Membranous urethral length and urinary incontinence following robot-assisted radical prostatectomy: a systematic review and meta-analysis

Association of bi-parametric MRI measures with continence after robot-assisted radical prostatectomy

OBJECTIVE

To investigate the association between pre- and postoperative magnetic resonance imaging (MRI) measurements of the membranous urethra and the prostate volume and continence following robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

From December 2018 to June 2022, 100 continent patients undergoing unilateral nerve-sparing or non-nerve-sparing RARP were included in this cohort study. Bi-parametric MRI scans were performed before and 12 months after RARP and measurements included the membranous urethral length (MUL) measured in cm (mMUL) and in the number of image slices (sMUL; 3 mm/slice), the membranous urethral diameter (MUD), and the prostate volume. Urinary function was evaluated by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and continence, defined as the use of zero pads and the answer 'never' to the ICIQ-UI SF question regarding incontinence frequency or <8 g urine-loss per 24 h. Regression with robust variance estimates was used to analyse the association between measurements and outcomes.

RESULTS

At 12 months, continence and MRI data were available for 82 patients. The continence rate was 63% and the median (interquartile range) ICIQ-UI SF score was 4 (0-9). Both preoperative MUL measurements were associated with continence at 12 months. Every extra 5 mm of MUL increased the likelihood of being continent by 13 percentage points (P = 0.03) and every additional slice of sMUL increased it by 6 percentage points (P = 0.05). Both postoperative MUL measurements were associated with better continence and lower ICIQ-UI SF scores (P < 0.01). A larger prostate volume was associated with urinary incontinence at 12 months, with a small effect size. The MUD was not associated with continence.

CONCLUSION

Preoperative mMUL and sMUL are associated with continence at 12 months after RARP. The sMUL may be a useful measurement when only the axial plane is available, and the slice gap is known. Postoperative MUL measurements are strongly associated with continence, while MUD and prostate volume hold minimal prognostic value.

Association between maximal urethral length preservation and postoperative continence after robot-assisted radical prostatectomy: a meta-analysis and systematic review

ABSTRACT

Urinary incontinence is a common complication following robot-assisted radical prostatectomy (RARP). Urethral length has been identified as a factor affecting postoperative continence recovery. In this meta-analysis, we examined the association between use of the maximal urethral length preservation (MULP) technique and postoperative urinary continence in patients undergoing RARP. We conducted a comprehensive search of PubMed, Web of Science, Embase, and the Cochrane Library up to December 31, 2023. The quality of the literature was assessed using the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed to synthesize data and calculate the odds ratio (OR) from eligible studies on continence and MULP. Six studies involving 1869 patients met the eligibility criteria. MULP was positively associated with both early continence (1 month after RARP; Z = 3.62, P = 0.003, OR = 3.10, 95% confidence interval [CI]: 1.68-5.73) and late continence (12 months after RARP; Z = 2.34, P = 0.019, OR = 2.10, 95% CI: 1.13-3.90). Oncological outcomes indicated that MULP did not increase the overall positive surgical margin rate or the positive surgical margin status at the prostate apex (both P > 0.05). In conclusion, the use of the MULP technique in RARP significantly improved both early and late postoperative continence outcomes without compromising oncological outcomes.

Bladder mucosal smoothness predicts early recovery of urinary continence after laparoscopic radical prostatectomy

BACKGROUND

To propose the bladder mucosal smoothness (BMS) grade and validate a predictive model including MRI parameters preoperatively that can evaluate the early recovery of urinary continence (UC) after laparoscopic radical prostatectomy (LRP).

METHODS

A retrospective analysis was conducted on 203 patients (83 patients experienced UI at the three-month follow-up) who underwent LRP in our medical center and were diagnosed with prostate cancer (PCa) from June 2016 to March 2020. Patients' clinicopathological data were collected. Prostate volume (PV), membranous urethra length (MUL), intravesical prostatic protrusion length (IPPL), and BMS grade were measured by MRI. The total sample was randomly divided into a training set (n = 142) and a validation set (n = 61). A model was developed to predict the risk of urinary incontinence (UI) at three months after LRP.

RESULTS

Age group, clinical T stage group, BMS grade group, PV group, IPPL group, and MUL group differed significantly between patients in the UI group and the UC group (all P values < 0.05). Multivariate analysis identified 3 MRI-related predictors selected for the prediction model: BMS grade (1 odds ratio [OR] 0.17, 95% CI 0.11-0.66; P value = 0.024) (2 + 3 OR 0.17, 95% CI 0.04-0.66; P value = 0.011), IPPL (> 5 mm OR 0.17, 95% CI 0.1-0.64; P = 0.004), and MUL (≥ 14 mm OR 6.41, 95% CI 2.72-15.09; P value < 0.001). The model achieved a highest area under the curve of 0.900 in the training set and the validation set. The sensitivity and specificity of the prediction model were 0.800 and 0.816.

CONCLUSION

Our study confirmed that patients with lower BMS grade are associated with early recovery of urinary continence after LRP. A prediction model was developed and validated to evaluate the early recovery of urinary continence after LRP.

CLINICAL TRIAL NUMBER

Not applicable.

Elevating precision: A thorough investigation of multiparametric prostate MRI for prolonged insights into early continence prediction after robot-assisted laparoscopic prostatectomy

BACKGROUND

While radical prostatectomy stands out as one of the most effective curative treatments for prostate cancer, it does come with annoying side effects, such as urinary incontinence (UI). We aimed to investigate the predictability of UI using MRI measurements, along with clinical and disease-related variables.

METHODS

We included 191 patients who underwent robot-assisted laparoscopic radical prostatectomy between July 2020 and October 2022 in the study. Preoperative MRIs of the patients are re-evaluated by an experienced uroradiologist, and membranous urethral length (MUL), urethra wall thickness, levator ani thickness, outer levator distance, Lee's apex shape, intravesical prostate protrusion length, prostate apex depth, and pubic height measurements were made. Additionally, retrospective data on patients' age, BMI, PSA, PSA density, prostate volume, IPSS, clinical stage, and nerve-sparing status were collected. Patients were categorized into two groups based on continence status in the third postoperative month: continent or incontinent. The definition of UI was accepted as the use of one or more pads per day.

RESULTS

UI was observed in 38.21 % of the patients in the postoperative third month. Among MRI measurements, only MUL showed a significant relationship with UI (p < 0.001). IPSS (p = 0.004) and Clinical Stage (p < 0.001) were also significantly associated with continence status. Logistic regression analysis identified BMI (p = 0.023; CI 0.73-0.97), IPSS (p = 0.002; CI 1.03-1.17), MUL (p = 0.001; CI 0.66-0.90), and Clinical Stage (p < 0.001; CI 1.53-2.71) as significant predictors. In Multivariable Regression analysis, Clinical Stage emerged as the most powerful predictor of UI (p < 0.001).

CONCLUSIONS

Except for MUL, MRI measurements may not predict postoperative UI. A combination of IPSS, clinical stage, and MUL effectively informs patients about postoperative outcomes. These findings contribute to enhancing preoperative counseling for patients undergoing radical prostatectomy.

The prostate-gland asymmetry affects the 3- and 12-month continence recovery after RARP in patients with small prostate glands: a single center study

To test the impact of the prostate-gland asymmetry on continence rates, namely 3- and 12-month continence recovery, in prostate cancer (PCa) patients who underwent robot-assisted radical prostatectomy (RARP). Within our institutional database, RARP patients with complete preoperative MRI features and 12 months follow-up were enrolled (2021-2023). The population has been stratified according to the presence or absence of prostate-gland asymmetry (defined as the presence of median lobe or side lobe dominance). Multivariable logistic regression models (LRMs) predicting the continence rate at 3 and 12 months after RARP were fitted in the overall population. Subsequently, the LRMs were repeated in two subgroup analyses based on prostate size (≤ 40 vs > 40 ml). Overall, 248 consecutive RARP patients were included in the analyses. The rate of continence at 3 and 12 months was 69 and 72%, respectively. After multivariable LRM the bladder neck sparing approach (OR 3.15, 95% CI 1.68-6.09, p value < 0.001) and BMI (OR 0.90, 95% CI 0.82-0.97, p = 0.006) were independent predictors of recovery continence at 3 months. The prostate-gland asymmetry independently predicted lower continence rates at 3 (OR 0.33, 95% CI 0.13-0.83, p = 0.02) and 12 months (OR 0.31, 95% CI 0.10-0.90, p = 0.03) in patients with prostate size ≤ 40 ml. The presence of prostate lobe asymmetry negatively affected the recovery of 3- and 12-months continence in prostate glands ≤ 40 mL. These observations should be considered in the preoperative planning and counseling of RARP patients.

Membranous urethral length is the single independent predictor of urinary continence recovery at 12 months following Retzius-sparing robot-assisted radical prostatectomy

The influence of anatomical parameters on urinary continence (UC) after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) remains uncharted. Our objective was to evaluate their association with UC at 3, 6 and 12 months post-operatively. Data from patients who underwent RS-RARP were prospectively collected. Continence was defined as no pad use. Anatomic variables were measured on preoperative magnetic resonance imaging (MRI). Regression analyses were performed to identify predictors of UC at each time point. We included 158 patients with a median age of 60 years, most of whom had a localized tumor (≤ cT2). On multivariate analyses, at 3 months post-surgery, urinary incontinence (UI) rises with age, odds ratio (OR) 1.07 [95% confidence interval (CI) 1.004-1.142] and with prostate volume (PV), OR 1.029 (95% CI 1.006-1.052); it reduces with longer membranous urethral length (MUL), OR 0.875 (95% CI 0.780-0.983) and with higher membranous urethral volume (MUV), OR 0.299 (95% CI 0.121-0.737). At 6 months, UI rises with PV, OR 1.033 (95% CI 1.011-1.056) and decreases with MUV, OR 0.1504 (95% CI 0.050-0.444). Significantly, at 12 months post-surgery, the only predictor of UI is MUL, OR 0.830 (95% CI 0.706-0.975), establishing a threshold associated with a risk of UI of 5% (MUL > 15 mm) in opposition to a risk of 25% (MUL < 10 mm). This single institutional study requires external validation. To our knowledge, this is the first prospective cohort study supporting MUL as the single independent predictor of UC at 12 months post-surgery. By establishing MUL thresholds, we enable precise patient counseling.

Precise Prediction of Long-Term Urinary Incontinence after Robot-Assisted Laparoscopic Radical Prostatectomy by Readily Accessible "Everyday" Diagnostics during Post-Surgical Hospitalization

Aim and Objectives: We aimed to test the predictive value of readily accessible and easily performed post-surgical "bedside tests" on their validity of long-term urinary incontinence (UI) (≥12 months) in patients following robot-assisted laparoscopic radical prostatectomy (RALP). Material and Methods: Patients undergoing RALP between July 2020 and March 2021 were prospectively included and subdivided into two groups based on their pad usage after 12 months (0 vs. ≥1 pad). After catheter removal, patients performed a 1 h pad test, documented the need for pad change in a micturition protocol and received post-voiding residual urine volume ultrasound. Univariate and multivariable analyses were used to demonstrate the predictive value of easily accessible tests applied after catheter removal for UI following RALP. Results: Of 109 patients, 47 (43%) had to use at least one pad (vs. 62 (57%) zero pads) after 12 months. Univariate testing showed a significant difference in urine loss between both groups evaluated by the 1 h pad test performed within 24 h after catheter removal (70% < 10 mL, vs. 30% ≥ 10 mL, p = 0.004) and in the need for pad change within the first 24 h after catheter removal (14% dry pads vs. 86% wet pads, p = 0.003). In multivariable analyses, the combination of both tests (synoptical incontinence score) could be confirmed as an independent predictor for UI after 12 months (p = 0.011). Conclusions: Readily accessible "everyday" diagnostics (pad test/change of pads after catheter removal) following RALP seem to be associated with a higher rate of long-term UI. This finding is crucial since patients with a potentially higher need for patient education and counselling can be identified using these readily accessible tests. This could lead to a higher patient satisfaction and improved outcomes.

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.