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Patient-reported Urinary Continence (Third-party Interview): Results of Post-radical Retropubic Prostatectomy in Singaporeans
Original Article
Patient-reported Urinary Continence (Third-party Interview): Results of Post-radical Retropubic Prostatectomy in Singaporeans Jaideepraj Rao, Siew Khim Koay,1 Weber Kam On Lau1 and Christopher Wai Sam Cheng,1 Department of General Surgery, Tan Tock Seng Hospital, and 1Department of Urology, Singapore General Hospital, Singapore.
OBJECTIVE: To determine the patient-reported urinary continence rate after retropubic radical prostatectomy (RRP) for prostate carcinoma through a third-party interview and to grade the severity of incontinence. METHODS: Between 1997 and 1999, 34 patients were evaluated through an independent third party about the degree of continence as well as the quality of life after RRP. Patients were interviewed either in person or over the telephone. Urinary continence was defined as wearing no diapers, pads or tissue paper. RESULTS: Of the 34 patients, 44% achieved immediate continence. Urinary incontinence gradually improved with time after surgery and 82% (n = 28) were fully continent at 12 months. Using the quality-of-life index, 91% of patients characterized their urinary incontinence as not or minimally bothersome. There was no significant difference between urologist- and patient-reported continence rates after RRP. CONCLUSION: Based on our grading system, urinary continence gradually improved with time and was 82% at 1 year. [Asian J Surg 2005;28(3):207–10] Key Words: prostate cancer, radical prostatectomy, urinary continence
Introduction Radical retropubic prostatectomy (RRP) is an established surgical procedure for clinically localized prostate cancer. There are many postoperative complications of radical prostatectomy, including sexual dysfunction, urethral stricture and incontinence.1 Urinary incontinence is a distressing complication of RRP and has been reported in 2.5–95% of patients.2 However, the incidence of this complication has decreased over the years with technical advances and the advent of low-morbidity anatomical approaches.3,4 Although globally published literature cite a post-RRP continence rate of 92– 95%,4–6 patients claim only 50% continence.1,7 It is not clear why there is such a large variation, but it may be attributable to several factors: data collection method, surgical volume and patient selection (younger, healthier patients). In addition,
there has been great concern that patients might minimize adverse outcomes during their consultation with physicians, or there may be a conscious or unconscious bias on the part of the surgeon or the interviewer towards minimizing the adverse outcome for positive end results. Hence, we conducted this study by employing an independent third party (known neither to the patient nor the doctor) to obtain the true incidence of post-RRP continence in Singaporean patients.
Patients and methods The RRP was performed by a single surgeon and 4% of patients had bilateral nerve-sparing surgery, based on the extent of clinical disease. Patients were evaluated prospectively (including the quality of life) according to their preference either by personal interview or over the telephone by a senior trained
Address correspondence and reprint requests to Dr. Weber K.O. Lau, Department of Urology, Singapore General Hospital, Outram Road, Singapore 169608. E-mail: [email protected] • Date of acceptance: 12 February 2004 © 2005 Elsevier. All rights reserved.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
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207
■ RAO et al ■
Table. Grading system to assess degree of urinary incontinence after radical retropubic prostatectomy Grade Tissue Pads Diapers
Continent
Very mild
Mild
Moderate
Severe
0 0 0
1–2 0 0
3–4 1–2 0
5–6 3–4 1–2
>6 >5 3–4
urinary continence nurse who had no prior knowledge of the patient’s records or data. Continence was assessed using an internationally validated questionnaire on health-related quality of life.8 Based on the number of pads, tissues and diapers used per day, a point system devised by our department and modified from the US national Medicare experience9 was used and continence was classified into no incontinence and very mild, mild, moderate or severe incontinence (Table). Patients were interviewed at 1 week and 1, 3, 6 and 12 months after surgery. Subsequently, the quality-of-life index, which categorizes patients according to no problem or a small, moderate or severe problem, was used to identify the degree of bother. Patients with preoperative incontinence were eliminated from the study. Patients were also followed up by the surgeon every 3 months, as per standard practice. Recovery status was noted on the patient record without knowledge of the questionnaire results.
Statistical analysis Cohen’s kappa was used to compare patient- and urologistreported continence rates and Spearman’s rho was used to find the correlation between age, Gleason score and prostate specific antigen (PSA). The Kruskal-Wallis test was employed to quantify the correlation between the degree of incontinence and the pathological stage of the disease.
patients could not be assessed fully as they did not respond to the follow-up protocol. The median age of patients in this study was 68 ( 6.5 years (range, 52–83 years). The clinical stage was T1 in 53% of patients, T2 in 27% and T3 in 20%. The mean PSA was 16.8 ( 12.4 ng/mL. The PSA level was less than 4 ng/mL in 3% of patients, 4–20 ng/mL in 67% and more than 20 ng/mL in 30%. The Gleason score was 5 or less in 32%, 5–7 in 62% and at least 7 in 6%. Postoperative pathological staging revealed 38% organ confinement (T2), 21% capsular penetration with a negative surgical margin (T3a), 9% seminal vesicle involvement (T3b), and 32% positive surgical margins. The mean postoperative stay was 9 days and duration of catheterization was 8 days. Patients were considered continent only when they did not use any incontinence aids, that is, tissue paper, pads or diapers. At 1 week, 44% (n = 15) achieved total continence. Urinary continence gradually improved until, at 12 months, 82% (n = 28) reported complete dryness (Figure 1). There was no significant difference between patient- and urologist-reported continence rates (p < 0.001) (Figure 2). There was no statistical correlation between the degree of incontinence and age (r = 0.170), Gleason score (r = 0.179) or PSA (r = 0.129). There was also no significant difference in the median incontinence scores across different stages of disease (p = 0.755). In total,
Results
90
208
Continence rate (%)
80
Between 1997 and 1999, 61 patients underwent RRP. At a median follow-up of 12 months, 34 patients could be fully assessed by the continence nurse from completed surveys. Fourteen patients were foreigners and underwent follow-up in their own countries. An effort was made to contact these patients by sending letters as well as questionnaires to their address. Only three patients responded and telephone interviews were conducted. These patients could not answer the questionnaire correctly, although there were encouraging overall results, so we could not use the results in this study. Three patients died of causes not related to prostate cancer and 10
70 60 50 40 30 20 10 0
1
4 12 24 Postoperative period (wk)
48
Figure 1. Post-radical retropubic prostatectomy continence rate in Singaporeans.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
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■ URINARY CONTINENCE AFTER RRP ■
Patient-reported 90
Urologist-reported
Continence rate (%)
80 70 60 50 40 30 20 10 0
1
4 12 24 Postoperative period (wk)
48
Figure 2. Comparison between patient- and urologist-reported continence rates 1 year after radical retropubic prostatectomy.
91% of patients (n = 31) stated that their problem was none or very small, and 9% cited moderate bother. In none of the patients was the problem severe. No patients required surgical intervention for their incontinence (Figure 3).
Discussion In our study, 1 year after RRP, patient-reported urinary continence was encouraging. In spite of our stringent criteria for complete continence after prostatectomy compared with that of Wei and Montie,10 our immediate and early continence rates (1 week to 3 months after surgery) were also satisfactory (Figure 1). Urinary continence gradually improved with time and, after 1 year, 82% of patients reported complete dryness. These results agree with the observations of Geary et al11 and Fowler et al9 in American patients, who found 80% and 84% complete dryness, respectively, at 1 year. In our study, 9% reported moderate incontinence. However, they did not re-
80 70
Patients (%)
60 50 40 30 20 10 0
No problem
Small Moderate Degree of bother
Severe
Figure 3. Quality of life as measured by degree of urinary bother in patients after radical retropubic prostatectomy.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
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quire any surgical intervention. Fowler et al reported surgical intervention for incontinence in 6% of post-RRP patients.1 Many of our patients with mild or moderate bother used a tissue or pad for security purposes rather than for urinary incontinence. Our promising continence rates could be attributed to various factors, such as the single-surgeon procedure and improved surgical skills over the years, but these were not statistically significant. In terms of surgical technique, we used the anatomic radical prostatectomy as modified by Walsh.12 We have modified the apical dissection to preserve the circumurethral sphincter muscles and refrain from closing the bladder neck too tightly to prevent postoperative strictures. There have been several other technical modifications including tubularization of the bladder neck closure and incorporation of Denonvilliers’ fascia posterior to the urethra in the vesicourethral anastomosis.11 The concern with any modification is the danger of compromising cancer clearance. In our study, only one patient was older than 75 years, an age when radical surgery is not an option in some Western countries. Various options of surveillance, radiotherapy, etc, were discussed with this patient as well as the increased morbidity associated with radical surgery. He was also referred preoperatively to the radiotherapist and to a patient support group for counselling. He was very fit for his age and very keen for surgery, fully understanding the prognosis and postoperative complications associated with radical surgery. Likewise, in patients with a high risk of non-organ confined disease (clinically, T3 or PSA > 20 ng/mL), various options were discussed. We found that our patients preferred surgery and this was related to the psychological factor of the cancer being removed in a quantitatively measurable, familiar manner. In this study, there was good correlation between patientreported and urologist-perceived continence rates compared with a similar study conducted by Wei and Montie.10 This was probably due to the method of reporting by the surgeon. Continence reported by the surgeon was based on the objective parameters as used by Fowler et al,9 that is, number of tissues, pads and diapers, and frequency and amount of urination. Patients were told to keep a note of these factors. Thus, at the time of follow-up, there was less bias on the part of the patients to downplay their symptoms. The validated questionnaire is an objective way of assessing urinary continence and it should be recommended for all patients who undergo radical prostatectomy. This could be conducted by the surgeon or by a continence nurse at followup. In this study, the similarity in patient- and surgeon-
209
■ RAO et al ■
reported continence rates could be attributed to the method and wording of questioning,1 which decreased subjective surgeon bias to a large extent. It is also very important to explain to the patient the nature of complications that he can expect after RRP so that he does not feel unduly anxious and can report and discuss the complications more freely with the surgeon during follow-up without downplaying his symptoms. There was no correlation between incontinence and age, Gleason score, PSA or pathological stage of the disease. Similarly, Catalona and Basler did not find correlation between recovery of continence and pathological stage.5 This might be because this was a comparatively small study. The quality-of-life index revealed no problem or a small problem in 91% of patients, for incontinence-related bothersome symptoms (Figure 2). Similarly, Eastham et al13 and Walsh et al14 reported that 90–93% of incontinence-related bothersome symptoms were mild to moderate in American patients. Though our results are encouraging, it may also be due, in part, to the fact that patients may be elated at the thought of a potential cure from a deadly disease and, hence, they are less particular about postoperative adverse events such as incontinence, sexual function and strictures. The quality-of-life index varies according to the mindset of various individuals based on individual self, cultural and religious values, environment, and so on. We are in the process of standardizing our post-RRP follow-up protocol so that all patients can be objectively followed up with respect to complications such as incontinence, quality of life, sexual dysfunction, and stricture, as well as follow-up treatment for cancer. The US national Medicare experience9 is an excellent study on which to base and standardize future universal protocols so that the results between various centres can be compared more readily with better correlation.
Conclusion The patient-reported continence rates after RRP in this study were very encouraging. Using a validated questionnaire is a
210
fairly accurate method of judging continence rates and this should be recommended to all patients who have undergone RRP, to minimize bias.
References 1. Fowler FJ, Barry MJ, Lu-Yao G, et al. Patient reported complications and follow-up treatment after radical prostatectomy. Urology 1993; 42:622–9. 2. Foote J, Yun S, Leach GE. Postprostatectomy incontinence: pathophysiology, evaluation and management. Urol Clin North Am 1991; 18:229–41. 3. Hautmann RE, Sauter TW, Wenderoth UK. Radical retropubic prostatectomy: morbidity and urinary continence in 418 consecutive cases. Urology 1994;43:47–51. 4. Steiner MS, Morton RA, Walsh PC. Impact of anatomical radical prostatectomy on urinary continence. J Urol 1991;145:512–4. 5. Catalona WJ, Basler JW. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J Urol 1993;150:905–7. 6. Leandri P, Rossignol G, Gautier JR, Ramon J. Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases. J Urol 1992;147:883–7. 7. Moul JW, Mooneyhan RM, Kao TC, et al. Pre-operative and operative factors to predict incontinence, impotence and stricture after radical prostatectomy. Prostate Cancer Prostatic Dis 1998;1:242–9. 8. Litwin MS, Hays RD, Fink A. Quality-of-life outcomes in men treated for localized prostate cancer. JAMA 1995;273:129–35. 9. Fowler FJ, Barry MJ, Lu-Yao G, et al. Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey. Urology 1995;45:1007–13. 10. Wei JT, Montie JE. Comparison of patient’s and physician’s rating of urinary incontinence following radical prostatectomy. Semin Urol Oncol 2000;18:76–80. 11. Geary ES, Dendinger DE, Freiha FS, Stamey TA. Incontinence and vesical neck strictures following radical retropubic prostatectomy. Urology 1995;45:1000–6. 12. Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol 1998;160:2418–24. 13. Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol 1996;156: 1701–13. 14. Walsh PC, Marschke P, Rocker D, Burnett AL. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 2000;55:58–61.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
070/20
Patient-reported Urinary Continence (Third-party Interview): Results of Post-radical Retropubic Prostatectomy in Singaporeans Jaideepraj Rao, Siew Khim Koay,1 Weber Kam On Lau1 and Christopher Wai Sam Cheng,1 Department of General Surgery, Tan Tock Seng Hospital, and 1Department of Urology, Singapore General Hospital, Singapore.
OBJECTIVE: To determine the patient-reported urinary continence rate after retropubic radical prostatectomy (RRP) for prostate carcinoma through a third-party interview and to grade the severity of incontinence. METHODS: Between 1997 and 1999, 34 patients were evaluated through an independent third party about the degree of continence as well as the quality of life after RRP. Patients were interviewed either in person or over the telephone. Urinary continence was defined as wearing no diapers, pads or tissue paper. RESULTS: Of the 34 patients, 44% achieved immediate continence. Urinary incontinence gradually improved with time after surgery and 82% (n = 28) were fully continent at 12 months. Using the quality-of-life index, 91% of patients characterized their urinary incontinence as not or minimally bothersome. There was no significant difference between urologist- and patient-reported continence rates after RRP. CONCLUSION: Based on our grading system, urinary continence gradually improved with time and was 82% at 1 year. [Asian J Surg 2005;28(3):207–10] Key Words: prostate cancer, radical prostatectomy, urinary continence
Introduction Radical retropubic prostatectomy (RRP) is an established surgical procedure for clinically localized prostate cancer. There are many postoperative complications of radical prostatectomy, including sexual dysfunction, urethral stricture and incontinence.1 Urinary incontinence is a distressing complication of RRP and has been reported in 2.5–95% of patients.2 However, the incidence of this complication has decreased over the years with technical advances and the advent of low-morbidity anatomical approaches.3,4 Although globally published literature cite a post-RRP continence rate of 92– 95%,4–6 patients claim only 50% continence.1,7 It is not clear why there is such a large variation, but it may be attributable to several factors: data collection method, surgical volume and patient selection (younger, healthier patients). In addition,
there has been great concern that patients might minimize adverse outcomes during their consultation with physicians, or there may be a conscious or unconscious bias on the part of the surgeon or the interviewer towards minimizing the adverse outcome for positive end results. Hence, we conducted this study by employing an independent third party (known neither to the patient nor the doctor) to obtain the true incidence of post-RRP continence in Singaporean patients.
Patients and methods The RRP was performed by a single surgeon and 4% of patients had bilateral nerve-sparing surgery, based on the extent of clinical disease. Patients were evaluated prospectively (including the quality of life) according to their preference either by personal interview or over the telephone by a senior trained
Address correspondence and reprint requests to Dr. Weber K.O. Lau, Department of Urology, Singapore General Hospital, Outram Road, Singapore 169608. E-mail: [email protected] • Date of acceptance: 12 February 2004 © 2005 Elsevier. All rights reserved.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
070/2001
207
■ RAO et al ■
Table. Grading system to assess degree of urinary incontinence after radical retropubic prostatectomy Grade Tissue Pads Diapers
Continent
Very mild
Mild
Moderate
Severe
0 0 0
1–2 0 0
3–4 1–2 0
5–6 3–4 1–2
>6 >5 3–4
urinary continence nurse who had no prior knowledge of the patient’s records or data. Continence was assessed using an internationally validated questionnaire on health-related quality of life.8 Based on the number of pads, tissues and diapers used per day, a point system devised by our department and modified from the US national Medicare experience9 was used and continence was classified into no incontinence and very mild, mild, moderate or severe incontinence (Table). Patients were interviewed at 1 week and 1, 3, 6 and 12 months after surgery. Subsequently, the quality-of-life index, which categorizes patients according to no problem or a small, moderate or severe problem, was used to identify the degree of bother. Patients with preoperative incontinence were eliminated from the study. Patients were also followed up by the surgeon every 3 months, as per standard practice. Recovery status was noted on the patient record without knowledge of the questionnaire results.
Statistical analysis Cohen’s kappa was used to compare patient- and urologistreported continence rates and Spearman’s rho was used to find the correlation between age, Gleason score and prostate specific antigen (PSA). The Kruskal-Wallis test was employed to quantify the correlation between the degree of incontinence and the pathological stage of the disease.
patients could not be assessed fully as they did not respond to the follow-up protocol. The median age of patients in this study was 68 ( 6.5 years (range, 52–83 years). The clinical stage was T1 in 53% of patients, T2 in 27% and T3 in 20%. The mean PSA was 16.8 ( 12.4 ng/mL. The PSA level was less than 4 ng/mL in 3% of patients, 4–20 ng/mL in 67% and more than 20 ng/mL in 30%. The Gleason score was 5 or less in 32%, 5–7 in 62% and at least 7 in 6%. Postoperative pathological staging revealed 38% organ confinement (T2), 21% capsular penetration with a negative surgical margin (T3a), 9% seminal vesicle involvement (T3b), and 32% positive surgical margins. The mean postoperative stay was 9 days and duration of catheterization was 8 days. Patients were considered continent only when they did not use any incontinence aids, that is, tissue paper, pads or diapers. At 1 week, 44% (n = 15) achieved total continence. Urinary continence gradually improved until, at 12 months, 82% (n = 28) reported complete dryness (Figure 1). There was no significant difference between patient- and urologist-reported continence rates (p < 0.001) (Figure 2). There was no statistical correlation between the degree of incontinence and age (r = 0.170), Gleason score (r = 0.179) or PSA (r = 0.129). There was also no significant difference in the median incontinence scores across different stages of disease (p = 0.755). In total,
Results
90
208
Continence rate (%)
80
Between 1997 and 1999, 61 patients underwent RRP. At a median follow-up of 12 months, 34 patients could be fully assessed by the continence nurse from completed surveys. Fourteen patients were foreigners and underwent follow-up in their own countries. An effort was made to contact these patients by sending letters as well as questionnaires to their address. Only three patients responded and telephone interviews were conducted. These patients could not answer the questionnaire correctly, although there were encouraging overall results, so we could not use the results in this study. Three patients died of causes not related to prostate cancer and 10
70 60 50 40 30 20 10 0
1
4 12 24 Postoperative period (wk)
48
Figure 1. Post-radical retropubic prostatectomy continence rate in Singaporeans.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
070/20
■ URINARY CONTINENCE AFTER RRP ■
Patient-reported 90
Urologist-reported
Continence rate (%)
80 70 60 50 40 30 20 10 0
1
4 12 24 Postoperative period (wk)
48
Figure 2. Comparison between patient- and urologist-reported continence rates 1 year after radical retropubic prostatectomy.
91% of patients (n = 31) stated that their problem was none or very small, and 9% cited moderate bother. In none of the patients was the problem severe. No patients required surgical intervention for their incontinence (Figure 3).
Discussion In our study, 1 year after RRP, patient-reported urinary continence was encouraging. In spite of our stringent criteria for complete continence after prostatectomy compared with that of Wei and Montie,10 our immediate and early continence rates (1 week to 3 months after surgery) were also satisfactory (Figure 1). Urinary continence gradually improved with time and, after 1 year, 82% of patients reported complete dryness. These results agree with the observations of Geary et al11 and Fowler et al9 in American patients, who found 80% and 84% complete dryness, respectively, at 1 year. In our study, 9% reported moderate incontinence. However, they did not re-
80 70
Patients (%)
60 50 40 30 20 10 0
No problem
Small Moderate Degree of bother
Severe
Figure 3. Quality of life as measured by degree of urinary bother in patients after radical retropubic prostatectomy.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
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quire any surgical intervention. Fowler et al reported surgical intervention for incontinence in 6% of post-RRP patients.1 Many of our patients with mild or moderate bother used a tissue or pad for security purposes rather than for urinary incontinence. Our promising continence rates could be attributed to various factors, such as the single-surgeon procedure and improved surgical skills over the years, but these were not statistically significant. In terms of surgical technique, we used the anatomic radical prostatectomy as modified by Walsh.12 We have modified the apical dissection to preserve the circumurethral sphincter muscles and refrain from closing the bladder neck too tightly to prevent postoperative strictures. There have been several other technical modifications including tubularization of the bladder neck closure and incorporation of Denonvilliers’ fascia posterior to the urethra in the vesicourethral anastomosis.11 The concern with any modification is the danger of compromising cancer clearance. In our study, only one patient was older than 75 years, an age when radical surgery is not an option in some Western countries. Various options of surveillance, radiotherapy, etc, were discussed with this patient as well as the increased morbidity associated with radical surgery. He was also referred preoperatively to the radiotherapist and to a patient support group for counselling. He was very fit for his age and very keen for surgery, fully understanding the prognosis and postoperative complications associated with radical surgery. Likewise, in patients with a high risk of non-organ confined disease (clinically, T3 or PSA > 20 ng/mL), various options were discussed. We found that our patients preferred surgery and this was related to the psychological factor of the cancer being removed in a quantitatively measurable, familiar manner. In this study, there was good correlation between patientreported and urologist-perceived continence rates compared with a similar study conducted by Wei and Montie.10 This was probably due to the method of reporting by the surgeon. Continence reported by the surgeon was based on the objective parameters as used by Fowler et al,9 that is, number of tissues, pads and diapers, and frequency and amount of urination. Patients were told to keep a note of these factors. Thus, at the time of follow-up, there was less bias on the part of the patients to downplay their symptoms. The validated questionnaire is an objective way of assessing urinary continence and it should be recommended for all patients who undergo radical prostatectomy. This could be conducted by the surgeon or by a continence nurse at followup. In this study, the similarity in patient- and surgeon-
209
■ RAO et al ■
reported continence rates could be attributed to the method and wording of questioning,1 which decreased subjective surgeon bias to a large extent. It is also very important to explain to the patient the nature of complications that he can expect after RRP so that he does not feel unduly anxious and can report and discuss the complications more freely with the surgeon during follow-up without downplaying his symptoms. There was no correlation between incontinence and age, Gleason score, PSA or pathological stage of the disease. Similarly, Catalona and Basler did not find correlation between recovery of continence and pathological stage.5 This might be because this was a comparatively small study. The quality-of-life index revealed no problem or a small problem in 91% of patients, for incontinence-related bothersome symptoms (Figure 2). Similarly, Eastham et al13 and Walsh et al14 reported that 90–93% of incontinence-related bothersome symptoms were mild to moderate in American patients. Though our results are encouraging, it may also be due, in part, to the fact that patients may be elated at the thought of a potential cure from a deadly disease and, hence, they are less particular about postoperative adverse events such as incontinence, sexual function and strictures. The quality-of-life index varies according to the mindset of various individuals based on individual self, cultural and religious values, environment, and so on. We are in the process of standardizing our post-RRP follow-up protocol so that all patients can be objectively followed up with respect to complications such as incontinence, quality of life, sexual dysfunction, and stricture, as well as follow-up treatment for cancer. The US national Medicare experience9 is an excellent study on which to base and standardize future universal protocols so that the results between various centres can be compared more readily with better correlation.
Conclusion The patient-reported continence rates after RRP in this study were very encouraging. Using a validated questionnaire is a
210
fairly accurate method of judging continence rates and this should be recommended to all patients who have undergone RRP, to minimize bias.
References 1. Fowler FJ, Barry MJ, Lu-Yao G, et al. Patient reported complications and follow-up treatment after radical prostatectomy. Urology 1993; 42:622–9. 2. Foote J, Yun S, Leach GE. Postprostatectomy incontinence: pathophysiology, evaluation and management. Urol Clin North Am 1991; 18:229–41. 3. Hautmann RE, Sauter TW, Wenderoth UK. Radical retropubic prostatectomy: morbidity and urinary continence in 418 consecutive cases. Urology 1994;43:47–51. 4. Steiner MS, Morton RA, Walsh PC. Impact of anatomical radical prostatectomy on urinary continence. J Urol 1991;145:512–4. 5. Catalona WJ, Basler JW. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J Urol 1993;150:905–7. 6. Leandri P, Rossignol G, Gautier JR, Ramon J. Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases. J Urol 1992;147:883–7. 7. Moul JW, Mooneyhan RM, Kao TC, et al. Pre-operative and operative factors to predict incontinence, impotence and stricture after radical prostatectomy. Prostate Cancer Prostatic Dis 1998;1:242–9. 8. Litwin MS, Hays RD, Fink A. Quality-of-life outcomes in men treated for localized prostate cancer. JAMA 1995;273:129–35. 9. Fowler FJ, Barry MJ, Lu-Yao G, et al. Effect of radical prostatectomy for prostate cancer on patient quality of life: results from a Medicare survey. Urology 1995;45:1007–13. 10. Wei JT, Montie JE. Comparison of patient’s and physician’s rating of urinary incontinence following radical prostatectomy. Semin Urol Oncol 2000;18:76–80. 11. Geary ES, Dendinger DE, Freiha FS, Stamey TA. Incontinence and vesical neck strictures following radical retropubic prostatectomy. Urology 1995;45:1000–6. 12. Walsh PC. Anatomic radical prostatectomy: evolution of the surgical technique. J Urol 1998;160:2418–24. 13. Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol 1996;156: 1701–13. 14. Walsh PC, Marschke P, Rocker D, Burnett AL. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 2000;55:58–61.
ASIAN JOURNAL OF SURGERY VOL 28 • NO 3 • JULY 2005
070/20