Association Between Postoperative Pelvic Anatomic Features on Magnetic Resonance Imaging and Lower Tract Urinary Symptoms After Radical Prostatectomy

De novo overactive bladder after robot-assisted radical prostatectomy is predicted by a high preoperative overactive bladder symptom score, preoperative dyslipidemia, and non-nerve-sparing surgery

OBJECTIVES

This study investigated whether preoperative patient characteristics and surgery-related factors affect postoperative de novo overactive bladder (OAB) after robot-assisted radical prostatectomy (RARP), and identified three predictive markers.

METHODS

Patients without preoperative OAB who underwent RARP at our hospital between February 2013 and October 2020 were included.　At 12 months post-RARP, patients were divided into OAB-free and de novo OAB groups based on the presence of overactive bladder.　Preoperative patient characteristics and surgery-related factors were compared between the two groups.

RESULTS

A total of 404 patients were analyzed (OAB-free group, 338; de novo OAB group, 66).　The preoperative Overactive Bladder Symptom Score (OABSS) and the percentage of patients with dyslipidemia were significantly higher in the de novo OAB group than in the OAB-free group (OABSS, 3.2 ± 1.6 points vs 2.1 ± 1.4, P<0.01; dyslipidemia, 45.5% vs 32.0%, P=0.04).　Nerve-sparing surgery was significantly less common in the de novo OAB group (10.6% vs 27.1%, P<0.01).　Preoperative age, blood pressure, BMI, HbA1c, uroflowmetry parameters, prostate volume, operative time and blood loss showed no significant differences between two groups.

CONCLUSIONS

High preoperative OABSS, preoperative dyslipidemia and non-nerve-sparing surgery may be predictive markers for de novo OAB after RARP.

Association between 3D membranous urethral parameters and urinary continence recovery after RARP

OBJECTIVES

To evaluate whether the urinary continence (UC) recovery after robotic-assisted radical prostatectomy (RARP) relates to the membranous urethral length (MUL) and the membranous urethral complex volume (MUV).

MATERIALS AND METHODS

120 patients who underwent RARP were enrolled according to the different times of UC recovery and examined using prostate magnetic resonance imaging (MRI) before surgery. The membranous urethral (MU) parameters were measured using the three-Dimensional (3D) model reconstructed by holographic technology, such as total MUV (tMUV), exposed MUV (eMUV), full MUL (fMUL) and exposed MUL (eMUL). Statistical software SPSS 26.0 was used to analyze the data and compare the MU parameters and baseline data in different groups.

RESULTS

Patients with larger tMUV (p = 0.038), eMUV (p = 0.003), longer fMUL (p = 0.025), eMUL (p = 0.044) had better UC after removal of the catheter, and eMUV (OR = 1.002, 95%CI = 1.001-1.004, p = 0.004) was a predictor; the patients with younger age (p = 0.021), lower VPSS score (p = 0.004) and larger eMUV (p = 0.012) and longer eMUL (p = 0.049) had better UC recovery one month after RARP while eMUV (OR = 1.002, 95% CI = 1.000-1.003, p = 0.008) and VPSS score (OR = 0.886, 95% CI = 0.806-0.973, p = 0.011) were independent risk factors; The patients with younger age (p = 0.018), larger tMUV (p = 0.029), eMUV (p = 0.016) had better UC recovery three months after RARP. eMUV (OR = 1.002, 95% CI = 1.000-1.004, p = 0.042) and age (OR = 0.904, 95% CI = 0.818-0.998, p = 0.046) were independent risk factors.

CONCLUSION

This clinical study shows that patients with larger MUV and longer MUL can return to UC earlier after surgery. Among that, eMUV is a better predictor.

Postoperative Bladder Neck to Pubic Symphysis Ratio Predictive for De Novo Overactive Bladder after Robot-Assisted Radical Prostatectomy

BACKGROUND

The aim was to investigate the incidence and clinical predictive factors of de novo overactive bladder (OAB) after robot-assisted radical prostatectomy (RARP), including a Retzius-sparing (RS) approach, in the same period at a single institution.

METHODS

Of a total of 113 patients with localized prostate cancer, 81 received conventional RARP (CON-RARP) and 32 received RS-RARP at our institution. The basic characteristics data of patients and self-assessment questionnaires, including IPSS and OABSS, were obtained preoperatively and 1, 3, and 6 months after RARP. In addition, a retrospective biomarker analysis was also performed of predictive clinical parameters obtained from cystography that included a postoperative bladder neck to pubic symphysis (BNPS) ratio.

RESULTS

Patients' basic characteristics were similar between CON-RARP and RS-RARP groups. With respect to the surgical procedure, anastomosing time was found to be significantly longer for patients in the RS-RARP compared to the CON-RARP group (p < 0.01). Compared to the CON-RARP group, the RS-RARP group showed a significantly lower postoperative BNPS and aspect ratio (p < 0.001). The incidence of de novo OAB in patients of the CON-RARP group was greater than for those in the RS-RARP group (40.7% CON-RARP vs. 25.0% RS-RARP), though this was not significant. Regarding the emergence of de novo OAB, the following were revealed in univariate analysis to be independent prognostic factors: age > 64 years (hazards ratio [HR]: 4.32, 95% confidence interval [CI]: 1.51-12.3), postoperative BNPS ratio > 0.44 (HR: 8.7, 95% CI: 6.43-54.5), postoperative aspect ratio > 1.18 (HR: 3.36, 95% CI: 1.49-7.61). Additionally, multivariate analysis identified a sole significant prognostic factor: postoperative BNPS ratio > 0.44 (HR: 13.3, 95% CI: 4.33-41.1).

CONCLUSION

Our findings indicate that the postoperative BNPS ratio may be a practical predictive indicator of the emergence of de novo OAB after RARP.

Use of Urinary Biomarkers in Discriminating Interstitial Cystitis/Bladder Pain Syndrome from Male Lower Urinary Tract Dysfunctions

To analyze the urinary biomarkers in men with lower urinary-tract symptoms (LUTS) and identify interstitial cystitis/bladder pain syndrome (IC/BPS) from the other lower urinary-tract dysfunctions (LUTDs) by the levels of characteristic urinary biomarkers. In total, 198 men with LUTS were prospectively enrolled and urine samples were collected before intervention or medical treatment. Videourodynamic studies were routinely performed and the LUTDs were diagnosed as having bladder-outlet obstruction (BOO) such as bladder-neck dysfunction, benign prostatic obstruction, or poor relaxation of external sphincter (PRES); and bladder dysfunction such as detrusor overactivity (DO), hypersensitive bladder (HSB), and IC/BPS. Patients suspicious of IC/BPS were further confirmed by cystoscopic hydrodistention under anesthesia. The urine samples were investigated for 11 urinary inflammatory biomarkers including eotaxin, IL-6, IL-8, CXCL10, MCP-1, MIP-1β, RANTES, TNF-α, NGF, BDNF, and PGE2; and 3 oxidative stress biomarkers 8-OHdG, 8-isoprostane, and TAC. The urinary biomarker levels were analyzed between LUTD subgroups and IC/BPS patients. The results of this study revealed that among the patients, IC/BPS was diagnosed in 48, BOO in 66, DO in 25, HSB in 27, PRES in 15, and normal in 17. Patients with BOO had a higher detrusor pressure and BOO index than IC/BPS, whereas patients with IC/BPS, BOO, and DO had a smaller cystometric bladder capacity than the PRES and normal subgroups. Among the urinary biomarkers, patients with IC/BPS had significantly higher levels of eotaxin, MCP-1, TNF-α, 8-OHdG, and TAC than all other LUTD subgroups. By a combination of different characteristic urinary biomarkers, TNF-α, and eotaxin, either alone or in combination, had the highest sensitivity, specificity, positive predictive value, and negative predictive value to discriminate IC/BPS from patients of all other LUTD subgroups, BOO, DO, or HSB subgroups. Inflammatory biomarker MCP-1 and oxidative stress biomarkers 8-OHdG and TAC, although significantly higher in IC/BPS than normal and PRES subgroups, did not have a diagnostic value between male patients with IC/BPS and the BOO, DO, or HSB subgroups. The study concluded that using urinary TNF-α and eotaxin levels, either alone or in combination, can be used as biomarkers to discriminate patients with IC/BPS from the other LUTD subgroups in men with LUTS.

Duration and Influencing Factors of Postoperative Urinary Incontinence after Robot-Assisted Radical Prostatectomy in a Japanese Community Hospital: A Single-Center Retrospective Cohort Study

OBJECTIVES

Post-operative urinary incontinence (PUI) after robotic-assisted radical prostatectomy (RARP) is an important complication; PUI occurs immediately after postoperative urethral catheter removal, and, although approximately 90% of patients improve within one year after surgery, it can significantly worsen their quality of life. However, information is lacking on its nature in community hospital settings, particularly in Asian countries. The purposes of this study were to investigate the time required to recover from PUI after RARP and to identify its associated factors in a Japanese community hospital.

METHODS

Data were extracted from the medical records of 214 men with prostate cancer who underwent RARP from 2019 to 2021. We then calculated the number of days elapsed from the surgery to the initial outpatient visit confirming PUI recovery among the patients. We estimated the PUI recovery rate using the Kaplan-Meier product limit method and evaluated associated factors using the multivariable Cox proportional hazards model.

RESULTS

The PUI recovery rates were 5.7%, 23.4%, 64.6%, and 93.3% at 30, 90, 180, and 365 days following RARP, respectively. After an adjustment, those with preoperative urinary incontinence experienced significantly slower PUI recovery than their counterparts, while those with bilateral nerve sparing experienced recovery significantly sooner than those with no nerve sparing.

CONCLUSION

Most PUI improved within one year, but a proportion of those experiencing recovery before 90 days was smaller than previously reported.

Clinical presentation, videourodynamic characteristics, and treatment outcome in men with interstitial cystitis-like lower urinary tract symptoms

PURPOSE

In men, lower urinary tract symptoms (LUTS) similar to interstitial cystitis/bladder pain syndrome (IC/BPS) are difficult to diagnose, and treatment outcomes are poor. This study investigated clinical characteristics and videourodynamic study (VUDS) parameters, pathophysiology, and treatment outcomes in men with IC-like LUTS.

METHODS

Men with frequency, urgency, dysuria, and bladder pain initially diagnosed as IC/BPS by ESSIC criteria were assessed to rule out other lower urinary tract diseases (LUTD) by voiding diary, digitorectal examination, urinalysis, VUDS, and cystoscopic hydrodistention. Subsequent treatments for LUTD and specific treatment for IC/BPS were based on VUDS and cystoscopic findings. Clinical VUDS characteristics and treatment outcomes were compared with those of women with IC/BPS.

RESULTS

Seventy consecutive men (median age 54.5 years) were enrolled. The median maximum bladder capacity under cystoscopic hydrodistention was 650 mL (IQR 495-763) and glomerulation grade was 2 (1.0-2.0). The patients had moderate anxiety and depression severity; 49% had improved treatment outcomes. On VUDS, 42 (60%) patients had variable LUTD, including detrusor overactivity (n = 14), bladder neck dysfunction (n = 15), dysfunctional voiding (n = 3), and poor relaxation of the external sphincter (n = 24); also, 22 (31.4%) had a previous bladder outlet procedure. The self-reported treatment outcome was significantly better for patients with vs. without LUTD (p = 0.014).

CONCLUSIONS

Men with IC-like LUTS diagnosed as IC/BPS may have bladder outlet dysfunction as well as bladder dysfunction, causing a hypersensitive and painful bladder. The IC-like symptoms in the patients with LUTD might, in part, originated from bladder outlet dysfunction rather than the bladder alone.

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.

Impact of Bladder Neck Angle Measured by Postoperative Magnetic Resonance Imaging on Midterm Recovery of Urinary Continence in Prostate Cancer Patients Undergoing Robot-Assisted Radical Prostatectomy

Introduction: MRI has helped clarify the relationship between pelvic anatomical structures and functional outcomes after robot-assisted radical prostatectomy (RARP). The objective of this study was to assess the impact of the bladder neck angle (BNA) measured by postoperative MRI on midterm recovery of urinary continence (UC) in patients undergoing RARP. Patients and Methods: This study retrospectively included 200 consecutive patients with prostate cancer who were treated by RARP and received MRI 3 months after RARP. Based on postoperative MRI, the BNA was measured as the angle between the anterior and posterior bladder walls. The midterm recovery of UC was defined as the use of either no pad or an occasional security pad at 6 months after RARP. Results: One hundred forty-four of the 200 patients (72.0%) achieved midterm recovery of UC and the median BNA was 70°. There were no significant differences in several parameters, including age, body mass index, total prostate volume, preservation of the neurovascular bundle, and postoperative membranous urethral length (MUL), between patients with BNA ≥70° and <70°. Of these parameters, only the BNA and postoperative MUL were independently associated with the midterm recovery of UC. The optimal cutoff points of the BNA and MUL (65° and 9 mm, respectively) were calculated by the receiver operating characteristics curve, and a scoring model for the prediction of midterm recovery of UC was developed according to the logistic regression analysis. This scoring model was demonstrated to be satisfactorily calibrated (p for Hosmer-Lemeshow test = 0.49) and provide good discrimination (area under the curve: 0.723; p < 0.001). Conclusions: These findings suggest that midterm recovery of UC after RARP is favorably affected by the large BNA and long postoperative MUL, and our scoring model can be used as a reliable tool for predicting the midterm continence status after RARP.

Evaluation of image-based prognostic parameters of post-prostatectomy urinary incontinence: A literature review

Prostate cancer is the second most common male cancer, and radical prostatectomy is a highly effective treatment for intermediate and high-risk disease. However, post-prostatectomy urinary incontinence remains a major functional side-effect in patients undergoing radical prostatectomy. Despite recent improvements in preoperative imaging quality and surgical techniques, it remains challenging to predict or prevent occurrence of this complication. The aim of this research was to review the current published literature on pre- and postoperative imaging evaluation of the prostate and pelvic structures, to identify added value in the prediction of post-prostatectomy urinary incontinence. A computerized bibliographic search of the PubMed library was carried out to identify imaging-based articles evaluating the pelvic floor and surrounding structures pre- and/or postradical prostatectomy to predict post-prostatectomy urinary incontinence. A total of 32 articles were included. Of these, 29 papers assessed the importance of magnetic resonance imaging evaluation, with a total of 16 parameters evaluated. The most common parameters were intravesical protrusion, the membranous urethral length, prostatic volume and periurethral fibrosis. Preoperative membranous urethral length and its preservation after surgery showed the strongest correlation with urinary incontinence. Three studies evaluated ultrasound, with all carried out postoperatively. This technique benefits from a dynamic evaluation, and the results are promising for proximal urethral hypermobility and the degree of bladder neck funneling on the Valsalva maneuver. Several imaging studies evaluated the predictors of post-prostatectomy urinary incontinence, with preoperative membranous urethral length offering the most promise. However, the current literature is limited by the single-center nature of studies, and the heterogeneity in patient populations and methodologies used.

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

AIMS

There is scarce evidence of anatomical risk factors that might affect long-term post-prostatectomy incontinence (PPI) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). This systematic review aims to identify anatomical measurements in preoperative magnetic resonance imaging (MRI) that might be associated with increased risk of urinary incontinence (UI) 1 year after RALP.

METHODS

A comprehensive search on Pubmed and Scopus databases up to November 2020 was performed. Eight articles met the inclusion criteria and were finally selected.

RESULTS

The selected studies included 1146 patients. Seven articles focused on membranous urethral length (MUL); all of them related MUL to long-term PPI in univariate analysis and five of them in multivariate analysis. Four studies presented MUL difference to measure the magnitude of the effect. Average MUL (mm) was 15.9 (SD, 2.6), 16.1 (95% confidence interval [CI]: 13.9-18.9), 12.1 (95% CI 9.7-14.9) and 14.5 in continent patients and 13.9 (SD, 2.9), 10 (95% CI: 8.7-12.1), 10.3 (95% CI: 8.7-12.4) and 9.3 in incontinent patients, with statistically significant differences in all cases. Five studies presented the odds ratio as a result; although there was substantial heterogeneity in the methods used to obtain it, there was consistency in finding an inverse association between MUL and PPI. Other measurements including prostatic-urethral angle, membranous urethral thickness, intraprostatic urethral length and intravesical prostatic protrusion have been reported in few studies, and no association with long-term PPI was found. Levator ani muscle thickness was related to long-term PPI in one article.

CONCLUSION

Greater MUL on preoperative MRI is associated with lower risk of UI 1 year after RALP.

Pelvic Anatomical Features After Retzius-Sparing Robot-Assisted Radical Prostatectomy Intended for Early Recovery of Urinary Symptoms

Purpose: To elucidate factors contributing to early urinary continence recovery after retzius-sparing robot-assisted radical prostatectomy (RS-RARP) by evaluating postoperative pelvic anatomical features between RS-RARP and conventional RARP (CON-RARP). Materials and Methods: We retrospectively examined 50 men who underwent RS-RARP (n = 25; the RS-RARP group) and CON-RARP (n = 25; the CON-RARP group) between October 2017 and June 2018. Perioperative outcomes and postoperative urinary continence were assessed in both groups. Anatomical features including the bladder neck-to-pubic symphysis ratio (determined from cystograms) and membranous urethral length (MUL) (determined from magnetic resonance imaging) were evaluated. Result: The daily urinary incontinence rate at discharge was significantly lower in the RS-RARP group than in the CON-RARP group (0.046 [range: 0.014-0.160] vs 0.357 [range: 0.139-0.616], p < 0.001). Postoperative urinary continence at 1, 3, 6, and 12 months was 80%, 92%, 96%, and 96% in the RS-RARP group and 24%, 40%, 68%, and 84% in the CON-RARP group, respectively (p < 0.001). The urgency scores in the international prostate symptom score (IPSS) questionnaire at 1 and 3 months were significantly lower in the RS-RARP than in the CON-RARP group (p = 0.028 and 0.033, respectively). The quality of life (QOL) indices were more significantly improved in the RS-RARP group than in the CON-RARP group 1 month (p = 0.027) and 3 months (p = 0.045) postoperatively. Receiver operating characteristic analysis revealed that a postoperative MUL of 12.1 mm (area under the curve: 0.852) was the optimal cutoff value predictive of continence recovery after 1 month. Multivariate analysis demonstrated that RS-RARP (odds ratio [OR]: 23.6; p < 0.001) and prostate volume (OR: 0.926; p = 0.049) were the independent factors of a longer MUL. Conclusions: RS-RARP results in an early continence recovery and a better urgency score in the IPSS by suppressing the descent of the bladder and maintaining a long MUL. RS-RARP may contribute to a better QOL recovery after RARP.

The preoperative pad test as a predictor of urinary incontinence and quality of life after robot-assisted radical prostatectomy: a prospective, observational, clinical study

PURPOSE

To assess whether the preoperative 1-h pad test could predict postoperative urinary incontinence and quality of life after robot-assisted radical prostatectomy.

METHODS

A total of 329 patients who underwent robot-assisted radical prostatectomy between 2013 and 2016 were prospectively enrolled in this study. These patients were divided into the preoperative urinary continence group and the preoperative urinary incontinence group according to the 1-h pad test. The time to achieve urinary continence, lower urinary tract function evaluated by uroflowmetry and post-voided residual urine volume, and quality of life evaluated by King's Health Questionnaire and International Consultation on Incontinence Questionnaire-Short Form were compared between these two groups.

RESULTS

There were 190 patients (58%) in the preoperative urinary continence group (1-h pad test ≤ 2 g) and 139 patients (42%) in the preoperative urinary incontinence group (1-h pad test > 2 g). In the preoperative urinary continence/incontinence groups, 83%/76% of patients achieved continence within 12 months, respectively, and urinary incontinence remained significantly longer in the preoperative incontinence group than in the preoperative continence group (P  = 0.042). Although there were no significant differences in all quality of life items between the two groups before surgery, several items were significantly higher in the preoperative urinary continence group.

CONCLUSION

Achievement of urinary continence and improvement of urinary quality of life are delayed in patients with preoperative urinary incontinence assessed by the 1-h pad test. The preoperative 1-h pad test could be a useful predictor of prolonged urinary incontinence and poor quality of life after robot-assisted radical prostatectomy.

Management of Overactive Bladder Symptoms After Radical Prostatectomy

PURPOSE OF REVIEW

Post-prostatectomy overactive bladder (OAB) is a common and challenging condition to manage. The aim of the present report was to review the recent evidences regarding OAB symptoms that develop in men after prostatectomy and how to manage them.

RECENT FINDINGS

The prevalence of OAB after radical prostatectomy may range from 15.2 to 37.8%. Recent studies have highlighted the role of the urethrogenic mechanism (facilitation of the urethrovesical reflex due to stress urinary incontinence (SUI)) in the genesis of post-prostatectomy OAB in a significant proportion of patients. Several other pathophysiological factors such as iatrogenic decentralization of the bladder, defunctionalized bladder due to severe SUI, detrusor underactivity, or bladder outlet obstruction might be involved. The evaluation should aim to identify the underlying mechanism to tailor the treatment, which could range from SUI surgery, to fixing a urethral stricture, improving bladder emptying or using the conventional spectrum of OAB therapies. There is a paucity of data for OAB therapies specific to post-prostatectomy patients, with the exception of solifenacin, tolterodine, and botulinum toxin. There is currently no data on how preoperative management or surgical technique may prevent post-prostatectomy OAB.

Artificial urinary sphincter implantation: an important component of complex surgery for urinary tract reconstruction in patients with refractory urinary incontinence

Background

We review our outcomes and experience of artificial urinary sphincter implantation for patients with refractory urinary incontinence from different causes.

Methods

Between April 2002 and May 2017, a total of 32 patients (median age, 40.8 years) with urinary incontinence had undergone artificial urinary sphincter placement during urinary tract reconstruction. Eighteen patients (56.3%) were urethral injuries associated urinary incontinence, 9 (28.1%) had neurogenic urinary incontinence and 5 (15.6%) were post-prostatectomy incontinence. Necessary surgeries were conducted before artificial urinary sphincter placement as staged procedures, including urethral strictures incision, sphincterotomy, and augmentation cystoplasty.

Results

The mean follow-up time was 39 months. At the latest visit, 25 patients (78.1%) maintained the original artificial urinary sphincter. Four patients (12.5%) had artificial urinary sphincter revisions. Explantations were performed in three patients. Twenty-four patients were socially continent, leading to the overall success rate as 75%. The complication rate was 28.1%; including infections (n = 4), erosions (n = 4), and mechanical failure (n = 1). The impact of urinary incontinence on the quality of life measured by the visual analogue scale dropped from 7.0 ± 1.2 to 2.2 ± 1.5 (P <0.001).

Conclusions

The primary sources for artificial urinary sphincter implantation in our center are unique, and the procedure is an effective treatment as a part of urinary tract reconstruction in complicated urinary incontinence cases with complex etiology.

Complete bladder neck preservation promotes long-term post-prostatectomy continence without compromising midterm oncological outcome: analysis of a randomised controlled cohort

PURPOSE

The only RCT available on complete bladder neck preservation (cBNP) during radical prostatectomy reported superior continence and QoL outcomes in the first 12 months after cBNP. We provide the first data on long-term urinary continence, QoL and biochemical recurrence (BCR) after complete bladder neck preservation in a randomised controlled cohort.

METHODS

After approval by IRB, 199 men recruited for the randomised, controlled single-blind Heidelberger cBNP Study had prostatectomy performed with (cBNP) or without (noBNP) complete bladder neck preservation. Only men with renewed consent for this follow-up were evaluated for continence, QoL outcomes and BCR by ICIQ-SF self-assessment questionnaire, Pad-use/day and PSA levels. Students-t test, Pearson´s Chi-square, Fishers exact test and multiple logistic regression analyses were applied.

RESULTS

Mean follow-up was approx. 4 years. There were no significant differences in baseline characteristics between responders/non-responders or between study groups. We noted significantly higher continence rates (p = 0.004), less pad-use (p < 0.001), reduced frequency (p = 0.023) and amount (p = 0.009) of urine loss, and higher QoL outcomes (p = 0.012) after cBNP. A younger age positively influenced continence (OR = 0.91), but the multivariate analysis found cBNP to be the only independent predictor of continence (p = 0.008; OR = 8.1). pT stage was the only predictor for positive surgical margins (PSM; p < 0.001). There was no significant difference in pT stage (p = 0.23) or BCR (p = 0.63) between study groups and also no significant correlation between BCR and presence (p = 0.26) or localisation (p = 0.11) of PSM, nerve sparing (p = 0.70), surgeon (p = 0.41), preoperative PSA (p = 0.53) or pT stage (p = 0.17). No cancer-related death was noted.

CONCLUSIONS

Results of this first follow-up on a prospective randomised controlled cohort demonstrate that cBNP is associated with significantly higher continence and QoL outcomes without compromising cancer control making cBNP a novel objective during radical prostatectomy.

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.

The impact of nerve-sparing robot-assisted radical prostatectomy on lower urinary tract function: Prospective assessment of patient-reported outcomes and frequency volume charts

AIMS

To elucidate the effects of a nerve-sparing (NS) procedure on lower urinary tract symptoms (LUTS) and urinary function after robot-assisted radical prostatectomy (RARP), the associations between the NS procedure and LUTS and urinary function were investigated.

METHODS

The participants in this study were 200 consecutive patients who underwent RARP. These patients were categorized into unilateral and bilateral NS groups and the non-NS group. The International Prostate Symptom Score (IPSS), quality of life (QOL) index, frequency-volume chart, uroflowmetry, 1-h pad test, and the 5-item International Index of Erectile Function (IIEF-5) questionnaire were evaluated before and after RARP.

RESULTS

The total IPSS score was significantly lower in the unilateral (P = 0.03) and bilateral NS groups (P = 0.03) than in the non-NS group after RARP. Diurnal maximum voided volume (MVV) values were significantly greater in the bilateral NS group than in the non-NS group after RARP (P = 0.002). Nocturnal frequency was significantly decreased in the unilateral NS group than in the non-NS group after RARP (3 months P = 0.01, 12 months P = 0.01). Erectile function was significantly better in both the unilateral NS group (P < 0.0001) and the bilateral NS group (P = 0.02) than in the non-NS group 12 months after RARP.

CONCLUSIONS

The NS procedure in RARP has the possibility to improve not only erectile function, but also LUTS, owing to both the increase of MVV and the decrease of nocturia. Therefore, the NS procedure is also recommended from the viewpoint of early improvement of LUTS and lower urinary tract dysfunction after RARP.

Impact of preoperative and postoperative membranous urethral length measured by 3 Tesla magnetic resonance imaging on urinary continence recovery after robotic-assisted radical prostatectomy

INTRODUCTION

We sought to investigate the impact of preoperative and postoperative membranous urethral length (MUL) on urinary continence using 3 Tesla (3T) magnetic resonance imaging (MRI) after robotic-assisted radical prostatectomy (RARP).

METHODS

Between 2008 and 2013, 190 men with RARP underwent preoperative and postoperative MRI. Patients who received adjuvant radiotherapy or who were lost to followup were excluded, leaving 186 patients eligible for analysis. Preoperative MUL was estimated from the prostate apex to the penile bulb, while postoperative MUL was estimated from the bladder neck to penile bulb. Patients with no pads or protection were considered to have complete continence. Logistic regression analysis was used to identify predictors associated with urinary incontinence at six and 12 months.

RESULTS

Age was commonly associated with urinary incontinence at six and 12 months. In addition, diabetes mellitus (DM) was another factor associated with urinary incontinence at 12 months. When adjusting these variables, preoperative MUL ≤16 mm (95% confidence interval [CI] 1.01-1.14; p=0.022), postoperative MUL ≤14 mm (95% CI 1.16-9.80; p=0.025) and percent change of MUL >18% (95% CI 1.17-7.23; p=0.021) were significantly associated with urinary incontinence at six months. However, at 12 months, preoperative MUL ≤13.5 mm (95% CI 1.85-19.21; p=0.003) and postoperative MUL ≤13 mm (95% CI 1.24-13.84; p=0.021) had impacts on urinary incontinence, but not percent change of MUL.

CONCLUSIONS

Preoperative and postoperative MUL were significantly associated with urinary continence recovery after RARP. Therefore, efforts to preserve MUL are highly recommended during surgery for optimal continence outcomes after RARP.