Early incontinence after radical prostatectomy: A community based retrospective analysis in 911 men and implications for preoperative counseling

Factors Contributing to Early Recovery of Urinary Continence Following Radical Prostatectomy: A Narrative Review

Stress urinary incontinence (SUI) is a common condition in patients following radical prostatectomy (RP), which has a significant impact on all aspects of quality of life and is associated with significant social stigma. The factors that improve urinary incontinence in patients following surgery remain controversial. The aim of our narrative review was to identify and synthesise the latest evidence on pre-, intra- and post-operative factors and predictors that contribute to early continence recovery after RP. In this narrative review, primary resources were identified by searching PubMed, EMBASE and Medline, and secondary resources were collected by cross-referencing citations in the relevant articles. We started our review by searching for systematic reviews of factors and predictors that contribute to early recovery of urinary continence after RP. We then reviewed societal guidelines such as the American Urological Association and European Urological Association guidelines on male urinary incontinence. This review focuses on the pre-, intra and postoperative factors that influence postoperative SUI after RP, as well as highlighting modifications in surgical techniques that lead to early continence recovery. Increasing age, higher BMI, shorter membranous urethral length (MUL), and larger PV are independent prognostic factors for SUI within 3 months after RP. Factors such as modified surgical technique preservation of anatomical structure lead to influence postoperative early continence recovery. SUI after RP is influenced by various factors. These factors include not only anatomical landmarks and patient-related factors such as age, BMI, length of MUL and prostate volume, but also prior transurethral resection or laser enucleation of the prostate, the surgeon's expertise, the surgical approach and NS technique.

Visceral adiposity is associated with worse urinary and sexual function recovery after radical prostatectomy: Results from a longitudinal cohort study

OBJECTIVE

A prospective longitudinal cohort study on the impact of anthropometric measures on the sexual function and continence recovery in patients treated with laparoscopic radical prostatectomy (LRP) is presented.

MATERIAL AND METHODS

Anthropometric measures, International Index of Erectile Function (IIEF-5) and International Prostatic Symptoms Score questionnaires, were collected before surgery and at the end of follow-up period. All patients were assigned into the following groups: A) non-obese; B) non-obese with central adiposity; C) obese without central adiposity; D) obese with central adiposity. Urinary and sexual functions were the outcome measures.

RESULTS

At the end of follow-up, in 29 patients with visceral adiposity (VA) the median IIEF-5 was 14 (IQR 7-18) while in 49 non-VA patients (62.8%) was 22 (IQR 17-24) (p < 0.001). Twenty-three patients (79.3%) with VA reported complete continence, while 6 (20.7%) used ≥ 2 pads per day. Forty-eight patients (97.9%) without VA reported complete continence. VA was confirmed as a strong independent predictor for worse continence (HR 3.67; 2.75-4.51 CI95% p = 0.003) and sexual function recovery (HR: 4.51; 3.09-5.63 CI95% p < 0.001).

CONCLUSION

We truly believe obese with visceral adiposity patients with prostate cancer should receive detailed preoperative counseling before surgery, including higher risk of suboptimal functional outcomes.

Predictors for lower urinary tract symptoms in patients underwent radical prostatectomy: implications for postoperative nursing care

Aims and Objectives

The aim of this study was to evaluate the risk factors for lower urinary tract symptoms in prostate cancer patients underwent radical prostatectomy, thus providing therapeutic evidence for post‐operative nursing.

Background

Prostate cancer is one of the most commonly diagnosed male malignancy in recent years. With surgical treatments, patients with prostate cancer indeed have satisfying survival rate. However, the presence of postprostatectomy lower urinary tract symptoms which affect quality of life significantly is more worthy of attention.

Design

Patients underwent surgical therapies were followed up and the symptoms were recorded.

Methods

A total of 65 prostate cancer patients underwent radical prostatectomy from January 2019 to October 2020, and pathologically diagnosed with prostate cancer were enrolled in our study. These patients were followed up 3 months after surgery and their medical records were retrospectively collected and analysed. Results were reported according to the STROBE Statement.

Results

The incidence of post‐operative lower urinary tract symptoms at 3 months after surgery is similar to that of pre‐operation. Univariate and multivariate analyses revealed that the independent risk factor for postprostatectomy lower urinary tract symptoms is body mass index, whereas pelvic floor muscle exercise is a protective factor.

Conclusions

The incidence of postprostatectomy lower urinary tract symptoms is non‐negligible, which significantly affects quality of life. Body mass index is found as an independent risk factor for postprostatectomy lower urinary tract symptoms, while pelvic floor muscle exercise is a strong protector.

Relevance to clinical practice

Patients with prostate cancer would benefit from post‐operative pelvic floor muscle exercise. These findings contribute to tailor post‐operative nursing strategy.

Effect of puboprostatic ligament preservation during robotic-assisted laparoscopic radical prostatectomy on early continence: Randomized controlled trial

Objective

To prove the effectiveness of puboprostatic ligament-preserving robotic-assisted laparoscopic radical (RARP) on enhancing early continence.

Methods

Ninety-two patients with localized adenocarcinoma of the prostate scheduled for RARP from April 2018 to January 2019 were prospectively single-blinded and randomized into two groups, standard RARP (Group A) and puboprostatic ligament-sparing RARP (Group B). The outcomes were continent status at Foley catheter removal and 3 months after surgery using the score from the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF), pad usage, pathological margin status, blood loss, operative time, and complications.

Results

Ninety-six patients were randomized (46 patients in each group), with a mean±SD age of 67.30±6.07 years. There were no differences in baseline characteristics. At 3 months after surgery, ICIQ-UI SF score (mean±SD) in Group A was significantly higher than Group B (8.74±4.28 vs. 6.93±3.96, p=0.038) but no difference at Foley catheter removal. Group A also had a significant higher score for interference with daily life (median [interquartile range, IQR]: 4 [1, 5] vs. 2 [0, 4]; p=0.041) and higher pad use (median [IQR]: 2 [0, 3] vs. 1 [1, 2]; p=0.041) at 3 months. One case in Group A had complete or severe incontinence (>5 pads/day) at 3 months. Groups A and B did not exhibit significant difference in margin status (p=0.828). There were no differences in operative time, blood loss, drain output or complications.

Conclusions

Use of puboprostatic ligament-sparing RARP could be a method to accelerate early continence without affecting the final oncological outcome.

Very Early Continence After Radical Prostatectomy and Its Influencing Factors

Introduction and Objectives: Surgical techniques such as preservation of the full functional-length of the urethral sphincter (FFLU) have a positive impact on postoperative continence rates. Thereby, data on very early continence rates after radical prostatectomy (RP) are scarce. The aim of the present study was to analyze very early continence rates in patients undergoing FFLU during RP.

Materials and Methods: Very early-continence was assessed by using the PAD-test within 24 h after removal of the transurethral catheter. The PAD-test is a validated test that measures the amount of involuntary urine loss while performing predefined physical activities within 1 h (e.g., coughing, walking, climbing stairs). Full continence was defined as a urine loss below 1 g. Mild, moderate, and severe incontinence was defined as urine loss of 1–10 g, 11–50 g, and >50 g, respectively.

Results: 90 patients were prospectively analyzed. Removal of the catheter was performed on the 6th postoperative day. Proportions for no, mild, moderate and severe incontinence were 18.9, 45.5, 20.0, and 15.6%, respectively. In logistic regression younger age was associated with significant better continence (HR 2.52, p = 0.04), while bilateral nerve-sparing (HR 2.56, p = 0.057) and organ-confined tumor (HR 2.22, p = 0.078) showed lower urine loss, although the effect was statistically not significant. In MVA, similar results were recorded.

Conclusion: Overall, 64.4% of patients were continent or suffered only from mild incontinence at 24 h after catheter removal. In general, reduced urine loss was recorded in younger patients, patients with organ-confined tumor and in patients with bilateral nerve sparing. Severe incontinence rates were remarkably low with 15.6%.

Preservation of continence in radical prostatectomy patients: a laparoscopic surgeon's perspective

Introduction

Preserving continence in patients who underwent radical prostatectomy is of utmost importance. Therefore, modification of surgical technique that would contribute to the regaining of continence with a shortest possible delay after the procedure and adequate evaluation of chances of continence recovery should be considered.

Material and methods

A PubMed database search was performed to review the current literature concerning the physiology and anatomy of sphincter mechanisms, perioperative risk factors, the effects of surgical techniques on post-prostatectomy continence and post-operative management.

Results

Modifications of surgical approach with an aim to minimize damage to the sphincter complex, maintenance of maximal urethral length to enable safe anastomosis, and the reconstruction of the urethral support system appears necessary. The patient should also be informed about the chances of regaining continence after surgery.

Conclusions

There is a need to develop a predictive model to stratify patients according to risk of incontinence and implement adequate action to minimize those risks including preoperative pelvic floor muscle training and/or surgical technique modification.

Literature review of factors affecting continence after radical prostatectomy

Radical prostatectomy (RP) is the most common cause of stress urinary incontinence (UI) in men. Several anatomic structures affect or may affect urinary continence - urethral sphincter, levator ani muscle, puboprostatic ligaments, bladder neck, endopelvic fascia, neurovascular bundle - and understanding of the anatomy of pelvic floor and urethra is crucial for satisfactory functional outcome of the procedure. Surgical techniques implemented to improve continence rates include nerve-sparing procedure, bladder neck preservation/plication, urethral length preservation, musculofascial reconstruction, puboprostatic ligaments preservation or seminal vesicle preservation. Perioperative (preoperative and postoperative) pelvic floor muscle training (PFMT) aims to shorten the duration of postoperative UI and thus, improve early continence rates postoperatively. In the review, complex information regarding anatomical, intra- and perioperative factors affecting urinary continence after RP is provided, including description of important anatomical structures, possible implications for surgical technique and evaluation of different PFMT strategies in perioperative period.

Integrative review on the non-invasive management of lower urinary tract symptoms in men following treatments for pelvic malignancies

AIM

To develop a non-invasive management strategy for men with lower urinary tract symptoms (LUTS) after treatment for pelvic cancer, that is suitable for use in a primary healthcare context.

METHODS

PubMed literature searches of LUTS management in this patient group were carried out, together with obtaining a consensus of management strategies from a panel of authors for the management of LUTS from across the UK.

RESULTS

Data from 41 articles were investigated and collated. Clinical experience was sought from authors where there was no clinical evidence. The findings discussed in this paper confirm that LUTS after the cancer treatment can significantly impair men's quality of life. While many men recover from LUTS spontaneously over time, a significant proportion require long-term management. Despite the prevalence of LUTS, there is a lack of consensus on best management. This article offers a comprehensive treatment algorithm to manage patients with LUTS following pelvic cancer treatment.

CONCLUSION

Based on published research literature and clinical experience, recommendations are proposed for the standardisation of management strategies employed for men with LUTS after the pelvic cancer treatment. In addition to implementing the algorithm, understanding the rationale for the type and timing of LUTS management strategies is crucial for clinicians and patients.

Urinary incontinence and neuropathy after radical prostatectomy: diagnosis and treatment

INTRODUCTION AND OBJECTIVE

The urinary incontinence after radical prostatectomy is secondary to neuropathy with various degrees from neurapraxia to neurotmesis. We propose to apply therapeutic and rehabilitative models appropriate to the diagnosis and to evaluate the results.

MATERIALS AND METHODS

We examined 79 homogeneous patients with urinary incontinence after radical prostatectomy. After having defined the diagnosis by a urodynamic examination, the study of pudendal nerve somatosensory-evoked potentials (SEPs) and perineal electromyography (EMG), patients were divided into four groups (A; B; C; D) and submitted to different clinical drug protocols and rehabilitation. After 3 months, patients were reevaluated.

RESULTS

Twenty-eight patients with idiopathic overactive bladder (Group A) have been treated with anticholinergics: two unchanged (7%); 14 improved (50%); and 12 recovered (43%). Sixteen patients with overactive bladder and sphincter incompetence (Group B) have practiced physiokinesis therapy (FKT) of pelvic floor and anticholinergic therapy: one unchanged (6%); eight improved (50%); and seven recovered (44%). Fourteen patients with perineal incompetence to continence (Group C) have been treated with FES, FKT of pelvic floor, and Biofeedback: three patients were unchanged (21%); five improved (36%); and six recovered (43%). Twenty-one patients with sphincter denervation (Group D) performed FES, FKT of pelvic floor, and Biofeedback: 16 unchanged (76%); five improved (24%); and zero recovered (0%). Of these 16 patients, six non-responders have placed a transobturator tape (TOT) sling and four an artificial sphincter.

CONCLUSIONS

A therapy adherent to the diagnosis increases success rate.

The effect of BMI on clinicopathologic and functional outcomes after open radical prostatectomy

OBJECTIVES

To analyze the effect of body mass index (BMI) on pathologic and functional outcomes after open radical retropubic prostatectomy.

PATIENTS AND METHODS

We retrospectively analyzed 2,471 patients who underwent RP. Clinicopathologic and patient characteristics were compared with respect to patients' BMI (normal weight: BMI < 25 kg/m(2) [n = 795], overweight: BMI ≥ 25 kg/m(2) and < 30 kg/m(2) [n = 1305], and obese: BMI ≥ 30 kg/m(2) [n = 371]). Multivariable logistic and linear regression models were used to quantify the effect of BMI on pathologic and functional outcomes.

RESULTS

Compared with normal weight patients, overweight and obese patients demonstrated higher pathologic Gleason grade and higher pathologic T stage, without any difference in preoperative prostate-specific antigen levels. Overweight and obese men were less likely to have a negative surgical margin (odds ratio (OR) 0.74 [confidence interval (CI) 0.65-0.84, P<0.001] for overweight men and OR 0.66 [CI 0.49-0.89, P<0.01] for obese men) and had a lower rate of postoperative erectile function (OR 0.60 [CI 0.48-0.76, P<0.001] for overweight patients and OR 0.34 [CI 0.27-0.44, P<0.001] for obese patients). Moreover, duration of surgery and intraoperative blood loss increased significantly with an increase in BMI. When using BMI as a continuous variable, the same trends were demonstrated. However, a lower rate of continence was not evident for overweight or obese men.

CONCLUSIONS

In contrast to many other studies, in this cohort of patients with prostate cancer, BMI was an independent risk factor for most analyzed pathologic and functional outcomes after radical prostatectomy, including negative surgical margin, potency, duration of surgery, and intraoperative blood loss.

Influence of preoperative and postoperative pelvic floor muscle training (PFMT) compared with postoperative PFMT on urinary incontinence after radical prostatectomy: a randomized controlled trial

BACKGROUND

The efficacy of preoperative pelvic floor muscle training (PFMT) for urinary incontinence (UI) after open radical prostatectomy (ORP) and robot-assisted laparoscopic radical prostatectomy (RARP) is still unclear.

OBJECTIVE

To determine whether patients with additional preoperative PFMT regain urinary continence earlier than patients with only postoperative PFMT after ORP and RARP.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial enrolled 180 men who planned to undergo ORP/RARP.

INTERVENTION

The experimental group (E, n=91) started PFMT 3 wk before surgery and continued after surgery. The control group (C, n=89) started PFMT after catheter removal.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary end point was time to continence. Patients measured urine loss daily (24-h pad test) until total continence (three consecutive days of 0 g of urine loss) was achieved. Secondary end points were 1-h pad test, visual analog scale (VAS), International Prostate Symptom Score (IPSS), and quality of life (King's Health Questionnaire [KHQ]). Kaplan-Meier analysis and Cox regression with correction for two strata (age and type of surgery) compared time and continence. The Fisher exact test was applied for the 1-h pad test and VAS; the Mann-Whitney U test was applied for IPSS and KHQ.

RESULTS AND LIMITATIONS

Patients with additional preoperative PFMT had no shorter duration of postoperative UI compared with patients with only postoperative PFMT (p=0.878). Median time to continence was 30 and 31 d, and median amount of first-day incontinence was 108 g and 124 g for groups E and C, respectively. Cox regression did not indicate a significant difference between groups E and C (p=0.773; hazard ratio: 1.047 [0.768-1.425]). The 1-h pad test, VAS, and IPSS were comparable between both groups. However, "incontinence impact" (KHQ) was in favor of group E at 3 mo and 6 mo after surgery.

CONCLUSIONS

Three preoperative sessions of PFMT did not improve postoperative duration of incontinence.

TRIAL REGISTRATION

Netherlands Trial Register No. NTR 1953.