To present the functional and oncological outcomes after ≥1 year of follow-up, following an experience of >1000 robot-assisted radical prostatectomies (RARPs) with our standardised total anatomical reconstruction (TAR) technique. To evaluate which factors influence postoperative continence recovery in order to obtain a nomogram to predict the risk of postoperative urinary incontinence (UI).

PATIENTS AND METHODS

The enrolment phase began in June 2013 and ended in May 2017. Patients were prospectively included in the study with the following inclusion criteria: (i) localised prostate cancer (clinical stages cT1-3, cN0, cM0); (ii) indication for RP; and (iii) preoperative multiparametric prostate magnetic resonance imaging. All patients underwent RARP with the TAR technique done at the end of the demolitive phase. The continence rates were assessed at 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal. Patients were defined as continent if they answered 'zero pad' or 'one safety pad' per day. A logistic regression model was used to evaluate the potential impact of some pre- and intraoperative factors on postoperative urinary continence recovery. Model discrimination was assessed using an area under (AUC) the receiver operating characteristic (ROC) curve. A nomogram to predict the risk of postoperative UI after RARP with the TAR technique was generated based on the logistic model.

RESULTS

In all, 1008 patients were enrolled in our study. At 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal, 621 (61.61%), 594 (58.93%), 803 (79.66%), 912 (90.48%), 950 (94.25%) and 956 (94.84%) patients were continent, respectively. In the logistic regression model, the variables analysed had a higher impact on continence recovery at 4 and 12 weeks. At 4 weeks, the postoperative odds of urinary continence recovery increased with the absence of diabetes [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.41-5.41] and D'Amico low vs high risk (OR 2.01, 95% CI 1.01-3.99). At 12 weeks, urinary continence increased with the absence of diabetes (OR 3.01, 95% CI 1.23-7.35), D'Amico low vs high risk (OR 4.04, 95% CI 1.56-10.47), and D'Amico intermediate vs high risk (OR 3.33, 95% CI 1.66-6.70). ROC curves were drawn and an AUC value of 61.9% (95% CI 57.49-66.36) at 4 weeks and 63.8% (95% CI 58.03-69.65) at 12 weeks were computed. Based on these parameters, two nomograms (at 4 and 12 weeks postoperatively) were generated.

CONCLUSION

The TAR technique conferred excellent results in the early recovery of urinary continence. Two nomograms were created, to predict preoperatively the postoperative odds of urinary continence recovery at 4 and 12 weeks after RARP by integrating the presence of diabetes and D'Amico risk classification.

Appropriate preoperative membranous urethral length predicts recovery of urinary continence after robot-assisted laparoscopic prostatectomy

PURPOSE

We investigated that preoperative membranous urethral length (MUL) would be associated with the recovery of urinary continence after robot-assisted laparoscopic prostatectomy (RALP).

PATIENTS AND METHODS

We studied 204 patients who underwent RALP between May 2013 and March 2016. All patients underwent pelvic magnetic resonance imaging (MRI) preoperatively to measure MUL. Urinary continence was defined as the use of one pad or less (safety pad). The 204 patients were divided into two groups: continence group, those who achieved recovery of continence at 3, 6, and 12 months after RALP, and incontinence group, those who did not. We retrospectively analyzed the patients in terms of preoperative clinical factors including age, body mass index (BMI), estimated prostate volume, neurovascular bundle salvage, history of preoperative hormonal therapy, and MUL.

RESULTS

The safety pad use rate was 69.6%, 86.9%, and 91.1% at 3, 6, and 12 months, respectively. On univariate and multivariate analyses, MUL were significant factors in every term of recovery of urinary continence in both groups. According to the receiver operating characteristic (ROC) curve analysis, the preoperative MUL that could best predict early recovery of urinary continence at 3 months after RALP was 12 mm.

CONCLUSIONS

We suggest that preoperative MUL > 12 mm would be a predictor of early recovery of urinary continence after RALP.

Prevalence analysis of urinary incontinence after radical prostatectomy and influential preoperative factors in a single institution

AIMS

To assess prevalence of urinary incontinence (UI) after radical prostatectomy (RP) and to analyze which preoperative characteristics of the patients have influence on UI.

METHODS

Between 2002 and 2012, 746 consecutive patients underwent RP for clinically localized prostate cancer. We defined UI according to International Continence Society (ICS) definition: "the complaint of any involuntary leakage of urine" after 12 months of recovery, international consultation on incontinence questionnaire (ICIQ-SF) and pads/day was collected too. Clinical features and magnetic resonance imaging measurements were assessed. A multivariable logistic regression model predicting incontinence were built-in after adjust by cofounding factors and bootstrapping.

RESULTS

About 172 (23%) of the patients were classified as incontinent according to the ICS definition. The mean value of the ICIQ-SF was 10.87 (±4). 17.8% of patients use at least one pad/day, 11.9% use more than one pad/day. The preoperative factors independently influential in UI are: age [OR: 1.055; CI 95% (1.006-1.107), p = .028], urethral wall thickness [OR: 5.03; CI 95% (1.11-22.8), p = .036], history of transurethral resection of the prostate [OR: 6.13; CI 95% (1.86-20.18), p = .003] and membranous urethral length [OR: 0.173; CI 95% (0.046-0.64), p = .009]. The predictive accuracy of the model is 78.7% and the area under the curve (AUC) value 71.7%.

CONCLUSIONS

Urinary incontinence after radical prostatectomy has different prevalence depending on the definition. Age, prior transurethral resection of the prostate (TURP), membranous urethral length (MUL) and urethral wall thickness (UWT) were risk factors.

Comprehensive approach for post-prostatectomy incontinence in the era of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) has enabled steady and stable surgical procedures due to both meticulous maneuvers and magnified, clear, 3-dimensional vision. Therefore, better surgical outcomes have been expected with RARP than with other surgical modalities. However, even in the RARP era, post-prostatectomy incontinence has a relatively high incidence as a bothersome complication. To overcome post-prostatectomy incontinence, it goes without saying that meticulous surgical procedures and creative surgical procedures, i.e., "Preservation", "Reconstruction", and "Reinforcement" of the anatomical structures of the pelvis, are most important. In addition, medication and appropriate pad usage might sometimes be helpful for patients with post-prostatectomy incontinence. However, patients who have 1) BMI > 26 kg/m², 2) prostate volume > 70 mL, 3) eGFR < 60 mL/min, or a 4) Charlson comorbidity index > 2 have a tendency to develop post-prostatectomy incontinence despite undergoing the same surgical procedures. It is important for patients who have a high risk for post-prostatectomy incontinence to be given information about delayed recovery of post-prostatectomy incontinence. Thus, not only the surgical procedures, but also a comprehensive approach, as mentioned above, are important for post-prostatectomy incontinence.

Selection Criteria for Active Surveillance of Patients with Prostate Cancer in Korea: A Multicenter Analysis of Pathology after Radical Prostatectomy

Purpose

Korean patients with prostate cancer (PC) typically present with a more aggressive disease than patients in Western populations. Consequently, it is unclear if the current criteria for active surveillance (AS) can safely be applied to Korean patients. Therefore, this study was conducted to define appropriate selection criteria for AS for patients with PC in Korea.

Materials and Methods

We conducted a multicenter retrospective study of 2,126 patients with low risk PC who actually underwent radical prostatectomy. The primary outcome was an unfavorable disease, which was defined by non-organ confined disease or an upgrading of the Gleason score to ≥ 7 (4+3). Predictive variables of an unfavorable outcome were identified by multivariate analysis using randomly selected training samples (n=1,623, 76.3%). We compared our selected criteria to various Western criteria for the primary outcome and validated our criteria using the remaining validation sample (n=503, 23.7%).

Results

A non-organ confined disease rate of 14.9% was identified, with an increase in Gleason score ≥ 7 (4+3) of 8.7% and a final unfavorable disease status of 20.8%. The following criteria were selected: Gleason score ≤ 6, clinical stage T1-T2a, prostate-specific antigen (PSA) ≤ 10 ng/mL, PSA density < 0.15 ng/mL/mL, number of positive cores ≤ 2, and maximum cancer involvement in any one core ≤ 20%. These criteria provided the lowest unfavorable disease rate (11.7%) when compared to Western criteria (13.3%-20.7%), and their validity was confirmed using the validation sample (5.9%).

Conclusion

We developed AS criteria which are appropriate for Korean patients with PC. Prospective studies using these criteria are now warranted.

Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis

CONTEXT

Membranous urethral length (MUL) measured prior to radical prostatectomy (RP) has been identified as a factor that is associated with the recovery of continence following surgery.

OBJECTIVE

To undertake a systematic review and meta-analysis of all studies reporting the effect of MUL on the recovery of continence following RP.

EVIDENCE ACQUISITION

A comprehensive search of PubMed, EMBASE, and Scopus databases up to September 2015 was performed. Thirteen studies comprising one randomized controlled trial and 12 cohort studies were selected for inclusion.

EVIDENCE SYNTHESIS

Four studies (1738 patients) that reported hazard ratio results. Every extra millimeter (mm) of MUL was associated with a faster return to continence (hazard ratio: 1.05; 95% confidence interval [CI]: 1.02-1.08, p<0.001). Eleven studies (6993 patients) reported the OR (OR) for the return to continence at one or more postoperative time points. MUL had a significant positive effect on continence recovery at 3 mo (OR: 1.08, 95% CI: 1.03-1.14, p=0.004), 6 mo (OR: 1.12, 95% CI: 1.09-1.15, p<0.0001). and 12 mo (OR: 1.12, 95% CI: 1.03-1.22, p=0.006) following surgery. After adjusting for repeated measurements over time and studies with overlapping data, all OR data combined indicated that every extra millimeter of MUL was associated with significantly greater odds for return to continence (OR: 1.09, 95% CI: 1.05-1.15, p<0.001).

CONCLUSIONS

A greater preoperative MUL is significantly and positively associated with a return to continence in men following RP. Magnetic resonance imaging measurement of MUL is recommended prior to RP.

PATIENT SUMMARY

We examined the effect that the length of a section of the urethra (called the membranous urethra) had on the recovery of continence after radical prostatectomy surgery. Our results indicate that measuring the length of the membranous urethra via magnetic resonance imaging before surgery may be useful to predict a longer period of urinary incontinence after surgery, or to explain a delay in achieving continence after surgery.

Predictors of early continence following robot-assisted radical prostatectomy

INTRODUCTION

Functional outcomes after robot-assisted radical prostatectomy (RARP) greatly influence patient quality of life. Data regarding predictors of early continence, especially 1 month following RARP, are limited. Previous reports mainly address immediate or 3-month postoperative continence rates. We examine preoperative predictors of pad-free continence recovery at the first follow-up visit 1 month after RARP.

METHODS

Between January 2007 and January 2013, preoperative and follow-up data were prospectively collected for 327 RARP patients operated on by 2 fellowship-trained surgeons (AEH and KCZ). Patient and operative characteristics included age, body mass index (BMI), staging, preoperative prostate-specific antigen (PSA), prostate weight, International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM) score and type of nerve-sparing performed. Continence was defined by 0-pad usage at 1 month follow-up. Univariate and multivariate logistic regression models were used to assess for predictors of early continence.

RESULTS

Overall, 44% of patients were pad-free 1 month post-RARP. In multivariate regression analysis, age (odds ratio [OR] 0.946, confidence interval [CI] 95%: 0.91, 0.98) and IPSS (OR: 0.953, CI 95%: 0.92, 0.99) were independent predictors of urinary continence 1 month following RARP. Other variables (BMI, staging, preoperative PSA, SHIM score, prostate weight and type of nerve-sparing) were not statistically significant predictors of early continence. Limitations of this study include missing data for comorbidities, patient use of pelvic floor exercises and patient maximal activity. Moreover, patient-reported continence using a 0-pad usage definition represents a semiquantitative and subjective measurement.

CONCLUSION

In a broad population of patients who underwent RARP at our institution, 44% of patients were pad-free at 1 month. Age and IPSS were independent predictors of early continence after surgery. Men of advanced age and those with significant lower urinary tract symptoms prior to RARP should be counselled on the increased risk of urinary incontinence in the early stages.