盆底筋膜保护与重建对腹腔镜下前列腺癌根治术后早期控尿的影响

目的：了解采用盆底筋膜保护与重建法对腹腔镜下前列腺癌根治术后患者早期控尿的影响.方法回顾性分析自同一术者2013年1月至2015年12月在广东省中医院泌尿外科行腹腔镜下前列腺癌根治术的40例患者资料,其中采用盆底筋膜保护与重建技术的前列腺癌患者17例(治疗组),采用常规腹腔镜下治疗的前列腺癌患者23例(对照组),对两组患者的年龄、术前BMI、术前前列腺体积、术前临床分期、术前 Gleason 评分、手术时间、术中出血量、术后吻合口漏尿率、术后病理切缘阳性率、术后病理分期、术后 Gleason 评分及早期尿控功能恢复的情况等临床指标进行统计学分析.结果40例腹腔镜下前列腺癌根治术均经腹膜外完成,术中无中转开放,无术中输血病例,术后吻合口无漏尿,两组均有1例术后病理切缘阳性.两组在年龄、术前 BMI、术前前列腺体积、术前临床分期、术前 Gleason 评分、手术时间、术中出血量、术后病理分期及术后 Gleason评分方面差异均无统计学意义(P ＞0．05);40例患者均在术后12~16 d 拔除尿管,治疗组拔除尿管后3 d 内、1个月内和3个月内的累积完全控尿比例分别为52．9％、64．7％和82．4％,显著高于对照组(分别为8．7％、26．1％和34．8％),两组差异有统计学意义(P ＜0．05).结论在腹腔镜前列腺癌根治术中使用盆底筋膜保护与重建技术可显著提高患者术后早期的控尿能力.     

Postoperative membranous urethral length is the single most important surgical factor predicting recovery of postoperative urinary continence

PurposeTo analyze the potential surgical factors affecting postoperative urinary continence, including postoperative membranous urethral length (MUL), in an era where open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) coexist.MethodsConsecutive patients undergoing either ORP or RARP between April 2009 and June 2017 were included in this study. Pericatheter urethrography (PCU) was performed the day of catheter removal to confirm healing of the vesicourethral anastomosis and to measure PCU-MUL. Daily usage of incontinence pad was self-reported by the patient at each post-operative visit through a questionnaire. Univariate and multivariate analyses were performed to identify factors that influenced recovery of continence.ResultsOf the 196 patients included, 121 and 75 patients received ORP and RARP, respectively. The cumulative full continence rates (0 pad/day) at 1 year in the ORP and RARP groups were 87% and 95%, respectively. In the univariate analysis, older age, high preoperative International Prostate Symptom Score (IPSS) irritative symptom domain, ORP, poorer NVB preservation, and shorter PCU-MUL were associated with delayed recovery of full continence. In the multivariate analysis, only older age, high preoperative IPSS irritative symptom domain, and shorter PCU-MUL remained as independent factors significantly associated with delayed recovery of full continence.ConclusionsOur study highlights the importance of saving the MUL as long as possible in terms of continence recovery. This holds true for ORP even in the era of RARP and surgeons should not simply give up the prospect of early urinary continence in exchange for the patient's choice of ORP instead of RARP.     

Preserving Continence During Robotic Prostatectomy

Preservation of postoperative urinary continence remains the primary concern of all men and their surgeons following robot-assisted radical prostatectomy (RARP). Without doubt, continence is the most important quality of life issue following radical prostatectomy. Identification of difficulties and lessons learned over time has helped focus efforts in order to improve urinary quality of life and continence. This review will examine definitions of continence and urinary quality of life evaluation, technical aspects and the impact of patient-related factors affecting time to and overall continence.     

A systematic review of PFE pre-prostatectomy

Male Stress Urinary Incontinence is a complication post robotic radical prostatectomy. This is a major problem that needs to be solved, since it has great impact on quality of life affecting the patient’s physical activity and social well-being. A systematic review relating to literature on impact of preoperative PFE on continence outcomes for patients undergoing prostatectomy was conducted. The search strategy aimed to identify all references related to pelvic floor exercises and post-prostatectomy. Search terms used were as follows: (Pelvic floor exercises) AND (incontinence) AND (prostatectomy). The following databases were screened from 2000 to September 2017: CINAHL, MEDLINE (NHS Evidence), Cochrane, AMed, EMBASE, PsychINFO, SCOPUS, Web of Science. In addition, searches using Medical Subject Headings (MeSH) and keywords were conducted using Cochrane databases. Two UK-based experts in prostate cancer and robotic surgery were consulted to identify any additional studies. In the 6 months following surgery, the continence rates, as defined by the use of one pad or less per day, were 94% (44 of 47) and 96% (48 of 50) in the PFE and biofeedback groups and control groups (PFE alone), respectively (P?=?0.596) (Bales et al. in Urology 56: 627–630, 2000). This demonstrates preoperative PFE may improve early continence after RP. Geraerts et al. (Eur Urol 64:766–772, 2013) demonstrated the “incontinence impact” was in favour of a group with PFE at 3 and 6 months after surgery. This demonstrates again the advantage of preoperative PFE. Cornel et al. [World J Urol 23:353–355, 2005] determined the benefit of starting pelvic floor muscle exercise (PFE) 30 days before RP and of continuing PFE postoperatively for early recovery of continence as part of a randomised, prospective study (Moher quality A). This demonstrated preoperative PFE may improve early continence and QoL outcomes after RP. Post-prostatectomy incontinence is a bothersome complication of radical prostatectomy [Chughtai et al. in Rev Urol 15:61–66, 2013]. Weak pelvic floor muscles compromised normal pelvic floor function and led to urinary incontinence and erectile dysfunction. Strengthening the pelvic floor muscles was shown to significantly improve post-prostatectomy urinary continence, post-micturition dribble and erectile function. It would be prudent for all men to exercise their pelvic floor muscles to maintain normal pelvic floor function and start prior to surgery.     

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.     

负压治疗联合盆底肌训练对前列腺癌根治术后患者控尿功能及性功能的影响

目的探讨负压治疗联合盆底肌训练对前列腺癌根治术后患者控尿功能及主观幸福感的影响。方法将中山大学附属第三医院2016年10月至2019年4月泌尿外科确诊为前列腺癌并行腹腔镜下前列腺癌根治术治疗的70例患者,按随机数字表法分为干预组和对照组各35例,其中对照组35例采用常规护理(盆底肌功能锻炼),干预组35例在常规护理基础上,术后6周起再增加负压治疗。比较对照组和干预组术后6周、10周、18周控尿功能恢复情况,同时进行国际勃起功能评分表(IIEF-5)评分及主观幸福感调查,观察其治疗效果。结果干预组术后6周、10周、18周尿失禁评分中位值分别2分、1分与0分,低于对照组的2分、2分与2分,提示干预组术后平均控尿功能恢复时间较对照组短,差异有统计学意义(P<0.05);此外干预组相比对照组,IIEF-5评分及主观幸福感评分上升速度较快,提示干预组术后勃起功能和生活质量改善情况明显优于对照组。结论负压治疗联合盆底肌训练对前列腺癌根治术后患者的控尿功能和性功能有明显改善,且缩短其恢复时间。     

机器人辅助腹腔镜根治性前列腺切除术130例

目的 评估da Vinci S机器人辅助腹腔镜根治性前列腺切除术（RARP）的疗效和安全性.方法 回顾分析2009年7月至2013年9月,复旦大学附属中山医院应用da Vinci S手术系统（da Vinci Intuitive Surgical Inc.,Sunnyvale,CA,USA.）完成RARP术130例的情况.年龄48～76岁,平均（67±6）岁;PSA水平为2.16～ 78.20 ng/ml,平均（26.05±8.41）ng/ml;Gleason评分6～10;肿瘤临床分期均为局限性前列腺癌.结果 130例均经腹腔途径,采用机器人3臂或4臂,5～6枚troc ar完成RARP,无机器人机械故障或其他原因导致的术式改变.术前机器人准备时间20 ～ 90 min,平均（48.5±15.4） min;手术时间90 ～ 300 min,平均（143.6±22.9） min;术中出血量50 ～ 600 ml,平均（158.2±59.6） ml,2例（1.5％）术后输血400ml.术后2～3d下床活动,平均（2.2±0.6）d;术后住院5～21d,平均（6.6±1.9）d;4～21d拔除导尿管,平均（6.1±2.0）d.术后主要并发症包括：漏尿6例（4.6％）,漏尿于术后3～15d停止.术后淋巴瘘8例（6.2％）,术后2～3周停止,未发现淋巴囊肿.术后下肢静脉栓塞、肺栓塞和附睾炎各1例,治疗后好转.术后病理切缘阳性12例（9.2％）,精囊见癌侵犯10例（7.7％）,闭孔淋巴结转移4例（3.1％）.术后1～12个月复查PSA均＜ 0.2 ng/ml,术后6个月和1年完全控尿率达86％和95％.结论RARP安全、可靠,具有出血更少、恢复更快等优势,是根治性前列腺切除术的首选方式.     

Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy

Radical prostatectomy directly affects urinary continence dynamics with incontinence being a major factor in patients’ quality of life, social and psychological status. In order to help maintain continence after robot-assisted radical prostatectomy (RARP), a number of surgical techniques have been described. In the present narrative review, we summarize the surgical techniques that have been applied during RARP and their effects on incontinence rates and time to continence recovery.     

Prospective assessment of time-dependent changes in quality of life of Japanese patients with prostate cancer following robot-assisted radical prostatectomy

The objective of this study was to characterize changes in the quality of life (QOL) of Japanese patients following robot-assisted radical prostatectomy (RARP). This study included 298 consecutive localized prostate cancer (PC) patients undergoing RARP. The health-related QOL and disease-specific QOL were assessed using The Medical Outcomes Study 8-Item Short Form (SF-8) and The Extended Prostate Cancer Index Composite (EPIC), respectively, before and 1, 3, 6, 12 and 24 months after RARP. At 1 month after RARP, four (physical function, role limitations because of physical health problems, social function and role limitations because of emotional problems) of the eight scores in SF-8 were significantly impaired compared with those of baseline scores. However, all eight scores on all postoperative assessments, except for at 1 month after RARP, showed no significant differences from baseline scores. Although there were no significant differences in the bowel function, bowel bother, sexual bother, hormonal function or hormonal bother between baseline and postoperative assessments of EPIC at all time points, the urinary function, urinary incontinence and sexual function scores at 1, 3 and 6 months after RARP were significantly inferior to those of baseline scores, and urinary bother and urinary irritation/obstruction scores at 1 month after RARP were significantly impaired compared with those of baseline scores. These findings suggest that the health-related QOL of Japanese PC patients undergoing RARP may not be markedly deteriorated following RARP; however, as for the disease-specific QOL, urinary and sexual functions, particularly those early after RARP, appeared to be significantly impaired.     

机器人辅助腹腔镜前列腺癌根治术中神经血管束保留技术的新进展

近年来机器人辅助腹腔镜前列腺癌根治术(RARP)已逐渐成为治疗局限性前列腺癌的一种安全有效措施,但术后性功能障碍一直困扰着患者及泌尿外科医师。本文将从RARP术中保留神经血管束的新技术以及对术后性功能恢复情况作一综述。     

The preoperative pad test as a predictor of urinary incontinence and quality of life after robot-assisted radical prostatectomy: a prospective,observational, clinical study

Purpose

To assess whether the preoperative 1-h pad test could predict postoperative urinary incontinence and quality of life after robot-assisted radical prostatectomy.

Methods

A total of 329 patients who underwent robot-assisted radical prostatectomy between 2013 and 2016 were prospectively enrolled in this study. These patients were divided into the preoperative urinary continence group and the preoperative urinary incontinence group according to the 1-h pad test. The time to achieve urinary continence, lower urinary tract function evaluated by uroflowmetry and post-voided residual urine volume, and quality of life evaluated by King’s Health Questionnaire and International Consultation on Incontinence Questionnaire-Short Form were compared between these two groups.

Results

There were 190 patients (58%) in the preoperative urinary continence group (1-h pad test?≤?2 g) and 139 patients (42%) in the preoperative urinary incontinence group (1-h pad test > 2 g). In the preoperative urinary continence/incontinence groups, 83%/76% of patients achieved continence within 12 months, respectively, and urinary incontinence remained significantly longer in the preoperative incontinence group than in the preoperative continence group (P? =?0.042). Although there were no significant differences in all quality of life items between the two groups before surgery, several items were significantly higher in the preoperative urinary continence group.

Conclusion

Achievement of urinary continence and improvement of urinary quality of life are delayed in patients with preoperative urinary incontinence assessed by the 1-h pad test. The preoperative 1-h pad test could be a useful predictor of prolonged urinary incontinence and poor quality of life after robot-assisted radical prostatectomy.

     

Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence

OBJECTIVES: Urinary incontinence after radical prostatectomy continues to be a distressing problem, even with preservation of the neurovascular bundles and meticulous apical dissection. Recent studies suggest that motor and sensory components of the pelvic nerve may be affected by surgery, since both components are anatomically located in intimate contact with the seminal vesicles. We propose seminal vesicle-sparing radical prostatectomy to preserve pelvic innervation and improve the rate of urinary continence. METHODS: Fifty-four patients were enrolled in this prospective study. A standard retropubic radical prostatectomy was performed in 34 patients. A seminal vesicle-sparing radical prostatectomy was performed in a pilot series of 20 consecutive patients. The seminal vesicle tip and surrounding tissue were preserved and carefully handled. In all patients, a modified pad test and posterior urethral sensory threshold test were performed preoperatively and 6 weeks and 6 months postoperatively and correlated with urinary continence. RESULTS: The intraoperative preservation of the seminal vesicle tip was possible in all patients in this pilot series (n = 20). In the seminal vesicle-sparing radical prostatectomy group, the continence rate was 60% after 6 weeks and 95% after 6 months. These rates were significantly higher than the continence rates in the standard prostatectomy group (18% and 82% at 6 weeks and 6 months, respectively). The sensory threshold levels in the seminal vesicle-sparing group were similar to the preoperative values and were significantly lower than the postoperative threshold levels in the standard prostatectomy group. CONCLUSIONS: Seminal vesicle tip-sparing radical prostatectomy may be a surgical option to preserve pelvic innervation and maintain urinary continence after radical prostatectomy. Further randomized studies are necessary to elucidate the impact of seminal vesicle-sparing radical prostatectomy on restoration of urinary continence.     

Significance of preoperatively observed detrusor overactivity as a predictor of continence status early after robot-assisted radical prostatectomy

Several recent studies have reported the involvement of bladder dysfunction in the delayed recovery of urinary continence following radical prostatectomy （RP）. The objective of this study was to investigate the significance of detrusor overactivity （DO） as a predictor of the early continence status following robot-assisted RP （RARP）. This study included 84 consecutive patients with prostate cancer undergoing RARP. Urodynamic studies, including filling cystometry, pressure flow study, electromyogram of the external urethral sphincter and urethral pressure profile, were performed in these patients before surgery. Urinary continence was defined as the use of either no or one pad per day as a precaution only. DO was preoperatively observed in 30 patients （35.7%）, and 55 （65.5%） and 34 （40.5%） were judged to be incontinent 1 and 3 months after RARP, respectively. At both 1 and 3 months after RARP, the incidences of incontinence in patients with DO were significantly higher than in those without DO. Of several demographic and urodynamic parameters, univariate analyses identified DO and maximal urethral closure pressure （MUCP） as significant predictors of the continence status at both 1 and 3 months after RARP. Furthermore, DO and MUCP appeared to be independently associated with the continence at both I and 3 months after RARP on multivariate analysis. These findings suggest that preoperatively observed DO could be a significant predictor of urinary incontinence early after RARP; therefore, it is recommended to perform urodynamic studies for patients who are scheduled to undergo RARP in order to comprehensively evaluate their preoperative vesicourethral functions.     

The impact of catheter removal time on urinary continence and overactive bladder symptoms after robot-assisted radical prostatectomy: a retrospective analysis of consecutive 432 cases from a single institution

BackgroundAfter radical prostatectomy, the optimal length of postoperative catheterization time remains to be determined. This study investigates the impact of catheter removal time on urinary continence and overactive bladder (OAB) symptoms after robot-assisted radical prostatectomy (RARP).MethodsFour hundred and thirty-two consecutive patients underwent RARP by a single surgeon between Nov 2020 and Oct 2021. Time to catheter removal was categorized into 7, 10, and ≥14 days. Continence was defined as no more than 1 pad used or no more than 20 g of urine leakage per 24 hours. The patients’ continence rates and overactive bladder symptom score (OABSS) were assessed at 48 hours, 1 week, 4, 12, and 24 weeks after catheter removal.ResultsOverall, continence rates were 37.3% 48 hours after catheter removal, 54.4% 1 week, 77.5% 4 weeks, 92.1% 12 weeks, and 97.9% 24 weeks after catheter removal. The median time to regain continence was 1 week. At 4 weeks after catheter removal, the continence rate in the ≥14 days group (70.5%) was significantly lower than the 7 days group (86.3%) and 10 days group (83.0%) (P=0.001). In a univariate Cox regression analysis, the presence of diabetes, higher pre-operative OABSS, and a catheterization time of 10 days were associated with worse continence recovery. The mean OABSS of patients in the continent group were significantly lower than the incontinent group at 48 hours, 4, 12 and 24 weeks after catheter removal. At 24 weeks after catheter removal, the mean OABSS in the 7 days group was significantly lower than in other groups.ConclusionsEarly catheter removal (7 days) was associated with better continence results and lower OABSS at 4 and 24 weeks after catheter removal respectively.     

Urinary continence following radical prostatectomy assessed by a self-administered questionnaire

OBJECTIVES: A total aim of this study was to assess the incidence of urinary incontinence in patients following radical prostatectomy and determine the factors that may influence this incidence. METHODS: A total of 135 men underwent radical retropubic prostatectomy at our center between 1987 and 1997. 120 patients were sent a questionnaire regarding preoperative and postoperative voiding habits. Data collected included preoperative and postoperative continence status, interval to postoperative continence status, associated urinary symptoms, willingness to undergo radical prostatectomy again if need be and additional postoperative procedures. Patient age, date of surgery, number of neurovascular bundles resected at prostatectomy and duration of follow-up were also noted. RESULTS: Of the 120 patients, 116 (96.7%), a mean of 65.2 (range 48-76) years old, responded to the questionnaire. Mean follow-up was 4.3 years (range 1-10.8). Continence was defined as no regular use of pads. Our overall urinary incontinence rate was 14.4%. Of the respondents, 88. 8% (103/116) had achieved final continence status by 6 months postoperatively, and 95% (110/116) would undergo surgery again if need be. Of the patients considered incontinent postoperatively, 66. 6% had associated urgency. Age, year of surgery, number of neurovascular bundles resected at prostatectomy, preoperative urinary leakage of postvoiding dribbling, postoperative pelvic floor exercises, and anastomotic stricture had no significant impact on postoperative continence status. CONCLUSIONS: Using an anonymous self-administered questionnaire, we found a 14.4% incontinence rate after radical prostatectomy. These results allow patients to have realistic expectations when counseled prior to this operation.     

The role of pelvic floor exercises on post-prostatectomy incontinence

PURPOSE: Post-radical prostatectomy incontinence occurs in 0.5% to 87% of patients. This condition may be attributable to intrinsic sphincteric deficiency, and/or detrusor abnormalities. Previous studies of pelvic floor exercise (PFE) for improving post-prostatectomy incontinence have shown mixed results. We determined whether preoperative and early postoperative biofeedback enhanced PFE with a dedicated physical therapist would improve the early return of urinary incontinence. MATERIALS AND METHODS: A total of 38 consecutive patients undergoing radical prostatectomy from November 1998 to June 1999 were randomly assigned to a control or a treatment group. The treatment group of 19 patients was referred to physical therapy and underwent PFE sessions before and after surgery. Patients were also given instructions to continue PFE at home twice daily after surgery. The control group of 19 men underwent surgery without formal PFE instructions. All patients completed postoperative urinary incontinence questionnaires at 6, 12, 16, 20, 28 and 52 weeks. Incontinence was measured by the number of pads used with 0 or 1 daily defined as continence. RESULTS: Overall 66% of the patients were continent at 16 weeks. A greater fraction of the treatment group regained urinary continence earlier compared with the control group at 12 weeks (p <0.05). Three control and 2 treatment group patients had severe incontinence (greater than 3 pads daily) at 16 and 52 weeks. Of all patients 82% regained continence by 52 weeks. CONCLUSIONS: PFE therapy instituted prior to radical prostatectomy aids in the earlier achievement of urinary incontinence. However, PFE has limited benefit in patients with severe urinary incontinence 16 weeks after surgery. There is a minimal long-term benefit of PFE training since continence rates at 1 year were similar in the 2 groups.     

Systematic Review and Meta-analysis of Studies Reporting Urinary Continence Recovery After Robot-assisted Radical Prostatectomy

Context

Robot-assisted radical prostatectomy (RARP) was proposed to improve functional outcomes in comparison with retropubic radical prostatectomy (RRP) or laparoscopic radical prostatectomy (LRP). In the initial RARP series, 12-mo urinary continence recovery rates ranged from 84% to 97%. However, the few available studies comparing RARP with RRP or LRP published before 2008 did not permit any definitive conclusions about the superiority of any one of these techniques in terms of urinary continence recovery.

Objective

The aims of this systematic review were (1) to evaluate the prevalence and risk factors for urinary incontinence after RARP, (2) to identify surgical techniques able to improve urinary continence recovery after RARP, and (3) to perform a cumulative analysis of all available studies comparing RARP versus RRP or LRP in terms of the urinary continence recovery rate.

Evidence acquisition

A literature search was performed in August 2011 using the Medline, Embase, and Web of Science databases. The Medline search included only a free-text protocol using the term radical prostatectomy across the title and abstract fields of the records. The following limits were used: humans; gender (male); and publication date from January 1, 2008. Searches of the Embase and Web of Science databases used the same free-text protocol, keywords, and search period. Only comparative studies or clinical series including >100 cases reporting urinary continence outcomes were included in this review. Cumulative analysis was conducted using the Review Manager v.4.2 software designed for composing Cochrane Reviews (Cochrane Collaboration, Oxford, UK).

Evidence synthesis

We analyzed 51 articles reporting urinary continence rates after RARP: 17 case series, 17 studies comparing different techniques in the context of RARP, 9 studies comparing RARP with RRP, and 8 studies comparing RARP with LRP. The 12-mo urinary incontinence rates ranged from 4% to 31%, with a mean value of 16% using a no pad definition. Considering a no pad or safety pad definition, the incidence ranged from 8% to 11%, with a mean value of 9%. Age, body mass index, comorbidity index, lower urinary tract symptoms, and prostate volume were the most relevant preoperative predictors of urinary incontinence after RARP. Only a few comparative studies evaluated the impact of different surgical techniques on urinary continence recovery after RARP. Posterior musculofascial reconstruction with or without anterior reconstruction was associated with a small advantage in urinary continence recovery 1 mo after RARP. Only complete reconstruction was associated with a significant advantage in urinary continence 3 mo after RARP (odds ratio [OR]: 0.76; p = 0.04).Cumulative analyses showed a better 12-mo urinary continence recovery after RARP in comparison with RRP (OR: 1.53; p = 0.03) or LRP (OR: 2.39; p = 0.006).

Conclusions

The prevalence of urinary incontinence after RARP is influenced by preoperative patient characteristics, surgeon experience, surgical technique, and methods used to collect and report data. Posterior musculofascial reconstruction seems to offer a slight advantage in terms of 1-mo urinary continence recovery. Update of a previous systematic review of literature shows, for the first time, a statistically significant advantage in favor of RARP in comparison with both RRP and LRP in terms of 12-mo urinary continence recovery.     

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.     

Extended nodal dissection reduces sexual function recovery after robot-assisted laparoscopic prostatectomy

Abstract Background and Purpose: Considering the anatomic proximity of the internal iliac lymph nodes and the pelvic plexus, it may be expected that more extensive pelvic nodal dissection is associated with an increased risk of damage to the small pelvis neural and vascular structures. We evaluate whether nodal dissection is associated with functional outcome after robot-assisted radical prostatectomy (RARP). Patients and Methods: In a series of 798 RARP procedures, 325 (40.7%) patients underwent a lymph node dissection. Continence, sexual function, and lower urinary tract symptoms (LUTS) were assessed using the International Consultation of Incontinence Questionnaire short form (ICIQ)-SF), International Index of Erectile Function-15, and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ)-PR25 questionnaires before and at 6 months intervals after RARP. Results: Preoperative ICIQ-SF, IIEF-15, and PR25-LUTS scores were similar for men with and without nodal dissection. Normal postoperative erectile function (IIEF-EF >24) at 6 months was reported by 1.7%, 9.1%, and 50.4% of men with no, unilateral, and bilateral nerve preservation and normal preoperative erectile function. All domains of the IIEF-15 score showed a negative correlation with the number of removed lymph nodes. In 70 of 325 (21%) cases with nodal dissection, more than 10 nodes were removed. Men with more than 10 nodes removed had lower IIEF-15 domain scores compared with men with 1 to 10 removed lymph nodes. The postoperative ICIQ-SF and PR25-LUTS scores were not associated with extent of nodal dissection. Nodal metastases were found in 5.9% and 15.7% of men with ≤10 nodes and >10 nodes removed (P=0.005). In a multivariate analysis, extent of fascia preservation (FP-score), preoperative IIEF-EF, and number of removed nodes were the strongest independent predictors of postoperative erectile function recovery. Conclusion: More extensive nodal dissection was associated with impaired postoperative sexual function recovery but not continence and voiding function after RARP, independent of preoperative function and nerve preservation.     

Causative factors for de novo inguinal hernia after robot-assisted radical prostatectomy

To determine causative factors for de novo inguinal hernia (IH), after robot-assisted radical prostatectomy (RARP). This was a retrospective, single-center study, which included patients undergoing RARP for prostate cancer at our institution, from February 2012 to January 2015. Cox proportional hazards models were used to determine the relationships between de novo IH and various factors. A total of 284 patients were included in the analysis. Forty-two (14.7%) patients developed IH at a median period of 8 months after RARP. On multivariate analysis, preoperative international prostate symptom score question 6 > 2, and a patent processus vaginalis were significantly correlated with de novo IH (hazard ratio (HR) 4.17, 95% confidence interval (CI) 2.07–8.37, p < 0.001; HR 3.67, 95% CI 2.36–5.69, p < 0.001). Preoperative urinary straining and a patent processus vaginalis were predictive of de novo IH after RARP.