Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy

Urinary incontinence rehabilitation of after radical prostatectomy: a systematic review and network meta-analysis

Purpose

The aim of this study is to provide treatment for patients with urinary incontinence at different periods after radical prostatectomy.

Methods

The PubMed, Embase, Cochrane, and Web of Science were searched for all literature on the effectiveness on urinary control after radical prostate cancer between the date of database creation and 15 November 2023 and performed a quality assessment. A network meta-analysis was performed using RevMan 5.3 and Stata 17.0 software and evaluated using the surface under the cumulative ranking curve.

Results

The results of the network meta-analysis showed that pelvic floor muscle therapy including biofeedback with professional therapist-guided treatment demonstrated better results at 1 month to 6 months; electrical stimulation, biofeedback, and professional therapist guidance may be more effective at 3 months of treatment; professional therapist-guided recovery may be less effective at 6 months of treatment; and combined therapy demonstrated better results at 1 year of treatment. During the course of treatment, biofeedback with professional therapist-guided treatment may have significant therapeutic effects in the short term after surgery, but, in the long term, the combination of multiple treatments (pelvic floor muscle training+ routine care + biofeedback + professional therapist-guided treatment + electrical nerve stimulation therapy) may address cases of urinary incontinence that remain unrecovered long after surgery.

Conclusion

In general, all treatment methods improve the different stages of functional recovery of the pelvic floor muscles. However, in the long term, there are no significant differences between the treatments. Given the cost-effectiveness, pelvic floor muscle training + routine care + biofeedback + professional therapist-guided treatment + electrical nerve stimulation therapy within 3 months and pelvic floor muscle + routine care after 3 months may be a more economical option to treat urinary incontinence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=331797, identifier CRD42022331797.

Barriers and facilitators of the implementation of the application of pelvic floor muscle training in patients with prostate cancer: a scoping review

Background

Patients with prostate cancer (PCa) benefit significantly from pelvic floor exercises, but recent results indicate that these exercises have not been fully promoted in clinical settings. This scoping review aimed to identify the facilitators of and barriers to pelvic floor muscle training (PFMT) in PCa survivors.

Methods

A scoping review was conducted in November 2022. Relevant studies were identified from CINAHL, Embase, PubMed, PsycINFO, and Web of Science databases from their inception to 20 November 2022. Data were analyzed and extracted by two formally trained researchers.

Results

A total of 53 studies were included, most of which were randomized controlled trials. The Tailored Implementation for Chronic Diseases (TICD) model framework was used to identify the contents of seven barriers and promotion areas, as well as a series of sub-domains. The most common barriers to implementing pelvic floor muscle training (PFMT) included the following: the lack of a common scheme in guidelines and the measurement of common standardized outcomes, inadequate self-monitoring or feedback from healthcare professionals to improve PFMT compliance, poor patient compliance, and a lack of implementation equipment and financial support. Good treatment effects and easy operation were the facilitators of PFMT.

Conclusion

The implementation of PFMT faces several challenges and opportunities that should be understood thoroughly before implementation. In terms of guidelines and clinical practice, more work is needed, and the possibility of PFMT implementation in various hospitals and community health centers or clinics should be considered.

Non-pharmacological and nonsurgical interventions in male urinary incontinence: A scoping review

AIMS

To describe and synthesize non-pharmacological and nonsurgical interventions for male urinary incontinence from the existing literature.

METHODS

A scoping review was conducted following the methodology suggested by Arksey and O'Malley: (1) identification of the research questions; (2) identification of relevant studies using a three-step search recommended by JBI: an initial search within PubMed and CINAHL, a comprehensive literature search within PubMed, CINAHL, EMBASE, PsycINFO, Cochrane Library, and literature search of references lists; (3) study selection; (4) data extraction and charting; (5) collation, summarization, and reporting of the results. The PRISMA-ScR Checklist was used to report.

RESULTS

A total of 4602 studies were identified, of which 87 studies were included. Approximately 78% were randomized controlled trials. More than 88% of the participants were men with prostate cancer. Exercising pelvic floor muscles 30 times per day for 12 weeks was the most frequently reported. Parameters of electrical stimulation were typically set up to 50 Hz and 300 μs for frequency and width of pulse, respectively, and lasted for 15 min. Pure pelvic floor muscle training, Pilates, Yoga, whole body vibration, diaphragm/abdominal muscle training, micturition interruption exercise, acupuncture, and auriculotherapy showed positive effects on reducing urinary incontinence.

CONCLUSION

The findings suggested implementing pelvic floor muscle training alone before or after surgery can both prompt the recovery of continence in men after prostate cancer surgery. The decision to use biofeedback or electrical stimulation to enhance the therapeutic effect of pelvic floor muscle training should be approached with caution. More rigorous designed studies are needed to validate the effectiveness of Traditional Chinese Medicine techniques and diverse novel methods.

RELEVANCE TO CLINICAL PRACTICE

Physicians and nurses need to be up to date on the latest evidence-based non-pharmacological and nonsurgical interventions in male urinary incontinence and select appropriate interventions based on available medical resources and patient preferences.

Preoperative pelvic floor muscle exercise for continence after radical prostatectomy: a systematic review and meta-analysis

Objective

We performed a systematic review and meta-analysis to evaluate the effect of preoperative pelvic floor muscle exercise on urinary incontinence after radical prostatectomy.

Methods

We searched the literature for randomized controlled trials evaluating the diagnostic analysis of preoperative pelvic floor muscle exercise (PFME) and postprostatectomy incontinence in the MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, China Biomedical Literature Database, China Journal Full-text Database, Wanfang Database and Weipu Database. The retrieval time limit is from the establishment of the database to January 2023. We used a risk ratio with accompanying 95% confidence interval (CI) to express estimates. Reviewer Manager (RevMan) 5.1.0 was used to complete all statistical analyses.

Results

Twelve studies were included based on the selection criteria. The total number of patients included in the final analysis was 1,365. At 1th month, there was no difference in continence rates between the groups [odds ratio (OR): 0.47; 95% confidence interval (CI), 0.22-1.02, p = 0.06]. At 3th month, there was statistically significant difference in PFME group before operation (OR: 0.61; 95% CI, 0.37-0.98, p = 0.04). At 6th and 12th months, there was no difference between groups (OR: 0.57; 95% CI, 0.28-1.17, p = 0.13), (OR: 0.56; 95% CI, 0.27-1.15, p = 0.12).

Conclusion

Preoperative pelvic floor muscle exercise can improve postoperative urinary incontinence at 3rd months after radical prostatectomy, but it cannot improve urinary incontinence at 6th months or longer after surgery, which indicates that preoperative PFME can improve early continence rate, but cannot improve long-term urinary incontinence continence rate.

The effect of perioperative pelvic floor muscle exercise on urinary incontinence after radical prostatectomy: a meta-analysis

BACKGROUND

Pelvic floor muscle exercise (PFME) is the most common conservative management for urinary incontinence (UI) after radical prostatectomy (RP). We performed this meta-analysis to investigate whether PFME during the entire perioperative period, including before and after RP, can significantly improve the recovery of postoperative UI.

METHODS

We systematically reviewed randomized controlled trials (RCT) from PubMed, Medline, web of science, Cochrane library, and clinicalitrials.com prior to October 2022. Efficacy data were pooled and analyzed using Review Manager Version 5.3. Pooled analyses of urinary incontinence rates 1, 3, 6, and 12 months postoperatively were conducted, using odds ratio (OR) and 95% confidence intervals (CIs).

RESULTS

We included a total of 15 RCT studies involving 2178 patients received RP. Postoperative UI could be improved after 1 month, 3 months and 6 months, and the OR were 0.26 (95%CI:0.15-0.46) 0.30 (95%CI: 0.11-0.80) 0.20 (95%CI: 0.07- 0.56) in postoperative PFME group compared to no PFME group. However, there was no significant difference between the two groups in 12 months after surgery, and the OR was 0.85(95%CI: 0.48,1.51). There were similar results in perioperative PFME group compared to no PFME group with the OR of 0.35 (95%CI: 0.12, 0.98) and 0.40 (95%CI: 0.21, 0.75) in 1 and 3 months after surgery. Our results indicated no significant difference between perioperative PFME group and postoperative PFME group. The OR was 0.58 (95%CI: 0.20-1.71) 0.58 (95%CI:0.20-0.71) and 0.66 (95%CI: 0.32-1.38) in 1, 3 and 6 months after surgery.

CONCLUSION

Application of PFME after RP significantly reduced the incidence of early postoperative UI, and additional preoperative PFME had no significant improvement on the recovery of UI.

Physiotherapy as an Effective Method to Support the Treatment of Male Urinary Incontinence: A Systematic Review

Urinary incontinence (UI) is a serious health issue that affects both women and men. The risk of UI increases in men with age and after treatment for prostate cancer and affects up to 32% of men. Furthermore, UI may affect up to 69% of men after prostatectomy. Considering such a high incidence, it is critical to search for effective methods to mitigate this issue. Hence, the present review aims to provide an overview of physiotherapeutic methods and evaluate their effectiveness in treating UI in men. This systematic review was performed using articles included in PubMed, Embase, WoS, and PEDro databases. A total of 6965 relevant articles were found. However, after a risk of bias assessment, 39 studies met the inclusion criteria and were included in the review. The research showed that the available physiotherapeutic methods for treating men with UI, including those after prostatectomy, involve pelvic floor muscle training (PFMT) alone or in combination with biofeedback (BF) and/or electrostimulation (ES), vibrations, and traditional activity. In conclusion, PFMT is the gold standard of UI therapy, but it may be complemented by other techniques to provide a personalized treatment plan for patients. The effectiveness of the physiotherapeutic methods varies from study to study, and large methodological differences make it difficult to accurately compare individual results and draw unequivocal conclusions.

Management of Urinary Incontinence Following Radical Prostatectomy: Challenges and Solutions

Urinary incontinence is a common and debilitating problem in patients undergoing radical prostatectomy. Current methods developed to treat urinary incontinence include conservative treatments, such as lifestyle education, pelvic muscle floor training, pharmacotherapy, and surgical treatments, such as bulking agents use, artificial urinary sphincter implants, retrourethral transobturator slings, and adjustable male sling system. Pelvic floor muscle exercise is the most common management to improve the strength of striated muscles of the pelvic floor to try to recover the sphincter weakness. Antimuscarinic drugs, phosphodiesterase inhibitors, duloxetine, and a-adrenergic drugs have been proposed as medical treatments for urinary incontinence after radical prostatectomy. Development of new surgical techniques, new surgical tools and materials, such as male slings, has provided an improvement of outcomes after UI surgery. Such improvement is still ongoing, and the uptake of new devices might lead to even better outcomes after UI surgery.

The Relationship between Anxiety and Depression Levels and General Health Status before and 12 Months after SUI Treatment in Postmenopausal Women from the Lower Silesian Population

Menopause is often the cut-off point from which most cases of stress urinary incontinence (SUI) in women begin. This dysfunction affects not only the physical experience of the patient, but is also related to the psychological aspects, leading to a reduced quality of life. Despite the large number of patients with SUI and the frequent use of surgical treatment for this condition, there are few scientific reports evaluating the effectiveness of the procedure in terms of reducing depressive symptoms or improving overall health. The aim of this study was to evaluate the relationship between anxiety and depression and general health status before and 12 months after surgical treatment for SUI in postmenopausal women. Seventy-five patients qualified for the study, but due to the long study duration, both sets of questionnaires were eventually obtained from 60 postmenopausal patients. All patients that qualified for the study had a trans obturator tape (TOT) procedure. All patients enrolled in the project were given the Hospital Anxiety and Depression Scale (hAdS) and King's Health Questionnaire (KHQ). After 12 months of surgery with midurethral slings, symptoms of depression were present in only a small number of subjects, 11.7%, and anxiety was present in 13.3% of the entire group. The study confirms that patients with a general poor health condition may suffer from depression or anxiety, and therefore may also need psychological treatment. Patients with SUI should therefore receive therapeutic care from a multidisciplinary team, in which therapeutic activities are divided between doctors, nurses, physiotherapists and psychologists. As a result of the treatment, after 12 months, we confirmed a significant improvement in patients with depression and anxiety disorders.

Supervised pelvic floor muscle exercise is more effective than unsupervised pelvic floor muscle exercise at improving urinary incontinence in prostate cancer patients following radical prostatectomy - a systematic review and meta-analysis

BACKGROUND

Urinary incontinence is one of the most clinically relevant side effects in the treatment of prostate cancer patients. The aim of this systematic review and meta-analysis was to analyze the specific exercise effects of supervised versus unsupervised pelvic floor muscle exercise (PFME) and exercise volume on urinary incontinence status after radical prostatectomy.

METHODS

A systematic data search was performed for studies published from January 2000 to December 2020 using the following databases: PubMed, Embase, SciSearch, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews and Effects. The review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A random-effects meta-analysis of urinary incontinence remission was performed. The relation between time since surgery and urinary incontinence remission was analyzed using a non-linear dose-response meta-analysis.

RESULTS

The meta-analysis included 20 randomized controlled trials involving 2188 men (n = 1105 in intervention groups; n = 1083 in control groups). PFME versus no PFME had a beneficial effect on urinary incontinence remission at 3 months, 3-6 months, and more than 6 months post-surgery, with risk differences ranging from 12 to 25%. These effects were particularly evident for higher volume, supervised PFME in the first 6 months post-surgery. Additional biofeedback therapy appeared to be beneficial but only during the first 3 months post-surgery.

CONCLUSIONS

There is good evidence that the supervised PFME causes a decrease in short-term urinary incontinence rates. Unsupervised PFME has similar effects as no PFME in postoperative urinary incontinence. PFME programs should be implemented as an early rehabilitative measure to improve postoperative short-term urinary incontinence in patients with prostate cancer.IMPLICATIONS FOR REHABILITATIONProstate cancer, surgery, and urinary incontinenceThe surgical treatment of prostate cancer often leads to urinary incontinence.Pelvic floor training leads to a significant improvement of this situation.Exercise therapy support is very important in this context and is even more effective than unsupported training.

Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy

Urinary incontinence is a common and predictable consequence among men with localized prostate cancer who have undergone radical prostatectomy. Despite advances in the surgical technique, urinary continence recovery time remains variable. A range of surgical and patient-related risk factors contributing to urinary incontinence after radical prostatectomy have been described, including age, BMI, membranous urethral length and urethral sphincter insufficiency. Physical activity interventions incorporating aerobic exercise, resistance training and pelvic floor muscle training programmes can positively influence the return to continence in men after radical prostatectomy. Traditional approaches to improving urinary continence after radical prostatectomy have typically focused on interventions delivered during the postoperative period (rehabilitation). However, the limited efficacy of these postoperative approaches has led to a shift from the traditional reactive model of care to more comprehensive interventions incorporating exercise-based programmes that begin in the preoperative period (prehabilitation) and continue after surgery. Comprehensive prehabilitation interventions include appropriately prescribed aerobic exercise, resistance training and specific pelvic floor muscle instruction and exercise training programmes. Transperineal ultrasonography is a non-invasive and validated method for the visualization of the action of the pelvic floor musculature, providing real-time visual biofeedback to the patient during specific pelvic floor muscle instruction and training. Importantly, the waiting time before surgery can be used for the delivery of comprehensive prehabilitation exercise-based interventions to increase patient preparedness in the lead-up to surgery and optimize continence and health-related quality-of-life outcomes following radical prostatectomy.

Preoperative pelvic floor muscle exercise does not reduce the rate of postprostatectomy incontinence: evidence from a meta-analysis and a systematic review

Background

A growing number of researches suggested that preoperative pelvic floor muscle exercise (PFME) was beneficial for urinary incontinence (UI) after a prostatectomy. However, these studies are debatable and inconclusive. Hence, this article aimed to determine whether PFME improves UI after a radical prostatectomy (RP).

Methods

PubMed, Embase, Medline and Cochrane Library were searched for articles published from 2014 to October 2019 based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). This study was evaluated based on the Oxford Evidence-Based Medicine Center. A total of 1,269 subjects (experimental group: 628, control group: 641) in 18 studies met the inclusion criteria. In 18 studies, enough quantitative data on postoperative incontinence were available for meta-analysis. UI was analyzed at 1, 3, 6 and 12 months and all comparative studies were pooled using fixed and random effects models. Contour-enhanced funnel plots were used to assess publication bias.

Results

Pooled data revealed a total of 1,269 UI patients that underwent preoperative PFME, including PFME (N=628, 49.48%) and control group (N=641, 50.51%). There was no significant difference in the postoperative incontinence rates at 1 month (RR: 0.85, 95% CI: 0.66–1.09, P=0.031, I²=62.4%), 6 weeks (RR: 0.95, 95% CI: 0.85–1.05, P=0.618, I²=0.0%), 3 months (RR: 0.92, 95% CI: 0.63–1.34, P=0.000, I²=83.2%), 6 months (RR: 0.86, 95% CI: 0.69–1.08, P=0.364, I²=8.4%) or 12 months (RR: 0.83, 95% CI: 0.47–1.47, P=0.596, I²=0.0%) after operation.

Conclusions

Contrary to previous work, the results presented here indicated that preoperative PFME protocols did not reduce the rate of UI. Further high-quality randomized controlled trials are necessary in the future to verify these findings.

Pelvic Floor Muscle Training in Radical Prostatectomy and Recent Understanding of the Male Continence Mechanism: A Review

OBJECTIVE

Pelvic floor muscle training (PFMT) is recommended as part of supportive care for patients with prostate cancer. It can assist in reducing treatment-related symptoms such as urinary incontinence. This literature review aims to discuss recent innovative findings on the pathophysiology of the male continence mechanism and implications for PFMT in radical prostatectomy.

DATA SOURCES

CINAHL, Embase, Web of Science, Emcare and PsycINFO were searched until January 2020.

CONCLUSION

Nurses providing supportive care for patients undergoing radical prostatectomy can engage in-clinic in the instruction and recommendation of pre- and postoperative PFMT and delivering guidance on home-based programs to promote motor learning.

IMPLICATIONS FOR NURSING PRACTICE

Optimal postoperative urinary incontinence outcomes are suggested to be promoted by preoperative PFMT. Training focused on the urethral and anterior pelvic floor muscle complex has been shown to facilitate mid urethral occlusion required for continence. Prescription of PFMT should be individualised, focusing on skill acquisition and motor learning, which is in line with recent knowledge developments in male pelvic floor anatomy.

Pelvic floor muscle exercise with biofeedback helps regain urinary continence after robot-assisted radical prostatectomy

Background

To determine the benefit of pelvic floor muscle exercise (PFME) with visual biofeedback on promoting patient recovery from incontinence, we investigated variables associated with the early restoration of continence for patients who robot-assisted radical prostatectomy (RARP).

Methods

Of the 83 patients enrolled, 41 consecutive patients completed PFME (the exercise group), and the other 42 consecutive patients just before the PFME program commenced (the control group). The primary outcome was whether PFME engagement was associated with zero pad continence restoration within 3 months of surgery.

Results

Continence restoration percentages (defined as zero pads used per day) at 1, 3, and 6 months after surgery were 49.4%, 77.1%, and 94.0%, respectively. The exercise group achieved significantly higher recovery rates at 1 month (p=0.037), 3 months (p<0.001), and 6 months (p=0.023). Cox regression analysis demonstrated that a lower Gleason score (<8; hazard ratio [HR], 2.167), lower prostate specific antigen (<20 ng/dL; HR, 2.909), and engagement in PFME (HR, 3.731) were independent predictors of early recovery from postprostatectomy incontinence. Stratification by age showed that those younger than 65 years did not benefit significantly from exercise (log-rank test, p=0.08), but that their elderly counterparts, aged 65–70 years (p=0.007) and >70 years old (p=0.002) benefited significantly.

Conclusion

This study suggests that postoperative engagement in PFME with biofeedback speeds up the recovery of continence in elderly patients (≥65 years old) that undergo RARP.

Early 3-month treatment with comprehensive physical therapy program restores continence in urinary incontinence patients after radical prostatectomy: A randomized controlled trial

AIMS

The objective of this study is to ascertain whether an early three-month treatment with electrotherapy and biofeedback restores continence in urinary incontinence patients after radical prostatectomy (RP).

METHODS

Design: The study performed a randomized, controlled trial of parallel and open groups. Configuration: Secondary care, urology department of a university hospital complex.

PARTICIPANTS

Patients sent for RP due to prostate cancer (n = 60), 47 patients finally completed the study.

INTERVENTIONS

The treatment group (TG) received physiotherapy consisting of electrotherapy and biofeedback, 3 days a week for 3 months, while the control group (CG) received no specific treatment. Both groups received a guide to perform pelvic floor exercises at home. The measurement instruments used were the 1- and 24-hour pad tests and the International Consultation on Incontinence Questionnaire Short-Form. The recording method used was a micturition (urinary) diary.

RESULTS

The results of the 1-hour pad test (PT) show statistically significant differences between groups at 3 months (P = .001) and 6 months (P = .001), in favor of those in the TG. Sixty-four percent of patients in the TG recovered continence as against 9.1% in the CG after 3 months in the 1-hour PT, in line with the objective of this study.

CONCLUSIONS

An early physiotherapy program helps RP patients with urinary incontinence recover continence after 3 months. Moreover, they lead a better quality life.

How can we prevent postprostatectomy urinary incontinence by patient selection, and by preoperative, peroperative, and postoperative measures? International Consultation on Incontinence-Research Society 2018

AIMS

To review current prevention strategies for urinary incontinence among patients undergoing radical prostatectomy (RP).

METHODS

This is a consensus report of the proceedings of a research proposal from the annual International Consultation on Incontinence-Research Society (ICI-RS), 14 to 16 June 2018 (Bristol, UK): "How can we prevent postprostatectomy incontinence by patient selection, and by preoperative, peroperative, and postoperative measures?"

RESULTS

Several baseline parameters were proposed as predicting factors for postprostatectomy urinary incontinence (PPUI), including age, tumor stage, prostate volume, preoperative lower urinary tract symptoms, maximum urethral closure pressure, and previous transurethral resection of the prostate. More recently, magnetic resonance imaging has been used to measure the membranous urethral length and sphincter volume. Peroperative techniques include preservative and reconstructive approaches. Bladder neck preservation improved early (6 months), as well as long-term (>12 months) continence rates. Several prospective studies have reported earlier return of continence following preservation of puboprostatic ligaments, although no long-term data are available. Preservation of the urethral length yielded controversial outcomes. Concerning postoperative strategies, it is probably optimal to remove the catheter in a window between 4 and 7 days if clinically appropriate; however, more research in this regard is still required. Postoperative PFME (preoperative pelvic floor muscle exercise) appears to speed up the recovery of continence after RP.

CONCLUSIONS

Conservative strategies to prevent PPUI include proper patient selection and PFME. Peroperative techniques have largely shown benefit in the short term. Postoperative complications and timing of trial without catheter can influence continence status. Future research initiatives must assess peroperative and postoperative measures, with longer-term follow-up.

The therapeutic effect of pelvic floor muscle exercise on urinary incontinence after radical prostatectomy: a meta-analysis

Pelvic floor muscle exercise (PFME) is the most common conservative management for urinary incontinence (UI) after radical prostatectomy (RP). However, whether the PFME guided by a therapist (G-PFME) can contribute to the recovery of urinary continence for patients after RP is still controversial. We performed this meta-analysis to investigate the effectiveness of G-PFME on UI after RP and to explore whether the additional preoperative G-PFME is superior to postoperative G-PFME alone. Literature search was conducted on Cochrane Library, Embase, Web of Science, and PubMed, to obtain all relevant randomized controlled trials published before March 1, 2018. Outcome data were pooled and analyzed with Review Manager 5.3 to compare the continence rates of G-PFME with control and to compare additional preoperative G-PFME with postoperative G-PFME. Twenty-two articles with 2647 patients were included. The continence rates of G-PFME were all superior to control at different follow-up time points, with the odds ratio (OR) (95% confidence interval [CI]) of 2.79 (1.53–5.07), 2.80 (1.87–4.19), 2.93 (1.19–7.22), 4.11 (2.24–7.55), and 2.41 (1.33–4.36) at 1 month, 3 months, 4 months, 6 months, and 12 months after surgery, respectively. However, there was no difference between additional preoperative G-PFME and postoperative G-PFME, with the OR (95% CI) of 1.70 (0.56–5.11) and 1.35 (0.41–4.40) at 1 month and 3 months after RP, respectively. G-PFME could improve the recovery of urinary continence at both early and long-term stages. Starting the PFME preoperatively might not produce extra benefits for patients at early stage, compared with postoperative PFME.

Do features of randomized controlled trials of pelvic floor muscle training for postprostatectomy urinary incontinence differentiate successful from unsuccessful patient outcomes? A systematic review with a series of meta-analyses

AIMS

Efficacy of pelvic floor muscle training (PFMT) for postprostatectomy incontinence (PPI) differs between randomized clinical trials (RCT). This might be explained by variation in content/delivery of PFMT (eg, biofeedback, muscles targeted, and time of commencement of training). This review investigated whether outcome of meta-analysis differs based on presence or not of specific RCT features.

METHODS

PubMed, CINAHL, EMBASE, Physiotherapy Evidence Database (PEDro), and Cochrane were searched for RCTs that investigated efficacy of PFMT on PPI. PFMT details and outcomes were extracted. Methodological quality and comprehensiveness of PFMT reporting was assessed using the PEDro scale and Consensus on Reporting Template, respectively. Effect size and 95% confidence intervals were calculated for incontinence rate at 3 months. To identify features that influenced efficacy, separate meta-analyses were performed for studies with and without specific features.

RESULTS

Twenty-two trials were included, and 15 were used for meta-analysis of 3-month outcomes. Overall, meta-analysis showed reduced incontinence with PFMT (risk ratio [RR] = 0.85; I² = 55%; P = .005). Meta-analyses showed better outcomes for PFMT than control groups when the study included preoperative PFMT (RR = 0.76; I² = 30%; P = .006), biofeedback (RR = 0.73; I² = 58%; P = .006), instruction to contract around the urethra (RR = 0.9; I² = 43%; P = .009), a control group without PFMT instruction (RR = 0.85; I² = 69%; P = .05), inclusion of all men irrespective of continence status (RR = 0.84; I² = 30%; P = .003) and continence defined as no leakage (RR = 0.85; I² = 48%; P = .05).

CONCLUSIONS

Preoperative PFMT, biofeedback, urethral instructions, no PFMT instruction for controls, inclusion of all men, and continence defined as no leakage are features associated with successful patient outcomes. Future studies should consider these features in design of interventions and pooling data for meta-analysis.

Effects of perioperative pelvic floor muscle training on early recovery of urinary continence and erectile function in men undergoing radical prostatectomy: a randomized clinical trial

Aims:

Radical prostatectomy (RP) can result in urinary incontinence (UI) and erectile dysfunction (ED), which negatively impact quality of life (QoL). This study aimed to evaluate the effects of a perioperative pelvic floor muscle training (PFMT) program versus usual care on early recovery of urinary continence and erectile function after RP.

Materials and Methods:

Of 59 eligible men, 31 were randomly allocated into 2 groups: Group 1 (Control, N=15) received usual post-RP care; and Group 2 (Physical therapy, N=16) received two pre-RP physical therapist-guided PFMT sessions, including exercises and electromyographic biofeedback, and verbal and written instructions to continue PFMT until RP, which was then resumed after urethral catheter removal. The International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and the 5-item version of the International Index of Erectile Function (IIEF-5) questionnaire were used to evaluate UI and ED, respectively.

Results:

Demographic characteristics were similar in both groups. Three months after RP, the UI rate was 72.7% and 70.0% in Groups 1 and 2, respectively (P >0.05). The severity and frequency of UI and its impact on QoL were evaluated by the ICIQ-Short Form, with scores of 6.9±6.26 in Group 1 and 7.0±5.12 in Group 2 (P >0.05). The IIEF-5 scores were similar in Groups 1 and 2 (5.73±7.43 vs. 6.70±6.68, respectively) (P >0.05).

Conclusion:

Our pre-RP protocol of two physical therapist-assisted sessions of PFMT plus instructions did not significantly improve urinary continence or erectile function at 3 months after RP.

Prehabilitation for adults diagnosed with cancer: A systematic review of long-term physical function, nutrition and patient-reported outcomes

OBJECTIVE

Prehabilitation is increasingly being used to mitigate treatment-related complications and enhance recovery. An individual's state of health at diagnosis, including obesity, physical fitness and comorbidities, are influencing factors for the occurrence of adverse effects. This review explores whether prehabilitation works in improving health outcomes at or beyond the initial 30 days post-treatment and considers the utility of prehabilitation before cancer treatment.

METHODS

A database search was conducted for articles published with prehabilitation as a pre-cancer treatment intervention between 2009 and 2017. Studies with no 30 days post-treatment data were excluded. Outcomes post-prehabilitation were extracted for physical function, nutrition and patient-reported outcomes.

RESULTS

Sixteen randomised controlled trials with a combined 2017 participants and six observational studies with 289 participants were included. Prehabilitation interventions provided multi-modality components including exercise, nutrition and psychoeducational aspects. Prehabilitation improved gait, cardiopulmonary function, urinary continence, lung function and mood 30 days post-treatment but was not consistent across studies.

CONCLUSION

When combined with rehabilitation, greater benefits were seen in 30-day gait and physical functioning compared to prehabilitation alone. Large-scale randomised studies are required to translate what is already known from feasibility studies to improve overall health and increase long-term cancer patient outcomes.

Design of programs to train pelvic floor muscles in men with urinary dysfunction: Systematic review

AIMS

Pelvic floor muscle training (PFMT) is a first line conservative treatment for men with urinary dysfunction, but reports of its efficacy are variable. This study aimed to systematically review the content of PFMT programs used for urinary dysfunction in men.

METHODS

Electronic databases (PubMed, CINAHL, EMBASE, Cochrane, PEDro) were searched for studies that used PFMT in the treatment of adult men with urinary dysfunction. Details of PFMT treatment sessions and home exercise protocols were extracted. Criteria specific to PFMT were developed, based on the Consensus on Exercise Reporting Template, and applied to all studies to measure the comprehensiveness of the PFMT description in the manuscript.

RESULTS

Results from the 108 included studies indicate substantial heterogeneity in both the content of PFMT and the quality of reporting of the components of the exercise regimes. There was notable disparity in the muscles targeted by the interventions (and few focused on urethral control despite the use in management of urinary conditions) and the intensity of the programs (eg, 18-240 contractions per day). Most studies were missing key details of description of the PFMT programs (eg, the position in which the pelvic floor muscle [PFM] contraction was taught and how it was assessed, methods used to ensure exercise adherence).

CONCLUSIONS

Variation in content of PFMT programs is likely to contribute to variation in the reported efficacy for management of urinary dysfunction in men, and unclear description of the details of the evaluated programs makes it difficult to identify the effective/ineffective components. PROSPERO registration number CRD42017071038.

Effects of Biofeedback in Preventing Urinary Incontinence and Erectile Dysfunction after Radical Prostatectomy

In this study, we present a biofeedback method for the strengthening of perineal muscles during the preoperative procedures for radical prostatectomy, and we evaluate this technique as a prevention measure against complications such as urinary incontinence (UI) and erectile dysfunction (ED), which affect prostatectomy patients after surgery. In the experimental protocol, the patients performed specific exercises with the help of a device that provided the patient with visual biofeedback, based on a plot of the anal pressure. For the experimental protocol, we selected 20 male patients, with an average age of 64.0 years, and submitted them to ten therapeutic sessions each. A control group consisting of 32 men with an average age of 66.3 years, who were treated with the same surgical procedure but not with the preoperative procedures, also took part in the experiment. To evaluate UI and ED after the surgery in both control and experimental groups, we used two validated questionnaires-to assess UI, we used the King's Health Questionnaire (KHQ) and, for ED, we used the International Index of Erectile Function (IIEF-5) Questionnaire. We compared the variables associated with UI and ED after the surgery for the control and experimental groups. The occurrence of UI after radical prostatectomy in the control group (100% of the patients) was higher than that for the experimental group (5% of the patients), with p < 0.0001. Likewise, the occurrence of erectile dysfunction after prostatectomy in the control group (48.6% of the patients) was higher than that for the experimental group (5% of the patients), with p < 0.0001. The number of nocturia events also decreased as a consequence of the intervention (p < 0.0001), as did the number of disposable underwear units for urinary incontinence (p < 0.0001). Furthermore, we compared, only for the experimental group, the anal pressure before the biofeedback intervention and after the surgery, and we verified that the anal pressure after surgery was significantly higher (p < 0.0001). The results strongly suggest that the preoperative biofeedback procedure was effective in decreasing urinary incontinence and erectile dysfunction after radical prostatectomy. As future work, we intend to extend this analysis for larger samples and considering a broader age range.

Pelvic floor muscle exercises with or without electric stimulation and post-prostectomy urinary incontinence: a systematic review

Abstract Introduction: Urinary incontinence (UI) after prostatectomy is difficult to treat and causes profound adverse impacts on the individual's quality of life. The main clinical treatments available for post-prostatectomy UI consist of behavioral techniques and physical therapy techniques, such as exercises, electrical stimulation and biofeedback for pelvic floor muscles (PFMs). Objective: To investigate the effectiveness of PFM exercises with or without electrical stimulation for reducing post-prostatectomy UI. Methods: We included only randomized controlled trials (RCTs) which used PFM exercises with or without electrical stimulation. The search was conducted in August of 2013 in the databases of the U.S. National Library of Medicine (MEDLINE), Scientific Electronic Library Online (SciELO), Physiotherapy Evidence Database (PEDro) and Virtual Health Library (VHL). We searched for RCTs published between 1999 and 2013. As keywords for our search, we used the following descriptors from the Health Sciences Descriptors (DeCS): urinary incontinence, pelvic diaphragm, prostatectomy, pelvic floor exercises, electrostimulation and electrical stimulation. We also used the following descriptors from the Medical Subject Headings (MeSH): electrical stimulation, pelvic floor, urinary incontinence, prostatectomy, physiotherapy and exercise therapy. Results: Of the 59 RCTs found, 26 were excluded as duplicates, and 28 were excluded for not displaying a minimum score of 5.0 on the PEDro Scale, which left us with five RCTs. Conclusion: PFM exercises can be effective for treating UI after radical prostatectomy, especially if begun soon after surgery. Associating electrical stimulation with PFM exercises did not show additional benefit for treating urinary incontinence. However, the selected studies presented some methodological weaknesses that may have compromised their internal validity.

Beneficial effects of biofeedback-assisted pelvic floor muscle training in patients with urinary incontinence after radical prostatectomy: A systematic review and metaanalysis

OBJECTIVES

This systematic review and metaanalysis compared the effects of biofeedback-assisted pelvic floor muscle training with those of pelvic floor muscle training alone in patients with urinary incontinence after radical prostetactomy.

DESIGN

A review and metaanalysis study design.

DATA SOURCES

The metaanalysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and MetaAnalyses guidelines. A systematic search of PubMed/Medline OVID, the Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, BioMed Central, Web of Science, Chinese Electronic Periodical Services, Chinese Journal and Thesis Database, and China National Knowledge Infrastructure was performed for retrieving records.

REVIEW METHODS

For determining the effects of training type on urinary incontinence, randomized controlled trials on biofeedback-assisted pelvic floor muscle training with or without electrical stimulation were compared with those on pelvic floor muscle training with or without electrical stimulation, respectively, in the metaanalysis. The Cochrane Collaboration tool in the Cochrane Handbook for Systematic Review of Interventions 5.1.0 was used to assess the methodological quality of the included trials. Subjective and objective measurement of urinary incontinence improvement and the quality of life were the primary and secondary outcome measures, respectively. Data were analyzed using Comprehensive Meta-Analysis software 2.0. In addition, subgroup analyses and metaregression were performed to explore the possible sources of heterogeneity.

RESULTS

Thirteen randomized controlled trials involving 1108 patients with prostatectomy incontinence were included. The immediate-, intermediate-, and long-term effects of objectively measured biofeedback-assisted pelvic floor muscle training on urinary incontinence were significant (mean effect size=-0.316, -0.335, and -0.294; 95% CI: -0.589 to -0.043, -0.552 to -0.118 and -0.535 to -0.053; p=0.023, 0.002, and 0.017, respectively) when compared with those of pelvic floor muscle training alone. However, when urinary incontinence was measured subjectively, only the intermediate and long-term effects of biofeedback were found (p=0.034 and 0.005, respectively). Small-to-moderate immediate- and intermediate-term effects on the quality of life were observed when biofeedback-assisted pelvic floor muscle training was compared with pelvic floor muscle training alone. No publication bias was observed among studies.

CONCLUSIONS

Biofeedback can be an adjunct treatment to pelvic floor muscle training for reducing urinary incontinence in patients who have undergone radical prostatectomy.

Preoperative Pelvic Floor Muscle Exercise and Postprostatectomy Incontinence: A Systematic Review and Meta-analysis

CONTEXT

Preoperative pelvic floor muscle exercise (PFME) is often prescribed to reduce the severity of postprostatectomy incontinence.

OBJECTIVE

Systematic review and meta-analysis of evidence regarding the effect of preoperative PFME on postoperative urinary incontinence following radical prostatectomy.

EVIDENCE ACQUISITION

A systematic search was performed of the Cochrane Library, Medline, Embase, and all potential articles from references in relevant articles on 4 October 2014. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Identified reports were critically appraised for quality and relevance. Only studies of preoperative PFME compared with no preoperative PFME were included.

EVIDENCE SYNTHESIS

Eleven studies were included based on the selection criteria. The total number of patients included in the final analysis was 739. In seven studies, sufficient quantitative data on postoperative incontinence were available for meta-analysis. At 1 mo, there was no difference in continence rates between the groups (odds ratio [OR]: 0.68; 95% confidence interval [CI], 0.45-1.03). At 3 mo, there was 36% improvement in the preoperative PFME group (OR: 0.64; 95% CI, 0.47-0.88). At 6 mo, there was no difference between groups (OR: 0.60; 95% CI, 0.32-1.15). When examining quality of life measures, four of seven studies demonstrated significant improvement in the preoperative PFME group at 3 mo, and two of these studies demonstrated significant differences at 6 mo.

CONCLUSIONS

Preoperative PFME improves postoperative urinary incontinence after radical prostatectomy at 3 mo but not at 6 mo, suggesting it improves early continence but not long-term continence rates.

PATIENT SUMMARY

We reviewed all evidence for preoperative pelvic floor muscle exercise (PFME) in treating urinary incontinence following radical prostatectomy. We found evidence to suggest that preoperative PFME improves early continence rates but not long-term continence rates.

Pelvic-Floor-Muscle Training Adherence: Tools, Measurements and Strategies-2011 ICS State-of-the-Science Seminar Research Paper II of IV

AIMS

This paper on pelvic-floor-muscle training (PFMT) adherence, the second of four from the International Continence Society's 2011 State-of-the-Science Conference, aims to (1) identify and collate current adherence outcome measures, (2) report the determinants of adherence, (3) report on PFMT adherence strategies, and (4) make actionable clinical and research recommendations.

METHOD

Data were amassed from a literature review and an expert panel (2011 conference), following consensus statement methodology. Experts in pelvic floor dysfunction collated and synthesized the evidence and expert opinions on PFMT adherence for urinary incontinence (UI) and lower bowel dysfunction in men and women and pelvic organ prolapse in women.

RESULTS

The literature was scarce for most of the studied populations except for limited research on women with UI.

OUTCOME MEASURES

Exercise diaries were the most widely-used adherence outcome measure, PFMT adherence was inconsistently monitored and inadequately reported. Determinants: Research, mostly secondary analyses of RCTs, suggested that intention to adhere, self-efficacy expectations, attitudes towards the exercises, perceived benefits and a high social pressure to engage in PFMT impacted adherence.

STRATEGIES

Few trials studied and compared adherence strategies. A structured PFMT programme, an enthusiastic physiotherapist, audio prompts, use of established theories of behavior change, and user-consultations seem to increase adherence.

CONCLUSION

The literature on adherence outcome measures, determinants and strategies remains scarce for the studied populations with PFM dysfunction, except in women with UI. Although some current adherence findings can be applied to clinical practice, more effective and standardized research is urgently needed across all the sub-populations.

Pattern of activation of pelvic floor muscles in men differs with verbal instructions

AIMS

To investigate the effect of instruction on activation of pelvic floor muscles (PFM) in men as quantified by transperineal ultrasound imaging (US) and to validate these measures with invasive EMG recordings.

METHODS

Displacement of pelvic floor landmarks on transperineal US, intra-abdominal pressure (IAP) recorded with a nasogastric transducer, and surface EMG of the abdominal muscles and anal sphincter were recorded in 15 healthy men during sub-maximal PFM contractions in response to different verbal instructions: "tighten around the anus," "elevate the bladder," "shorten the penis," and "stop the flow of urine." In three men, fine-wire EMG recordings were made from puborectalis and bulbocavernosus, and trans-urethral EMG recordings from the striated urethral sphincter (SUS). Displacement data were validated by analysis of relationship with invasive EMG. Displacement, IAP, and abdominal/anal EMG were compared between instructions.

RESULTS

Displacement of pelvic landmarks correlated with the EMG of the muscles predicted anatomically to affect their locations. Greatest dorsal displacement of the mid-urethra and SUS activity was achieved with the instruction "shorten the penis." Instruction to "elevate the bladder" induced the greatest increase in abdominal EMG and IAP. "Tighten around the anus" induced greatest anal sphincter activity.

CONCLUSIONS

The pattern of urethral movement measured from transperineal US is influenced by the instructions used to teach activation of the pelvic floor muscles in men. Efficacy of PFM training may depend on the instructions used to train activation. Instructions that optimize activation of muscles with a potential to increase urethral pressure without increasing abdominal EMG/IAP are likely ideal. Neurourol. Urodynam. 35:457-463, 2016. © 2015 Wiley Periodicals, Inc.

Conservative management for postprostatectomy urinary incontinence

BACKGROUND

Urinary incontinence is common after radical prostatectomy and can also occur in some circumstances after transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training with or without biofeedback, electrical stimulation, extra-corporeal magnetic innervation (ExMI), compression devices (penile clamps), lifestyle changes, or a combination of methods.

OBJECTIVES

To determine the effectiveness of conservative management for urinary incontinence up to 12 months after transurethral, suprapubic, laparoscopic, radical retropubic or perineal prostatectomy, including any single conservative therapy or any combination of conservative therapies.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (5 February 2014), CENTRAL (2014, Issue 1), EMBASE (January 2010 to Week 3 2014), CINAHL (January 1982 to 18 January 2014), ClinicalTrials.gov and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (both searched 29 January 2014), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence in men after prostatectomy.

DATA COLLECTION AND ANALYSIS

Two or more review authors assessed the methodological quality of the trials and abstracted data. We tried to contact several authors of included studies to obtain extra information.

MAIN RESULTS

Fifty trials met the inclusion criteria, 45 in men after radical prostatectomy, four trials after TURP and one trial after either operation. The trials included 4717 men of whom 2736 had an active conservative intervention. There was considerable variation in the interventions, populations and outcome measures. Data were not available for many of the pre-stated outcomes. Men's symptoms improved over time irrespective of management.There was no evidence from eight trials that pelvic floor muscle training with or without biofeedback was better than control for men who had urinary incontinence up to 12 months after radical prostatectomy; the quality of the evidence was judged to be moderate (for example 57% with urinary incontinence in the intervention group versus 62% in the control group, risk ratio (RR) for incontinence after 12 months 0.85, 95% confidence interval (CI) 0.60 to 1.22). One large multi-centre trial of one-to-one therapy showed no difference in any urinary or quality of life outcome measures and had narrow CIs. It seems unlikely that men benefit from one-to-one PFMT therapy after TURP. Individual small trials provided data to suggest that electrical stimulation, external magnetic innervation, or combinations of treatments might be beneficial but the evidence was limited. Amongst trials of conservative treatment for all men after radical prostatectomy, aimed at both treatment and prevention, there was moderate evidence of an overall benefit from pelvic floor muscle training versus control management in terms of reduction of urinary incontinence (for example 10% with urinary incontinence after one year in the intervention groups versus 32% in the control groups, RR for urinary incontinence 0.32, 95% CI 0.20 to 0.51). However, this finding was not supported by other data from pad tests. The findings should be treated with caution because the risk of bias assessment showed methodological limitations. Men in one trial were more satisfied with one type of external compression device, which had the lowest urine loss, compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remained undetermined as no trials involving these interventions were identified.

AUTHORS' CONCLUSIONS

The value of the various approaches to conservative management of postprostatectomy incontinence after radical prostatectomy remains uncertain. The evidence is conflicting and therefore rigorous, adequately powered randomised controlled trials (RCTs) which abide by the principles and recommendations of the CONSORT statement are still needed to obtain a definitive answer. The trials should be robustly designed to answer specific well constructed research questions and include outcomes which are important from the patient's perspective in decision making and are also relevant to the healthcare professionals. Long-term incontinence may be managed by an external penile clamp, but there are safety problems.

Effectiveness of preoperative pelvic floor muscle training for urinary incontinence after radical prostatectomy: a meta-analysis

BACKGROUND

Radical prostatectomy (RP) is the most common treatment for patients with localized prostate cancer. Urinary incontinence (UI) is a significant bothersome sequela after radical prostatectomy that may dramatically worsen a patient's quality of life. Pelvic floor muscle training (PFMT) is the main conservation treatment for men experiencing urinary incontinence; however, whether additional preoperative PFMT can hasten the reestablishment of continence is still unclear. The objective of this meta-analysis is to determine whether the effectiveness of preoperative plus postoperative PFMT is better than postoperative PFMT only for the re-establishment of continence after RP.

METHODS

A meta-analysis was performed after a comprehensive search of available randomized controlled trials (RCTs). Quality of the included studies was assessed by the Cochrane Risk of Bias tool. Efficacy data were pooled and analyzed using Review Manager (RevMan) Version 5.0. Pooled analyses of continence rates 1, 3, 6, and 12 months postoperatively, using relative risk (RR) and 95% confidence intervals (CIs), were conducted. For data deemed not appropriate for synthesis, a narrative overview was conducted.

RESULTS

Five eligible studies were ultimately included in this analysis. No significant differences in continence rates were detected at the early (1- and 3-month) time points: RR = 1.21, 95% CI = 0.71-2.08, P = 0.48; RR = 1.1, 95% CI = 0.09-1.34, P = 0.34, respectively), interim (6-month time point: RR = 0.98, 95% CI = 0.93-1.04, P = 0.59), or late recovery stage (RR = 0.93, 95% CI = 0.67-1.29, P = 0.66). Outcomes reported were time to continence in two trials and quality of life in three, but results were inconclusive because of insufficient data.

CONCLUSION

According to this meta-analysis, additional preoperative PFMT did not improve the resolution of UI after RP at early (≤3-month), interim (6-month), or late (1-year) recovery stages. However, the results of time to continence and quality of life were inconclusive because of insufficient data. More high-quality RCTs are needed for better evaluation of the effectiveness of preoperative PFMT on post-prostatectomy UI.

Pre-operative training induces changes in the histomorphometry and muscle function of the pelvic floor in patients with indication of radical prostatectomy

OBJECTIVE

To evaluate the efficacy of preoperative pelvic floor muscle training (PFMT) on histomorphometry, muscle function, urinary continence and quality of life of patients undergoing radical prostatectomy (RP).

MATERIAL AND METHODS

A prospective intervention clinical study was designed in 16 patients with indication of RP who were randomized into two groups. The Control Group received routine pre-surgical education (hygienic-dietary measures). The intervention group received a training session with supervised PFMT, three times a day, for four weeks, 30 days before the PR. Muscle function of the external urethral sphincter, contraction pressure of the levator ani, urinary continence and quality of life related to health (HRQoL) were evaluated before and after the intervention. At the end of the intervention and day of the surgery, samples of residual muscle tissue were obtained from the external sphincter muscle of the urethra for histomorphometric analysis.

RESULTS

After the intervention, those participants who carried out PFMT showed an increase in the cross-sectional area of the muscle fibers of the external urethral sphincter (1,313 ± 1,075 μm(2)vs. 1,056 ± 844 μm(2), P=.03) and higher pressure contraction of the levator ani (F=9.188; P=.010). After catheter removal, 62% of patients in the experimental group and 37% in the control group showed no incontinence. After removal of the catheter, 75% of the experimental group did not require any pad compared to 25% in the control group (p=NS). There were no significant differences between the two groups in any of the HRQoL domains studied.

CONCLUSIONS

Pre-surgical PFMT in patients with RP indication induces changes in the histology and function of the pelvic floor muscles, without changes in urogenital function and HRQoL. These results provide new evidence regarding the benefit of PFMT in preventing RP associated complications.

Efficacy of physiotherapy for urinary incontinence following prostate cancer surgery

The study enrolled 81 with urinary incontinence following radical prostate-only prostatectomy for prostatic carcinoma. The patients were divided into two groups. The patients in Group I were additionally subdivided into two subgroups with respect to the physiotherapeutic method used. The patients of subgroup IA received a rehabilitation program consisting of three parts. The patients of subgroup IB rehabilitation program consist of two parts. Group II, a control group, had reported for therapy for persistent urinary incontinence following radical prostatectomy but had not entered therapy for personal reasons. For estimating the level of incontinence, a 1-hour and 24-hour urinary pad tests, the miction diary, and incontinence questionnaire were used, and for recording the measurements of pelvic floor muscles tension, the sEMG (surface electromyography) was applied. The therapy duration depended on the level of incontinence and it continued for not longer than 12 months. Superior continence outcomes were obtained in Group I versus Group II and the difference was statistically significant. The odds ratio for regaining continence was greater in the rehabilitated Group I and smaller in the group II without the rehabilitation. A comparison of continence outcomes revealed a statistically significant difference between Subgroups IA versus IB. The physiotherapeutic procedures applied on patients with urine incontinence after prostatectomy, for most of them, proved to be an effective way of acting, which is supported by the obtained results.

Electrostimulation, response of the pelvic floor muscles, and urinary incontinence in elderly patients post prostatectomy

Objective to investigate the response of the pelvic floor muscles (PFM), and urinary incontinence (UI), in patients having undergone a prostatectomy, after treatment using electrical stimulation. Materials and methods this observational study was conducted in an outpatient urogynecologic physical therapy clinic of Hospital dos Servidores in Rio de Janeiro, Brazil from August to September 2012. Ten patients (aged, 64 ± 7 years) with urinary incontinence resulting from radical prostatectomy, having received surgery within six months of study entry, without urinary infection, and without metallic implants underwent electrical stimulation of the PFM, while in lateral decubitus position with knees and hips flexed. The parameters used were 65 Hz frequency, pulse width of 500 µs, biphasic current, intensity according to the tolerance level reported by the patient, perineal contraction time of four seconds, and rest time of eight seconds for 20 minutes twice a week, totaling 16 sessions of electrical stimulation with active-assisted contraction. Patients were evaluated before and after electrical stimulation through physical therapy evaluation of urinary incontinence, by being asked about the number of disposable guards used daily, using a visual analogue scale (VAS) to measure how the UI interfered with activities of daily living, and by electromyographic biofeedback to measure the work of the PFM. Data were analyzed using Student’s paired t-tests and a significance level of 0.05. Results after 16 sessions of electrical stimulation, the electromyographic biofeedback evaluation showed a significant increase in muscle strength of 10.73 ± 8.64 to 17.16 ± 9.00 µV (t = -3.39, P = 0.008), a significant decrease in the number of diapers used before and after treatment (3.9 ± 1.2 to 1.8 ± 1.5, respectively; t = 5.16, P = 0.0006), and a significant decrease in the interference of urinary incontinence on daily activities of 9.6 ± 0.5 to 4.0 ± 3.8 (t = 5.15, P = 0.0006). Conclusion electrical stimulation may represent a novel way to strengthen the pelvic floor muscles and decrease urinary incontinence resulting from radical prostatectomy.

Potential risk factors and outcomes of artificial urinary sphincter placement after radical cystectomy and orthotopic neobladder urinary diversion

AIMS

Stress urinary incontinence (SUI) is a known possibility after radical cystectomy (RC) and orthotopic neobladder (ONB) urinary diversion. We retrospectively reviewed the outcomes and complications of patients who underwent artificial urinary sphincter (AUS) placement for treatment of SUI and evaluated potential risk factors (PRFs) for AUS failure.

METHODS

Patients who underwent AUS placement after RC/ONB from 1994 to 2009 were identified. Variables evaluated included: demographics, cancer type, AUS characteristics, urinary incontinence (UI), revision procedures data, and PRFs for AUS failure.

RESULTS

Demographic data was reviewed on 36 patients. Mean age at AUS placement was 72 (58-79) years. Mean time to AUS after RC/ONB was 28 (2-120) months. Mean follow up after AUS was 40 (2-132) months. TCC was the indication for RC in 94% of patients. The most commonly placed AUS cuff and reservoir size was 4.5 cm and 61-70 H2 O, respectively. Incontinence data was available in 29 patients. Pre-AUS placement 22, 3, and 4 patients were totally, daytime and nighttime only incontinent, respectively. Post-AUS placement, incontinence persisted in 5, 1, and 2 patients with total, daytime and nighttime incontinence, respectively. Prior to AUS placement 11/36 patients received chemotherapy and 10/36 had radiation. Mean time to the first revision/explantation due to UI/erosion/infection/malfunction was an average of 28 (3-96) months after AUS placement and occurred in 21/35 (60%) patients. There was no significant correlation noted between PRFs and UI pre-/post-AUS or between PRFs and the need for AUS revision.

CONCLUSIONS

AUS is a safe, effective treatment with an acceptable complication rate for patients after RC/ONB with SUI.

A systematic review of pre-surgical exercise intervention studies with cancer patients

BACKGROUND

Recent reviews suggest that enhancing fitness and functional capacity prior to surgery can accelerate post-surgery recovery and reduce mortality. However, the effect of pre-surgical exercise interventions in cancer patients is not fully explained. The aim of this paper is to systematically review the available literature regarding pre-surgery exercise training interventions in cancer patients and examine their effects on physiological outcomes as well as quality of life (QOL) and length of hospital stay.

METHODS

Relevant studies were identified through a search on MEDLINE, PreMEDLINE, AMED, MEDLINE Daily Update, CINAHL and SPORTDiscus. All randomized controlled trials (RCTs) and non-RCTs that had some form of physical exercise undertaken prior to surgery were included. Descriptive characteristics such as participant characteristics, study design, types of cancer, length of study, and primary outcomes were extracted. Methodological rigour was assessed using a modified Delphi List. Due to the heterogeneity and the dearth of pre-surgical studies, we were limited to a systematic review rather than a meta-analysis.

RESULTS

Eighteen studies were included consisting of a total of 966 participants. Lung cancer studies were the predominant group represented. Most of the studies prescribed an aerobic intervention programs done prior to surgery. Mode, frequency, duration, and intensity of exercise intervention varied across the different cancer groups. The majority of studies showed preliminary positive change in clinical outcomes with significant improvements in the rate of incontinence, functional walking capacity and cardiorespiratory fitness.

CONCLUSION

Pre-surgical exercise may benefit cancer patients through positive effects on function and physical capacity. Surgical oncologists may consider pre-surgical exercise interventions as a potential adjuvant therapy to improve patients' outcomes.

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.

Does physiotherapist-guided pelvic floor muscle training increase the quality of life in patients after radical prostatectomy? A randomized clinical study

OBJECTIVE

The aim of this study was to study the effect of postoperative physiotherapist-guided pelvic floor muscle training (PFMT) on health-related quality of life (HRQoL) parameters in patients treated with radical prostatectomy (RP).

MATERIAL AND METHODS

A prospective randomized controlled trial was conducted at St. Olavs Hospital, Trondheim University Hospital, Norway. Eighty-five men were randomized into two intervention groups (A and B). patients in group A (n = 42) were offered physiotherapist-guided PFMT (in groups or by DVD) once weekly throughout the first 12 months after RP, while those in group B (n = 43) trained on their own. HRQoL data were assessed using the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI) and the Short Form-12 (SF-12) health survey. The physical component summary (PCS) and mental component summary (MCS) scores of the SF-12 plus the urinary, sexual and bowel function and bother of the UCLA-PCI make up the eight quality of life outcomes used in this study. Data were obtained preoperatively (baseline), 6 weeks, and 3, 6 and 12 months postoperatively.

RESULTS

Eighty patients completed at least one follow-up assessment, 38 in group A and 42 in group B, giving a dropout rate of 5.9%. The overall response rates were 96% at baseline, 83% at 6 weeks, 90% at 3 months, 88% at 6 months and 68% at 12 months. No statistically significant difference in HRQoL was found between groups A and B.

CONCLUSIONS

Even though physiotherapist-guided training of the pelvic floor muscles after RP improved postoperative urinary incontinence significantly compared to those patients receiving standard care/training, this was not reflected in better outcome in HRQoL parameters.

Conservative management for postprostatectomy urinary incontinence

BACKGROUND

Urinary incontinence is common after both radical prostatectomy and transurethral resection of the prostate (TURP). Conservative management includes pelvic floor muscle training with or without biofeedback, electrical stimulation, extra-corporeal magnetic innervation (ExMI), compression devices (penile clamps), lifestyle changes, or a combination of methods.

OBJECTIVES

To assess the effects of conservative management for urinary incontinence after prostatectomy.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 24 August 2011), EMBASE (January 1980 to Week 48 2009), CINAHL (January 1982 to 20 November 2009), the reference lists of relevant articles, handsearched conference proceedings and contacted investigators to locate studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating conservative interventions for urinary continence in men after prostatectomy.

DATA COLLECTION AND ANALYSIS

Two or more review authors assessed the methodological quality of trials and abstracted data. We tried to contact several authors of included studies to obtain extra information.

MAIN RESULTS

Thirty-seven trials met the inclusion criteria, 33 amongst men after radical prostatectomy, three trials after transurethral resection of the prostate (TURP) and one trial after either operation. The trials included 3399 men, of whom 1937 had an active conservative intervention.  There was considerable variation in the interventions, populations and outcome measures.  Data were not available for many of the pre-stated outcomes.  Men's symptoms improved over time irrespective of management. Adverse effects did not occur or were not reported.There was no evidence from eight trials that pelvic floor muscle training with or without biofeedback was better than control for men who had urinary incontinence after radical prostatectomy (e.g. 57% with urinary incontinence versus 62% in the control group, risk ratio (RR) for incontinence after 12 months 0.85, 95% confidence interval (CI) 0.60 to 1.22) as the confidence intervals were wide, reflecting uncertainty. However, one large multicentre trial of one-to-one therapy showed no difference in any urinary or quality of life outcome measures and had narrower confidence intervals. There was also no evidence of benefit for erectile dysfunction (56% with no erection in the pelvic floor muscle training group versus 55% in the control group after one year, RR 1.01, 95% CI 0.84 to 1.20). Individual small trials provided data to suggest that electrical stimulation, external magnetic innervation or combinations of treatments might be beneficial but the evidence was limited. One large trial demonstrated that there was no benefit for incontinence or erectile dysfunction from a one-to-one pelvic floor muscle training based intervention to men who were incontinent after transurethral resection of the prostate (TURP) (e.g. 65% with urinary incontinence versus 62% in the control group, RR after 12 months 1.05, 95% CI 0.91 to 1.23).In eight trials of conservative treatment of all men after radical prostatectomy aimed at both treatment and prevention, there was an overall benefit from pelvic floor muscle training versus control management in terms of reduction of UI (e.g. 10% with urinary incontinence after one year versus 32% in the control groups, RR for urinary incontinence 0.32, 95% CI 0.20 to 0.51). However, this finding was not supported by other data from pad tests. The findings should be treated with caution, as most trials were of poor to moderate quality and confidence intervals were wide. Men in one trial were more satisfied with one type of external compression device, which had the lowest urine loss, compared to two others or no treatment. The effect of other conservative interventions such as lifestyle changes remains undetermined as no trials involving these interventions were identified.

AUTHORS' CONCLUSIONS

The value of the various approaches to conservative management of postprostatectomy incontinence after radical prostatectomy remains uncertain. It seems unlikely that men benefit from one-to-one pelvic floor muscle training therapy after transurethral resection of the prostate (TURP).  Long-term incontinence may be managed by external penile clamp, but there are safety problems.