The effect of nerve-sparing surgery on patient-reported continence post-radical prostatectomy

Introduction:

Urinary continence significantly affects quality of life after radical prostatectomy (RP). The impact of nerve-sparing surgery on continence is unclear from the current literature.

Methods:

We identified men with prostate cancer from the University Health Network Prostate Centre database who underwent RP. Preoperatively and at each postoperative visit, patients completed the Patient-Oriented Prostate Utility Scale (PORPUS), a validated psychometric and health utility instrument. Incontinence was defined by a single questionnaire item. Patients with radiotherapy or less than 10 months follow-up were excluded. Chi-squared tests and ANOVA were used to compare groups. Multivariable logistic regression was used to control for effects of nerve-sparing and other covariates.

Results:

Of the 253 eligible patients from 2003 to 2007, 159 patients had bilateral nerve-sparing, 32 had unilateral nerve-sparing and 62 had non-nerve-sparing surgery. Of these patients, 27%, 17% and 34%, respectively, were classified as incontinent at 1 year. These proportions were not significantly different between groups (p = 0.23). Multivariable logistic regression showed baseline urinary continence and urinary frequency to be significant predictors of patient-reported continence at 1 year postoperatively, with odds ratios of 1.7 (95% confidence interval [CI] 1.1–2.9) and 1.5 (95% CI 1.0–2.3), respectively.There was a significant difference in the proportion of PORPUS sexual function scores between nerve-sparing groups after excluding those with baseline sexual dysfunction (p = 0.003). Similarly, health-related utility scores were different across groups (p < 0.001).

Conclusion:

Our results do not suggest a difference in 1-year patient-reported continence based on the type of nerve-sparing RP. However, baseline continence and urinary frequency were significant predictors of continence at 1 year.     

Patient-reported urinary continence (third-party interview): results of post-radical retropubic prostatectomy in Singaporeans

OBJECTIVE: To determine the patient-reported urinary continence rate after retropubic radical prostatectomy (RRP) for prostate carcinoma through a third-party interview and to grade the severity of incontinence. METHODS: Between 1997 and 1999, 34 patients were evaluated through an independent third party about the degree of continence as well as the quality of life after RRP. Patients were interviewed either in person or over the telephone. Urinary continence was defined as wearing no diapers, pads or tissue paper. RESULTS: Of the 34 patients, 44% achieved immediate continence. Urinary incontinence gradually improved with time after surgery and 82% (n = 28) were fully continent at 12 months. Using the quality-of-life index, 91% of patients characterized their urinary incontinence as not or minimally bothersome. There was no significant difference between urologist- and patient-reported continence rates after RRP. CONCLUSION: Based on our grading system, urinary continence gradually improved with time and was 82% at 1 year.     

前列腺癌根治术后尿失禁的处理

目的:探讨前列腺癌根治术后并发尿失禁的处理方法。方法:报告31例经外科手术和非手术综合治疗前列腺癌根治术后尿失禁患者的临床资料。结果:手术治疗7例,尿失禁处理有效率为100%;非手术综合治疗26例,24例有效,有效率为92.3%。结论:对轻度或不完全性尿失禁(1,2度)采用盆底肌锻炼、生物反馈和电刺激、药物治疗等非手术综合治疗效果好,对重度或完全性尿失禁(3度)则需手术治疗。     

Artificial urinary sphincter for post-radical prostatectomy urinary incontinence: long-term subjective results

PURPOSE: Incontinence affects between 3% and 60% of patients after radical prostatectomy. Insertion of an artificial urinary sphincter is a mainstay therapeutic option available to these patients. We assessed patient satisfaction, outcome and complications long after artificial urinary sphincter implantation. MATERIALS AND METHODS: From a data bank of 131 patients who underwent artificial urinary sphincter prosthesis insertion we identified 71 with a mean age of 72 years who had also undergone radical prostatectomy and were available for evaluation. This group included 29 patients (40.8%) who received an earlier version of the AMS-800 (American Medical Systems, Minnetonka, Minnesota) and 42 (59.2%) who received the newer narrow back cuff device. Information on surgical procedures and followup were obtained from a computerized database. Patients were also contacted by an impartial reviewer who administered a standard telephone questionnaire on the degree of continence, complications, other means used to help with urinary continence, proficiency in device operation and satisfaction. RESULTS: At a mean followup of 7.7 years (range 0.5 to 16) 19 patients (27%) used 0, 23 (32%) used 1, 11 (15%) used 1 to 3 and 18 (25%) used more than 3 daily, while 1 used an external catheter. Surgical revision in 21 cases (29%) was required due to mechanical failure in 18 (25%), device erosion in 3 (4%) and infection in 1 (1.4%). The need for revision correlated significantly with the design of the sphincter (p = 0.005). Only 7 of the 42 patients in whom a narrow cuff AMS-800 was implanted needed revision versus 18 of the 23 with a previous design. Mean time to revision was 2.5 years (range 0.5 to 8). The device was removed in 2 cases (2.8%). Of the patients 41 (58%) are very satisfied, 14 (19%) are satisfied and 16 (23%) are unsatisfied with the device. The degree of satisfaction correlated with the number of pads used (p = 0.0005) and sphincter design (0.028) but not with the number of surgical revisions (p = 0.521) or patient age. CONCLUSIONS: The artificial urinary sphincter is a viable treatment option for post-radical prostatectomy incontinence with a high rate of continence and satisfaction for a long period after the procedure. Patients should be informed that complications necessitating device revision and explantation may appear late in followup. A standard definition of treatment success and studies of homogenous groups of patients with an artificial urinary sphincter would enable better understanding and patient education in the future.     

Laparoscopic versus open bilateral intrafascial nerve-sparing radical prostatectomy after TUR-P for incidental prostate cancer: surgical outcomes and effect on postoperative urinary continence and sexual potency

Objective

To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRPT) and nerve-sparing retropubic radical prostatectomy (nsRRPT) after TUR-P for incidental prostate cancer.

Materials and methods

Between January 2003 and August 2011, 125 nsLRPT and 128 nsRRPT for incidental prostate cancer diagnosed after TUR-P were performed at our clinic. Demographic data, peri- and postoperative measurements and functional outcomes were compared.

Results

The mean operative time was 153.1 ± 35.4 min for nsLRPT and 122.5 ± 67.5 min for nsRRPT (p = 0.03). The mean catheterization time was 8 ± 1 days in the laparoscopic group and 11 ± 2 days in the open group (p = 0.02). Also, the length of hospitalization presents statistical significant difference in the two groups. Positive margins were detected in 2.4 and 4.7 % of patients with pT2c tumours in the laparoscopic and open groups, respectively (p = 0.09). At a mean follow-up of 26.9 ± 9.3 months for the nsLRPT group and of 27.8 ± 9.7 months for the nsRRPT group, all patients were alive with no evidence of tumour recurrence. Twelve months postoperatively, complete continence was reported in 96.8 % of patients who underwent an nsLRPT and in 89.4 % of patients in the nsRRPT group (p = 0.02). At that time, 74.4 % of patients in the nsLRPT group and 53.1 % in the nsRRPT group reported the ability to engage in sexual intercourse (p = 0.0004).

Conclusion

nsLRPT after TUR-P, performed by expert surgeons, results to be a safe procedure with excellent functional outcomes with regard to the urinary continence and sexual potency.     

Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy

OBJECTIVE: To study the anatomical effects of placing a transobturator tape (TOT) in cadavers as well as determining the clinical outcome in men with urinary incontinence. METHODS: The study was a two stage study. The first phase was a cadaver study to examine the placement of the sling. The second part involved the placement of the sling in 20 men with incontinence, which occurred post-radical prostatectomy in 15 men. All patients had pre-operative and post-operative videourodynamics, maximum flow rate (Qmax) and residual urine measurement. Urethral pressure profiles and membranous urethral length were measured in five patients pre- and postoperatively. Incontinence was assessed on the basis of pad usage. Patients' satisfaction was recorded using a non-validated patient questionnaire at 6 weeks post-operatively. RESULTS: The cadaver study revealed that a leak point pressure of 60cmH(2)O was achieved on tensioning of the tape. In the clinical series, the mean (range) urethral closure pressure improved from 13.2 (8-22) to 86.4 (70-100) cmH(2)O following placement of the TOT. The membranous urethral length increased from a mean (range) of 3 (0-7) to 17.2 (10-22) mm following tensioning of the tape. No significant differences in Qmax pre- and postoperatively were observed. Incontinence cure rate (no pad usage) was 40% and improved rate (1-2 pads per day) was 30%. The majority of patients (12/20) were very satisfied with the procedure. CONCLUSIONS: The TOT, a novel procedure for treatment of post-radical prostatectomy incontinence, was shown to be effective and well accepted by patients.     

Early recovery of urinary continence after laparoscopic versus retropubic radical prostatectomy: evaluation of preoperative erectile function and nerve-sparing procedure as predictors

The aim of this study was to evaluate preoperative erectile function and attempted nerve-sparing procedure as predictors for early recovery of urinary continence after retropubic and laparoscopic radical prostatectomy. Patients were divided into two groups according to surgical approach (retropubic or laparoscopic) and learning curve for laparoscopic approach: group 1—retropubic approach (37 patients operated on from April 2000 to June 2006), group 2—laparoscopic approach (109 patients operated on from April 2003 to June 2006). We assessed state of urinary continence at 1, 3, 6, and 12 months after removal of the urinary catheter. Overall rates of urinary continence were 18%, 49%, 68%, and 80% at 1, 3, 6, and 12 months, respectively. Between groups 1 and 2, no statistically significant differences in recovery of urinary continence were evident, being 27% versus 15% at 1 month, 54% versus 47% at 3 months, 77% versus 65% at 6 months, and 91% versus 77% at 12 months in groups 1 and 2, respectively. An attempted nerve-sparing procedure (one or both neurovascular bundles) was statistically associated with urinary continence at 3 month, and International Index of Erectile Function-5 (IIEF-5) score (≥14) was identified as a significant factor predicting urinary continence at 6 months after laparoscopic radical prostatectomy. Younger age tended to result in early recovery of urinary continence after retropubic radical prostatectomy.     

Transrectal ultrasound guided implantation of the ProACT adjustable continence therapy system in patients with post-radical prostatectomy stress urinary incontinence: a pilot study

PURPOSE: We evaluate the feasibility and potential advantages of ProACT system implantation using transrectal ultrasound rather than fluoroscopy for guidance. MATERIALS AND METHODS: The transrectal ultrasound guided procedure was done between June and October 2005 in 7 patients with a mean age of 68.4 years (range 53 to 76) with mild to severe stress urinary incontinence after laparoscopic transperitoneal radical prostatectomy. RESULTS: The ProACT system was successfully implanted in all cases without perioperative complications. Time needed to complete the overall procedure was 15 to 30 minutes. All transrectal ultrasound studies performed during the mean followup of 4.2 months (range 2 to 6) confirmed the exact location of the devices. CONCLUSIONS: ProACT system implantation is feasible using transrectal ultrasound for guidance. Transrectal ultrasound enables excellent imaging of all anatomical landmarks during the entire procedure and it seems to provide considerable advantages over fluoroscopy in terms of safety and accuracy.     

Radical retropubic prostatectomy. Improved anastomosis and urinary continence

The striated urethral sphincter is the predominant muscular structure divided posteriorly during the apical dissection in radical prostatectomy. The authors have long realized the value of this maneuver in obtaining excellent apical surgical margins and in identifying the correct plane on the anterior surface of the rectum. Recently, they also have recognized the importance of incorporating this musculature into the vesicourethral anastomosis to fix the bladder neck and thus re-establish anatomic continuity. Identification of the striated urethral sphincter ranks in importance with elucidation of the anatomy of the dorsal vein complex and the anatomic identification of the neurovascular bundle in improving the patient's quality of life postoperatively.     

The mechanism of urinary continence after prostatectomy.

An anatomical and neuropharmacological study of the urethra was performed in 19 patients after prostatetectomy to investigate the mechanism of continence. Anatomically, the urethral segment responsible for the postprostatectomy continence was located distal to the open prostatic fossa in the external sphincter which is comprised of intrinsic striated muscle and is called arbitrarily rhabdosphincter by the author. This unique striated muscle in the rhabdosphinecter appears to be primarily under the alpha-adrenergic influence in view of the change in the urethral pressure profile observed following alpha-adrenergic drugs.     

Impact of anatomical radical prostatectomy on urinary continence

Urinary continence following an anatomical approach to radical prostatectomy was evaluated in 593 consecutive patients, 547 (92%) of whom achieved complete urinary control. Stress incontinence was present in 46 patients (8%), of whom 34 (6%) wore 1 or fewer pads per day and 2 (0.3%) required placement of an artificial sphincter. No patient was totally incontinent. Age, weight of the prostate, prior transurethral resection of the prostate, pathological stage and preservation or wide excision of the neurovascular bundles had no significant influence on preservation of urinary control. These data suggest that anatomical factors rather than preservation of autonomic innervation may be responsible for the improved urinary control associated with an anatomical approach to radical prostatectomy.     

Postoperative urinary continence after robot-assisted laparoscopic radical prostatectomy

OBJECTIVE: Laparoscopic radical prostatectomy has shown excellent results concerning patient morbidity, with less blood loss compared to conventional surgery. Robot-assisted laparoscopy offers several additional important technical improvements and therefore it might be suggested that robotic radical prostatectomy would also offer surgical advantages. The objective of this study was to evaluate urinary continence for the first 72 cases of robot-assisted radical prostatectomy performed by a single surgical team. MATERIAL AND METHODS: We analysed the outcomes of the first 72 consecutive patients to undergo robot-assisted prostatectomy for localized prostate cancer at our hospital between January 2002 and May 2004. A self-administered questionnaire concerning urinary status was mailed to the patients 3 and 6 months after surgery. Pre- and peroperative characteristics were obtained from patient medical records. The mean age was 61.2 years (range 36-71 years) and the mean preoperative prostate-specific antigen level was 6.3 ng/ml (range 2.3-10.7 ng/ml). The preoperative clinical stage was T1c, 67%, T2, 28% and T3, 5% and the mean Gleason sum was 6 (range 5-9). RESULTS: Sixty-one of the 68 patients (90%) reported no use of pads and 6 (9%) used a maximum of 1 pad/day 3-6 months after surgery. One patient reported use of >1 pad/day 6 months after surgery. Three significant complications were noted: ureter injury, haemorrhage and femoral nerve injury. CONCLUSIONS: In this series, which represents the learning curve for one surgical team, only a tenth of the patients still required pads 3-6 months after surgery. Considering the short follow-up period, the results in this series will probably improve over time.