Early Continence Recovery Research Articles

Uroflow stop test with electromyography: a novel index of urinary continence recovery after RARP.

Urinary incontinence (UI) is one of the most bothersome surgical side effects after robot-assisted radical prostatectomy (RARP). Alteration of both smooth and striate urethral sphincter occurs after RARP. Since the contraction of perineal muscles is involved in the complex mechanism of urinary continence, the uroflow stop test (UST) seems to predict early continence recovery after RARP. The UST was added of perineal surface electromyography (EMG) evaluation to evaluate the latency time (LT) between muscular contraction and the complete stop of urine flow. Our aim was to present UST-EMG as a new tool in the investigation of UI, implying pelvic floor integrity, and to evaluate whether an early return (≤ 3 months) to preoperative LT could be associated with early recovery of UC (≤ 3 months). After prospectively enrolling 137 patients who underwent RARP with a minimum follow-up of 6 months, we identified two groups: Group 1 (93 patients) with early (≤ 3 months) pre-surgical LT recovery and Group 2 (44 patients) with late > 3 months or not able to reach pre-surgical LT recovery. Between the two groups, there were significant differences in terms of different surgical technique (nerve-sparing versus non-nerve-sparing) and pads use at 3 and 6 months after RARP (p < 0.05). No differences were recorded neither in postoperative maximum flow-rate, nor in postoperative symptoms score. UST with EMG can be considered as a noninvasive, reproducible and easily performable tool. LT is applicable in the clinical evaluation to predict urinary continence recovery after RARP.

Objective assessment of early urinary continence by analysis and visualisation of intraoperative variables of radical robotic prostatectomies with a video editor

IntroductionUI after RP is a factor that has a major impact on patients’ quality of life and the associated healthcare costs. The definition of UI is very variable in the literature. Similarly, a great many predictors have been studied that affect recovery of continence after surgery, the most important of which are intraoperative. Material and methodsA retrospective and observational study performed between September 2008 and March 2015. We studied intraoperative factors through visualisation using a video editor of 148 patients who underwent robot-assisted radical prostatectomy, together with other perioperative factors associated with continence, and described in the literature. We assessed continence through ICQ questionnaires, urinary loss calculated by pad count, and clinical interview in the first, third, sixth month and at one year after surgery. We defined continence as not having to use a pad or using a pad for protection socially, or an ICQ≤7. We used binary and lineal logistic regression analysis to study the relationship between the intraoperative and perioperative variables on urinary continence measured at the first, third, sixth month and one year after the operation, and on continence stability. ResultsIn our study, 72.9% of the patients were continent at one year after surgery with a mean continence stabilisation time at 4.3 months. In our lineal logistic regression analyses we found no significant relationship with the continence variable analysed during the first year.In the lineal logistic regression analysis we found that tension-free sutures had a direct positive effect (p≤0.05) on the stability time of continence, as well as the urinary losses measured in the first month after surgery. ConclusionIn conclusion, we found in our study that the tension-free sutures were able to help towards early stability of continence. We found no other intraoperative predictors that influenced urinary continence. The urinary losses measured in the first month related to early recovery of continence.

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.

Valoración objetiva de la continencia urinaria precoz mediante el análisis y la visualización de variables intraoperatorias de prostatectomías radicales robóticas con un editor de vídeos

IntroductionUI after RP is a factor that has a major impact on patients’ quality of life and the associated healthcare costs. The definition of UI is very variable in the literature. Similarly, a great many predictors have been studied that affect recovery of continence after surgery, the most important of which are intraoperative. Material and methodsa retrospective and observational study performed between September 2008 and March 2015. We studied intraoperative factors through visualisation using a video editor of 148 patients who underwent robot-assisted radical prostatectomy, together with other perioperative factors associated with continence, and described in the literature. We assessed continence through ICQ questionnaires, urinary loss calculated by pad count, and clinical interview in the first, third, sixth month and at one year after surgery. We defined continence as not having to use a pad or using a pad for protection socially, or an ICQ ≤ 7. We used binary and lineal logistic regression analysis to study the relationship between the intraoperative and perioperative variables on urinary continence measured at the first, third, sixth month and one year after the operation, and on continence stability. ResultsIn our study, 72.9% of the patients were continent at one year after surgery with a mean continence stabilisation time at 4.3 months. In our lineal logistic regression analyses we found no significant relationship with the continence variable analysed during the first year.In the lineal logistic regression analysis we found that tension-free sutures had a direct positive effect (P≤.05) on the stability time of continence, as well as the urinary losses measured in the first month after surgery. ConclusionIn conclusion, we found in our study that the tension-free sutures were able to help towards early stability of continence. We found no other intraoperative predictors that influenced urinary continence. The urinary losses measured in the first month related to early recovery of continence.

PE40 - Learning curves of retzius-sparing robotic assisted radical prostatectomy for early continence recovery and margin outcomes: Results from a UK high-volume centre

PE40 - Learning curves of retzius-sparing robotic assisted radical prostatectomy for early continence recovery and margin outcomes: Results from a UK high-volume centre

Technical details to achieve perfect early continence after radical prostatectomy.

Urinary incontinence after radical prostatectomy (RP) is still an issue and may compromise patient quality of life and psychosocial behavior, regardless of oncologic outcomes. As this condition usually resolves by the end of the first postoperative year, many surgeons focused their attention on "early" return of urinary continence (UC). The aim of this non-systematic review is to present an overview of the current knowledge on the anatomy and the surgical techniques addressed to early functional recovery of continence after RP. The available literature data suggest that the preservation of bladder neck, pubo-prostatic ligaments, endopelvic fascia and vesico-urethral complex may play a role in recovery of early UC. Similarly, bladder neck reconstruction, anterior and/or posterior myo-fascio-ligamentous support to the anastomosis and tension-free watertight vesico-urethral anastomosis can improve early UC recovery post RP. More recently surgical approaches (i.e. Retzius-sparing technique) seem to add a piece in the jigsaw in the scenario of the early recovery of UC. Notwithstanding the efforts of the surgeons, more evidence from randomized studies is required to prove benefits of the different approaches and the "ideal" RP is far to be standardized.

Retrograde Release of the Neurovascular Bundle with Preservation of Dorsal Venous Complex During Robot-assisted Radical Prostatectomy: Optimizing Functional Outcomes

BackgroundRobot-assisted laparoscopic radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP which preserves the nerves and vascular structures anterior to the prostate aiming to optimize functional outcomes. ObjectiveTo present oncological and functional results of a modified technique for RARP. Design, setting, and participantsProspective, noncontrolled case series including 128 consecutive patients undergoing RARP performed by a single surgeon (R.F.C). Surgical procedureRARP with retrograde release of the neurovascular bundle and preservation of dorsal venous complex. MeasurementsPotency was defined as a Sexual Health Inventory for Men score of ≥17; continence was defined as use of no pads. Oncological results analyzed were positive surgical margins (PSM) rates and biochemical recurrence (BCR)-free survival. BCR was defined as prostate-specific antigen >0.2ng/ml. Complications were graded according to the Clavien-Dindo classification. Results and limitationsMedian patient age was 63.5 yr. Median skin-to-skin time was 78min. Median length of hospital stay was 1 d, with seven patients (5.5%) hospitalized for more than 24h. Median intraoperative bleeding was 200ml and two patients required postoperative blood transfusion (1.6%). Four patients (3.1%) had grade ≥3 complications. Biochemical recurrence (BCR) occurred in nine of 128 patients (7%) and median time to BCR was 6 mo. Overall PSM rate was 13.3% (17 of 128 patients). PSM rate was 9% among patients with pT2 disease (8/89) and 27% in patients with pT3 (9/38). Continence was reached immediately in 85.9% of the patients and 98.4% were continent at1 yr. At 1 mo postoperatively, 60 patients were potent (53%), while 98 patients among 113 (86%) were potent 1 yr after surgery. A limitation of this study is that it was a noncomparative study. ConclusionsRetrograde release of the neurovascular bundle with preservation of dorsal venous complex during RARP is safe and associated with excellent oncological and functional outcomes. Future comparative studies are needed. Patient summaryRobot-assisted radical prostatectomy (RARP) presents consistent oncological outcomes for prostate cancer; yet continence and potency results are not uniform. We present a technical modification for RARP aiming to preserve the nerves and vascular structures anterior to the prostate. We evaluated 128 consecutive patients with clinically localized or locally advanced prostate cancer undergoing RARP with our modified technique of retrograde release of the neurovascular bundles with dorsal vein sparing. We have shown that this technique is safe, effective and associated with early recovery of continence and sexual function after surgery.

Intrafascial nerve-sparing radical prostatectomy improves patients' postoperative continence recovery and erectile function: A pooled analysis based on available literatures.

Intrafascial nerve-sparing prostatectomy has been currently applied based on the updated anatomic understanding of periprostatic cavernous nerves, in order to provide patients better postoperative recovery of continence and potency. The aim of our study is to perform a pooled analysis of available literatures regarding the functional outcomes following intrafascial nerve-sparing technique. The authors performed database searches of articles published till October 2017 on PubMed using following keywords across the "title" and "abstract" field of the records: intrafascial, veil, curtain dissection, high anterior release, incremental nerve sparing, and radical prostatectomy. Fulfilled papers were screened and data were extracted independently by 3 reviewers. Main outcome was the postoperative continence and potency rate stratified by follow-up durations. Both 1-arm and comparative meta-analyses were performed and meta-regression models were conducted to evaluate the confounding factors. Using the electronic search strategy, a total of 71 records were retrieved and 20 studies were finally included, of which 6 were surgical series and 14 were controlled studies. Our 1-arm meta-analysis summarized the pooled continence rates after intrafascial prostatectomy were 59.4%, 76.2%, 89.9%, and 92.2% at postoperative follow-up of 1, 3, 6, and 12 months, respectively. Regardless of the variance in potency definition, the pooled potency rates after intrafascial prostatectomy were 42.2%, 54.2%, and 72.2% at 3, 6, and 12 months, respectively. Comparative analysis showed that the intrafascial group offered better continence rates at 1, 3, and 6 months with an odds ratio (OR) of 2.38 (95% confidence interval [CI]: 1.73-3.26), 1.82 (95% CI: 1.18-2.82), and 2.19 (95% CI: 1.43-3.34) as compared with the interfascial group. Moreover, potency rate in the intrafascial group was higher at 12 months than in the interfascial group, with an OR of 2.44 (95% CI: 1.35-4.42). Based on the limited evidence, our study demonstrated that intrafascial nerve-sparing prostatectomy could provide patients with earlier recovery of continence and better erectile function compared with conventional interfascial approach, but physiological mechanisms about this technique still need further study.

Membranous urethral length and pelvic anatomical structures as predictors of continence outcome after robot-assisted radical prostatectomy

Introduction: Aim of our study was to determine whether preoperative prostate/pelvic anatomical structures predict continence recovery after robot-assisted radical prostatectomy (RARP). Materials and Methods: Between January 2012 and March 2016, 439 prostate cancer (PCa) patients with normal preoperative continence were retrospectively included. Anatomical prostate structures were measured on endorectal preoperative Magnetic Resonance Imaging. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess urinary incontinence (UI). Cox analysis was used to determine predictive factors for early continence recovery. Finally a binary logistic regression analysis was performed. Results: At a median follow up of 12.1 months 50.8% of men reported UI. In the Cox multivariate analysis longer membranous urethral length (MUL; P < 0.0001; OR 1.309; CI 1.211, 1.415) and shorter inner levator distance (ILD; P < 0.0001; OR 0.904; CI 0.85, 0.961) were predictors of earlier continence recovery. In the multivariate binary logistic regression analysis longer MUL and shorter ILD were independent predictors of continence outcome. Conclusions: Preoperative longer MUL and shorter ILD, independently improve continence recovery after RARP. These measurements could be used to identify patients at high risk of UI.

Possible predictor of early recovery on urinary continence after laparoscopic radical prostatectomy - Bladder neck level and urodynamic parameters.

To investigate the relationship between post-operative bladder neck levels and urodynamic parameters and their effect on urinary incontinence after laparoscopic radical prostatectomy (LRP). Forty-eight consecutive patients undergoing LRP were retrospectively reviewed. All patients were assessed using retrograde cystography after LRP and were grouped according to their bladder neck position: Level 0: at or above the superior margin of the symphysis pubis (SMSP); Level -1: at <2cm below SMSP; and Level -2: at >2cm below SMSP. Urodynamic studies were conducted at baseline as well as at 1 and 3 months post-operatively. Early recovery of urinary continence was defined as no urine leakage or only one pad/day used within 3 months after surgery. Demographic characteristics, changes in urodynamic parameters, and continence outcomes were analyzed. Overall rate of early recovery of urinary continence was 33.3%. Patients with higher bladder neck levels experienced a significantly earlier recovery of urinary continence in univariate analysis (77.8%, 29.2%, and 13.3% for bladder neck levels 0, -1, and -2, respectively, p=0.004). Patients with early recovery of urinary continence had significantly longer functional profile lengths (FPLs) 1 month post-surgery (21.0mm vs 14.8mm, p=0.019). Higher bladder neck levels were significantly associated with longer FPLs at 1 month (p=0.032). Bladder neck level is associated with FPLs at 1 month post-surgery, which is the possible predictor of early recovery of urinary continence after LRP. Patients with longer FPL at 1 month after LRP have a higher rate of early recovery of urine continence.

MP05-04 ANATOMICAL BENCHMARKS IN PREOPERATIVE MAGNETIC RESONANCE IMAGING PREDICT EARLY CONTINENCE RECOVERY FOLLOWING ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I1 Apr 2018MP05-04 ANATOMICAL BENCHMARKS IN PREOPERATIVE MAGNETIC RESONANCE IMAGING PREDICT EARLY CONTINENCE RECOVERY FOLLOWING ROBOTIC RADICAL PROSTATECTOMY Lucas Regis, Merce Cuadras, Enric Miret, Ricardo Lopez, Aina Salazar, Sarai Roche, Ana Celma, David Lorente, Jose Placer, Jacques Planas, Enrique Trilla, and Juan Morote Lucas RegisLucas Regis More articles by this author , Merce CuadrasMerce Cuadras More articles by this author , Enric MiretEnric Miret More articles by this author , Ricardo LopezRicardo Lopez More articles by this author , Aina SalazarAina Salazar More articles by this author , Sarai RocheSarai Roche More articles by this author , Ana CelmaAna Celma More articles by this author , David LorenteDavid Lorente More articles by this author , Jose PlacerJose Placer More articles by this author , Jacques PlanasJacques Planas More articles by this author , Enrique TrillaEnrique Trilla More articles by this author , and Juan MoroteJuan Morote More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.175AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary incontinence (UI) is one of the most distressful complications of radical prostatectomy. Recently, several variations in the reconstruction technique aimed to change the final anastomosis position and virtual angles between anatomical benchmarks. The aim of the present study is to elucidate anatomical characteristics assessed preoperatively using 3 Tesla magnetic resonance imaging (MRI) that contribute to early recovery of urinary continence (UC) after robotic assisted radical prostatectomy (RARP). METHODS We prospectively analyzed 72 consecutive patients that had undergone for RARP due prostate cancer diagnose and posterior rhabdosphinter reconstruction was performed as the standard technique. All patients underwent 3-T mpMRI (3.0 T Trio® Siemens) before surgery due to the study protocol. Functional outcomes were assessed with EPIC26 questionnaires (1, 6 and 12mo after surgery) and with self-reported first continence date. Membranous urethral length (MUL) and the angle between MUL and prostatic axis (aMUP) were assessed in T2-weighted sagittal preoperative images. Univariate and multivariate analysis were performed with STATA v13.1. RESULTS The median age was 63years (47-75), rate of abnormal DRE was 31.94%, and median PSA was 6.5ng/ml (1.5-22.8). UC median assessed with self-reported continence date was 4 weeks after catheter removal (0-32). Date-based UC rates were 81.48% and 90.48% at 6 and 12 months, respectively. When considering UC as need of <=1 PAD/day, those rates were 67.21%, 92.59% and 95.24% at 1, 6 and 12mo respectively. Patients with lower aMUP parameters achieved UC early: 1 month after catheter removal continents had preoperative mean aMUP of 107.21°(95%CI 90.28-124.15), while among those with UI it was 118.53° (95%CI 117.72-133.98); p=0.014. At 6 months aMUP was 114.24° (95%CI 104.62-123.85) and 141.99° (95%CI 126.49-157.59), respectively; p=0.015. At 12mo, continents had greater preoperative MUL 16.06mm (95%CI 13.85-18.28), while patients with UI had 10.03mm (95%CI 8.72-12.13) p=0.048. No differences in aMUP were found at 12mo, neither in MUL at the 1st or 6th mo according UC status. Multivariate analyses were performed including prostate volume, BMI, clinical stage, imaging stage, aMUP and MUL. Only aMUP was an independent predictor of UC at 6 months OR 0.007 (95%CI: 0.002-0.012), p= 0.012. CONCLUSIONS Assessment of virtual angles between anatomical benchmarks as aMUP before procedure may help define which patients will recovery UC early, helping in treatment decision make. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e43 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Lucas Regis More articles by this author Merce Cuadras More articles by this author Enric Miret More articles by this author Ricardo Lopez More articles by this author Aina Salazar More articles by this author Sarai Roche More articles by this author Ana Celma More articles by this author David Lorente More articles by this author Jose Placer More articles by this author Jacques Planas More articles by this author Enrique Trilla More articles by this author Juan Morote More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Terapias alternativas para recuperação precoce da continência urinária pós-prostatectomia: revisão sistemática

Objetivo: Realizar una revisión sistemática de la evidencia sobre la eficacia de entrenamiento de los músculos del suelo pélvico (EMSP) en el tratamiento de la incontinencia urinaria posterior a la prostatectomía. Métodos: Una revisión sistemática realizada em Ovid MEDLINE, EMBASE y LILACS en Portugués, Inglés y Español, límite de tiempo: 2005-2015. Resultados: 9 estudios examinaron la eficacia de los asociados o no con la biorretroalimentación y la estimulación eléctrica TMAP. Conclusión: El EMSP con o sin biorretroalimentación y la estimulación eléctrica pueden contribuir a la pronta recuperación de la continencia. Los pacientes con dificultad inicial de la identificación de los músculos del suelo pélvico pueden beneficiarse de sesiones de electroestimulación de biofeedback. Una mayor integración de la enfermera es posible en la atención relacionada con el pronto retorno de la continencia en pacientes post-prostatectomía mediante el establecimiento de los ejercicios de fortalecimiento del suelo pélvico y terapia conductual. Aim: To conduct a systematic review of the evidence of the effectiveness of Pelvic Floor Muscle Training (PFMT) in the treatment of post-prostatectomy urinary incontinence. Method: Systematic review conducted in Ovid MEDLINE, EMBASE and LILACS in Portuguese, English and Spanish, with the time limit: 2005-2015. Results: 9 studies analyzed the effectiveness of PFMT associated or not with biofeedback (BFB) and electrical stimulation (ES). Conclusion: PFMT with or without the biofeedback and electrical stimulation may contribute to the early recovery of continence. Patients with initial difficulty of identifying the pelvic floor muscles can benefit from ES followed BFB sessions of structured PFMT. A greater participation of nurses in the care related to the early return of continence in post-prostatectomy patients is possible through the implementation of pelvic floor muscle exercises and behavioral therapy. Objetivo: Conduzir uma revisão sistemática a cerca das evidências da efetividade do Treinamento dos Músculos do Assoalho Pélvico (TMAP) no tratamento da incontinência urinária pós-prostatectomia. Método: Revisão sistemática realizada nas bases de dados MEDLINE/OVID, EMBASE e LILACS nos idiomas português, inglês e espanhol, limite temporal: 2005-2015. Resultados: 9 estudos analisaram a efetividade do TMAP associado ou não ao biofeedback e eletroestimulação. Conclusão: TMAP associados ou não ao biofeedback e eletroestimulação podem contribuir na recuperação precoce da continência. Pacientes com dificuldade inicial de identificação dos músculos do assoalho pélvico podem se beneficiar de sessões de eletroestimulação e biofeedback. É poss

EARLY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

Background. Urinary incontinence after radical prostatectomy bothers patients and leads to a deterioration in quality of life. Continence is the most important functional outcome of treatment of patients with prostate cancer. Objective. To evaluate the effectiveness of pelvic anatomy preservation for early continence recovery. Design and methods. We investigated 142 patients who underwent robot-assisted radical prostatectomy (RARP) in 2011-2015. Patients were divided into 3 groups: nerve-sparing RARP (N-RARP, n=44), nerve-sparing RARP with preservation of pelvic fascia, pubo-prostatic ligaments and pubo-perineal muscles (RARP-A, n=64) and RARP with preservation of the anatomical structures of the pelvis without preservation of the neurovascular bundles (RARP-B, n=34). Results . Groups did not differ in operation time (p=0.17), blood loss (p=0.77), intraoperative (p&gt;0.1) and postoperative complications (p=0.64). Immediately after catheter removal and 1 month after surgery 53.9 %, 79.7 %, 54.6 % (p=0.012) and 61.4 %, 87,5 %, 84,6 % (p=0.005) of patients were continent in groups N-RARP, RARP-A and RARP-B, respectively. Correlation was found between the preserving of pelvic anatomical and continence recovery immediately after catheter removal (p=0.019) and at 1 month after surgery (p=0.001). Conclusion. Careful preservation of the pelvic anatomy leads to an early continence after RARP.

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 6months 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 6months 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) 30days 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.

Clinical significance of preservation of bladder neck by sling suspension technique at seminal vesicle for urinary continence in laparoscopic radical prostatectomy

Objective To investigate the clinical significance of urinary continence after laparoscopic radical prostatectomy with the technique of preserving bladder neck with sling suspension technique by the seminal vesicle. Methods Sixty-eight patients’ clinical data from January 2014 to December 2016 in our hospital who underwent laparoscopic radical prostatectomy were retrospectively analyzed. 35 cases with sling suspension(experimental group). Preoperative Gleason score ≤6, 11 cases; Gleason score 7, 15 cases; Gleason score ≥8, 9 cases. Stage T1 1 cases, stage T2 28 cases, and T3a 6 cases .The traditional method of bladder neck group(control group) contained 33 cases.Preoperative Gleason score ≤6, 9 cases; Gleason score 7, 14 cases; Gleason score ≥8, 10 cases. Stage T1 2 cases, stage T2 29 cases, and T3a 2 cases. The mean ages[(64.3±4.3)years old and (62.6±3.8)years old], BMI[(22.85±1.69)kg/m2 and (22.15±1.32)kg/m2], prostate volume[(45.93±9.08)ml and (44.12±6.85)ml], preoperative PSA[(18.76±5.43)ng/ml and (21.18±6.55)ng/ml], preoperative Gleason of the two groups were not statistically different (both P>0.05). All patients had no urinary incontinence.All the surgery was done by the same senior surgeon. The continence status was assessed at 1 month, 2 month, 3 month, and 6 month after operation. The operation time, bleeding volume, urinary leakage rate, the length of hospital stay, and positive margin between the two groups were compared. Urinary continence was assessed by daily urinary pad volume: 0-1 /d for urinary continence was normal, 2-3/d for mild urinary incontinence, and >3/d for severe urinary incontinence. Results 68 cases were operated successfully. There was no conversions to open surgery.1 month, 2 month, 3 month and 6 month after operations, the continence rates of the experimental group were 57.1%(20/35), 77.1%(27/35), 85.7%(30/35), 97.14%(34/35), respectively. The control group’s continence rates were 36.4%(12/35), 54.5%(18/35), 75.8%(25/35), 93.9%(31/35), respectively. At 1 month and 2 month after surgery, there was a statistically significant difference in urinary continence between the two groups (P=0.047 and P=0.040), and there was no significant difference in urinary continence between the two groups at 3 and 6 month (P=0.274 and P=0.523). There were 3 cases and 4 cases of positive margins in the experimental group and the control group, with no statistical significance(P=0.705). Conclusions Technique of preservation of bladder neck by sling suspension technique at seminal vesicle may improve the recovery of early postoperative urinary continence, and does not increase the rate of positive margin. Key words: Laparoscopic radical prostatectomy; Sling suspension by seminal vesicle; Preservation of bladder neck; Urinary continence

Bidirectional barbed suture for posterior musculofascial reconstruction and knotless vesicourethral anastomosis during robot-assisted radical prostatectomy.

The aim of the work is to describe an original technique of posterior musculofascial reconstruction (PMFR) during robot-assisted radical prostatectomy (RARP). From January 2015 to June 2016, 121 consecutives patients underwent RARP and were submitted to a novel technique of PMFR, using a single 3/0 barbed bidirectional (Filblock®, Assut Europe) suture. The first step of this new technique of PMFR, is to approximate the posterior layer of Denonvilliers fascia (DF) to the posterior part of the sphincteric apparatus. Then, the second step consists in the anastomosis of the posterior blabber neck edge with the posterior urethra edge. We realize the completion of anastomosis clockwise from 7 to 12 o'clock and anticlockwise from 5 to 12 o'clock. No leakage of anastomosis was observed and the catheter was removed in the 5th day after surgery. After catheter removal, the urinary recovery of early continence at 3 days was 45% and at 7 days was 75%, while the urinary continence recovery at 1 month was 88% and at 3 months was 94%. In our experience this novel approach results feasible in all patient, without extending the operation time and gives a good safety in terms of reduction of bleeding and leakage with shorter urinary continence recovery's time. The aim of the combination of the PMFR and the vesicourethral anastomosis with one bidirectional barbed suture is to have all the advantages of both techniques plus the stability of a single running suture.

The problem of early continence recovery after radical prostatectomy

Background. The highest rate of incontinence after radical prostatectomy (RP) is observed in the first 2–6 months after surgery. In order to decrease the period of incontinence, virous surgical methods aimed at preservation and reconstruction of structures participating in the mechanism of urine retention has been developed and improved. The study objective is to evaluate effectiveness of an original method of formation of an urethral anastomosis in the early continence recovery. Materials and methods. Data on 126 patients who underwent retropubic RP were analyzed. Depending on the method of urethral anastomosis formation, patients were divided into 2 groups: in the 1 st group (n = 52) the patients underwent PR with urethra suspension m. levator ani, in the 2 nd (n = 74) – standard RP. In the 1 st group, 6 ligatures were applied to the anterior and posterior urethra walls: at the 12 and 6 hour projections through the mucosa, submucosa, and smooth muscle; at the 10, 2, 4, and 8 hour projections – more laterally with capture of the m. levator ani medial margins. Continence recovery was evaluated on days 1, 7, and 14 after urinary catheter removal and then at days 30, 90, 180, and 365 after RP. The criteria of continence were absence of urine leakage at rest and during physical activity and a necessity of using a safety liner. Results. There weren’t any significant differences at day 1 after urinary catheter removal between the two groups (р &gt; 0.05). In the 1 st group, continence values at days 30, 90, and 180 after RP were significantly higher (57.7, 69.2, and 71.1 %, respectively) compared to the 2 nd group (35.1, 41.9, and 51.3 %, respectively) (р &lt;0.05). Conclusion. Results of this work show significant benefits of RP with urethra suspension m. levator ani compared to standard RP per continence recovery criteria at days 7, 14, 30, 90, and 180 after the surgery. The technique of urethra suspension m. levator ani is easy to perform and ensures early continence recovery after RP.

Three-Layer Two-Step Posterior Reconstruction Using Peritoneum During Robot-Assisted Radical Prostatectomy to Improve Recovery of Urinary Continence: A Prospective Comparative Study

We present our experience with a novel three-layer two-step posterior reconstruction (PR) technique using peritoneum during robot-assisted radical prostatectomy (RARP) to improve recovery of postoperative urinary continence. Forty-eight patients with localized prostate cancer were enrolled in this study and were divided randomly into two groups, which were treated by the standard PR technique (standard PR group; n = 24) or the three-layer PR technique using peritoneum (three-layer PR group; n = 24) during RARP. We prospectively analyzed the continence rate by the 1-hour pad test. All patients underwent urethrocystography at 6 days postoperatively to evaluate position of vesicourethral junction. Pelvic MRI was also performed at 6 months postoperatively for anatomical evaluation. Four weeks after RARP, the urinary continence rate was significantly higher in the three-layer PR group (57%) than in the standard PR group (26%, p = 0.036). Urethrocystography demonstrated that the postoperative craniocaudal distance from the symphysis pubis to the level of the vesicourethral junction was significantly shorter in the three-layer PR group than in the standard PR group (p < 0.01), suggesting that there was less tension on the vesicourethral anastomosis after three-layer PR. MRI confirmed that three-layer PR provided firmer reinforcement of the structures, supporting the posterior aspect of the urethral sphincter complex. This prospective comparative study might suggest that three-layer two-step PR using peritoneum during RARP is a simple and feasible method seeming to improve early recovery of postoperative continence compared with standard two-step PR, although larger multicenter randomized controlled trials will be needed.

Impact of metabolic syndrome on early recovery of continence after robot-assisted radical prostatectomy.

To evaluate the impact of metabolic syndrome on the early recovery of urinary continence after robot-assisted radical prostatectomy. The present study included a total of 302 consecutive Japanese patients with clinically localized prostate cancer who underwent robot-assisted radical prostatectomy. In this study, postoperative urinary continence was defined as no leak or the use of a security pad. The continence status was assessed by interviews before and 1 and 3 months after robot-assisted radical prostatectomy. Metabolic syndrome was defined as follows: body mass index ≥25 kg/m2 and two or more of the following: hypertension, diabetes mellitus and dyslipidemia. The effect of the presence of metabolic syndrome on the continence status of these patients was retrospectively examined. A total of 116 (38.4%) and 203 (67.2%) of the 302 patients were continent at 1 and 3 months after robot-assisted radical prostatectomy, respectively. A total of 31 (10.3%) patients were judged to have metabolic syndrome. Despite the operative time being longer in patients with metabolic syndrome, no significant differences were observed in the remaining preoperative, intraoperative or postoperative variables between patients with or without metabolic syndrome. On multivariate logistic regression analysis, metabolic syndrome and the duration of hospitalization were significantly correlated with the 1-month continence status. Similarly, metabolic syndrome and estimated blood loss during surgery were independent predictors of continence rates at 3 months after robot-assisted radical prostatectomy. These findings suggest that the presence of metabolic syndrome could have a significant impact on the early recovery of urinary continence after robot-assisted radical prostatectomy.

The Null Effect of Bladder Neck Size on Incontinence Outcomes after Radical Prostatectomy.

We sought to determine whether bladder neck size is associated with incontinence scores after robot-assisted laparoscopic radical prostatectomy. Consecutive eligible patients undergoing robot-assisted laparoscopic radical prostatectomy between July 19 and December 28, 2016 were enrolled in a prospective, longitudinal, observational cohort study. The primary outcome was patient reported urinary incontinence on the EPIC (Expanded Prostate Cancer Index Composite) scale 6 and 12 weeks postoperatively. The relationship between the EPIC score of urinary incontinence and bladder neck size was evaluated by multiple regression. Predicted EPIC scores for incontinence were displayed graphically after using restricted cubic splines to model bladder neck size. A total of 107 patients were enrolled. The response rate was 98% and 87% at 6 and 12 weeks, respectively. Bladder neck size was not significantly associated with incontinence scores at 6 and 12 weeks. Comparing the 90th percentile for bladder neck size (18 mm) with the 10th percentile (7 mm) revealed no significant difference in adjusted EPIC scores for incontinence at 6 weeks (βcoefficient 0.88, 95% CI -10.92-12.68, p = 0.88) or at 12 weeks (β coefficient 5.80, 95% CI -7.36-18.97, p = 0.39). These findings question the merit of creating an extremely small bladder neck during robot-assisted laparoscopic radical prostatectomy. We contend that doing so increases the risk of positive margins at the bladder neck without facilitating early recovery of continence.