Early continence after radical prostatectomy: A systematic review

State of art of robotic prostatectomy: the way we do it in Catalonia, Spain

INTRODUCTION AND OBJECTIVE

Robotic-assisted laparoscopic prostatectomy (PLAR) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the PLAR "state of art" in Catalonia, Spain.

MATERIAL AND METHODS

This was a cross-sectional survey-based study conducted among urologists across Catalonia, Spain. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v20.

RESULTS

59 urologists completed the survey, revealing PLAR as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the Airseal technology. The intraperitoneal approach is performed in >90% of cases. Endopelvic fascia preservation is not routinely performed. 34.5% of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. 34% performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage. Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95%CI 0.07-0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95%CI 1.07-127.60) and endopelvic fascia preservation (OR 13.64, 95%CI 1.087-201.27), but there was no correlation with time the bladder catheter or days hospitalized.

CONCLUSIONS

The study provides an overview of the state of PLAR in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Continence-Sparing Techniques in Radical Prostatectomy: A Systematic Review of Randomized Controlled Trials

Background: Numerous continence-sparing radical prostatectomy techniques have been developed to enhance postoperative early continence (EC) recovery; however, evidence regarding the best approach remains controversial. The objectives are to provide a critical appraisal of various prostatectomy techniques, based on the evidence of quality-assessed randomized control trials (RCTs); to summarize the immediate continence and the EC reported; and to propose a new standardization for continence outcomes reporting. Methods: Data acquired from five medical registries were reported to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Evidence from published, English, full-text RCTs reporting postoperative urinary continence outcomes within 6 months from surgery was included. The heterogeneity of surgical techniques and continence definitions did not allow a meta-analysis. All RCTs were critically appraised, and quality assessed. Results: In total, 39 RCTs were included: 19 of 39 studies were low-quality RCTs, presenting small cohort, monocentric, or single-surgeon data. The best RCT-supported evidence is in favor of robot-assisted radical prostatectomy (RARP) compared with laparoscopic radical prostatectomy (LRP) and of the Retzius-sparing (RS) technique over the traditional prostatectomy. Other techniques such as bladder neck and puboprostatic ligament (PPL) preservation, posterior reconstruction with or without combination of anterior suspension technique, and nerve-sparing (NS) approach seem to enhance EC. Oppositely, the endopelvic fascia preservation, bladder neck mucosa eversion/plication/slings, and the selective ligature of dorsal venous complex (DVC) were not significantly associated with EC improvements. RCTs are lacking on pubovesical complex-sparing, seminal vesicle preservation, anterior reconstruction of the puboprostatic collar, musculofascial reconstruction, and DVC suspension to the periosteum of the pubic bone techniques. Conclusions: RARP and RS have high-quality evidence supporting their ability to enhance postoperative EC recovery. NS, bladder neck, and PPL preservation may contribute to better EC recovery, although the evidence level is low. Further multicenter RCTs are needed to establish the optimal combination of standard surgical techniques. A new continence outcome-reporting standardization was proposed.

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.

Quality of Life of Prostate Cancer Patients Undergoing Prostatectomy and Affective Temperament

Purpose

Prostate cancer (PC) is one of the most common malignancies in men. The population of PC survivors is growing, and understanding the roles of different factors that affect quality of life (QoL) is important. We investigated the effects of affective temperament on the QoL of PC patients.

Patients and Methods

All subjects (n=100) underwent medical evaluation [including demographic data, medical history, physical examination, biochemical tests, and assessment of urinary incontinence (ICIQ-UI SF scale) and erectile dysfunction (ED) (IIEF-5 and subjective ED scale)] and psychological evaluation [including assessment of affective temperament using the TEMPS-A scale, depression and anxiety (using HADS), and QoL (EORTC-QLQ-C30 and EORTC-PR25)]. The relationships between individual variables were examined.

Results

Erection quality after treatment was associated with better QoL in most parameters. Similar strong relationships were observed between the urinary incontinence scale and QoL. Depressive, cyclothymic, irritable, and anxious temperaments were associated with decreased QoL. On the EORTC-PR25 scale, associations were observed between a depressive temperament and worse sexual function and urinary symptoms, between a cyclothymic temperament and worse urinary symptoms, and between an irritable temperament and worse sexual functioning. Multivariate analysis identified the severity of anxiety and depression symptoms measured by HADS as the most important psychological factors affecting QoL.

Conclusion

QoL in PC survivors depends on many factors, including age, interval since diagnosis, tumor stage, treatment, complications, and affective temperament profile. Depressive, cyclothymic, irritable, and anxious temperaments were associated with poorer QoL in selected domains, which was not observed for a hyperthymic temperament. The temperament profile of patients was associated with mood and anxiety level, which were important determinants of a poorer QoL.

Continence definition and prognostic factors for early urinary continence recovery in posterior rhabdosphincter reconstruction after robot-assisted radical prostatectomy. Post-hoc analysis of a randomised controlled trial

INTRODUCTION

Urinary incontinence after radical prostatectomy (RP) is an adverse event with high impact on patient's quality of life. Nowadays there is no standardized method for urinary continence measurement. Posterior rhabdosphincter reconstruction (PRR) is a surgical step that can improve early urinary continence after RP. Our objective was to analyse different continence definitions and predictors of urinary continence recovery after robot-assisted RP (RARP).

MATERIAL AND METHODS

We conducted a double-blind, randomised controlled trial (NCT03302169) including 152 consecutive patients with localized prostate cancer subjected to RARP. Patients were randomised to single urethrovesical anastomosis (control arm) or PRR before urethrovesical anastomosis (PRR arm). Urinary continence was measured with the EPIC-26 and ICIQ-SF validated questionnaires, and pad use (0-1 pads and no pads), at 7, 15, 30, 90, 180 and 365 days after catheter removal. Prognostic factors for early urinary continence recovery were analysed.

RESULTS

72 patients were included in the control arm and 80 in the PRR arm. Baseline characteristics were similar between arms, except body mass index, which was higher in PRR arm. "No pad" was the only definition assessing the benefit of PRR at 30 days, 33.8% in PRR arm and 18.1% in control arm, p = 0.022; and at 90 days, 58.8 and 43.1% respectively, p = 0.038. Questionnaires did not detect differences in terms of continence recovery. PRR was the only predictor for early continence recovery, p = 0.03.

CONCLUSIONS

PRR increased early urinary continence recovery after RARP. Continence definition was critical to assess benefit. The only predictive factor for early continence recovery was PRR.