Postoperative Membranous Urethral Length Research Articles

Predictors of Early Continence Recovery Following Radical Prostatectomy, Including Transperineal Ultrasound to Evaluate the Membranous Urethra Length (CHECK-MUL Study).

To predict early continence recovery following radical prostatectomy (RP) using baseline demographic and clinical data, as well as dynamic transperineal ultrasound (TPUS) parameters of membranous urethral length (MUL). A retrospective CHECK-MUL (check of membranous urethral length) study was conducted. We evaluated 154 patients who underwent RP between August 2018 and April 2023. All patients underwent pre- and postoperative dynamic TPUS to measure MUL. Urinary continence was defined as the use of one safety pad or less 3 months post surgery. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess urinary incontinence (UI). We used logistic regression to assess the association between MUL and early continence recovery. A multivariable logistic regression model was then constructed for the prediction of early continence recovery based on the MUL. The median MUL observed pre- and postoperatively in this study were similar (14.6 mm and 12.9 mm). In the univariable logistic regression analysis, the pre- and postoperative MUL measured by TPUS (odds ratio (OR): 1.12; 95%-CI: 1.02-1.79; p = 0.05 and OR: 1.01; 95%-CI: 1.02-1.12; p < 0.01) directions were independent predictors of early continence recovery 3 months post surgery. In addition, age (OR: 1.23; 95%-CI: 1.11-1.42; p = 0.03), BMI (OR: 1.44; 95%-CI: 1.18-2.92; p = 0.05), and bilateral nerve sparing (OR: 1.24; 95%-CI: 1.02-1.9; p = 0.05) were independent predictors of urinary continence in univariable logistic regression models. Preoperative MUL >15 mm (95% CI 1.28-1.33; p = 0.03) and postoperative MUL >14 mm (95% CI 1.2-1.16; p = 0.05) were significantly associated with early continence recovery at 3 months post surgery. The likelihood of continence recovery increases with membranous urethral length and decreases with age, BMI, and lack of nerve sparing. Preoperative MUL >15 mm and postoperative MUL >14 mm were significantly associated with early continence recovery at 3 months post surgery.

Ultrasound-Based Prognostic Anatomical Parameters for Post-Prostatectomy Incontinence: A Systematic Review

Background: A number of assessment methods for the pelvic floor have been described. Male pelvic floor ultrasound is an accessible, noninvasive assessment tool. Objective: To evaluate current published literature on anatomical parameters on pre- and postoperative ultrasound imaging of the male pelvic floor and correlation with continence status following radical prostatectomy (RP). Methods: A comprehensive literature search was conducted using the PRISMA guidelines to identify publications up to November 2022. Exclusion criteria consisted of animal studies, non-English articles, case reports, reviews and abstracts or reports from conferences. A full-text review was performed on 12 papers using ultrasound to assess pelvic floor anatomy and correlation with continence status following RP. Results: A total of 18 anatomical parameters were evaluated using US. Membranous urethral length (MUL), striated urethral sphincter (SUS) morphology and activation were most commonly studied. Shorter pre- and postoperative MUL, decreased preoperative SUS thickness and vascularity, postoperative discontinuity of SUS muscle fibres and decreased SUS activation are associated with post-prostatectomy incontinence (PPI). There is a paucity of data comparing anatomical changes in men prior to and following RP. The benefits of transperineal ultrasound are that it is minimally invasive, accessible, provides dynamic imaging of all three striated muscle complexes simultaneously and includes a bony landmark to reference measures of pelvic floor muscle displacement. Conclusions: Ultrasound evaluation of the male pelvic floor is an evolving field as there is development in technology and understanding of pelvic floor anatomy. It is an accessible and dynamic imaging modality, which allows both morphological and functional assessment of pelvic floor anatomy and its role in PPI. MUL and SUS morphology and activation are associated with continence status following RP. Several other anatomical parameters that may predict PPI were identified. Current literature is limited by small, single-centre studies with heterogeneous cohorts and methodologies.

Significance of postoperative membranous urethral length and position of vesicourethral anastomosis for short-term continence recovery following robot-assisted laparoscopic radical prostatectomy

BackgroundWe assess whether short-term recovery of urinary incontinence following robot-assisted laparoscopic radical prostatectomy (RARP) is associated with postoperative membranous urethral length (MUL) and position of vesico-urethral anastomosis (PVUA).MethodsClinical variables including PVUA and pre-and postoperative MUL were evaluated in 251 patients who underwent RARP from August 2019 to February 2021. Continence recovery was defined as no pad or one security liner per day assessed by patient interview at least 6 months follow-up. Univariate and multivariate logistic regression analyses were used to assess variables associated with continence recovery at 3 months after the operation.ResultsContinence recovery rates at 3 and 6 months were 75% and 84%, respectively. Lower BMI (< 25 kg/m2) (p = 0.040), longer preoperative MUL (≥ 9.5 mm) (p = 0.013), longer postoperative MUL (≥ 9 mm) (p < 0.001), higher PVUA (< 14.5 mm) (p = 0.019) and shorter operating time (< 170 min) (p = 0.013) were significantly associated with continence recovery at 3 months in univariate analysis. Multivariate analysis revealed that postoperative MUL (OR 3.75, 95% CI 1.90–7.40, p < 0.001) and higher PVUA (OR 2.02, 95% CI 1.07–3.82, p = 0.032) were independent factors for continence recovery. Patients were divided into 3 groups based on the multivariate analysis, with urinary continence recovery rates found to have increased in turn with rates of 43.7% versus 68.2% versus 85.0% (p < 0.001) at 3 months.ConclusionsPVUA and postoperative MUL were significant factors for short-term continence recovery. Preservation of urethral length might contribute to continence recovery after RARP.

A1136 - Significance of position of vesico-urethral anastomosis together with postoperative membranous urethral length for short term continence recovery following robot-assisted laparoscopic radical prostatectomy

A1136 - Significance of position of vesico-urethral anastomosis together with postoperative membranous urethral length for short term continence recovery following robot-assisted laparoscopic radical prostatectomy

Impact of Bladder Neck Angle Measured by Postoperative Magnetic Resonance Imaging on Midterm Recovery of Urinary Continence in Prostate Cancer Patients Undergoing Robot-Assisted Radical Prostatectomy.

Introduction: MRI has helped clarify the relationship between pelvic anatomical structures and functional outcomes after robot-assisted radical prostatectomy (RARP). The objective of this study was to assess the impact of the bladder neck angle (BNA) measured by postoperative MRI on midterm recovery of urinary continence (UC) in patients undergoing RARP. Patients and Methods: This study retrospectively included 200 consecutive patients with prostate cancer who were treated by RARP and received MRI 3 months after RARP. Based on postoperative MRI, the BNA was measured as the angle between the anterior and posterior bladder walls. The midterm recovery of UC was defined as the use of either no pad or an occasional security pad at 6 months after RARP. Results: One hundred forty-four of the 200 patients (72.0%) achieved midterm recovery of UC and the median BNA was 70°. There were no significant differences in several parameters, including age, body mass index, total prostate volume, preservation of the neurovascular bundle, and postoperative membranous urethral length (MUL), between patients with BNA ≥70° and <70°. Of these parameters, only the BNA and postoperative MUL were independently associated with the midterm recovery of UC. The optimal cutoff points of the BNA and MUL (65° and 9 mm, respectively) were calculated by the receiver operating characteristics curve, and a scoring model for the prediction of midterm recovery of UC was developed according to the logistic regression analysis. This scoring model was demonstrated to be satisfactorily calibrated (p for Hosmer-Lemeshow test = 0.49) and provide good discrimination (area under the curve: 0.723; p < 0.001). Conclusions: These findings suggest that midterm recovery of UC after RARP is favorably affected by the large BNA and long postoperative MUL, and our scoring model can be used as a reliable tool for predicting the midterm continence status after RARP.

MP64-16 ELUCIDATION OF URINARY INCONTINENCE MECHANISM AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY BY ANATOMICAL AND FUNCTIONAL ANALYSIS OF THE URETHRAL SUPPORT MECHANISM

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VI (MP64)1 Sep 2021MP64-16 ELUCIDATION OF URINARY INCONTINENCE MECHANISM AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY BY ANATOMICAL AND FUNCTIONAL ANALYSIS OF THE URETHRAL SUPPORT MECHANISM Masao Kataoka, Akihisa Hasegawa, Yuki Harigane, Syunta Makabe, Kei Yaginuma, Akifumi Onagi, Ruriko Honda, Kanako Matsuoka, Tomoyuki Koguchi, Junya Hata, Yuichi Sato, Hidenori Akaihata, Souichiro Ogawa, and Yoshiyuki Kojima Masao KataokaMasao Kataoka More articles by this author , Akihisa HasegawaAkihisa Hasegawa More articles by this author , Yuki HariganeYuki Harigane More articles by this author , Syunta MakabeSyunta Makabe More articles by this author , Kei YaginumaKei Yaginuma More articles by this author , Akifumi OnagiAkifumi Onagi More articles by this author , Ruriko HondaRuriko Honda More articles by this author , Kanako MatsuokaKanako Matsuoka More articles by this author , Tomoyuki KoguchiTomoyuki Koguchi More articles by this author , Junya HataJunya Hata More articles by this author , Yuichi SatoYuichi Sato More articles by this author , Hidenori AkaihataHidenori Akaihata More articles by this author , Souichiro OgawaSouichiro Ogawa More articles by this author , and Yoshiyuki KojimaYoshiyuki Kojima More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002104.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The aim of this study was to clarify the mechanism of urinary incontinence after robot-assisted radical prostatectomy (RARP) focusing on changes in the pelvic floor muscles. METHODS: A total of 323 patients underwent RARP in our hospital from 2014 to 2019 were included and retrospectively analyzed. All patients were analyzed membranous urethral length (MUL), puborectalis muscle (PRM) and rectourethral muscle (RUM) by preoperative and postoperative MRI, and underwent a one-hour pad test 1, 3, 6, 9, 12 months after surgery. The maximum urethral closure pressure (MUCP) was also measured before and after surgery by measuring urethral pressure (UPP). The correlation between postprostatectomy incontinence (PPI) and various factors analyzed by regression analysis. RESULTS: The PRM cross-sectional area was significantly decreased after surgery (-19%, p<0.001). The urinary incontinence rates at 1, 3, 6, 9 and 12 months after surgery were 40.2%, 63.5%, 73.1%, 74.6% and 76.8%, respectively. A significant correlation between PPI (1,3,6,9,12M) and postoperative MUL (OR:0.10,0.04,0.07,0.04,0.05, p-value: <0.001, <0.001, <0.001, <0.001, <0.001, respectively), or PRM cross-sectional area change after RARP (OR: 2.27, 3.19, 4.60, 2.39, 4.25, p-value: <0.01, <0.001, <0.001, <0.01, <0.001, respectively) was observed. A significant correlation was also observed between post-operative PRM cross sectional area and postoperative MUCP (R=0.510, p<0.001). CONCLUSIONS: The levator ani muscle is thought to be directly or indirectly connected to the RUM. It is speculated that the levator ani muscle and the RUM work like a sling and affect urinary continence. Postoperative reduction of PRM cross-sectional area caused a decrease in the function of the support mechanism as a urethral sling, which affected MUCP and PPI. It was considered important to perform surgery with an awareness of reducing damage to PRM. Furthermore, PPI can be improved by novel techniques to make new support mechanism as a urethral sling using the levator ani muscle. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1116-e1116 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Masao Kataoka More articles by this author Akihisa Hasegawa More articles by this author Yuki Harigane More articles by this author Syunta Makabe More articles by this author Kei Yaginuma More articles by this author Akifumi Onagi More articles by this author Ruriko Honda More articles by this author Kanako Matsuoka More articles by this author Tomoyuki Koguchi More articles by this author Junya Hata More articles by this author Yuichi Sato More articles by this author Hidenori Akaihata More articles by this author Souichiro Ogawa More articles by this author Yoshiyuki Kojima More articles by this author Expand All Advertisement Loading ...

Pelvic Anatomical Features After Retzius-Sparing Robot-Assisted Radical Prostatectomy Intended for Early Recovery of Urinary Symptoms.

Purpose: To elucidate factors contributing to early urinary continence recovery after retzius-sparing robot-assisted radical prostatectomy (RS-RARP) by evaluating postoperative pelvic anatomical features between RS-RARP and conventional RARP (CON-RARP). Materials and Methods: We retrospectively examined 50 men who underwent RS-RARP (n = 25; the RS-RARP group) and CON-RARP (n = 25; the CON-RARP group) between October 2017 and June 2018. Perioperative outcomes and postoperative urinary continence were assessed in both groups. Anatomical features including the bladder neck-to-pubic symphysis ratio (determined from cystograms) and membranous urethral length (MUL) (determined from magnetic resonance imaging) were evaluated. Result: The daily urinary incontinence rate at discharge was significantly lower in the RS-RARP group than in the CON-RARP group (0.046 [range: 0.014-0.160] vs 0.357 [range: 0.139-0.616], p < 0.001). Postoperative urinary continence at 1, 3, 6, and 12 months was 80%, 92%, 96%, and 96% in the RS-RARP group and 24%, 40%, 68%, and 84% in the CON-RARP group, respectively (p < 0.001). The urgency scores in the international prostate symptom score (IPSS) questionnaire at 1 and 3 months were significantly lower in the RS-RARP than in the CON-RARP group (p = 0.028 and 0.033, respectively). The quality of life (QOL) indices were more significantly improved in the RS-RARP group than in the CON-RARP group 1 month (p = 0.027) and 3 months (p = 0.045) postoperatively. Receiver operating characteristic analysis revealed that a postoperative MUL of 12.1 mm (area under the curve: 0.852) was the optimal cutoff value predictive of continence recovery after 1 month. Multivariate analysis demonstrated that RS-RARP (odds ratio [OR]: 23.6; p < 0.001) and prostate volume (OR: 0.926; p = 0.049) were the independent factors of a longer MUL. Conclusions: RS-RARP results in an early continence recovery and a better urgency score in the IPSS by suppressing the descent of the bladder and maintaining a long MUL. RS-RARP may contribute to a better QOL recovery after RARP.

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.

PD37-04 BLADDER ELEVATION IN PELVIC FLOOR MUSCLE TRAINING EVALUATED BY CINE MRI (MAGNETIC RESONANCE IMAGING) IS ASSOCIATED WITH EARLY RECOVERY OF CONTINENCE AFTER RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVE: Postprostatectomy incontinence (PPI) is a major complication of prostatectomy. MRI (magnetic resonance imaging) is a good tool to evaluate the risk factors of PPI such as membranous urethral length (MUL). Pelvic floor muscle training (PFMT) is a good treatment of PPI, and ultrasound-based training of the muscle as physical therapy has been effective. However, there is no evidence of how muscle movement affects recover of continence. In the present study, we evaluated some dynamic factors of prostatectomy patients with cine MRI, and identified the risk factors of PPI. METHODS: A total of 128 male prostate cancer patients were enrolled in the present study. The all prostatectomy were robot assisted laparoscopic surgery. Cine MRI was performed preoperatively and at 6 months after surgery. Continence was defined as pad free or safety pad. We defined bladder neck elevation length in PFMT as “bladder elevation length (BEL)”. Other undynamic or dynamic parameters were also measured. Patients who got recovery of continence within a month were divided into Continence-group (n=48), and others were into Incontinence- group (n=80). We analyzed the parameters between two groups using Mann-Whitney U test or chi-square test, and between pre-post operations using Wilcoxon signed rank test. Preoperative parameters were also analyzed using multivariable analysis. RESULTS: In the two groups, there was no significant difference in any parameters of patient characteristics, perioperative data, pathological results and with or without nerve-sparing technique. In Continence-group, postoperative BEL was significantly longer than Incontinence- group (p=0.0001). Postoperative BEL of Continence-group also tended to be longer (p=0.0569). Only in postoperative state, posterior urethrovesical angle of Continence-group was significantly smaller than Incontinence- group at both resting and voiding phase (p=0.0046, p=0.0264). Postoperative MUL of Continence-group was significantly longer (p=0.004). Multivariable analysis showed that preoperative BEL and MUL significantly contributed to getting recovery of continence (p=0.0156, p=0.0329). CONCLUSIONS: Cine MRI enables us to evaluate dynamic and highly accurate measurement. From the present study, BEL was strongly related to recovery of early continence. Cine MRI could provide the patients the risk of PPI and better PFMT guidance. Source of Funding: None

Improvement in early urinary continence recovery after robotic-assisted radical prostatectomy based on postoperative pelvic anatomic features: a retrospective review

BackgroundWe investigated the impact of postoperative membranous urethral length and other anatomic characteristics of the pelvic floor shape as measured by magnetic resonance imaging on the improvement in continence following robotic-assisted radical prostatectomy.MethodsWe retrospectively reviewed data from 73 patients who underwent postoperative prostate magnetic resonance imaging following robotic-assisted radical prostatectomy between 2013 and 2018. Patient demographics; pre-, peri-, and post-operative parameters; and pelvic anatomic features on magnetic resonance imaging were reviewed. Patients who used no urinary incontinence pads or pads for protection were considered to have achieved complete continence.ResultsUrinary continence was restored in 27.4, 53.4, 68.5, and 84.9% of patients at 1, 3, 6, and 12 months after robotic-assisted radical prostatectomy, respectively. When patients were divided into early and late continence groups based on urinary continence at 3 months after robotic-assisted radical prostatectomy, no significantly different clinical characteristics or surgical outcomes were found. However, the mean membranous urethral length (18.5 mm for the early continence group vs. 16.9 mm for the late continence group), levator muscle width (7.1 vs. 6.5 mm, respectively), and bladder neck width on the trigone side (7.2 mm vs. 5.4 mm, respectively) were significantly different between groups (all p < 0.05). Multivariate logistic regression analysis showed that membranous urethral length (odds ratio, 1.227; 95% confidence interval, 1.011–1.489; p = 0.038) and bladder neck width (odds ratio, 1.585; 95% confidence interval, 1.050–2.393; p = 0.028) were associated with the period of early urinary continence.ConclusionsPostoperative membranous urethral length and bladder neck width were significantly associated with early urinary continence recovery after robotic-assisted radical prostatectomy. It is highly recommended that surgeons focus on preserving the membranous urethral length and increasing the bladder neck width on the trigone side during surgery to achieve optimal continence outcomes after robotic-assisted radical prostatectomy.

Usefulness of a novel classification based on perioperative changes of membranous urethral length using hierarchical cluster analysis of urinary incontinence and overactive bladder symptoms after robot-assisted radical prostatectomy: A prospective observational study.

The aim of the present study was to construct a novel classification based on perioperative changes of membranous urethral length (MUL) using hierarchical cluster analysis to predict urinary incontinence (UI) and overactive bladder (OAB) symptoms after robot-assisted radical prostatectomy (RARP). A total of 299 patients who underwent RARP with complete pre and postoperative MUL data were included in the present study. Hierarchical cluster analysis was performed to identify the groups with similar perioperative MUL and prostate size. UI and OAB symptoms after RARP were evaluated in each cluster for 12 months after RARP. Four groups were identified by the cluster analysis of these factors: preservation of MUL type (cluster 1, n = 92); standard type (cluster 2, n = 137); large prostate type (cluster 3, n = 23); and loss of MUL type (cluster 4, n = 47). Although there was significantly more UI in clusters 3 and 4 than in clusters 1 and 2 up to 3 months after RARP, UI improvement was the most delayed in cluster 3. Improvement of OAB symptoms was also most delayed in cluster 3. Urinary quality of life (QOL) was significantly worse in cluster 4 than in clusters 1 and 2. Cluster analysis successfully classified patients after RARP into four characteristic groups based on perioperative MUL. Recovery from UI and OAB symptoms and urinary QOL after RARP were significantly different among these groups. This classification based on cluster analysis might be useful to predict recovery from UI and OAB symptoms when following QOL after RARP.

MP31-09 ASSOCIATION BETWEEN POSTOPERATIVE URETHRAL AND VESICAL ANATOMICAL FEATURES ON MRI AND LOWER TRACT URINARY SYMPTOMS AFTER RADICAL PROSTATECTOMY.

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction I1 Apr 2017MP31-09 ASSOCIATION BETWEEN POSTOPERATIVE URETHRAL AND VESICAL ANATOMICAL FEATURES ON MRI AND LOWER TRACT URINARY SYMPTOMS AFTER RADICAL PROSTATECTOMY. Nobuhiro Haga, Tomohiko Yanagida, Ken Aikawa, and Yoshiyuki Kojima Nobuhiro HagaNobuhiro Haga More articles by this author , Tomohiko YanagidaTomohiko Yanagida More articles by this author , Ken AikawaKen Aikawa More articles by this author , and Yoshiyuki KojimaYoshiyuki Kojima More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.963AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To elucidate the etiology of lower urinary tract symptoms (LUTS) after radical prostatectomy (RP), the present study investigated association between postoperative urethral and vesical anatomical features on magnetic resonance imaging (MRI) and LUTS. METHODS Fifty-three consecutive patients undergoing RP also underwent pre- and postoperative MRI. Preoperative MRI only evaluated preoperative membranous urethral length (MUL). Postoperative MRI evaluated postoperative MUL, posterior-urethral vesical angle, depth of the urethrovesical junction (UVJ), and urinary pooling inside the urethra and bladder neck configuration (Figure 1 and 2). At the same time as postoperative MRI, International Prostate Symptom Score (IPSS), quality of life (QOL) index, continence grade, and uroflowmetry was investigated. Associations between pre- or postoperative MRI variables and questionnaire results or uroflowmetry were analyzed to examine the relationship between morphology of the urethral and vesical anatomical features and LUTS. RESULTS Pre- and postoperative MRI variables were not significantly associated with parameters of IPSS total score and uroflowmetry. Urinary pooling inside the urethra was significantly associated with the urgency score in IPSS (p=0.006). Postoperative MUL (p<0.001), depth of UVJ (p=0.002) and urinary pooling inside the urethra (p=0.04) were significantly associated with continence grade. CONCLUSIONS Urinary pooling inside the urethra might induce urgency, and postoperative MUL and depth of UVJ were related to urinary incontinence. Avoiding damage to the continence nerve to prevent inflow of urine into the urethra, preserving the MUL, and developing procedures to prevent declines in the bladder neck during surgery are therefore recommended. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e401-e402 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Nobuhiro Haga More articles by this author Tomohiko Yanagida More articles by this author Ken Aikawa More articles by this author Yoshiyuki Kojima More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of preoperative and postoperative membranous urethral length measured by 3 Tesla magnetic resonance imaging on urinary continence recovery after robotic-assisted radical prostatectomy.

We sought to investigate the impact of preoperative and postoperative membranous urethral length (MUL) on urinary continence using 3 Tesla (3T) magnetic resonance imaging (MRI) after robotic-assisted radical prostatectomy (RARP). Between 2008 and 2013, 190 men with RARP underwent preoperative and postoperative MRI. Patients who received adjuvant radiotherapy or who were lost to followup were excluded, leaving 186 patients eligible for analysis. Preoperative MUL was estimated from the prostate apex to the penile bulb, while postoperative MUL was estimated from the bladder neck to penile bulb. Patients with no pads or protection were considered to have complete continence. Logistic regression analysis was used to identify predictors associated with urinary incontinence at six and 12 months. Age was commonly associated with urinary incontinence at six and 12 months. In addition, diabetes mellitus (DM) was another factor associated with urinary incontinence at 12 months. When adjusting these variables, preoperative MUL ≤16 mm (95% confidence interval [CI] 1.01-1.14; p=0.022), postoperative MUL ≤14 mm (95% CI 1.16-9.80; p=0.025) and percent change of MUL >18% (95% CI 1.17-7.23; p=0.021) were significantly associated with urinary incontinence at six months. However, at 12 months, preoperative MUL ≤13.5 mm (95% CI 1.85-19.21; p=0.003) and postoperative MUL ≤13 mm (95% CI 1.24-13.84; p=0.021) had impacts on urinary incontinence, but not percent change of MUL. Preoperative and postoperative MUL were significantly associated with urinary continence recovery after RARP. Therefore, efforts to preserve MUL are highly recommended during surgery for optimal continence outcomes after RARP.

Factors Contributing to Early Recovery of Urinary Continence Analyzed by Pre- and Postoperative Pelvic Anatomical Features at Robot-Assisted Laparoscopic Radical Prostatectomy.

The aim of the present study is to elucidate factors contributing to early recovery of urinary continence after robot-assisted laparoscopic radical prostatectomy (RARP) from the perspective of urethral and vesical anatomical features after RARP. Sixty consecutive patients undergoing RARP also underwent pre- and postoperative urethrovesicography (UVG). Both pre- and postoperative UVG evaluated the posterior-urethral vesical angle and position of the urethrovesical junction. Postoperative UVG was performed 7 days after RARP and also evaluated postoperative membranous urethral length (MUL) and the postoperative degree of atony of the external urethral sphincter. Associations were analyzed between pre- or postoperative UVG variables and urinary incontinence as well as between UVG variables significantly correlating with urinary incontinence and neurovascular bundle-preservation procedures. Postoperative MUL was the only factor significantly associated with the state of continence in the early postoperative period according to multivariate logistic regression analysis (odds ratio, 1.94; 95% confidence interval, 1.22-3.12; p<0.005). A cutoff value of 17 mm offered the best accuracy in receiver operating characteristics analysis. Postoperative MUL was significantly increased in the group with preservation of the neurovascular bundle (p=0.01). Postoperative MUL is the most important factor for recovery of urinary continence in the early postoperative period after RARP. Postoperative MUL >17 mm as measured on UVG can be expected to predict early recovery of urinary continence. Postoperative MUL was greater with preservation of the neurovascular bundle, thus allowing early recovery of urinary continence.

Association Between Postoperative Pelvic Anatomic Features on Magnetic Resonance Imaging and Lower Tract Urinary Symptoms After Radical Prostatectomy

To elucidate the etiology of lower urinary tract symptoms (LUTS) after radical prostatectomy, the present study investigated associations between postoperative urethral and vesical anatomic features on magnetic resonance imaging (MRI) and LUTS. Fifty consecutive patients undergoing radical prostatectomy also underwent preoperative and postoperative MRI. Preoperative MRI only evaluated preoperative membranous urethral length (MUL). Postoperative MRI evaluated postoperative MUL, posterior-urethral vesical angle, depth of the urethrovesical junction (UVJ), and urinary pooling inside the urethra and bladder neck configuration. At the same time as postoperative MRI, International Prostate Symptom Score (IPSS), quality of life index, continence grade, and uroflowmetry parameters were investigated. Associations between preoperative or postoperative MRI variables and questionnaire results or uroflowmetry were analyzed to examine the relationships between the morphology of urethral and vesical anatomic features and LUTS. Preoperative and postoperative MRI variables were not significantly associated with IPSS total score or uroflowmetry results. Urinary pooling inside the urethra was significantly associated with urgency score in the IPSS (P = .005). Postoperative MUL (P <.001), depth of the UVJ (P = .002), and urinary pooling inside the urethra (P = .04) were significantly associated with continence grade. Urinary pooling inside the urethra might induce urgency, and postoperative MUL and depth of UVJ were related to urinary incontinence. Avoiding damage to the nerves involved in continence to prevent inflow of urine into the urethra, preservation of MUL, and development of procedures to prevent descent of the bladder neck during surgery are therefore recommended.

Urinary continence following laparoscopic radical prostatectomy: Association with postoperative membranous urethral length measured using real-time intraoperative transrectal ultrasonography

Urinary incontinence is a major complication following radical prostatectomy. The aim of the present study was to assess the association between urinary continence following laparoscopic radical prostatectomy (LRP) and various factors measured using real-time intraoperative transrectal ultrasonography (TRUS). Patients (n=53) with localized prostate cancer underwent LRP in combination with real-time intraoperative TRUS navigation and were evaluated for urinary continence for more than 6 months following LRP. Prostate size, membranous urethral length (MUL) and bladder-urethra angle were measured using real-time intraoperative TRUS immediately before and after surgery. Urinary continence was regained by 4, 15 and 27 patients 1, 3 and 6 months after LRP, respectively. Longer postoperative MUL was significantly correlated with recovery of urinary continence 1, 3 and 6 months after LRP. In addition, an increase in difference between preoperative and postoperative MUL was also associated with superior continence. No correlation was observed between postoperative MUL and the rate of tumor-positive surgical margins. Larger prostate volume was correlated to postoperative continence 6 months after surgery. Shorter operation time and less blood loss resulted in postoperative urinary continence 1 month after LRP. Preoperative MUL, bladder-urethra angle, age and body mass index had no correlation with urinary continence. Postoperative MUL was the most significant factor for early recovery of urinary continence following LRP. These results indicate that preservation of longer urethra during surgery may be recommended without tumor-positive surgical margins.

Editorial Comment

This is a nice review of the techniques of reconstruction of the posterior periurethral plate and their effect on continence. The clinical series reviewed were of 2 categories: cohort studies with historical controls 1 Rocco F. Carmignani L. Acquati P. et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007; 52: 376-383 Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar , 2 Rocco B. Gregori A. Stener S. et al. Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol. 2007; 51: 996-1003 Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar , 3 Tewari A. Jhaveri J. Rao S. et al. Total reconstruction of the vesicourethral junction. BJU Int. 2008; 101: 871-877 Crossref PubMed Scopus (166) Google Scholar , 4 Nguyen M.M. Kamoi K. Stein R.J. et al. Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int. 2008; 101: 1135-1139 Crossref PubMed Scopus (96) Google Scholar , 5 Woo J.R. Shikanov S. Zorn K.C. et al. Impact of posterior rhabdosphincter reconstruction during robot-assisted radical prostatectomy: retrospective analysis of time to continence. J Endourol. 2009; 23: 1995-1999 Crossref PubMed Scopus (22) Google Scholar and randomized clinical trials (1 published and 1 as an abstract). As the authors point out, the interpretation of the results is bedeviled by slight differences in technique, length of follow-up, and definitions of continence. The cohort studies showed a 30%-50% improvement of continence from a baseline of 30%-40% without reconstruction to 80%-85% with reconstruction, if using 0-1 pad were considered continent. If the definition of continence were no pads, the continence rates were much lower at about 40%. The 1 published randomized trial was powered to detect a 30% difference in continence rates. It showed that the 0-1 pad continence rate was 74% without reconstruction and 80% with reconstruction. 6 Menon M. Muhletaler F. Campos M. et al. Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol. 2008; 180: 1018-1023 Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar Thus, it did not show a significant difference in continence, primarily because the continence results were close to 80% without any reconstruction. The unpublished abstract showed no difference in continence or EPIC scores with reconstruction, although the overall continence rates were somewhat lower than in the other studies. 7 Sutherland D. Tacoma W.A. Hong M. et al. Posterior rhabdosphincter reconstruction after RARP: results from a phase 2 RCT. J Urol. 2009; 181: 457 Abstract Full Text PDF Google Scholar Posterior Rhabdosphincter Reconstruction During Robot-assisted Radical Prostatectomy: Critical Analysis of Techniques and OutcomesUrologyVol. 76Issue 3PreviewMany centers have recently implemented posterior rhabdosphincter reconstruction (PRR) into robot-assisted radical prostatectomy (RARP) with the objective of earlier continence recovery. We comprehensively review the anatomic and functional changes occurring post prostatectomy along with the reconstructive techniques and published outcomes of PRR. Several case control studies show a better continence rate within the first 3 months, whereas the only randomized control trial presents a conflicting conclusion. Full-Text PDF ReplyUrologyVol. 76Issue 3PreviewAlthough radical prostatectomy (RP) delivers excellent long-term survival outcomes, postoperative incontinence remains a potential complication. Increasing age, shorter pre- and postoperative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations in surgical technique, and previous prostate surgery have been reported as negative risk factors for delayed continence recovery after radical prostatectomy. Over the past decade, with increased use of robotic and laparoscopic technology, coupled with cadaveric and video urodynamic studies, there has been an increased interest in elucidating the functional anatomy and physiology of the male continence mechanism. Full-Text PDF

Transrectal ultrasound navigation during minilaparotomy retropubic radical prostatectomy: Impact on positive margin rates and prediction of earlier return to urinary continence

To assess the impact of transrectal ultrasound (TRUS) navigation on positive margin rates and membranous urethral length (MUL) after minilaparotomy radical retropubic prostatectomy (MRP). Rates of positive distal margins prior to and after the application for TRUS navigation during MRP were assessed. Of the 189 men undergoing MRP at our institution, 70 were evaluated for the clinical usefulness of preoperative and postoperative MUL. Patients filled out self-administrated questionnaires concerning continence status at 1, 3, 6, 9, and 12 months after the MRP. Surgery-related factors including MUL were analyzed for the prediction of urinary continence after MRP. With the application of TRUS, the rate of positive distal margins decreased by 14%. Postoperative MUL was an independent variable predictive of urinary continence 1 month after surgery. Patients with a MUL longer than 12 mm showed a significantly more favorable recovery from urinary incontinence after surgery. Application of TRUS results in a lower rate of positive margins, and a longer postoperative MUL is associated with an earlier return to urinary continence after MRP.

Scientific and technical advances in continence recovery following radical prostatectomy

The advent of prostate-specific antigen screening has changed the global epidemiology of prostate cancer, with men being diagnosed with organ-confined cancer at a younger age. Radical prostatectomy with curative intent for these patients, while delivering excellent long-term survival outcomes, still has significant side effects, chiefly postprostatectomy incontinence. Increasing age, shorter pre- and post-operative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations of surgical technique and previous prostate surgery have been reported as negative risk factors for delayed continence recovery and/or permanent incontinence following radical prostatectomy. Significant progress in elucidating the functional anatomy and physiology of the male continence mechanism from cadaveric and videourodynamic studies have enabled surgeons to propose innovative surgical techniques during radical prostatectomy for augmenting continence preservation and early return. These have included optimizing the preservation of urethral rhabdosphincter length; avoiding rhabdosphincter injury; posterior reconstruction of Denonvilliers’ musculofascial plate; preservation of the bladder neck and internal sphincter; bladder neck intussusception; bladder neck mucosal eversion; preservation of the puboprostatic ligaments and arcus tendineus; and preservation of putative nerves supplying the continence mechanism. We review the scientific and technical advances in continence recovery following radical prostatectomy, identify the key principles undergirding early return of continence, highlight various treatment strategies for early and refractory postprostatectomy incontinence and describe our experience with a paradigm of these unified key principles. Increasing application of these principles in computer-aided (robotic), minimally invasive and minimal-access (i.e., single-port or natural orifice transluminal) approaches will hopefully enable patients to derive maximal benefit from curative prostatectomy while experiencing early return of continence in the not too distant future.

Recovery of Urinary Continence after Radical Prostatectomy: Association with Urethral Length and Urethral Fibrosis Measured by Preoperative and Postoperative Endorectal Magnetic Resonance Imaging

BackgroundLimited data on endorectal magnetic resonance imaging (MRI) features and urinary continence after radical prostatectomy (RP) are available. ObjectiveTo assess whether recovery of urinary continence after RP is associated with endorectal MRI findings regarding preoperative and postoperative membranous urethral length (MUL), percent change in MUL, and postoperative urethral and periurethral fibrosis. Design, setting, and participantsSixty-four patients who received an MRI scan before and after RP for localized prostate cancer were evaluated in a retrospective study at a single institution. InterventionAll patients underwent RP. MeasurementsThe postoperative scan was performed to detect local recurrence in patients with rising levels of prostate-specific antigen. Urinary continence was graded on a five-point scale. MUL was measured on T2-weighted images. Urethral and periurethral fibrosis was graded from 0 to III based on axial T2-weighted images. Univariate Cox proportional hazards regression was performed to assess variables associated with continence. Results and limitationsForty-eight patients regained continence following surgery. The median follow-up for patient who were incontinent at their last assessment was 7 mo. The median interval from RP to postoperative endorectal MRI was 10 mo. A longer preoperative or postoperative MUL was associated with superior continence (both p<0.01). The MUL loss ratio was significantly associated with postoperative continence (p=0.02). Patients with a high grade of postoperative periurethral fibrosis tended to have worse postoperative continence; nevertheless a statistical correlation was not reached (hazard ratio: 0.64, p=0.16). This is a retrospective study. ConclusionsPreoperative and postoperative MUL and the MUL loss ratio are related to the recovery time and level of urinary continence after RP. Therefore, preservation of urethral length during surgery is recommended. Periurethral fibrosis might impede the recovery of continence after RP by altering the elasticity of the external sphincter.