Continent Patients Research Articles

Effect of prostatic apex shape (Lee types) and urethral sphincter length in preoperative MRI on very early continence rates after radical prostatectomy

PurposeTo test the effect of anatomic variants of the prostatic apex overlapping the membranous urethra (Lee type classification), as well as median urethral sphincter length (USL) in preoperative multiparametric magnetic resonance imaging (mpMRI) on the very early continence in open (ORP) and robotic-assisted radical prostatectomy (RARP) patients.MethodsIn 128 consecutive patients (01/2018–12/2019), USL and the prostatic apex classified according to Lee types A–D in mpMRI prior to ORP or RARP were retrospectively analyzed. Uni- and multivariable logistic regression models were used to identify anatomic characteristics for very early continence rates, defined as urine loss of ≤ 1 g in the PAD-test.ResultsOf 128 patients with mpMRI prior to surgery, 76 (59.4%) underwent RARP vs. 52 (40.6%) ORP. In total, median USL was 15, 15 and 10 mm in the sagittal, coronal and axial dimensions. After stratification according to very early continence in the PAD-test (≤ 1 g vs. > 1 g), continent patients had significantly more frequently Lee type D (71.4 vs. 54.4%) and C (14.3 vs. 7.6%, p = 0.03). In multivariable logistic regression models, the sagittal median USL (odds ratio [OR] 1.03) and Lee type C (OR: 7.0) and D (OR: 4.9) were independent predictors for achieving very early continence in the PAD-test.ConclusionPatients’ individual anatomical characteristics in mpMRI prior to radical prostatectomy can be used to predict very early continence. Lee type C and D suggest being the most favorable anatomical characteristics. Moreover, longer sagittal median USL in mpMRI seems to improve very early continence rates.

To sling or not to sling? Impact of intraoperative sling procedures during radical prostatectomy on postoperative continence outcomes: A systematic review and meta-analysis.

PurposeThis systematic review and meta‐analysis investigates the efficacy of intraoperative sling procedures in reducing postprostatectomy urinary incontinence compared to having no slings.MethodsA comprehensive search of PubMed, Medline, Embase, and the Cochrane library from inception to November 2020 was performed. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized studies and Newcastle‐Ottawa Scale for nonrandomized studies. The GRADE approach was used for critical appraisal of evidences and meta‐analyses were conducted using random‐effects models.ResultsTen studies were included (n = 1,447). Quality of evidence ranged from moderate to very low. Sling procedure was generally favorable for short‐term continence outcomes, although discrepancies exist due to variability in continence definition. Sling procedure resulted in reduced urinary pad weight at 1 month postoperatively (MD: 21.55; 95%CI: 12.58 to 30.52). Patient‐reported questionnaires were also favorable for the sling group for up to 3 months (IPSS; (MD: 1.44; 95%CI: 0.14 to 2.74), ICIQ‐SF; (MD: 2.25; 95%CI: 1.26 to 3.24), EPIC‐U; (MD: 5.30; 95%CI: 1.12 to 9.39)) postoperatively. Sling procedure improved the number of continent patients at 1 month with continence definition of zero pad use/day (RR:1.41; 95%CI: 1.10 to 1.83) but not with the definition of ≤ 1pad/day. Similarly, it reduced the time to continence with the ≤ 1 pad/day definition (MD: 0.5; 95%CI: 0.1 to 0.9) but not with the zero pad/day definition.ConclusionThe current literature suggests that intraoperative sling procedures during radical prostatectomy may promote early return of continence compared to having no sling, however, there are no long‐term differences.

Prospective evaluation of urinary continence after laparoscopic radical prostatectomy using a validated questionnaire and daily pad use assessment: which definition is more relevant to the patient's perception of recovery?

IntroductionNo standard definition for urinary continence after radical prostatectomy exists, and there are discrepancies in continence rates reported in the literature, as well as rates reported by physicians and patients. Therefore, we used two tools, a validated questionnaire and daily pad use, to identify the criteria that best reflects patients’ perceptions of continence recovery.Material and methodsThis is a prospective study of 74 patients who underwent nerve-sparing laparoscopic radical prostatectomy. Continence was assessed monthly for 3 months following catheter removal using the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) and by recording the number of pads the patients used on a daily basis. According to daily pad use, patients were categorized as either dry (no-pads), socially continent (0–1 pad) or incontinent (≥2 pads).ResultsSeventy-four patients were enrolled with a mean age of 64.3 (±5.6) years. There were no significant differences in continence rates using scores from the International Consultation on Incontinence Questionnaire- Short Form (ICIQ-UI SF) or no-pad use (29.7% vs 32.4%, 45.9% vs 48.6% and 54.1% vs. 54.1%, at the 1-, 2- and 3-month follow-ups, respectively). However, the number of socially continent patients was significantly higher (59.5%, 70.3% and 81.1%, at the 1-, 2- and 3-month follow-ups, respectively [p <0.001]).ConclusionsThe totally dry definition better reflected patients’ perceptions rather than the socially continent definition for the evaluation of continence recovery following laparoscopic radical prostatectomy. To avoid discrepancies, we recommend the use of a validated questionnaire as well as the no-pad definition to standardize the reporting of post radical prostatectomy continence rates.

Retzius-sparing robot-assisted radical prostatectomy: perioperative and immediate continence outcomes of an initial series

ObjectiveThe objective of this work is to present initial perioperative, immediate continence and oncological results in a series of 25 prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy. Material and methodsWe retrospectively analyzed a series of 25 patients treated with Retzius-sparing robot-assisted radical prostatectomy for cT1–T2b prostate cancer between 2018−2019. The 5 stages of surgery are described. We make a descriptive statistic of our initial series and its outcomes in terms of immediate continence, defined as 0–1 safety pads/24 h in the first week after catheter removal. ResultsMedian follow-up, 6 months (3−18). Median PSA, 6.1 ng/mL (4−14.3). All surgeries were performed with posterior approach and 84% of the patients received intrafascial bilateral nerve-sparing. Affected surgical margins were present in 28%, being the apex the most frequent site of affectation. Surgical complications: 1 (4%) patient required transfusion of blood products in the immediate postoperative period. Mean hospital stay was 48 h. Functional results: Immediate continence is shown by 80% of the patients, and 80% of the continent patients do not require safety liner/pad. Oncological results: With a median follow-up of 6 months, 84% do not present biochemical-progression. ConclusionsInitial functional results in terms of immediate continence are very satisfactory in patients who have undergone Retzius-sparing robot-assisted radical prostatectomy without negative impact on prognosis.

Long-term functional and clinical outcomes following transanal advancement flap for complex anal fistula repair: are there predictors of recurrence and incontinence?

Transanal flap is an attractive technique for complex fistulas. The aim of this study was to identify factors associated with poor outcome, recurrence and incontinence. All patients who underwent an advancement flap for the treatment of a complex anal fistula between 1995 and 2019 were prospectively enrolled. The patient data obtained included age, sex, body mass index, comorbid conditions and smoking history. The fistula characteristics analysed included previous anal surgery, anatomy of the fistula according to Park's classification, horseshoe or supralevator extension and preoperative seton drainage. The postoperative data registered included complications, postoperative stay, recurrence and incontinence. Predictive factors for recurrence and incontinence were identified using univariate and multivariate analysis. One hundred and ninety patients were included; 134 (70.5%) were men and the mean patient age was 50years. The median length of follow-up was 44.6months. The fistula recurred in 14 patients (7.3%). Before surgery, 20 patients (10.5%) reported incontinence symptoms. In the continent patients a Wexner postoperative score of 0 was identified in 79.4%. Wexner scores between 1 and 3 were observed in 17% and scores of 4 or more in five patients (3%). Factors associated with recurrence included age <50years (OR=4.8, P=0.02, 95% CI 1.2-19), smoking (OR=4.1, P=0.03, 95% CI 1-16.5) and suprasphincteric fistula (OR=0.5, P=0.01, 95% CI 0.2-0.8) in multivariate log regression analysis. Major incontinence was influenced by female sex and previous anal surgery (OR=7.5, P=0.003, 95% CI 1.6-34 and OR=0.1, P=0.007, 95% CI 0.1-0.7, respectively). Full-thickness transanal advancement flap is a good treatment for complex anal fistula repair. This study provides relevant information on risk factors for failure of therapy and incontinence, which can help in advising patients before surgery and planning a good treatment strategy.

Development of Late Continence in Bladder Exstrophy and Epispadias Patients

To evaluate to what extend urinary continence develops during puberty in patients with classic bladder exstrophy (CBE) and epispadias. The operative database was reviewed for surgical procedures and urinary continence in all 65 CBE and epispadias patients born in 1976-2005. Excluded were 2 patients who had insufficient data for evaluation. Thirty-five patients with volitional voiding were incontinent at the age of 10 years, 27 had daily incontinence, and 8 had rare incontinence. Sixteen patients (46%) became later fully continent without any major surgery (except Deflux injections in 3 patients) or CIC treatment. Among these 16 fully continent patients there were 7/8 with rare incontinence, 9/23 with daily incontinence (P=.04); 3/9 males with CBE, 10/13 males with epispadias, 3/5 females with CBE, and 0/4 females with epispadias (P=.25 between sex and P=.48 between diagnosis). Of the 15 patients remaining incontinent, 10 had daily and 5 had rare incontinence episodes. The latest control was at the median age of 19 years (interquartile range 17-21 years). Twenty-five patients (40% of the whole material) were fully continent (11/38 (29%) with CBE and 14/25 (56%) with epispadias, P=.04) and 8 (13%) had rare incontinence with volitional voiding (1/38 [3%] with CBE and 7/25 [28%] with epispadias). Almost half of the incontinent CBE and epispadias patients with volitional voiding achieved continence after the age of 10 without major surgery. Prognosis for pubertal development of continence was best in patients with rare incontinence and in males with epispadias.

Prostatectomía radical robot-asistida con preservación del espacio de Retzius: resultados perioperatorios y de continencia inmediata en una serie inicial

ObjectiveThe objective of this work is to present initial perioperative, immediate continence and oncological results in a series of 25 prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy. Material and methodsWe retrospectively analyzed a series of 25 patients treated with Retzius-sparing robot-assisted radical prostatectomy for cT1-T2b prostate cancer between 2018-2019. The 5 stages of surgery are described. We make a descriptive statistic of our initial series and its outcomes in terms of immediate continence, defined as the use of 0 pad/diapers or 1 safety pad/diaper every 24 hours, one week after catheter removal. ResultsMedian follow-up, 6 months (3-18). Median PSA, 6.1 ng/ml (4-14.3). All surgeries were performed through a posterior intrafascial approach, and bilateral nerve-sparing was carried out in 84% of the cases. Affected surgical margins were present in 28%, being the apex the most frequent site of affectation. Surgical complications: 1 (4%) patient required transfusion of blood products in the immediate postoperative period. Mean hospital stay was 48 hours. Functional outcomes: 80% of the patients present immediate continence. 80% of continent patients do not require the use of any safety pads/diapers. Oncological outcomes: 84% are free of biochemical-progression in a median follow-up of 6 months. ConclusionsInitial functional results in terms of immediate continence are very satisfactory in patients who have undergone Retzius-sparing robot-assisted radical prostatectomy without negative impact on prognosis.

Othotopic ileal neobladder “Belgrade pouch” in females

Background/Aim. Orthotopic continent neobladder pro-vides adequate capacity, low pressure reservoir, acceptable rate of continence and satisfactory voiding frequency. Standard surgical techniques require the usage of an ileal segment in the length of 50?65 cm for neobladder creation with favorable results. However, the usage of a long intestinal segment is associated with high neobladder capacity, voiding problems, and metabolic complications. The aim of this study was to analyze clinical outcomes of the ?Belgrade pouch? orthotopic bladder replacement in female patients and to promote the usage of shorter ileal segment for neobladder creation. Methods. A prospective study conducted in our institution from 2009 to 2019 included 37 female patients who underwent orthotopic bladder replacement ac-cording to ?Belgrade pouch? technique with the usage of shorter ileal segment whose average length for neobladder creation was 28 cm. Inclusion criteria were: female continent patients older than 18, organ-confined muscle-invasive bladder carcinoma and, the American Society of Anestesiologists (ASA) score 1 or 2. Exclusion criteria were: diabetes mellitus, obstructive pulmonary diseases, systemic illnesses and metabolic diseases which may have some influence on results interpretation, renal deterioration and preoperative incontinence. We analyzed operative time, blood loss, histopathological findings, continence rate, metabolic disorders, immediate and delayed complications and survival rate in two-year periods of follow-up. Results. Average age of patients was 58 (32?67) years. Average time of surgical procedures was 199 (155?320) min. Blood transfusion was intraoperatively applied in 32.43% of the patients in average volume of 385 (300?640) mL. A total of 29.47% patients had anemia preoperatively. In the early postoperative period we reported one patient with paralytic ileus which was resolved conservatively and one patient with urinary fistula appearance; 56.75% of the patients were in pT2 stage. Two years following the surgery, day-time continence was achieved in 91.89% of the patients, neobladder capacity was 459 (345?592 ) mL, post-void residual urine volume was 27 (0?40) mL, 24 h voiding frequency 6, metabolic acidosis appeared in 2.7% of the patients. Survival rate in 2-year period was 86.48%. Conclusion. Orthotropic ileal neobladder created from the shorter ileal segment (?Belgrade pouch?) in females provides a high level of continence without a significant increase of voiding frequency, with adequate capacity, without urinary tract retention and with decrease of metabolic complications.

Concomitant stress urinary incontinence and pelvic organ prolapse surgery: Opportunity or overtreatment?

ObjectivesThe association between pelvic organ prolapse (POP) and stress urinary incontinence (SUI) is very common. When POP surgery is indicated and the patient has concomitant SUI, there are two treatment strategies: the one-step strategy (concomitant correction of POP and SUI) and the two-step strategy (correction of POP with subsequent evaluation of SUI). Guidelines from the International Continence Society and International Consultation on Incontinence recommend that a urodynamic assessment (UA) should be performed before surgery as this can reveal the presence of urodynamic SUI, but the role of UA is the subject of debate as it does not seem to improve treatment decisions. The aim of this study was to identify the presence of pre-operative urodynamic parameters that were predictive of POSUI, and to identify patients who could benefit from concomitant correction of SUI during POP surgery Study designA retrospective evaluation was undertaken of 155 patients with at least second-degree POP who underwent POP surgery after UA between 2009 and 2016 in an Italian gynaecology and obstetrics department. Of these, 61 patients were clinically incontinent before surgery and 94 patients were clinically continent. After UA, patients were stratified using a maximum urethral closure pressure (MUCP) cut-off of 50 cmH2O; the risk of POSUI was calculated using this value. ResultsPOP surgery alone resolved SUI in 60 % of the 61 clinically incontinent patients; only 30 % of these patients had urodynamic SUI and >50 % did not have POSUI. Thirty-six percent of the 94 continent patients had occult SUI on UA and 16 % developed de-novo POSUI. Seventy-five percent of all patients with occult SUI did not develop de-novo SUI. MUCP was lower in patients with POSUI than in patients without POSUI (p=0.013). The probability of POSUI was higher in patients with MUCP ≤50 cmH2O. The number needed to treat (NNT) to prevent one case of POSUI in these patients was 2, compared with an NNT of 4 in the continent group. Eight percent of patients underwent further surgery for SUI. ConclusionsClinically incontinent patients with MUCP ≤50 cmH2O will gain the greatest benefit from concomitant POP and SUI surgery. However, concomitant surgery has more severe adverse events. Given that 62.3 % of patients resolved SUI after POP surgery alone, it is important not to overtreat these women. Clinical pre-operative SUI is the best indicator of POSUI and was found to increase the risk of POSUI (odds ratio 3.2, 95 % confidence interval 1.5–6.8; p=0.003). Despite the small sample size, the two-step strategy appears to result in lower use of mid-urethral slings and a clear reduction in complications. It is important not to focus on the diagnosis of urodynamic SUI in continent patients but to evaluate MUCP carefully.

Reliability and Diagnostic Accuracy of a New Vaginal Dynamometer to Measure Pelvic Floor Muscle Strength.

Assess the intrarater and interrater reliabilities and diagnostic accuracy of a new vaginal dynamometer to measure pelvic floor muscle (PFM) strength in incontinent and continent women. A test-retest reliability study including 152 female patients. history of urge urinary incontinence, prolapse of pelvic organ, pregnancy, previous urogynecological surgery, severe vaginal atrophy, or neurological conditions. The examination comprised digital assessment using the modified Oxford scale (MOS) and dynamometry measurements with a new prototype hand-held dynamometer. The MOS score ranges from 0 to 5: 0, no contraction; 1, flicker; 2, weak; 3, moderate; 4, good; 5, strong. Examinations were performed by a physiatrist, a physiotherapist and a midwife. The rest period between each rater measurement was 5 minutes. Assessment of intrarater and interrater reliability was calculated with the intraclass correlation coefficient. One hundred twenty-two incontinent women and 30 continent women were included. Scores between 0 and 2 in MOS were recorded in 72% of incontinent women versus 20% in continent patients (P < 0.001). Intrarater reliability of the dynamometer was 0.942 (95% confidence interval [CI], 0.920-0.958) and the interrater reliability was 0.937 (95% CI, 0.913-0.954). The analysis of variance analysis showed significant differences in PFM strength across digital assessment categories. The post-hoc analysis showed statistical differences between adjacent categories of MOS 1-2 and 2-3. The diagnostic accuracy showed an area under the curve of 0.82 (95% C,: 0.75-0.89), 0.87 (95% CI, 0.81-0.92), and 0.83 (95% CI, 0.77-0.90) for the physiatrist, midwife, and physiotherapist, respectively. The results obtained show a good reliability and validity of this new vaginal dynamometer to quantify PFM strength.

Clinical urologic and urodynamic outcomes in patients with anorectal malformation and absent vagina after vaginal replacement

Introduction and objectivesAnorectal malformations (ARMs) represent a complex spectrum of anorectal and genitourinary anomalies and a paucity of evidence is available on long-term urologic outcomes in all ARM subtypes. It was our subjective bias from being a referral center for ARM patients that the subtype of rectovestibular fistula and absent vagina had higher risk of renal and bladder abnormalities than typical rectovestibular fistula patients. Therefore, to confirm or refute our clinical suspicions, the purpose of this study was to review this specific cohort of ARM patients and describe both the clinical urological and urodynamic outcomes. MethodsA retrospective cohort study was performed for 120 patients who were treated for ARM and vaginal replacement at our institution between 1991 and 2017. Fifteen patients with rectovestibular fistula and absent vagina were included in our review. Demographic and clinical data were abstracted from their medical records, including urodynamic findings, need for clean intermittent catheterization (CIC), urinary continence, and renal function. ResultsVaginal replacement surgery was undertaken concomitantly with ARM repair in 10 of the 15 patients (67%). One patient was lost to follow up, and mean follow up postoperatively was 39 months. In all but one patient, rectum or colon was used as the substrate for vaginal replacement. Of the 15 patients, 13 had continence data available. A total of 10 patients (77%) were able to achieve social continence. Overall six patients used CIC to manage their bladder and 40% of continent patients used CIC. Urinary continence outcomes in patients who had partial vaginal replacement compared to those with total vaginal replacement did not reveal a clinically significant difference. Continence was achieved in 3/4 patients (75%) with a history of tethered cord compared to 7/9 patients (78%) without a history of tethered cord release. Urodynamics were performed postoperatively in 7 of the 157 patients (47%). Uninhibited detrusor contractions (UDCs) were present in 3 out of 7 patients, and a cystometric capacity greater than expected was noted in 4 patients. Additionally, 2 patients had end filling detrusor pressure greater than 40 cm H2O. GFR data were available for 13 of the 15 patients and (85%) were classified as chronic kidney disease (CKD) stage I or not having any significant loss of renal function. ConclusionsIn this cohort of rectovestibular fistula and absent vagina, 77% reported achieving urinary continence. However CIC was employed in 40% of the patients which is higher than prior published noncloaca female ARM patient population. Urodynamic abnormalities were noted when performed and led to change in bladder management. Renal function measured with GFR was normal in 85%. Patients with rectovestibular fistula and absent vagina benefit from urologic screening given higher rates of lower urinary tract dysfunction that can require CIC to protect the upper urinary tract and achieve urinary continence. Type of studyCase series. Level of evidenceLevel IV.

Anorectal Function and Quality of Life in IBD Patients With A Perianal Complaint

Purpose Anorectal function of inflammatory bowel disease (IBD) patients is still poorly understood, with contradictory results. This prospective observational study aimed to analyze the effect of perianal disease on anorectal function and quality of life in IBD patients. Methods: Patient assessment included full clinical examination, validated scores, anorectal manometry, three-dimensional endoanal ultrasonography, and endoscopy. The Inflammatory Bowel Disease Questionnaire was adopted to evaluate patients’ quality of life. Results: From January to November 2016, 37 consecutive IBD patients (30 Crohn’s disease, 7 ulcerative colitis) and 20 controls were enrolled in the study. Twenty-five patients had a history of perianal fistula, 9 reported fecal incontinence, and 2 had anal fissure. Fecal incontinent patients were older, had a longer disease duration, and higher bowel movement number than continent patients. Endoanal ultrasound findings were normal in all volunteers, while pathological features were found in 31/37 patients. Rectal sensory testing and anal pressure did not differ between the IBD patients and controls. However, the rectoanal inhibitory reflex was normally elicited in all controls vs. 32/37 (86%) IBD patients; 25/37 (68%) IBD patients showed manometric features of dyssynergic defecation. Rectal inflammation and incontinence were associated with low maximum anal resting pressure. The quality of life score was lower in ulcerative colitis patients than in Crohn’s patients and significantly lower in fecal incontinent patients. Conclusions: Anorectal function is impaired in IBD patients with perianal disease. Fecal incontinence correlates with poorer quality of life. Anorectal manometry and ultrasonography are useful tools for evaluating IBD patients.

Évaluation urodynamique de patients guéris d’incontinence urinaire d’effort post-prostatectomie radicale après implantation d’une bandelette sous-urétrale transobturatrice

The mechanism(s) responsible(s) for continence recovery after male sling implantation for post-radical prostatectomy incontinence are imperfectly known. The goal of this study was to evaluate urodynamic parameters before and after male sling insertion, only in patients cured of their stress urinary incontinence. In total, 10 continent patients after transobturator male sling, with no history of urethral stenosis or pelvic radiation, were randomly selected from a database for urodynamic studies. Urodynamic parameters included urethral pressure profiles (UPP), with measurements of maximal urethral closure pressure (MUCP) and functional urethral length (FUL), and were compared with preoperative urodynamic data. Paired sampled were compared with the use of the Wilcoxon signed-rank test (StatPlus®). Urodynamic studies were performed after a median time of 9months (min 4-max 34) following sling implantation. Postoperatively, a rise of 11cm H2O in median MUCP (P=0.09) and an increase of 14mm in median FUL (P=0.13) were observed. None of the urodynamic changes was statistically significant. Following sling implantation, modifications in UPPs were observed, with increases in MUCP and FUL but these increments were not statistically significant. Limitations to our study include biases inherent to the interpretation and reproducibility of urethral profilometry, the sample size, and the variable delay between sling implantation and postoperative urodynamic studies. 4.

Proposal of a new way to evaluate the external sphincter function prior male sling surgey.

ABSTRACTObjective:To propose a new way to objectively evaluate the external sphincter function prior to male sling surgery.Materials and Methods:We evaluated the pre-operative sphincter function throughout sphincter pressure at rest (SPAR) and sphincter pressure under contraction (SPUC) obtained throughout urethral profilometry profile (UPP) of 10 consecutive patients (age range, 54-79 years) treated with the retrourethral transobturator sling (RTS) for stress urinary incontinence (SUI) because of prostate surgery. The primary endpoint for surgery success rate was post-operative pad weight test. This was correlated to pre-operative pad test, RT, SPAR and SPUC. Post-operatively patients were classified as continent (no pad use) and those who still were incontinent.Results:Mean SPUC in the continent and incontinent group was respectively 188 + 8.8 (median 185.1, range 181 to 201) and 96.9 + 49.4 (median 109.9, range 35.6 to 163.6) (P = 0.008). Mean 24-hour pad test was 151 + 84.2gm (median 140, range 80 to 245) and 973 + 337.1gm (median 1940, range 550 to 1200) in post-operative continent and incontinent groups respectively (P = 0.008). The repositioning test (RT) was positive in all continent patients except one. The RT was also positive in three incontinence patients (false positive). In all post-operative continent patients SPUC was higher than 180cmH2O and pre-operative pad test was less than 245gm.Conclusions:SPUC seems to be a way for optimizing the sphincter evaluation as well to become a useful tool for patient selection prior to RTS surgery.

Posterior muscle-fascial reconstruction and knotless urethro-neo bladder anastomosis during robot-assisted radical cystectomy: Description of the technique and its impact on urinary continence.

The aim of our study is to describe the use of posterior muscle-fascial reconstruction during urethro-ileal anastomosis in bladder cancer (BC) patients submitted to robot-assisted radical cystectomy (RC) with orthotopic neobladder (ON) and its role in facilitating day- and night-time continence recovery during a 12-month follow up. We prospectively collected data from 42 consecutive patients who underwent RARC with totally intracorporeal ON and extended pelvic lymph node dissection (PLND) at our Institution from June 2014 to October 2017. Prior to the urethro-neobladder anastomosis we reconstructed the Denonvilliers Fascia (DF) as previously described for radical prostatectomy using a bidirectional barbed suture. Day and night-time recovery rates were reported at 3, 6 and 12 months after surgery, with continent patients being those using either no urinary pads or 1 safety pads. Median age at surgery was 63 yrs, 41 (97.6%) patients were male. 28 (66.7%) patients presented a clinical T2 disease. Median operative time and median ON reconstruction time were 450 minutes and 180 minutes respectively. 13 (31%) individuals had non-organ confined disease, with 11 (26.2%) patients with positive lymph nodes (median 3 positive lymph nodes) and 2 (4.8%) with non-urothelial cancer at final pathologic examination. Median hospital stay and median catheterization time were 7 (IQR 7-8) and 21 (IQR 19-22). During first 30 post-operative days we recorded 7 (16.7%) low-grade Clavien and 2 (4.8%) IIIa Clavien complications, whereas between 30 and 90 postoperative days we recorded 4 (9.5%) low-grade, 4 (9.5) IIIa and 1 (2.4%) IIIb complications. Day-time and night-time continence rates were 61.9% vs 52.4%, 73.8% vs 64.3% and 90.5% vs 73.8% at three, six and twelve months follow up. Day-time continence was significantly superior in the younger group (97% vs 57%, p 0.01); night-time continence rates were also superior among < 70 yrs patients, despite not reaching statistical significance (77% vs 57%, p 0.3). Posterior muscle-fascial reconstruction aids continence recovery in BC patients undergoing RARC with ON, with younger and fitter patients most benefitting from ON reconstruction.

Preoperative magnetic resonance imaging in predicting early continence recovery after robotic radical prostatectomy

Introduction and aimsUrinary incontinence is a common complication after radical prostatectomy. The aim of our study was to describe the preoperative anatomical features using magnetic resonance imaging in order to predict early continence recovery after robotic radical prostatectomy. Material and methods72 patients who underwent robotic radical prostatectomy were prospectively analysed. EPIC questionnaire (1, 6 and 12 mo) and first self-reported continence were used to assess functional outcomes. Membranous urethral length (MUL) and MUL-prostate axis angle (aMULP) were assessed preoperatively on T2 weighted sagittal images. ResultsContinence rate was 67.2%, 92.6% and 95.2% at 1, 6 and 12 months, respectively. Early continence was achieved in patients with the lower aMULP. At 1 month, average aMULP in continent patients was 107.21° (CI 95% 90.3–124.6) vs. 118.5° (CI 95% 117.7–134) in incontinent ones (p=0.014). At 6 month differences in aMULP among groups were found: 114.24° (CI 95% 104.6–123.9) in continents vs. 142° (CI 95% 126.5–157.6) in incontinents (p=0.015). At 12 month, continent group showed a significantly higher preoperative aMULP. aMULP was revealed as the only independent predictor of urinary continence at 6 mo in multivariate analysis, OR 0.007 (CI 95% 0.002–0.012), p=0.012. ConclusionsPreoperative anatomical parameters assessment prior surgery can help to identified those patients will achieve early continence recovery and it supports therapeutic decisions making.

Outcomes after salvage radical prostatectomy and first-line radiation therapy or HIFU for recurrent localized prostate cancer: results from a multicenter study.

Despite no consensus on the optimal management of recurrent prostate cancer after primary radiation or HIFU therapy, salvage prostatectomy (sRP) is reserved for only 3% of patients because of technical challenges and frequent post-operative complications. We assessed outcomes after sRP in a series of patients with localized PCa and that had received radiation therapy or HIFU as a first-line treatment. Data from nine French referral centers on patients treated with sRP between 2005 and 2017 were collected. Pre- and post-operative data, including oncological and functional outcomes after first treatment and sRP, were analyzed to determine the predictors for biochemical recurrence (BCR) and cancer-specific survival (CSS) after sRP. First-line treatments were external beam-radiation therapy (EBRT) for 30 (55%), brachytherapy (BT) for 10 (18%), and high-intensity focused ultrasound (HIFU) for 15 (27%). Median (IQR) PSA at diagnosis was 6.4 (4.9-9.5)ng/mL, median PSA at nadir was 1.9 (0.7-3.0) ng/mL, and median (IQR) to first BCR was 13 (6-20) months. Of the 55 patients, 44 (80%) received robot-assisted salvage radical prostatectomy and 11 (20%) received salvage retropubic radical prostatectomy. Restoration of continence was achieved in 90% of preoperatively continent patients; 24% that had received nerve-sparing (NS) procedures were potent after surgery. Prolonged catheterization due to anastomotic leakage was the most common complication. Age, preoperative clinical stage, NS procedure, and a pathological Gleason score were predictors for BCR. sRP was safe, feasible, and effective using either an open or robot-assisted approach, in experienced hands. Age, preoperative clinical stage, NS procedure, and pathological GS were linked with BCR after sRP.

Defecation disorders in Spina Bifida: Realistic goals and best therapeutic approaches.

Spina Bifida (SB) is a rare congenital condition that frequently impairs the neurological control of both fecal continence and defecation. Several therapeutic strategies have been proposed but impact assessment is lacking. Our objectives were to quantify the symptomatic improvement and to determine the optimal strategy in this rare condition where randomized controlled trials are difficult to conduct. Data were extracted from a prospective database. The present analysis focused on patients having undergone at least two gastroenterological assessments. A standardized therapeutic approach was used from the first visit. Improvement was quantified by the variation of quantified symptomatic scores. The data of of 57 adults with SB (gender F/M: 30/27 [52.6/47.4%]; mean age: 33.8 [18.5] years) were extracted. After a mean follow-up of 46 months, 23/57 patients (40.4%) had at least improvement of one point of the Cleveland Clinic Incontinence score (CCIS); 13/57 (22.8%) reported a significant improvement of continence (delta score >50%). Five of the twelve patients (41.6%) with CCIS < 5 at baseline became incontinent over time. The neurological level was not associated with a worse continence outcome. Work on stool consistency and transanal irrigation were the most useful strategies in those with significant improvement of continence. Using conventional strategies, a benefit on fecal continence occurs in only one out of five patients suffering from Spina Bifida and continent patients at baseline can develop fecal incontinence over time. A strategy targeting improved control of defecation (transanal irrigation) and a standardization of follow-up protocol might be beneficial.

47. Dependence from dose and fractionation of late severe urinary toxicities after radical radiotherapy for prostate cancer

Purpose Development of NTCP models of late severe urinary symptoms after radical RT for prostate cancer (PCa). Methods Patients were enrolled in a prospective, multicentre, observational trial in 2010–2014 and treated with conventional (74–80 Gy at 1.8–2 Gy/fr) or moderately hypofractionated IMRT (65–75.2 Gy at 2.2–2.7 Gy/fr). Bladder dose-surface histograms were corrected to 2 Gy/fr equivalent doses (EQD2) and reduced to Equivalent Uniform Doses at varying α / β and n. Urethral stricture requiring urethrotomy and bleeding (assessed by the physicians) and late obstructive symptoms and incontinence (through ICIQ and IPSS questionnaires) were evaluated before RT, at its completion and every 6 months until 5 years of follow-up. Incidence of late obstructive symptoms was defined as an increase of ⩾10 points with respect to baseline in the IPSS, at least once between 6–36 months after RT; incidence of incontinence as the sum ICIQ3 + ICIQ4 > 5, with the same timing, in continent patients before RT (ICIQ3 + ICIQ4 = 0). Maximum likelihood estimation (MLE) was employed for calculating the best-fit NTCP parameters (EUD50 and k) of all symptoms. Results 319 patients were followed for ⩾36 months with at least 3 follow-up evaluations. 27/319 (23%) patients exhibited at least one severe late urinary symptom (details in Table). Bleeding, obstructive symptoms and incontinence showed greater incidence for hypofractionation and EQD2 > 78 Gy. The highest likelihood was obtained for very low n in all cases; low α / β was found for all the endpoints except stricture. Figure shows the best-fit NTCP parameters: incontinence and bleeding curves were steeper with rising EUD. Conclusions Incidence of late severe urinary symptoms in patients treated with IMRT for PCa was about 20%. Bladder seems to act as a serial organ and all the symptoms significantly depend on the prescribed dose. In addition, all the symptoms, except for stenosis, show a surprisingly important effect of hypofractionation.

La resonancia magnética preoperatoria predice la recuperación temprana de la continencia urinaria tras la prostatectomía radical robótica

Introduction and aimsUrinary incontinence is a common complication after radical prostatectomy. The aim of our study was to describe the preoperative anatomical features using magnetic resonance imaging in order to predict early continence recovery after robotic radical prostatectomy. Material and methods72 patients who underwent robotic radical prostatectomy were prospectively analysed. EPIC questionnaire (1, 6 and 12 mo) and first self-reported continence were used to assess functional outcomes. Membranous urethral length (MUL) and MUL-prostate axis angle (aMULP) were assessed preoperatively on T2 weighted sagittal images. ResultsContinence rate was 67.2%, 92.6% and 95.2% at 1, 6 and 12 months, respectively. Early continence was achieved in patients with the lower aMULP. At 1 month, average aMULP in continent patients was 107.21° (IC 95% 90.3-124.6) vs. 118.5° (IC 95% 117.7-134) in incontinent ones (P=.014). At 6 month differences in aMULP among groups were found: 114.24° (IC 95% 104.6-123.9) in continents vs. 142° (IC 95% 126.5-157.6) in incontinents (P=0.015). At 12 month, continent group showed a significantly higher preoperative aMULP. aMULP was revealed as the only independent predictor of urinary continence at 6 mo in multivariate analysis, OR 0.007 (IC 95% 0.002-0.012), P=0.012. ConclusionsPreoperative anatomical parameters assessment prior surgery can help to identified those patients will achieve early continence recovery and it supports therapeutic decisions making.