- Email: [email protected]
Early continence after radical prostatectomy: A systematic review
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Actas Urol Esp. 2019;xxx(xx):xxx---xxx
Actas Urol´ ogicas Espa˜ nolas www.elsevier.es/actasuro
REVIEW ARTICLE
Early continence after radical prostatectomy: A systematic review夽 A. Salazar ∗ , L. Regis, J. Planas, A. Celma, F. Díaz, I. Gallardo, E. Trilla, J. Morote Servicio de Urología, Hospital Universitari Vall d’Hebron; Universistat Autònoma de Barcelona, Barcelona, Spain Received 28 February 2019; accepted 23 June 2019
KEYWORDS Radical prostatectomy; Urinary incontinence; Prostate cancer
Abstract Background and objective: Urinary incontinence is the adverse effect with more impact on patients' quality of life after undergoing radical prostatectomy. The objective of this study is to review the present evidence that describes the variations on surgical techniques which aim to preserve urinary continence after radical prostatectomy. Evidence acquisition: We searched the literature on PubMed, Cochrane, and ScienceDirect according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement, using the PICO review protocol. The search terms were urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot-assisted laparoscopic prostatectomy, robotic prostatectomy. We identiˇed 1603 registers, and 27 articles were reviewed for meeting the inclusion criteria. Six of them are randomized clinical trials and 4 of them, meta-analysis. Evidence synthesis: The surgical techniques more frequently used to achieve early urinary continence are bladder neck and neurovascular bundles preservation, as well as the reconstruction of the rhabdosphincter. The latter has been presented in three randomized clinical trials. Even though some approaches have obtained improved functional outcomes, the lack of consensus on the deˇnition of urinary incontinence and its measurement methods have not advocated for the creation of technical recommendations based on scientiˇc evidence. Conclusions: The reconstruction of the rhabdosphincter is the only technique that has shown improved functional results through randomized trials. The current evidence is limited and heterogenous, and more studies with consistent criteria are needed in order to establish a standard surgical technique. © 2019 AEU. Published by Elsevier Espa~ na, S.L.U. All rights reserved.
夽 Please cite this article as: Salazar A, Regis L, Planas J, Celma A, Díaz F, Gallardo I, et al. Variaciones de la prostatectomía radical para una recuperación de la continencia urinaria precoz: una revisión sistemática. Actas Urol Esp. 2019. https://doi.org/10.1016/j.acuro.2019.06.003 ∗ Corresponding author. E-mail address: [email protected] (A. Salazar).
2173-5786/© 2019 AEU. Published by Elsevier Espa~ na, S.L.U. All rights reserved.
ACUROE-1190; No. of Pages 10
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A. Salazar et al.
PALABRAS CLAVE Prostatectomía radical; Incontinencia urinaria; Cáncer de próstata
Variaciones de la prostatectomía radical para una recuperación de la continencia urinaria precoz: una revisión sistemática Resumen Contexto y objetivo: La incontinencia urinaria es el efecto secundario con mayor impacto en la calidad de vida después de la prostatectomía radical. El objetivo de nuestro artículo es revisar la evidencia cientíˇca actual sobre las variaciones quirúrgicas descritas para preservar la continencia urinaria después de la prostatectomía radical. Adquisición de la evidencia: Se realizó una revisión sistemática de la literatura en PubMed, Cochrane y ScienceDirect según los criterios PRISMA (Preferred reporting items for systematic reviews and meta-analyses), utilizando los términos: urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot assisted laparoscopic prostatectomy, robotic prostatectomy y los criterios de selección PICO. Se identiˇcaron 1.603 referencias de las que se seleccionaron 27 publicaciones que cumplieron los criterios de inclusión, 6 fueron ensayos clínicos aleatorizados y 4 metaanálisis. Síntesis de la evidencia: Las técnicas más empleadas para alcanzar una continencia urinaria precoz son la preservación del cuello vesical, de las bandeletas neurovasculares y la reconstrucción del rabdoesfínter, siendo esta la técnica con mayor evidencia, ya que existen 3 ensayos clínicos aleatorizados. Pese que algunas variaciones técnicas han conseguido mejorías en los resultados funcionales, la ausencia de consenso en la deˇnición de incontinencia urinaria y la manera de evaluarla no permiten elaborar recomendaciones técnicas basadas en evidencia cientíˇca de calidad. Conclusiones: La reconstrucción del rabdoesfínter es la única técnica que ha demostrado mejoría en la recuperación precoz de la continencia urinaria tras la prostatectomía radical. La evidencia cientíˇca actual es heterogénea y limitada, por lo que son necesarios estudios aleatorizados bien dise~ nados para evaluar las modiˇcaciones técnicas. © 2019 AEU. Publicado por Elsevier Espa~ na, S.L.U. Todos los derechos reservados.
Introduction
Evidence acquisition
Radical prostatectomy (RP) is the treatment of choice for localized and locally advanced prostate cancer in cases with no contraindications to surgery with life expectancy greater than 10 years.1,2 Since urinary incontinence is the side effect with the greatest impact on the patients' quality of life, extensive research on the pathophysiological mechanisms related to its appearance has been carried out.2 The introduction of laparoscopy in the 1990s improved the postoperative evolution of patients undergoing RP. However, the development of robotic RP has been essential to provide better functional results after this intervention. Due to an improved visualization of the anatomical structures and the expanded movement range, certain technical variations can be achieved.3,4 Although the exact pathophysiological mechanism involved in the development of urinary incontinence after PR remains unknown, we do know that anatomical and functional changes after prostate removal are related to alterations in the bladder-sphincter complex and pelvic ˚oor structures.3 The preservation of the bladder neck and neurovascular bundles, or the posterior reconstruction of the rhabdosphincter are technical variations which have been described aiming to achieve higher urinary continence rates in shorter post-surgical time.3 The objective of our review has been to analyze the current scientiˇc evidence on the surgical techniques described to preserve or improve urinary continence after RP.
Two authors (AS and LR) conducted a literature search in PubMed, Cochrane and ScienceDirect on July 18, 2018 and have carried out a systematic review following the PRISMA (Preferred reporting items for systematic reviews and meta-analyses)5 statement. The Medical Subject Headings search terms were urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot assisted laparoscopic prostatectomy, robotic prostatectomy. According to the PICO (Participants, Interventions, Comparisons and Outcomes) selection strategy, the authors included articles published in English or Spanish, clinical trials of human adults and having been submitted to RP for the treatment of histologically proven prostate cancer, with analysis on the surgical technique variations in search for early urinary continence. Initially, 1603 records met the established criteria and were identiˇed. 103 original, comparative, prospective or retrospective articles, clinical trials and meta-analyses were evaluated, and 27 were ˇnally selected for this review for meeting the search speciˇc criterion. The ˚ow chart of this selection is shown in Fig. 1. A quality analysis was also performed to reduce the risk of bias.6 Fig. 2 synthesizes the risk of bias of the selected original articles.
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Early continence after radical prostatectomy
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Articles identified through search on Pubmed, Cochrane and ScienceDirect Urinary continence, urinary incontinence, urinary leakage, radical prostatectomy,open radical prostatectomy, laparoscopic prostatectomy, robot assisted laparoscopic prostatectomy, robotic prostatectomy 1.603 records obtained
SCREENING
1.318 duplicates or not relevant articles excluded 285 abstracts screened
ELEGIBILITY
182 abstracts excluded (no confirmation of technique to maintain continence)
103 full-text articles assessed
INCLUDED
75 articles excluded for not meeting inclusion criteria
27 articles included in the review
Figure 1
Flowchart of the systematic review according to the PRISMA criteria.
Evidence synthesis The variations of the surgical technique aimed to preserve urinary continence in PR can be classiˇed in several ways. We have divided them into: I. Continence preserving techniques, II. Continence mechanism reconstruction techniques and III. Continence reinforcement techniques.7 There are tables that synthesize the evidence about the most commonly used techniques.
Continence preservation techniques These are surgical techniques aimed at preserving the mechanism of continence. These include bladder neck and neurovascular bundle preservation, apical dissection, puboprostatic ligament preservation, preservation of the membranous urethral length, seminal vesicle and Retzius (space) sparing. Bladder neck preservation The preservation of the bladder neck for the improvement of urinary continence outcomes after RP was proposed after anatomical studies in traumatic patients which demonstrated the importance of the bladder neck in the absence of rhabdosphincter.8 Careful dissection of the prostatebladder junction can maintain most of the circular muscle ˇbers of the BN, accelerating the return of urinary continence. In 2013, Nyarangi-Dix et al. published the ˇrst prospective, randomized study on the impact of bladder neck preservation on urinary incontinence after RP. Their results show improved urinary continence rates with a recovery of continence after catheter removal at 3, 6, and 12-month of 7.4 vs. 0%; 87.4 vs. 60.6%; 88.4 vs.
68% and 91.6 vs. 79.4% for patients in the bladder neck preservation group vs. the bladder neck sparing group, respectively. In addition to evaluating continence with questionnaires, the study also carried out 24 h pad-tests, thus providing objective and precise information regarding the degree of urinary incontinence and a consistent methodology.8 Recently, Ma et al. published a meta-analysis of this technical approach, including 13 articles, 2 randomized clinical trials, conducted in open, laparoscopic or robotic RP, ˇnding bladder neck preservation beneˇcial in the early (<6 m) and long-term (>12 m) recovery of urinary continence. The bladder neck preservation group had better outcomes for urinary continence after bladder catheter removal (OR 3.24, 95% CI 1.61---6.52), at one (OR 2.45, 95% CI 1.32---4.55), three (OR 2.04, 95% CI 1.39---3), six (OR 1.72, 95% CI 1.25---2.37) and 12 (OR 1.46, 95% CI 1.06---2.02) months. However, this metaanalysis includes studies with diverse deˇnitions of urinary continence and only two comparative randomized studies. Therefore, it is not possible to establish clear evidence that supports the recommendation of this technique in the surgical practice.9 Table 1 shows the results of the evaluated studies.
Preservation of the neurovascular bundles The ˇrst studies that postulated the importance of pelvic nerve preservation in urinary incontinence secondary to PR were published at the end of the 1980s. Reeves et al. observed in their meta-analysis, that the preservation of neurovascular bundles favors an improvement in early urinary continence rates, but not in the long term.10 The authors of this meta-analysis deˇned 6 months after surgery as the limit of early continence. 27 studies were included,
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Rocco, 200722
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Coelho, 201123 Dal Moro, 201430 Deliveliotis, 200214 Freire, 200935 Hurtes, 201227 Jeong, 201225 John, 200018 Kojima, 201431 Menon, 20081 Michl, 201611 Nakashima, 200415 Nguyen, 200838 Nyarangi-Dix, 20138 Patel,
200929
Rocco, 200737
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Stolzenburg, 200613
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Stolzenburg, 201036
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Sutherland, 201128 Tewari, 200826 Walsh, 200219
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Blinded participants and study staff
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Rocco, 200621
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Asimakopoulos, 201819
Leakage monitoring
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A. Salazar et al. Randomization
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Figure 2 Summary of the risk of bias in the included studies. Green dot (+): low risk of bias. Yellow dot (?): unclear risk bias. Red dot (−): high risk of bias.
12 of them were prospective, non-randomized. Patients with preservation of the neurovascular bundles had better results of urinary continence at 6 weeks (RR 1.48; 95% CI 1.34---1.63), 3---4 months (RR 1.24; 95% CI 1.09---1.42) and 6 months (RR 1.20; 95% CI 1.04---1.39). No statistically signiˇcant differences were observed regarding late urinary continence (12 and 24 months). The study also included a subgroup analysis regarding the type of preservation performed: unilateral or bilateral. Bilateral preservation showed different urinary continence rates in comparison to unilateral preservation at 6 weeks (RR 1.21; 95% CI 1.02---1.42) only.10 However, Michl et al. published a retrospective study in 2016, comparing 3 groups: Patients with bilateral NS RP, with primary NNS RP, and with bilateral secondary resection of the NVBs for positive frozen-section results. Their outcomes showed differences in short- and longterm urinary continence ˇgures, both in the primary preservation group and in the secondary preservation group. Following these results, they proposed that the meticulous apical dissection associated with the nerve sparing technique, rather than the preservation of the NVBs itself, is responsible for preserving the innervation of the urinary sphincter.11
Apical dissection Due to its deep location in the pelvis and its close contact with the rectum, the urethral sphincter, vessels and nerves, the apex is the most difˇcult area of the prostate to approach. The prostate meets the sphincter complex and the urethra at the apical level, so the transition between prostate tissue and the sphincter muscle is imperceptible. This is why meticulous tissue dissection at this level is essential for early recovery of urinary continence.12 When identifying the point where the prostate and sphincter join, the surgeon must keep in mind the anatomical variability of the apex, the horseshoe-shaped external sphincter and the proximity of the deep venous complex.12 As previously mentioned, Michl et al. concluded that meticulous dissection favors urinary continence by preserving sphincter innervation, after carrying out a comparative study evaluating the preservation of neurovascular bundles.11 Despite this, there are no comparative studies available that demonstrate improvement in continence rates. Preservation of puboprostatic ligaments It has been proposed that the role of the puboprostatic ligaments in the preservation of urinary continence resides in the ˇxation or suspension of the membranous urethra.
Author, year
No. of patients (with/without BNP)
RP type
Study type
Deˇnition of continence
Continence rates (%)
Deliveliotis et al., 200214
101 (48/51)
Open
Prospective
Freire et al., 200937
619 (348/271)
Robotic
Prospective
Nyarangi-Dix et al. 20138
Stolzenburg et al., 201038
199 (95/104)
240 (150/90)
Open and robotic
Laparoscopic
RCT
Retrospective
Continence with BNP (%)
Continence without BNP (%)
P value
No pad.
3 6 9 12
69 79 88 92
45 61 82 92
0.016 0.039 0.457 0.927
No pad.
4 12 24
65.6 86.4 100
26.5 81.4 96.1
<0.001 0.303 0.308
0---1 pad
0 days 3 6 12
7.4 87.4 88.4 91.6
1 60.6 68 79.4
<0.001 <0.001 0.004 0.035
0---1 pad
Day 1 3 6 12
19.5 73.3 86.5 93.5
9.4 61.3 80.6 91.5
0.038 0.045 0.416 0.92
RCT: randomized clinical trial; BNP: bladder neck preservation; RP: radical prostatectomy; BC: bladder catheter.
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Studies and results analyzing bladder neck preservation.
Early continence after radical prostatectomy
Table 1
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6 Stolzenburg et al. conducted a prospective, randomized study in patients undergoing laparoscopic PR with preservation of neurovascular bundles and observed improved early urinary continence rates (2 weeks and 3 months) in the group of patients treated with puboprostatic ligament preservation. This surgical technique does not affect the entire endopelvic fascia, so the preservation of the periurethral support tissue would provide or facilitate the early recovery of continence.13 A comparative, prospective study in 3 groups had been previously published: preservation of puboprostatic ligaments, preservation of bladder neck and preservation of both. Their results showed earlier recovery of urinary continence (3 and 6 months) in groups with bladder neck preservation, with no long-term differences (9 and 12 months).14 The membranous urethra is anteriorly ˇxed to the posterior part of the pubis with a suspension mechanism that includes the puboprostatic ligaments.15 Following this approach, Nakashima et al. proposed the suspension of the vesicourethral anastomosis by suturing to the puboprostatic ligaments. They initially conducted a retrospective control study in 2004 and published a randomized prospective study in 2008. It obtained better urinary continence rates at one and three months in patients who underwent suspension of uretrovesical anastomosis with puboprostatic ligaments with respect to the control group.15 Preservation of the membranous urethral length Several preoperative MRI studies have been conducted with the aim of predicting functional outcomes after RP. The length of the membranous urethra is one of the most widely evaluated parameters. A meta-analysis published in 2016 showed higher urinary continence rates at 3, 6 and 12 months in patients with longer membranous urethra.16 Other studies have analyzed the angle of the membranous urethra and its impact on early continence recovery.17 However, several authors postulate that the beneˇts obtained from longer MUL could be a re˚ection of a better apical dissection.11 Therefore, the advantages attributed to the length of the membranous urethra may be due to a confounding factor. Seminal vesicle preservation The motor and sensory components of the pelvic nerve have a close anatomical relationship with the seminal vesicles. Although it is an incomplete technique, the preservation of the seminal vesicles avoids nerve damage at that level and provides improved functional outcomes. There are few comparative studies with small patient cohorts. John and Hauri obtained urinary continence rates of 60 and 95% at 6 weeks and 6 months, respectively, in the seminal vesicle preservation group, evaluated with quantitative measurements through the pad-test.18 Retzius space preservation Galfano et al. described the preservation of all anteriorly located structures, a variation that allows avoidance of the Retzius space structures involved in continence preservation.19 A randomized clinical trial of 102 patients has recently been published, obtaining continence rates of 51% in the group treated with this technique vs. 21% in the control group after removal of the urinary catheter. These
A. Salazar et al. rates were 81 vs. 47.4%; 90.5 vs. 60% and 90.5 vs. 64.1% at 1, 3 and 6 months, respectively.20
Reconstruction techniques These techniques are performed with the objective to reconstruct the supportive structures involved in the continence mechanism. Among them we ˇnd i. bladder neck reconstruction; ii. posterior reconstruction; iii anterior and posterior reconstruction; iv. anterior suspension; v. reconstruction of posterior urethral support. Bladder neck reconstruction As the preservation of the urethral sphincter is not enough to maintain continence and ensure control of the urinary function, the approach of the reconstruction of the bladder neck arose, aiming to improve the recovery of urinary continence.21 Several technical variations have been proposed for the reconstruction of the bladder neck. One of these was published in 2002 and proposes reinforcing sutures to prevent the bladder neck from opening during bladder ˇlling.21 A comparative study (2005) was carried out on 272 patients, obtaining improved urinary incontinence at 3 months with the use of the technique. After these results, it was postulated that the bladder neck reconstruction allows for a better ˇxation to the urethra while reducing sphincter pressure during bladder ˇlling. The latter could especially be beneˇcial toward improved sphincter functions. However, these analyses do not evaluate early continence (<3 months).21 Posterior reconstruction In 2001, Rocco et al. described a technique for reconstructing the posterior aspect of the rhabdosphincter, based on previous anatomical studies. They postulated that the posterior aspect of the prostate with Denonvilliers' fascia, as well as the median raphe with the dorsal part of the rhabdosphincter, constitute an important supporting structure.22 The results of the application of posterior reconstruction in open RP23 and laparoscopic RP24 were published in 2006 and 2007, respectively. Later, Coelho et al. described the technique applied to robotic RP and published their results in 2008.25 The most recent meta-analysis, published by Grasso et al. in 2016, includes 21 studies, with 3 randomized clinical trials. The authors conclude that posterior reconstruction improves early urinary continence assessed 3---7 days after removal of the bladder catheter (RR 1.9, 95% CI 1.25---2.9), at 30 days (RR 1.77, 95% CI 1.43---2.20) and at 90 days (RR 1.32, 95% CI 1.10---1.59).26 Numerous variations of the classical posterior reconstruction technique have been described. In 2015, Jeong et al. proposed the posterior reconstruction with the posterior part of the detrusor, which is muscle tissue (unlike Denonvilliers' fascia, which is connective tissue) and can provide stronger sutures. They carried out a prospective, randomized study in robotic RP performing classical posterior reconstruction to the control group and the technique described by them in the intervention group. The only differences observed were regarding social urinary continence, deˇned as the use of 0---1 safety pads.27
Author, year
No. of patients (with RP type PR/without PR)
Study type
Reconstruction Continence type deˇnition
TContinence rates (%) Time after BC Continence removal (days) with PR (%)
Rocco et al., 200623
Rocco et al., 200724
Tewari et al., 200828
Menon et al., 20081
Nguyen et al., 200840
Open
Retrospective
Posterior
0---1 pad
3---7 30 90 1 year
72 78.8 86.3 96
14 30 46 90
<0.001 <0.001 <0.001 0.132
62.4 74 85.2 94
14 30 46 90
<0.001 <0.001 <0.001 0.301
300 (250/50)
Open
Retrospective
Posterior
0---1 pad
3---7 30 90 1 year
62 (31/31)
Laparoscopic
Prospective
Posterior
0---1 pad
3---7 30 90
74.2 83.8 92.3
25 32.3 76.7
<0.001 <0.001 0.25
Retrospective
Anterior and posterior
0---1 pad
3---7 30 90 180
38.4 82.6 91.3 97.1
13.5 35.2 50.2 62
<0.001 <0.001 <0.001 <0.001
RCT
0---1 pad Pad test ≤30 g/d
1 2 7 30
34 46 54 80
26 49 51 74
>0.1
Anterior and posterior
0---1 pad
3---7 30
34 56
3 17
0.007 0.006
28.7 51.6 91.1 97
22.7 42.7 91.8 96.3
0.045 0.016 0.908 0.741
396 (182/214)
116 (59/57)
62 (32/30)
Robotic
Robotic
Laparoscopic and robotic
Retrospective
Posterior
>0.1
Coelho et al., 201125
803 (473/330)
Robotic
Prospective
Posterior
0 pad
3---7 30 90 180
Sutherland et al., 201130
94 (47/47)
Robotic
RCT
Posterior
0---1 pad
90
63
81
0.1
Hurtes et al., 201229
72 (39/33)
Robotic
RCT
Anterior and posterior
0 pad
30 90 180
26.5 45.2 65.4
7.1 15.4 57.9
0.047 0.016 0.609
RCT: randomized clinical trial; RP: radical prostatectomy; PR: posterior reconstruction; BC: bladder catheter.
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211 (161/20)
Continence P value without PR (%)
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Studies and results analyzing posterior and anteroposterior reconstruction.
Early continence after radical prostatectomy
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8 Anterior and posterior reconstruction Tewari et al. propose reconstruction of the anterior and posterior structures of the bladder neck to provide a stable urethrovesical anastomosis. The technique involves the preservation of the puboprostatic ligaments and the tendon arch, with posterior reconstruction of the Denonvilliers' fascia. They obtained better continence rates in the group of patients treated with this technique. The main drawback of this study is that it is not randomized.28 The posterior and anteroposterior reconstruction are the techniques with most scientiˇc evidence available. The trials of Hurtes et al. and Menon et al. are the only ones with comparable outcomes at 1 month after the removal of the catheter, performing the same type of reconstruction, and with the same criteria and deˇnition for continence (0 pads). Hurtes et al. demonstrated statistically signiˇcant improved continence rates with this technique. However, Menon et al. they did not observe differences between both groups.1,29 Sutherland et al. did not evidence signiˇcant improvement regarding urinary continence (Table 2), but their assessment intervals were different.30 Anterior suspension In 2009, Patel et al. describe the anterior suspension technique, which consists in the placement of a puboperiurethral stitch after the ligation of the dorsal venous complex and then through the periostium on the pubic bone. They only observed improvement in urinary continence (92.5 vs.83%) at 3 months in a non-randomized study.31 Reconstruction of the posterior urethral support Given the good functional results obtained with the use of the AdVance® sling in urinary incontinence secondary to RP, dal Moro et al. uses ˇbers of the bilateral portions of the puborectalis muscle to create a posterior hammock for the urethra. They carried out a comparative study and obtained immediate urinary continence of 50 and at 30 days of 83% in the intervention group and 16 and 61%, respectively, in the control group, treated with classical posterior reconstruction posterior.32
Reinforcement techniques The objective of these techniques is to reinforce the continence mechanism. The suburethral sling is the only one which has been described. Suburethral sling The suburethral sling has been used for the treatment of female stress urinary incontinence and is based on supporting the membranous urethra. Many technical variations have been proposed with different meshes and materials; however, there is no quality scientiˇc evidence regarding their use. Kojima et al. proposed the creation of an autologous vas deferens suburethral sling and observed better urinary continence outcomes with objective measurement with the pad-test33 Nguyen et al. carried out the only randomized study, which did not show beneˇts from the use of an autologous sling in the recovery of continence at 6 months.34
A. Salazar et al.
Discussion Nowadays, functional results, in addition to oncological outcomes, are becoming increasingly important after certain surgical interventions. Regarding urinary continence, in-depth anatomical studies on the structures involved in its mechanism have been carried out. However, the exact functioning of each of these structures is not known, especially concerning anatomical alterations, as happens after RP. Male urinary continence is based on the sphincter complex and the urethral support mechanism reconstruction.33 There have been multiple studies conducted, aiming to analyze the pathophysiological mechanisms of urinary incontinence development after PR.35 It is currently considered to have a multifactorial etiology that includes anatomical and functional alterations, and the surgeon's experience and the technique employed are also relevant factors.4 The introduction of robotic surgery has provided greater precision and accuracy, relevant features when aiming to minimize perioperative complications and preserving key anatomical structures related to urinary continence and sexual potency.4 The main limitation of this review is that there is no clear deˇnition, nor an objective, standardized measurement of urinary continence. For this reason, there is great variability in the publications, regarding the surgical technique and the methods for evaluating urinary continence. There are few randomized clinical trials that provide quality clinical evidence and allow establishing recommendations on the surgical practice. Furthermore, few studies carry out a quantitative analysis of urinary leakage, a factor that would provide objective data and add scientiˇc quality to these studies, as well as enabling joint analysis and comparison. Multiple variations have been developed in the surgical technique of RP, with the purpose to achieve a rapid recovery of urinary continence through the preservation and/or maintenance of pelvic structures. These include the posterior reconstruction of the rhabdosphincter, the preservation of the bladder neck, puboprostatic ligaments and neurovascular bundles, as these are the most accepted techniques with more scientiˇc evidence available. The posterior reconstruction of the rhabdosphincter is the technical variation with a greater number of randomized clinical trials. Despite this, the most effective technique for the recovery of early urinary continence has not yet been described, perhaps because it is multifactorial. The combination of several techniques may lead to improved results.36 In spite of the limitations and difˇculties, it is necessary to improve the evaluation of urinary continence after PR and to advise patients correctly, adapting their expectations to the results of each center. Models based on pre-surgical tests are currently being developed with the objective to predict and individualize functional results after RP.17
Conclusions There are numerous technical variations of RP aimed at early recovery of urinary continence. However, there is no consensus on its deˇnition and assessment methodology, which conditions the evaluation of the scientiˇc evidence about it. We found a wide variability when evaluating the surgical variations that have been developed. The reconstruction of the rhabdosphincter is the only technique that appears to improve early urinary continence. The current scientiˇc evidence is limited and heterogeneous, so new well-designed studies with in-depth, uniform criteria are needed to standardize the most appropriate surgical technique.
Conflicts of interest The authors declare that they have no con˚icts of interest.
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References 1. Menon M, Muhletaler F, Campos M, Peabody JO. 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---23, http://dx.doi. org/10.1016/j.juro.2008.05.046. 2. Mottet N, Bellmunt J, Briers E, Bolla M, Bourke L, Cornford P, et al. Members of the EAU --- ESTRO --- ESUR ---SIOG Prostate Cancer Guidelines Panel. EAU --- ESTRO --- ESUR --- SIOG Guidelines on Prostate Cancer. Edn. presented at the EAU Annual Congress Copenhagen 2018. 978-94-9267102-8. Publisher: EAU Guidelines Ofˇce. Available from: https://uroweb.org/guideline/prostate-cancer/ [accessed 15.10.18]. 3. Porpiglia F, Bertolo R, Manfredi M, de Luca S, Checcucci E, Morra I, et al. Total anatomical reconstruction during robot-assisted radical prostatectomy: Implications on early recovery of urinary continence. Eur Urol. 2016;69:485---95, http://dx.doi.org/10. 1016/j.eururo.2015.08.005. 4. Ficarra V, Novara G, Rosen RC, Artibani W, Carroll PR, Costello A, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012;62:405---17, http://dx.doi. org/10.1016/j.eururo.2012.05.045. 5. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349:1---25, http://dx.doi.org/10. 1136/bmj.i4086. 6. Linares-Espinós E, Hernández V, Domínguez-Escrig JL, Fernández-Pello S, Hevia V, Mayor J, et al. Methodology of a systematic review. Actas Urol Esp. 2018;42:499---506, http://dx.doi.org/10.1016/j.acuro.2018.01.010. 7. Sridhar AN, Abozaid M, Rajan P, Sooriakumaran P, Shaw G, Nathan S, et al. Surgical techniques to optimize early urinary continence recovery post robot assisted radical prostatectomy for prostate cancer. Curr Urol Rep. 2017;18:71, http://dx.doi.org/10.1007/s11934-017-0717-4. 8. Nyarangi-Dix JN, Radtke JP, Hadaschik B, Pahernik S, Hohenfellner M. Impact of complete bladder neck preservation on urinary continence, quality of life and surgical margins after radical prostatectomy: a randomized, controlled, single blind trial. J Urol. 2013;189:891---8, http://dx.doi.org/10. 1016/j.juro.2012.09.082. 9. Ma X, Tang K, Yang C, Wu G, Xu N, Wang M, et al. Bladder neck preservation improves time to continence after radical prostatectomy: a systematic review and meta-analysis. Oncotarget [Internet]. 2016;7:67463---75, http://dx.doi.org/10. 18632/oncotarget.11997. 10. Reeves F, Preece P, Kapoor J, Everaerts W, Murphy DG, Corcoran NM, et al. Preservation of the neurovascular bundles is associated with improved time to continence after radical prostatectomy but not long-term continence rates: Results of a systematic review and meta-analysis. Eur Urol. 2015;68:692---704, http://dx.doi.org/10.1016/j.eururo.2014.10.020. 11. Michl U, Tennstedt P, Feldmeier L, Mandel P, Oh SJ, Ahyai S, et al. Nerve-sparing surgery technique, not the preservation of the neurovascular bundles, leads to improved long-term continence rates after radical prostatectomy. Eur Urol. 2016;69:584---9, http://dx.doi.org/10. 1016/j.eururo.2015.07.037. 12. Tewari AK, Srivastava A, Mudaliar K, Tan GY, Grover S, el Douaihy Y, et al. Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity dur-
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ing robotic radical prostatectomy. BJU Int. 2010;106:1364---73, http://dx.doi.org/10.1111/j.1464-410X. 2010.09318.x. Stolzenburg J-U, Liatsikos EN, Rabenalt R, Do M, Sakelaropoulos G, Horn LC, et al. Nerve sparing endoscopic extraperitoneal radical prostatectomy --- effect of puboprostatic ligament preservation on early continence and positive margins. Eur Urol. 2006;49:103---12, http://dx.doi.org/10. 1016/j.eururo.2005.10.002. Deliveliotis C, Protogerou V, Alargof E, Varkarakis J. Radical prostatectomy: bladder neck preservation and puboprostatic ligament sparing --- effects on continence and positive margins. Urology. 2002;60:855---8, http://dx.doi.org/10. 1016/S0090-4295(02)01956-8. Nakashima O, Matsuoka KEI. Suspension technique improves rapid continence following radical prostatectomy recovery retropubic of urinary. Kurume Med J. 2004;51:245---51, http://dx.doi.org/10.2739/kurumemedj.51.245. Mungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI. Preoperative membranous urethral length measurement and continence recovery following radical prostatectomy: a systematic review and meta-analysis. Eur Urol. 2017;71:368---78, http://dx.doi.org/10.1016/j.eururo.2016.06.023. Regis L, Salazar A, Cuadras M, Miret E, Roche S, Celma A, et al. Preoperative magnetic resonance imaging in predicting early continence recovery after robotic radical prostatectomy. Actas Urol Esp. 2019;43:137---42, http://dx.doi.org/10. 1016/j.acuro.2018.07.003. John H, Hauri D. Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence. Urology. 2000;55:820---4, http://dx.doi.org/10. 1016/S0090-4295(00)00547-1. Galfano A, di Trapani D, Sozzi F, Strada E, Petralia G, Bramerio M, et al. Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the ˇrst 200 patients with ≥1 year of follow-up. Eur Urol. 2013;64:974---80, http://dx.doi.org/10.1016/j.eururo.2013.06.046. Asimakopoulos AD, Topazio L, de Angelis M, Finazzi E, Antonio A, Pastore L, et al. Retzius-sparing versus standard robotassisted radical prostatectomy: a prospective randomized comparison on immediate continence rates. Surg Endosc. 2018, http://dx.doi.org/10.1007/s00464-018-6499-z. Walsh PC. Intussusception of the reconstructed bladder. Urology. 2002;59:934---8, http://dx.doi.org/10.1016/ S0090-4295(02)01596-0. Rocco F, Gadda F, Acquati P, Carmignani L, Favini P, Dell'Orto P, et al. Personal research: reconstruction of the urethral striated sphincter. Arch Ital Urol Androl. 2001;73:127---37. Rocco F, Carmignani L, Acquati P, Gadda F, Dell'Orto P, Rocco B, et al. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol. 2006;175:2201---6, http://dx.doi.org/10. 1016/S0022-5347(06)00262-X. Rocco B, Gregori A, Stener S, Santoro L, Bozzola A, Galli 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, http://dx.doi.org/10.1016/j.eururo.2006.10.014. Coelho RF, Chauhan S, Orvieto MA, Sivaraman A, Palmer KJ, Coughlin G, et al. In˚uence of modiˇed posterior reconstruction of the rhabdosphincter on early recovery of continence and anastomotic leakage rates after robot-assisted radical prostatectomy. Eur Urol. 2011;59:72---80, http://dx.doi.org/10. 1016/j.eururo.2010.08.025. Grasso AAC, Mistretta FA, Sandri M, Cozzi G, de Lorenzis E, Rosso M, et al. Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a
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A. Salazar et al. meta-analysis. BJU Int. 2016;118:20---34, http://dx.doi.org/10. 1111/bju.13480. Jeong CW, Oh JJ, Jeong SJ, Hong SK, Byun SS, Choe G, et al. Novel posterior reconstruction technique during robot-assisted laparoscopic prostatectomy: description and comparative outcomes. Int J Urol. 2012;19:683---7, http://dx.doi.org/10. 1111/j.1442-2042.2012.02988.x. Tewari A, Jhaveri J, Rao S, Yadav R, Bartsch G, Te A, et al. Total reconstruction of the vesico-urethral junction. BJU Int. 2008;101:871---7, http://dx.doi.org/10.1111/j. 1464-410X. 2008.07424.x. Hurtes X, Rouprêt M, Vaessen C, Pereira H, Faivre D'Arcier B, Cormier L, et al. Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial. BJU Int. 2012;110:875---83, http://dx.doi.org/10.1111/j.1464-410X. 2011.10849.x. Sutherland DE, Linder B, Guzman AM, Hong M, Frazier HA, Engel JD, et al. Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: results from a phase II randomized clinical trial. J Urol. 2011;185:1262---7, http://dx.doi.org/10.1016/j.juro.2010.11.085. Patel VR, Coelho RF, Palmer KJ, Rocco B. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol. 2009;56:472---8, http://dx.doi.org/10.1016/j. eururo.2009.06.007. Dal Moro F, Crestani A, Valotto C, Zattoni F. CORPUS --novel COmplete Reconstruction of the Posterior Urethral Support after robotic radical prostatectomy: preliminary data of very early continence recovery. Urology. 2014;83:641---7, http://dx.doi.org/10.1016/j.urology.2013.12.010. Kojima Y, Hamakawa T, Kubota Y, Ogawa S, Haga N, Tozawa K, et al. Bladder neck sling suspension during robot-assisted radical prostatectomy to improve early return of urinary
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continence: a comparative analysis. Urology. 2014;83:632---9, http://dx.doi.org/10.1016/j.urology.2013.09.059. Nguyen HG, Punnen S, Cowan JE, Leapman M, Cary C, Welty C, et al. A randomized study of intraoperative autologous retropubic urethral sling on urinary control after robotic assisted radical prostatectomy. J Urol. 2017;197:369---75, http://dx.doi.org/10.1016/j.juro.2016.08.122. Heesakkers J, Farag F, Bauer RM, Sandhu J, De Ridder D, Stenzl A. Pathophysiology and contributing factors in postprostatectomy incontinence: a review. Eur Urol. 2017;71:936---44, http://dx.doi.org/10.1016/j.eururo.2016.09.031. Yanagida T. Current techniques to improve outcomes for early return of urinary continence following robot-assisted radical prostatectomy. Fukushima J Med Sci. 2014;60:1---13, http://dx.doi.org/10.5387/fms.2013-25. Freire MP, Weinberg AC, Lei Y, Soukup JR, Lipsitz SR, Prasad SM, et al. Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol. 2009;56:972---80, http://dx.doi.org/10.1016/j.eururo.2009.09.017. Stolzenburg JU, Kallidonis P, Hicks J, Do M, Dietel A, Sakellaropoulos G, et al. Effect of bladder neck preservation during endoscopic extraperitoneal radical prostatectomy on urinary continence. Urol Int. 2010;85:135---8, http://dx.doi. org/10.1159/000314842. Rocco F, Carmignani L, Acquati P, Gadda F, Dell'Orto P, Rocco B, et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007;52:376---83, http://dx.doi. org/10.1016/j.eururo.2007.01.109. Nguyen MM, Kamoi K, Stein RJ, Aron M, Hafron JM, Turna B, et al. Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int. 2008;101:1135---9, http://dx.doi.org/10. 1111/j.1464-410X. 2007.07425.x.
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Actas Urol Esp. 2019;xxx(xx):xxx---xxx
Actas Urol´ ogicas Espa˜ nolas www.elsevier.es/actasuro
REVIEW ARTICLE
Early continence after radical prostatectomy: A systematic review夽 A. Salazar ∗ , L. Regis, J. Planas, A. Celma, F. Díaz, I. Gallardo, E. Trilla, J. Morote Servicio de Urología, Hospital Universitari Vall d’Hebron; Universistat Autònoma de Barcelona, Barcelona, Spain Received 28 February 2019; accepted 23 June 2019
KEYWORDS Radical prostatectomy; Urinary incontinence; Prostate cancer
Abstract Background and objective: Urinary incontinence is the adverse effect with more impact on patients' quality of life after undergoing radical prostatectomy. The objective of this study is to review the present evidence that describes the variations on surgical techniques which aim to preserve urinary continence after radical prostatectomy. Evidence acquisition: We searched the literature on PubMed, Cochrane, and ScienceDirect according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement, using the PICO review protocol. The search terms were urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot-assisted laparoscopic prostatectomy, robotic prostatectomy. We identiˇed 1603 registers, and 27 articles were reviewed for meeting the inclusion criteria. Six of them are randomized clinical trials and 4 of them, meta-analysis. Evidence synthesis: The surgical techniques more frequently used to achieve early urinary continence are bladder neck and neurovascular bundles preservation, as well as the reconstruction of the rhabdosphincter. The latter has been presented in three randomized clinical trials. Even though some approaches have obtained improved functional outcomes, the lack of consensus on the deˇnition of urinary incontinence and its measurement methods have not advocated for the creation of technical recommendations based on scientiˇc evidence. Conclusions: The reconstruction of the rhabdosphincter is the only technique that has shown improved functional results through randomized trials. The current evidence is limited and heterogenous, and more studies with consistent criteria are needed in order to establish a standard surgical technique. © 2019 AEU. Published by Elsevier Espa~ na, S.L.U. All rights reserved.
夽 Please cite this article as: Salazar A, Regis L, Planas J, Celma A, Díaz F, Gallardo I, et al. Variaciones de la prostatectomía radical para una recuperación de la continencia urinaria precoz: una revisión sistemática. Actas Urol Esp. 2019. https://doi.org/10.1016/j.acuro.2019.06.003 ∗ Corresponding author. E-mail address: [email protected] (A. Salazar).
2173-5786/© 2019 AEU. Published by Elsevier Espa~ na, S.L.U. All rights reserved.
ACUROE-1190; No. of Pages 10
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PALABRAS CLAVE Prostatectomía radical; Incontinencia urinaria; Cáncer de próstata
Variaciones de la prostatectomía radical para una recuperación de la continencia urinaria precoz: una revisión sistemática Resumen Contexto y objetivo: La incontinencia urinaria es el efecto secundario con mayor impacto en la calidad de vida después de la prostatectomía radical. El objetivo de nuestro artículo es revisar la evidencia cientíˇca actual sobre las variaciones quirúrgicas descritas para preservar la continencia urinaria después de la prostatectomía radical. Adquisición de la evidencia: Se realizó una revisión sistemática de la literatura en PubMed, Cochrane y ScienceDirect según los criterios PRISMA (Preferred reporting items for systematic reviews and meta-analyses), utilizando los términos: urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot assisted laparoscopic prostatectomy, robotic prostatectomy y los criterios de selección PICO. Se identiˇcaron 1.603 referencias de las que se seleccionaron 27 publicaciones que cumplieron los criterios de inclusión, 6 fueron ensayos clínicos aleatorizados y 4 metaanálisis. Síntesis de la evidencia: Las técnicas más empleadas para alcanzar una continencia urinaria precoz son la preservación del cuello vesical, de las bandeletas neurovasculares y la reconstrucción del rabdoesfínter, siendo esta la técnica con mayor evidencia, ya que existen 3 ensayos clínicos aleatorizados. Pese que algunas variaciones técnicas han conseguido mejorías en los resultados funcionales, la ausencia de consenso en la deˇnición de incontinencia urinaria y la manera de evaluarla no permiten elaborar recomendaciones técnicas basadas en evidencia cientíˇca de calidad. Conclusiones: La reconstrucción del rabdoesfínter es la única técnica que ha demostrado mejoría en la recuperación precoz de la continencia urinaria tras la prostatectomía radical. La evidencia cientíˇca actual es heterogénea y limitada, por lo que son necesarios estudios aleatorizados bien dise~ nados para evaluar las modiˇcaciones técnicas. © 2019 AEU. Publicado por Elsevier Espa~ na, S.L.U. Todos los derechos reservados.
Introduction
Evidence acquisition
Radical prostatectomy (RP) is the treatment of choice for localized and locally advanced prostate cancer in cases with no contraindications to surgery with life expectancy greater than 10 years.1,2 Since urinary incontinence is the side effect with the greatest impact on the patients' quality of life, extensive research on the pathophysiological mechanisms related to its appearance has been carried out.2 The introduction of laparoscopy in the 1990s improved the postoperative evolution of patients undergoing RP. However, the development of robotic RP has been essential to provide better functional results after this intervention. Due to an improved visualization of the anatomical structures and the expanded movement range, certain technical variations can be achieved.3,4 Although the exact pathophysiological mechanism involved in the development of urinary incontinence after PR remains unknown, we do know that anatomical and functional changes after prostate removal are related to alterations in the bladder-sphincter complex and pelvic ˚oor structures.3 The preservation of the bladder neck and neurovascular bundles, or the posterior reconstruction of the rhabdosphincter are technical variations which have been described aiming to achieve higher urinary continence rates in shorter post-surgical time.3 The objective of our review has been to analyze the current scientiˇc evidence on the surgical techniques described to preserve or improve urinary continence after RP.
Two authors (AS and LR) conducted a literature search in PubMed, Cochrane and ScienceDirect on July 18, 2018 and have carried out a systematic review following the PRISMA (Preferred reporting items for systematic reviews and meta-analyses)5 statement. The Medical Subject Headings search terms were urinary continence, urinary incontinence, urinary leakage, radical prostatectomy, open radical prostatectomy, laparoscopic prostatectomy, robot assisted laparoscopic prostatectomy, robotic prostatectomy. According to the PICO (Participants, Interventions, Comparisons and Outcomes) selection strategy, the authors included articles published in English or Spanish, clinical trials of human adults and having been submitted to RP for the treatment of histologically proven prostate cancer, with analysis on the surgical technique variations in search for early urinary continence. Initially, 1603 records met the established criteria and were identiˇed. 103 original, comparative, prospective or retrospective articles, clinical trials and meta-analyses were evaluated, and 27 were ˇnally selected for this review for meeting the search speciˇc criterion. The ˚ow chart of this selection is shown in Fig. 1. A quality analysis was also performed to reduce the risk of bias.6 Fig. 2 synthesizes the risk of bias of the selected original articles.
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Articles identified through search on Pubmed, Cochrane and ScienceDirect Urinary continence, urinary incontinence, urinary leakage, radical prostatectomy,open radical prostatectomy, laparoscopic prostatectomy, robot assisted laparoscopic prostatectomy, robotic prostatectomy 1.603 records obtained
SCREENING
1.318 duplicates or not relevant articles excluded 285 abstracts screened
ELEGIBILITY
182 abstracts excluded (no confirmation of technique to maintain continence)
103 full-text articles assessed
INCLUDED
75 articles excluded for not meeting inclusion criteria
27 articles included in the review
Figure 1
Flowchart of the systematic review according to the PRISMA criteria.
Evidence synthesis The variations of the surgical technique aimed to preserve urinary continence in PR can be classiˇed in several ways. We have divided them into: I. Continence preserving techniques, II. Continence mechanism reconstruction techniques and III. Continence reinforcement techniques.7 There are tables that synthesize the evidence about the most commonly used techniques.
Continence preservation techniques These are surgical techniques aimed at preserving the mechanism of continence. These include bladder neck and neurovascular bundle preservation, apical dissection, puboprostatic ligament preservation, preservation of the membranous urethral length, seminal vesicle and Retzius (space) sparing. Bladder neck preservation The preservation of the bladder neck for the improvement of urinary continence outcomes after RP was proposed after anatomical studies in traumatic patients which demonstrated the importance of the bladder neck in the absence of rhabdosphincter.8 Careful dissection of the prostatebladder junction can maintain most of the circular muscle ˇbers of the BN, accelerating the return of urinary continence. In 2013, Nyarangi-Dix et al. published the ˇrst prospective, randomized study on the impact of bladder neck preservation on urinary incontinence after RP. Their results show improved urinary continence rates with a recovery of continence after catheter removal at 3, 6, and 12-month of 7.4 vs. 0%; 87.4 vs. 60.6%; 88.4 vs.
68% and 91.6 vs. 79.4% for patients in the bladder neck preservation group vs. the bladder neck sparing group, respectively. In addition to evaluating continence with questionnaires, the study also carried out 24 h pad-tests, thus providing objective and precise information regarding the degree of urinary incontinence and a consistent methodology.8 Recently, Ma et al. published a meta-analysis of this technical approach, including 13 articles, 2 randomized clinical trials, conducted in open, laparoscopic or robotic RP, ˇnding bladder neck preservation beneˇcial in the early (<6 m) and long-term (>12 m) recovery of urinary continence. The bladder neck preservation group had better outcomes for urinary continence after bladder catheter removal (OR 3.24, 95% CI 1.61---6.52), at one (OR 2.45, 95% CI 1.32---4.55), three (OR 2.04, 95% CI 1.39---3), six (OR 1.72, 95% CI 1.25---2.37) and 12 (OR 1.46, 95% CI 1.06---2.02) months. However, this metaanalysis includes studies with diverse deˇnitions of urinary continence and only two comparative randomized studies. Therefore, it is not possible to establish clear evidence that supports the recommendation of this technique in the surgical practice.9 Table 1 shows the results of the evaluated studies.
Preservation of the neurovascular bundles The ˇrst studies that postulated the importance of pelvic nerve preservation in urinary incontinence secondary to PR were published at the end of the 1980s. Reeves et al. observed in their meta-analysis, that the preservation of neurovascular bundles favors an improvement in early urinary continence rates, but not in the long term.10 The authors of this meta-analysis deˇned 6 months after surgery as the limit of early continence. 27 studies were included,
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Figure 2 Summary of the risk of bias in the included studies. Green dot (+): low risk of bias. Yellow dot (?): unclear risk bias. Red dot (−): high risk of bias.
12 of them were prospective, non-randomized. Patients with preservation of the neurovascular bundles had better results of urinary continence at 6 weeks (RR 1.48; 95% CI 1.34---1.63), 3---4 months (RR 1.24; 95% CI 1.09---1.42) and 6 months (RR 1.20; 95% CI 1.04---1.39). No statistically signiˇcant differences were observed regarding late urinary continence (12 and 24 months). The study also included a subgroup analysis regarding the type of preservation performed: unilateral or bilateral. Bilateral preservation showed different urinary continence rates in comparison to unilateral preservation at 6 weeks (RR 1.21; 95% CI 1.02---1.42) only.10 However, Michl et al. published a retrospective study in 2016, comparing 3 groups: Patients with bilateral NS RP, with primary NNS RP, and with bilateral secondary resection of the NVBs for positive frozen-section results. Their outcomes showed differences in short- and longterm urinary continence ˇgures, both in the primary preservation group and in the secondary preservation group. Following these results, they proposed that the meticulous apical dissection associated with the nerve sparing technique, rather than the preservation of the NVBs itself, is responsible for preserving the innervation of the urinary sphincter.11
Apical dissection Due to its deep location in the pelvis and its close contact with the rectum, the urethral sphincter, vessels and nerves, the apex is the most difˇcult area of the prostate to approach. The prostate meets the sphincter complex and the urethra at the apical level, so the transition between prostate tissue and the sphincter muscle is imperceptible. This is why meticulous tissue dissection at this level is essential for early recovery of urinary continence.12 When identifying the point where the prostate and sphincter join, the surgeon must keep in mind the anatomical variability of the apex, the horseshoe-shaped external sphincter and the proximity of the deep venous complex.12 As previously mentioned, Michl et al. concluded that meticulous dissection favors urinary continence by preserving sphincter innervation, after carrying out a comparative study evaluating the preservation of neurovascular bundles.11 Despite this, there are no comparative studies available that demonstrate improvement in continence rates. Preservation of puboprostatic ligaments It has been proposed that the role of the puboprostatic ligaments in the preservation of urinary continence resides in the ˇxation or suspension of the membranous urethra.
Author, year
No. of patients (with/without BNP)
RP type
Study type
Deˇnition of continence
Continence rates (%)
Deliveliotis et al., 200214
101 (48/51)
Open
Prospective
Freire et al., 200937
619 (348/271)
Robotic
Prospective
Nyarangi-Dix et al. 20138
Stolzenburg et al., 201038
199 (95/104)
240 (150/90)
Open and robotic
Laparoscopic
RCT
Retrospective
Continence with BNP (%)
Continence without BNP (%)
P value
No pad.
3 6 9 12
69 79 88 92
45 61 82 92
0.016 0.039 0.457 0.927
No pad.
4 12 24
65.6 86.4 100
26.5 81.4 96.1
<0.001 0.303 0.308
0---1 pad
0 days 3 6 12
7.4 87.4 88.4 91.6
1 60.6 68 79.4
<0.001 <0.001 0.004 0.035
0---1 pad
Day 1 3 6 12
19.5 73.3 86.5 93.5
9.4 61.3 80.6 91.5
0.038 0.045 0.416 0.92
RCT: randomized clinical trial; BNP: bladder neck preservation; RP: radical prostatectomy; BC: bladder catheter.
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Studies and results analyzing bladder neck preservation.
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6 Stolzenburg et al. conducted a prospective, randomized study in patients undergoing laparoscopic PR with preservation of neurovascular bundles and observed improved early urinary continence rates (2 weeks and 3 months) in the group of patients treated with puboprostatic ligament preservation. This surgical technique does not affect the entire endopelvic fascia, so the preservation of the periurethral support tissue would provide or facilitate the early recovery of continence.13 A comparative, prospective study in 3 groups had been previously published: preservation of puboprostatic ligaments, preservation of bladder neck and preservation of both. Their results showed earlier recovery of urinary continence (3 and 6 months) in groups with bladder neck preservation, with no long-term differences (9 and 12 months).14 The membranous urethra is anteriorly ˇxed to the posterior part of the pubis with a suspension mechanism that includes the puboprostatic ligaments.15 Following this approach, Nakashima et al. proposed the suspension of the vesicourethral anastomosis by suturing to the puboprostatic ligaments. They initially conducted a retrospective control study in 2004 and published a randomized prospective study in 2008. It obtained better urinary continence rates at one and three months in patients who underwent suspension of uretrovesical anastomosis with puboprostatic ligaments with respect to the control group.15 Preservation of the membranous urethral length Several preoperative MRI studies have been conducted with the aim of predicting functional outcomes after RP. The length of the membranous urethra is one of the most widely evaluated parameters. A meta-analysis published in 2016 showed higher urinary continence rates at 3, 6 and 12 months in patients with longer membranous urethra.16 Other studies have analyzed the angle of the membranous urethra and its impact on early continence recovery.17 However, several authors postulate that the beneˇts obtained from longer MUL could be a re˚ection of a better apical dissection.11 Therefore, the advantages attributed to the length of the membranous urethra may be due to a confounding factor. Seminal vesicle preservation The motor and sensory components of the pelvic nerve have a close anatomical relationship with the seminal vesicles. Although it is an incomplete technique, the preservation of the seminal vesicles avoids nerve damage at that level and provides improved functional outcomes. There are few comparative studies with small patient cohorts. John and Hauri obtained urinary continence rates of 60 and 95% at 6 weeks and 6 months, respectively, in the seminal vesicle preservation group, evaluated with quantitative measurements through the pad-test.18 Retzius space preservation Galfano et al. described the preservation of all anteriorly located structures, a variation that allows avoidance of the Retzius space structures involved in continence preservation.19 A randomized clinical trial of 102 patients has recently been published, obtaining continence rates of 51% in the group treated with this technique vs. 21% in the control group after removal of the urinary catheter. These
A. Salazar et al. rates were 81 vs. 47.4%; 90.5 vs. 60% and 90.5 vs. 64.1% at 1, 3 and 6 months, respectively.20
Reconstruction techniques These techniques are performed with the objective to reconstruct the supportive structures involved in the continence mechanism. Among them we ˇnd i. bladder neck reconstruction; ii. posterior reconstruction; iii anterior and posterior reconstruction; iv. anterior suspension; v. reconstruction of posterior urethral support. Bladder neck reconstruction As the preservation of the urethral sphincter is not enough to maintain continence and ensure control of the urinary function, the approach of the reconstruction of the bladder neck arose, aiming to improve the recovery of urinary continence.21 Several technical variations have been proposed for the reconstruction of the bladder neck. One of these was published in 2002 and proposes reinforcing sutures to prevent the bladder neck from opening during bladder ˇlling.21 A comparative study (2005) was carried out on 272 patients, obtaining improved urinary incontinence at 3 months with the use of the technique. After these results, it was postulated that the bladder neck reconstruction allows for a better ˇxation to the urethra while reducing sphincter pressure during bladder ˇlling. The latter could especially be beneˇcial toward improved sphincter functions. However, these analyses do not evaluate early continence (<3 months).21 Posterior reconstruction In 2001, Rocco et al. described a technique for reconstructing the posterior aspect of the rhabdosphincter, based on previous anatomical studies. They postulated that the posterior aspect of the prostate with Denonvilliers' fascia, as well as the median raphe with the dorsal part of the rhabdosphincter, constitute an important supporting structure.22 The results of the application of posterior reconstruction in open RP23 and laparoscopic RP24 were published in 2006 and 2007, respectively. Later, Coelho et al. described the technique applied to robotic RP and published their results in 2008.25 The most recent meta-analysis, published by Grasso et al. in 2016, includes 21 studies, with 3 randomized clinical trials. The authors conclude that posterior reconstruction improves early urinary continence assessed 3---7 days after removal of the bladder catheter (RR 1.9, 95% CI 1.25---2.9), at 30 days (RR 1.77, 95% CI 1.43---2.20) and at 90 days (RR 1.32, 95% CI 1.10---1.59).26 Numerous variations of the classical posterior reconstruction technique have been described. In 2015, Jeong et al. proposed the posterior reconstruction with the posterior part of the detrusor, which is muscle tissue (unlike Denonvilliers' fascia, which is connective tissue) and can provide stronger sutures. They carried out a prospective, randomized study in robotic RP performing classical posterior reconstruction to the control group and the technique described by them in the intervention group. The only differences observed were regarding social urinary continence, deˇned as the use of 0---1 safety pads.27
Author, year
No. of patients (with RP type PR/without PR)
Study type
Reconstruction Continence type deˇnition
TContinence rates (%) Time after BC Continence removal (days) with PR (%)
Rocco et al., 200623
Rocco et al., 200724
Tewari et al., 200828
Menon et al., 20081
Nguyen et al., 200840
Open
Retrospective
Posterior
0---1 pad
3---7 30 90 1 year
72 78.8 86.3 96
14 30 46 90
<0.001 <0.001 <0.001 0.132
62.4 74 85.2 94
14 30 46 90
<0.001 <0.001 <0.001 0.301
300 (250/50)
Open
Retrospective
Posterior
0---1 pad
3---7 30 90 1 year
62 (31/31)
Laparoscopic
Prospective
Posterior
0---1 pad
3---7 30 90
74.2 83.8 92.3
25 32.3 76.7
<0.001 <0.001 0.25
Retrospective
Anterior and posterior
0---1 pad
3---7 30 90 180
38.4 82.6 91.3 97.1
13.5 35.2 50.2 62
<0.001 <0.001 <0.001 <0.001
RCT
0---1 pad Pad test ≤30 g/d
1 2 7 30
34 46 54 80
26 49 51 74
>0.1
Anterior and posterior
0---1 pad
3---7 30
34 56
3 17
0.007 0.006
28.7 51.6 91.1 97
22.7 42.7 91.8 96.3
0.045 0.016 0.908 0.741
396 (182/214)
116 (59/57)
62 (32/30)
Robotic
Robotic
Laparoscopic and robotic
Retrospective
Posterior
>0.1
Coelho et al., 201125
803 (473/330)
Robotic
Prospective
Posterior
0 pad
3---7 30 90 180
Sutherland et al., 201130
94 (47/47)
Robotic
RCT
Posterior
0---1 pad
90
63
81
0.1
Hurtes et al., 201229
72 (39/33)
Robotic
RCT
Anterior and posterior
0 pad
30 90 180
26.5 45.2 65.4
7.1 15.4 57.9
0.047 0.016 0.609
RCT: randomized clinical trial; RP: radical prostatectomy; PR: posterior reconstruction; BC: bladder catheter.
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211 (161/20)
Continence P value without PR (%)
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Studies and results analyzing posterior and anteroposterior reconstruction.
Early continence after radical prostatectomy
Table 2
7
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8 Anterior and posterior reconstruction Tewari et al. propose reconstruction of the anterior and posterior structures of the bladder neck to provide a stable urethrovesical anastomosis. The technique involves the preservation of the puboprostatic ligaments and the tendon arch, with posterior reconstruction of the Denonvilliers' fascia. They obtained better continence rates in the group of patients treated with this technique. The main drawback of this study is that it is not randomized.28 The posterior and anteroposterior reconstruction are the techniques with most scientiˇc evidence available. The trials of Hurtes et al. and Menon et al. are the only ones with comparable outcomes at 1 month after the removal of the catheter, performing the same type of reconstruction, and with the same criteria and deˇnition for continence (0 pads). Hurtes et al. demonstrated statistically signiˇcant improved continence rates with this technique. However, Menon et al. they did not observe differences between both groups.1,29 Sutherland et al. did not evidence signiˇcant improvement regarding urinary continence (Table 2), but their assessment intervals were different.30 Anterior suspension In 2009, Patel et al. describe the anterior suspension technique, which consists in the placement of a puboperiurethral stitch after the ligation of the dorsal venous complex and then through the periostium on the pubic bone. They only observed improvement in urinary continence (92.5 vs.83%) at 3 months in a non-randomized study.31 Reconstruction of the posterior urethral support Given the good functional results obtained with the use of the AdVance® sling in urinary incontinence secondary to RP, dal Moro et al. uses ˇbers of the bilateral portions of the puborectalis muscle to create a posterior hammock for the urethra. They carried out a comparative study and obtained immediate urinary continence of 50 and at 30 days of 83% in the intervention group and 16 and 61%, respectively, in the control group, treated with classical posterior reconstruction posterior.32
Reinforcement techniques The objective of these techniques is to reinforce the continence mechanism. The suburethral sling is the only one which has been described. Suburethral sling The suburethral sling has been used for the treatment of female stress urinary incontinence and is based on supporting the membranous urethra. Many technical variations have been proposed with different meshes and materials; however, there is no quality scientiˇc evidence regarding their use. Kojima et al. proposed the creation of an autologous vas deferens suburethral sling and observed better urinary continence outcomes with objective measurement with the pad-test33 Nguyen et al. carried out the only randomized study, which did not show beneˇts from the use of an autologous sling in the recovery of continence at 6 months.34
A. Salazar et al.
Discussion Nowadays, functional results, in addition to oncological outcomes, are becoming increasingly important after certain surgical interventions. Regarding urinary continence, in-depth anatomical studies on the structures involved in its mechanism have been carried out. However, the exact functioning of each of these structures is not known, especially concerning anatomical alterations, as happens after RP. Male urinary continence is based on the sphincter complex and the urethral support mechanism reconstruction.33 There have been multiple studies conducted, aiming to analyze the pathophysiological mechanisms of urinary incontinence development after PR.35 It is currently considered to have a multifactorial etiology that includes anatomical and functional alterations, and the surgeon's experience and the technique employed are also relevant factors.4 The introduction of robotic surgery has provided greater precision and accuracy, relevant features when aiming to minimize perioperative complications and preserving key anatomical structures related to urinary continence and sexual potency.4 The main limitation of this review is that there is no clear deˇnition, nor an objective, standardized measurement of urinary continence. For this reason, there is great variability in the publications, regarding the surgical technique and the methods for evaluating urinary continence. There are few randomized clinical trials that provide quality clinical evidence and allow establishing recommendations on the surgical practice. Furthermore, few studies carry out a quantitative analysis of urinary leakage, a factor that would provide objective data and add scientiˇc quality to these studies, as well as enabling joint analysis and comparison. Multiple variations have been developed in the surgical technique of RP, with the purpose to achieve a rapid recovery of urinary continence through the preservation and/or maintenance of pelvic structures. These include the posterior reconstruction of the rhabdosphincter, the preservation of the bladder neck, puboprostatic ligaments and neurovascular bundles, as these are the most accepted techniques with more scientiˇc evidence available. The posterior reconstruction of the rhabdosphincter is the technical variation with a greater number of randomized clinical trials. Despite this, the most effective technique for the recovery of early urinary continence has not yet been described, perhaps because it is multifactorial. The combination of several techniques may lead to improved results.36 In spite of the limitations and difˇculties, it is necessary to improve the evaluation of urinary continence after PR and to advise patients correctly, adapting their expectations to the results of each center. Models based on pre-surgical tests are currently being developed with the objective to predict and individualize functional results after RP.17
Conclusions There are numerous technical variations of RP aimed at early recovery of urinary continence. However, there is no consensus on its deˇnition and assessment methodology, which conditions the evaluation of the scientiˇc evidence about it. We found a wide variability when evaluating the surgical variations that have been developed. The reconstruction of the rhabdosphincter is the only technique that appears to improve early urinary continence. The current scientiˇc evidence is limited and heterogeneous, so new well-designed studies with in-depth, uniform criteria are needed to standardize the most appropriate surgical technique.
Conflicts of interest The authors declare that they have no con˚icts of interest.
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Early continence after radical prostatectomy
9
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