Two- and three-/four dimensional perineal ultrasonography in men with urinary incontinence after radical prostatectomy

Transperineal Ultrasound Before and After Prostatectomy: Technical Approach and Description

This study assessed the feasibility of dynamic transperineal ultrasound (TPUS) pre/post-radical prostatectomy (RP). Ninety-eight patients were scanned pre-operatively and at four time-points post-operatively. TPUS was performed in 98 patients using an abdominal transducer at rest, during pelvic floor contraction (PFC) and Valsalva (VS) maneuver in supine and standing positions. Urodynamic evaluations included bladder neck angle at rest/PFC/VS, and degree of bladder neck movement. Pre-operative and post-operative measurements were technically feasible in >85% (supine) and >90% (standing) of patients. TPUS offers a reliable non-invasive dynamic assessment of the pelvic floor post-prostatectomy and may prove a useful adjunct for guiding exercises to preserve continence.

The relationship between pre- and postprostatectomy measures of pelvic floor muscle function and development of early incontinence after surgery

AIMS

The aim of this study is to investigate (i) whether pelvic floor muscle (PFM) shortening can be enhanced by provision of training focused on striated urethral sphincter (SUS) with feedback before prostatectomy, (ii) whether PFM shortening during voluntary efforts and coughing before and after prostatectomy differs between men who do and do not report symptoms of urinary incontinence 1 month after prostatectomy, and (iii) the relationship between severity of incontinence after prostatectomy and features of pelvic floor function (muscle shortening) and urethral length before and after prostatectomy.

METHODS

Sixty men referred for preoperative PFM training before radical prostatectomy participated. The International Continence Society Male Short Form questionnaire was used to quantify continence status. Transperineal ultrasound (US) imaging was used to record pelvic displacements related to activation of striated urethral sphincter, bulbocavernosus (BC) and puborectalis muscles during cough, "natural" voluntary contraction following pamphlet instruction, and trained voluntary contraction after formal physiotherapist instruction including US feedback.

RESULTS

Pelvic floor displacements following training differed between continent and incontinent men; continent participants demonstrated increased SUS shortening after training (compared with "natural"), but no difference was observed between trained and "natural" contractions for incontinent participants. Motion at ano-rectal junction during cough was reduced following surgery, but voluntary and involuntary activation of SUS or BC was not consistently affected by surgery.

CONCLUSIONS

Participants' capacity to improve function of the SUS with training appears related to postprostatectomy continence outcome.

Shear Wave Elastography in the Evaluation of the Urethral Sphincter Complex after Radical Prostatectomy

Post-prostatectomy pelvic floor muscle rehabilitation has a significant impact on urinary continence recovery. The aim of our study was the evaluation of urethral sphincter complex using shear wave elastography in patients after radical prostatectomy, with and without postsurgical pelvic floor muscle rehabilitation. Thirty-three patients were included in the study. The severity of urinary incontinence after radical prostatectomy was evaluated. Transrectal ultrasound examination was performed in all patients with shear wave elastography to visualize the urethral sphincter complex and estimate its length. Statistical analysis revealed that higher than average urethral sphincter complex stiffness correlates with a smaller number of pads used per day (p < 0,05) and better urine continence based on scales: subjective 0-10 (p < 0.05) and International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) (p < 0.05). The post-prostatectomy pelvic floor muscle rehabilitation group had statistically significant higher stiffness of the urethral sphincter complex compared with the group without rehabilitation (p < 0.05). The study found that shear wave elastography is a valuable method in evaluation of the urethral sphincter complex.

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

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

Transperineal ultrasound as a reliable tool in the assessment of membranous urethra length in radical prostatectomy patients

To evaluate the usefulness of transperineal ultrasound (TPUS) as a method of membranous urethra length (MUL) measurement and investigate whether preoperative (MULpre) and postoperative (MULpost) would be associated with the degree and time of urinary continence recovery after laparoscopic radical prostatectomy (LRP). 84 patients who underwent LRP between January 2017 and December 2018 were selected for final analysis. All patients had preoperative and postoperative measurement of MUL in TPUS. Urinary continence was defined as no pad or a safety pad. Recovery of continence was assessed at 1, 3, 6 and 12 months after catheter removal. We prospectively analyzed correlation of MULpre, MULpost and a percent change in membranous urethral length (MULratio) with the urinary continence status. 69 (82%) patients regained continence in the follow-up of 12 months. MULpre, MULpost and MULratio assessed in TPUS were larger in subgroups of patients who regained continence earlier and in the entire continent group. Spearman rank test showed strong correlations between MULpost and MULratio (R-0.6 and R-0.56, respectively, p < 0.0001) with the time to continence recovery in the cumulative 12 months follow-up. TPUS allowed a reliable measurement of MUL before and after LRP. MULpre, MULpost as well as MULratio are related with time to regain continence and recovery rate after LRP. Sparing longest possible sphincteric urethra, with respect to oncological outcomes is a key factor in recovering continence after prostate cancer surgery.

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.

Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy

Urinary incontinence is common after radical prostatectomy. Pelvic floor muscle training provides a plausible solution. Although early trials provided promising results, systematic reviews have questioned the efficacy of this intervention. A major consideration is that most clinical trials in men have applied principles developed for pelvic floor muscle training for stress urinary incontinence in women, despite differences in anatomy between sexes and differences in the mechanisms for continence/incontinence. Literature regarding continence control in men has been conflicting and often based on erroneous anatomy. New understanding of continence mechanisms in men, including the complex contribution of multiple layers of striated pelvic floor muscles, and detailed consideration of the impact of radical prostatectomy on continence anatomy and physiology, have provided foundations for a new approach to pelvic floor muscle training to prevent and treat incontinence after prostatectomy. An approach to training can be designed to target the pathophysiology of incontinence. This approach relies on principles of motor learning and exercise physiology, in a manner that is tailored to the individual patient. The aims of this review are to consider new understanding of continence control in men, the mechanisms for incontinence after radical prostatectomy, and to review the characteristics of a pelvic floor muscle training program designed to specifically target recovery of continence after prostatectomy.

Parameters of 2-Dimensional Perineal Ultrasonography Before and After Male Sling Procedure for Urinary Incontinence After Radical Prostatectomy

OBJECTIVE

To compare ultrasonographic patterns of 2-dimensional perineal ultrasonography in men in the preoperative and postoperative periods after transobturator sling deployment for the treatment of urinary incontinence after radical prostatectomy. Radiotherapy and radical prostatectomy are the primary treatments for localized prostate cancer. Studies comparing anatomic changes in men before and after radical prostatectomy based on perineal ultrasonography are scarce in the literature.

METHODS

Thirty-one patients from 2 centers were selected for examination and surgery. They were allocated into mild and/or moderate and severe incontinence groups who underwent the transobturator sling procedure between August 2014 and August 2018. Perineal ultrasonography was performed in the preoperative period for 21 of these patients and 3-6 months postoperatively after the transobturator sling procedure for 30 patients. Hypermobility of the proximal urethra and voluntary contraction of the pelvic floor were evaluated during the Valsalva maneuver, perineal contraction and at rest.

RESULTS

Clinical improvements of >50% were significantly more frequent in the mild and/or moderate vs severe incontinence group after male sling surgery (P = .035). Patients who demonstrated clinical improvement >50% showed a significantly greater displacement of the posterior portion of the bladder neck during contraction than those with clinical improvement <50% (P = .024).

CONCLUSION

The most important finding of this study was the significant difference in the posterior displacement of the bladder neck during contraction in patients who showed an improvement >50% compared with those with an improvement <50%. These data support the use of perineal ultrasonography in evaluating and selecting patients for the male sling procedure.

The measurement of membranous urethral length using transperineal ultrasound prior to radical prostatectomy

OBJECTIVE

To compare preoperative membranous urethral length (MUL) measurements using magnetic resonance imaging (MRI) with two-dimensional transperineal ultrasound imaging (TPUS) in two supine positions on two separate days in men prior to radical prostatectomy.

MATERIALS AND METHODS

MUL was prospectively measured in 18 male volunteers using MRI and on two separate occasions in two different patient positions using TPUS; the patient supine with the knees extended (Supine) and supine with the knees flexed to 70 degrees (Supine KF). Agreement between TPUS and MRI measurements of MUL was assessed using Bland-Altman method comparison techniques and a two-way mixed-effects single measures intraclass correlation (ICC). Test-retest reliability was assessed using a two-way random effects single measures ICC.

RESULTS

The mean difference in MUL measurements between MRI and i) TPUS Supine was -0.8 mm (95% limits of agreement (LOA): -3.2, 1.7) and ii) TPUS Supine KF was -0.8mm (95% LOA: -3.5, 1.9). ICC indicated a point estimate of excellent agreement between MRI and TPUS Supine ICC 0.93 (95% CI: 0.76, 0.98) and TPUS Supine KF ICC 0.91 (95%CI 0.79, 0.97). There was excellent agreement between TPUS Supine and TPUS Supine KF (ICC 0.98, 95% CI: 0.96, 0.99) with a mean difference of 0.3mm (95% LOA: -1.2 to 1.3mm).

CONCLUSIONS

Preoperative MUL can be reliably measured using TPUS and demonstrates excellent agreement with MRI measurements of MUL. TPUS provides clinicians with an accessible non-invasive alternative to MRI for the measurement of MUL that can be used in outpatient urological settings and for patients where MRI is contraindicated.

The Role of Preoperative Puborectal Muscle Function Assessed by Transperineal Ultrasound in Urinary Continence Outcomes at 3, 6, and 12 Months After Robotic-Assisted Radical Prostatectomy

PURPOSE

The efficacy of pelvic floor muscle training (PFMT) for men with postprostatectomy incontinence (PPI) after robotic-assisted radical prostatectomy (RARP) is controversial and the mechanism for its possible effect remains unclear. The aim of this study was to investigate the relationship between bladder neck (BN) displacement, as a proxy for puborectal muscle activation, and continence outcomes after RARP.

METHODS

Data were extracted from the South Australian Prostate Cancer Clinical Outcomes Collaborative database for men undergoing RARP by high volume surgeons who attended preoperative pelvic floor physiotherapy for pelvic floor muscle (PFM) training between 2012 and 2015. Instructions were to contract the PFM as if stopping the flow of urine. BN displacement was measured with 2-dimensional transperineal ultrasound, without digital rectal examination. Urinary continence status was assessed preoperatively and at 3, 6, and 12 months using the Expanded Prostate Cancer Index Composite 26. Data were analysed using logistic regression and mixed effects linear modelling. Confounding variables considered were baseline continence, age at diagnosis, margin status, nerve sparing procedures and pathological stage.

RESULTS

Of 671 eligible men, 358 met the inclusion criteria and were available for analysis, with 136 complete datasets at 12-month follow-up. While BN movement was associated with preoperative continence, there was no significant effect of BN displacement on the change in urinary continence at 12 months postprostatectomy (P=0.81) or on the influence of time on continence over 3-12 months.

Conclusions

Continence outcomes were not associated with BN displacement, produced by activity of the puborectal portion of the levator ani muscle, at 3, 6, or 12 months after RARP. These results suggest that the puborectal muscle does not play a role in the recovery of continence after RARP and may help to explain the negative findings of many studies of PFMT for PPI.

Postprostatectomy incontinence is related to pelvic floor displacements observed with trans-perineal ultrasound imaging

AIMS

To investigate the relationship between post-prostatectomy incontinence and dynamic features of activation of specific pelvic floor muscles in addition to anatomical parameters of the urethra.

METHODS

Forty-two men aged 66 (7) years (incontinent [N = 19] and continent [N = 23]) who had undergone prostatectomy participated. Transperineal ultrasound imaging was used to record sagittal images of pelvic structures during involuntary coughing and sustained maximal voluntary contractions. Imaging data were analyzed to calculate displacements of pelvic floor landmarks associated with activation of the puborectalis, striated urethral sphincter, and bulbocavernosus muscles. Anatomical features of functional urethral length and the resting position of the ano-rectal and urethra-vesical junctions were calculated. A principal component analysis and multiple logistic regression were used to consider which combinations of variables best distinguish between men with and without incontinence.

RESULTS

Five principal components were identified that together explained 72.0% of the data. Two principal components that represented (i) striated urethral sphincter activation and (ii) bulbocavernosus and puborectalis muscle activation were significantly different between participants with and without incontinence. Together these components correctly identified 88.1% of incontinent men, with a specificity and sensitivity of 91.3% and 84.2%, respectively. Poor function of the bulbocavernosus and puborectalis muscles could be compensated by good striated urethral sphincter function, but the bulbocavernosus and puborectalis muscles had less potential to compensate for poor striated urethral sphincter function.

CONCLUSIONS

Dynamic features of pelvic floor muscle activation, particularly shortening of the striated urethral sphincter during cough and voluntary contraction, are related to continence status after prostatectomy.

Size Does Not Make the Difference: 3D/4D Transperineal Sonographic Measurements of the Female Urethra in the Assessment of Urinary Incontinence Subtypes

Purpose. The objective was to evaluate the usefulness of transperineal ultrasound in the assessment of the urethral length and urethral lumen by 3D/4D transperineal sonography to discriminate between female patients with subtypes of urinary incontinence. Methods. A total of 150 female patients underwent an examination because of urinary incontinence. 41 patients were diagnosed with urgency urinary incontinence (OAB), 67 patients were diagnosed with stress urinary incontinence (SUI), and 42 patients were in the control group (CTRL). Three diameters of the urethral lumen (proximal (U1), medial (U2), and distal (U3)) and the urethral length were measured. By the assessment of the urethral lumen, the presence of the urethral funneling was evaluated. Results. We found a significant difference in the urethral length and urethral lumen U2 of OAB and SUI versus CTRL. The urethral length was significantly greater (P < 0.05) and the urethral lumen was significantly wider (P < 0.05) in the patients with urinary incontinence. The incidence of the urethral funneling was significantly higher (P < 0.05) in the study groups with urinary incontinence than in the control group. Conclusions. Our results have shown the urethral changes obtained by ultrasound in patients with urinary incontinence, but they are still insufficient to distinguish between subtypes of urinary incontinence.

Is a wider angle of the membranous urethra associated with incontinence after radical prostatectomy?

PURPOSE

To investigate whether differences in the anatomy and dynamics of the pelvic floor (PF) in patients after radical prostatectomy (RP) depicted on magnetic resonance imaging (MRI) are associated with continence status.

METHODS

In the prospective designed study, 24 patients with post-prostatectomy stress urinary incontinence were enrolled. Additionally, 10 continent patients after RP were matched for age, body mass index and perioperative parameters. All patients underwent continence assessment and MRI (TrueFISP sequence; TR 4.57 ms; TE 2.29 ms; slice thickness 7 mm; FOV 270 mm) 12 months after RP. Images were analyzed for membranous urethra length (MUL), angle of the membranous urethra (AMU), severity of periurethral/urethral fibrosis, lifting of the levator ani muscle, lowering of the posterior bladder wall (BPW), bladder neck (BN) and external urinary sphincter (EUS), and symphyseal rotation of these structures during the Valsalva maneuver and voiding.

RESULTS

Compared to continent controls, incontinent patients showed a significant wider AMU during voiding (p = 0.002) and more pronounced lowering of the BN and EUS (p < 0.001). No differences between the groups were found in symphyseal rotation of the analyzed structures, MUL and severity of periurethral/urethral fibrosis.

CONCLUSIONS

The angle of the membranous urethra as a result of anchoring of the BN and EUS in the PF appears to be an important functional factor with an essential impact on continence after RP. Functional MRI seems to be a helpful imaging tool for morphologic and dynamic evaluation of the PF.

Transperineal Sonography Evaluation of Muscles and Vascularity in the Male Pelvic Floor

Idiopathic chronic male pelvic pain is difficult to diagnose and treat. Currently, diagnosis relies on subjective symptoms; objective measures of neuromuscular mechanisms have not been investigated. Sonographic imaging has been used to investigate these neuromuscular mechanisms in the female pelvic floor, but neither research nor books describe sonography evaluation of the male pelvic floor. The purpose of this study was to develop and evaluate a perineal sonographic technique for the examination of the male pelvic floor muscles. Anatomic landmarks were identified with images collected from two subjects, one with intermittent reports of pelvic pain and one with no history of pain in the pelvic region. A description of the equipment settings, the examination protocol, and the resulting comparative image analysis is included. A validated protocol such as this may be useful in documenting differences in the soft tissue structures between asymptomatic individuals and patients with chronic pelvic pain to aid in diagnosis and treatment. This is the first known study to report sonographic findings of the individual muscles in the male pelvic floor, and additional research is needed to validate the techniques that have been deemed feasible.

[Imaging diagnostics of the male pelvic floor]

The understanding of the female pelvic floor during the last 20 years was very much influenced by the new techniques of sonographic and magnetic resonance imaging (MRI). Functional imaging of the male pelvic floor is, however, still in its infancy. In analogy to ultrasound examinations of the female pelvic floor, perineal ultrasound can be also be applied to men. The mobility of the proximal urethra, scarring of the bladder neck or implanted suburethral meshes can be easily visualized. Studies on healthy men provide information about different muscular structures during micturition. Morphology and function of the external sphincter can be visualized with transrectal or intraurethral ultrasound and also with a perineal approach. Using functional MRI the complex interactions of bladder, urethra, external sphincter and pelvic floor muscles can be evaluated. Functional MRI is so far not generally available but enables a better understanding of the function of the male pelvic floor. Imaging of the male pelvic floor makes a substantial contribution for improving surgical procedures for male incontinence in the future.

Novel insight into the dynamics of male pelvic floor contractions through transperineal ultrasound imaging

PURPOSE

Transperineal ultrasound imaging enables the minimally invasive assessment of pelvic floor muscle function. Although commonly used in women, the approach has rarely been reported in men. This approach has advantages because the midsagittal view visualizes a bony landmark and the entire urethral length. This allows investigation of the displacement of multiple points along the urethra and the unique mechanical actions of multiple muscles that could influence continence. We used a new transperineal ultrasound technique to compare the relative displacement of urethrovesical junction, anorectal junction and distal urethra during voluntary pelvic floor muscle contractions in continent men.

MATERIALS AND METHODS

We performed measurement and comparison of urethral displacement at specific urethral regions in 10 continent men (age range 28 to 41 years). Measures made on 2-dimensional midsagittal plane ultrasound images included the displacements of specific points along the urethra. Anatomical considerations suggest that these are caused by contraction of the levator ani, striated urethral sphincter and bulbocavernosus muscles. Pearson's correlation coefficient was used to investigate the relationship between displacements of pairs of points.

RESULTS

Data show individual variation in displacement of the distal urethra (striated urethral sphincter contraction) and urethrovesical junction (levator ani contraction). A strong inverse linear relationship (0.723) between displacements of these points indicates 2 alternative strategies of urethral movement.

CONCLUSIONS

Transperineal ultrasound imaging allows the simultaneous investigation of multiple pelvic floor muscles by measuring urethral displacement. The data provide evidence of different but coordinated strategies of urethral displacement in men.