Minimal residual membranous urethral length and membranous urethral length predict poor recovery from incontinence after robot-assisted radical prostatectomy and after open radical prostatectomy

Surgical experience overcomes the impact of prostatic-urethral anatomy on continence recovery after robotic prostatectomy: comprehensive analysis on 366 cases

PURPOSE

To investigate the relationship between a set of prostate-urethral complex (PUC) measurements and incontinence after robot-assisted radical prostatectomy (RARP).

METHODS

The study included data from patients undergoing RARP performed by 2 expert surgeons between 2019 and 2022, with data about preoperative magnetic resonance imaging (MRI) and functional follow-up. Continence status was assessed according to a stringent definition (no PADS used). MRIs were evaluated to calculate prostatic urethral length, membranous urethral length, membranous urethral width, levator ani thickness, and prostate shape. The association of PUC measurements with continence after RARP was studied. Secondarily, we evaluated whether pre-determined cut-off values of PUC measurements could be associated with time to continence. Cumulative hazard incidence analysis was performed by the Nelson-Aalen hazard function. Cumulative incidence hazard curves were built; the Peto-Peto test was used to evaluate the difference among the curves.

RESULTS

366 patients were included. At the 12-month follow-up, 333 patients (90.1%) were continent. Classification of PUC measurements overlapped between continent and noncontinent patients. However, a statistically significant difference was observed for levator ani thickness, greater in continent patients (12.8 mm vs. 11.7; p = 0.02). Multivariable models found BMI as independent predictor of incontinence (HR 1.04, 95% C.I 1.00-1.07, p = 0.04). None of PUC measurements associated with incontinence. Also, cumulative hazard incidence analysis at 3 / 6 / 12-months found no statistically significant difference in PUC measurements.

CONCLUSION

No association was found between anatomical characteristics of PUC and continence or time to continence after RARP performed by proficient surgeons. Our data would suggest that once the surgeon has surpassed the learning curve, anatomical variations do not significantly affect the appropriate and proficient execution of the prostate apex dissection during RARP.

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

OBJECTIVE

To provide an update on the association between preoperative membranous urethral length (MUL) and postoperative urinary incontinence (UI) in men who undergo robot-assisted radical prostatectomy (RARP)/robot-assisted laparoscopic prostatectomy (RALP).

MATERIALS AND METHODS

Urinary incontinence is common after RARP/RALP, and early recovery of continence is one of the most important functional outcomes following surgery. MUL has been identified as a factor associated with continence recovery after RARP/RALP. A systematic review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Embase, and Scopus databases. Inclusion criteria were English language full journal articles authored within the last 5 years that assessed continence using the Expanded Prostate Cancer Index Composite. The Critical Appraisal Skills Programme tool for retrospective cohort studies was used to evaluate study quality. A random-effects meta-analysis was performed to pool odds ratios (ORs) from available studies relating to continence as a function of MUL. The Grading of Recommendations, Assessment, Development and Evaluations framework was used to synthesise evidence.

RESULTS

Six studies including 970 patients reported an association between MUL and continence at 12 months. Longer MUL was associated with reduced UI odds at 12 months after surgery (pooled OR 0.74, 95% confidence interval 0.68-0.87, P < 0.001). Significant methodological and statistical heterogeneity was encountered.

CONCLUSIONS

Preoperative MUL measured on magnetic resonance imaging (MRI) is significantly associated with postoperative continence in men undergoing RARP/RALP. We recommend consideration of MRI measurement of MUL prior to RARP/RALP to guide treatment decisions in this population.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation and long-term outcomes for a single surgeon

Although novel techniques for avoiding incontinence during robot-assisted radical prostatectomy have been developed, long-term oncological outcomes are unknown. The objective of this study was to determine the long-term oncological outcomes and functional outcomes of novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation for a single surgeon. Data from 100 patients who underwent structure-preserving prostatectomies performed by a single surgeon were retrospectively analyzed. The median console time was 123 min. Bilateral nerve-sparing was performed in 43% of patients underwent, and 57% underwent unilateral nerve-sparing surgery. Most patients (96%) reached complete pad-zero urinary continence by one year after surgery. Satisfactory erectile function was achieved in 97% of patients who underwent bilateral nerve-sparing surgery, and 80% of patients who underwent unilateral nerve-sparing surgery. The surgical margin was positive for 25% of patients, and the biochemical recurrence-free rate at 5 years was 77%. The cancer-specific survival rate was 100% during the median follow-up period of 4.5 years. Clavien-Dindo grade III complications occurred in 1% of cases. The outcomes for novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation were similar to previously reported oncological outcomes, with satisfactory functional outcomes. This operative method may be useful for patients who are eligible for nerve-sparing surgery.