Original Article

Yonago Acta Medica 2017;60:52–55

Evaluation of Incontinence after Robot-Assisted Laparoscopic Radical 		
Prostatectomy: Using the International Consultation on Incontinence Modular
Questionnaire Short Form and Noting the Number of Safety Pads Needed by
Japanese Patients
Katsuya Hikita, Masashi Honda, Bunya Kawamoto, Panagiota Tsounapi, Kuniyasu Muraoka, Takehiro Sejima
and Atsushi Takenaka
Division of Urology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACT

naire is also needed.

BackgroundThe definition of continence after robot-assisted laparoscopic radical prostatectomy (RARP)
has not been consistently defined, with many studies
only noting the amount of safety pads used. We therefore examined what definition of continence would beappropriate, employing both the International Consultation on Incontinence Modular Questionnaire Short Form
(ICIQ-SF) and the number of pads used by patients. We
also evaluated the relationship between the number ofpads used and degree of incontinence.
Methods Patients who underwent RARP between
October 2010 and July 2014 in our department were included in the present study. All patients were evaluatedby ICIQ-SF and the number of pads used 1, 3, 6 and 12
months after surgery. Frequency of incontinence andamount of incontinence were evaluated by ICIQ-SF
Questions 1 and 2 respectively at 12 months. Quality oflife (QOL) was evaluated by ICIQ-SF Question 3 at 1, 3,
6, and 12 months after RARP.
Results The overall study population was 156 patients.
In Question 1, 19 patients answered that they leakedurine several times a day, but 5 patients did not use pads,
and 8 patients were using only 1 pad a day. In Question 2,
8 patients answered that they leaked a moderate amountof urine, but 2 patients did not use any pads, and 3 patients used only 1 pad a day. QOL showed significant
differences between using no pad, 1 pad, or ≥ 2 pads at 1,
3, 6, and 12 months after RARP.
Conclusion Simply noting the number of pads used bya patient is an insufficient way to evaluate incontinence
after RARP. Assessment by an appropriate question-

Key words

incontinence; International Consultation
on Incontinence Modular Questionnaire Short Form;robot-assisted laparoscopic radical prostatectomy
Patients with localized prostate cancer are candidates
for active surveillance, radiation therapy, and/or radical prostatectomy. Robot-assisted laparoscopic radical
prostatectomy (RARP) has become widely used and isincreasingly adopted as the best method of cure. Some
reports have suggested that RARP offers short-term
benefits over historical controls with open radical prostatectomy (ORP) in terms of better visualization, lower
perioperative complication and transfusion rates, andshorter hospital stay.1 Various surgical techniques havebeen devised to reduce incontinence after RARP.2
Postoperative urinary incontinence after radical
prostatectomy for prostate cancer has a relevant negative effect on satisfaction and quality of life (QOL).3 In
addition, urinary incontinence has been suggested tohave a higher impact on QOL than lack of sexual functioning.3 Some studies have shown that patients achieved
continence much earlier after RARP than after ORP or
laparoscopic radical prostatectomy (LRP). Ficarra et al.
reported that a 12-month urinary recovery after ORP
ranged from 60% to 93%, and after LRP, from 66%
to 95%. A previous systematic review shows that the
12-month urinary recovery after RARP ranged from
84% to 97%.1 In addition, Sammon et al. reported that
only 17.3% of patients undergoing RARP showed thatthey were able to achieve urinary continence right after
catheter removal.4 On the other hand, the definition ofcontinence after RARP has not been determined correctly. The most common definition of incontinence isthe use of urinary safety pads.1 Many reports have determined that continence is defined as “no pad” or “onesafety pad per day.”1 However, this definition excludes
patients who may be incontinent but don’t use pads forwhatever reason.
We therefore examined what definition of conti-

Corresponding author: Katsuya Hikita, MD, PhD
k-hikita@med.tottori-u.ac.jp
Received 2016 December 26
Accepted 2017 February 15
Abbreviations: EPIC, Expanded Prostate Cancer Index Composite; ICIQ-SF, International Consultation on Incontinence Modular
Questionnaire Short Form; LRP, laparoscopic radical prostatectomy; ORP, open radical prostatectomy; PSA, prostate specific antigen; QOL, quality of life; RARP, robot-assisted laparoscopic radical
prostatectomy

52

Evaluation of incontinence after RARP

nence would be appropriate, employing both the International Consultation on Incontinence Modular Questionnaire Short Form (ICIQ-SF) and noting the number ofpads used. We also evaluated the relationship between
the number of pads used and degree of incontinence frominformation given by the patient on the questionnaire.

Table 1. Characteristics of study patients
Factors

Mean ± SD or number

No. of patients156
Age (years old)
65.2 ± 6.7
PSA (ng/mL)
9.4 ± 6.8
Prostate volume (mL)
32.1 ± 13.5
Clinical stage
T1c
33
T2a
67
T2b
7
T2c
34
T2c
15
Nerve sparing
Yes
77
No
79
No., number; PSA, prostate specific antigen.

MATERIALS AND METHODS
EthicsThis study was conducted at the Division of Urology,
Tottori University Hospital, Tottori, Japan. The study
was approved by the Tottori University Ethics Committee (No. 2545).
Patients

All patients who underwent RARP between October2010 and July 2014 in the Division of Urology at Tottori
University Hospital for clinically localized prostatic cancer (stages cT1c–cT3a N0 M0) were included in the present study. All patients were evaluated by ICIQ-SF andthe number of pads used.

RESULTSA total of 210 patients underwent RARP, but 54 patients were excluded from this study since there was alack of data based on their questionnaires. As a result,
Follow-up and Questionnaire
156 patients formed the overall study population. Mean
Frequency of incontinence was evaluated by ICIQpatient age was 65.2 years (range, 50–75 years), mean
SF Question 1: “How often does your urine leak?”prostate-specific antigen (PSA) concentration was 9.44
Responses were scored as follows: “Never,” 0; “About
ng/mL (range, 4.20–25.7 ng/mL), and mean prostate volonce a week or less,” 1; “Two or three times a week,” 2;
ume was 32.1 mL (range, 8.9–75 mL). In terms of clin“About once a day,” 3; “Several times a day,” 4; and “Allical stage, 33 patients were T1c, 67 patients were T2a, 7
the time,” 5. The amount of incontinence was evaluatpatients were T2b, 34 patients were T2c, and 15 patientsed by ICIQ-SF Question 2: “How much urine usually
were T3a. Seventy-seven patients received nerve-sparleaks?” Responses were scored as follows: “None,” 0; “Aing procedures on at least unilateral side (Table 1). One
small amount,” 2; “A moderate amount,” 4; and “A large
month after RARP, 31.4% of patients had achieved 0
amount,” 6. QOL was evaluated using ICIQ-SF Quespad usage and 58.3% had achieved 0–1; this increasedtion 3: “Overall, how much does leaking urine interfere
to 67.3% with 0 pads and 90.1% with 0–1 pads after 6
with your everyday life?” Responses were scored on amonths and 78.8% with 0 pads and 94.9% with 0–1 pads
range from 0, “Not at all” to 10, “A great deal.”
after 12 months (Table 2).
Twelve months after RARP, in response to ICIQ-SF
Statistical analysis
Question 1, 73 patients answered that they never leaked
All data were presented as number as the mean withurine, but 1 patient used 1 pad. Thirty-four patients anstandard deviation. Comparisons of mean values amongswered that they leaked urine about once a week or less,the groups were done using ANOVA with the Tukeyand 4 patients used 1 pad. Sixteen patients answered
test. A P value of less than 0.05 (P < 0.05) was considthat they leaked urine two or three times a week, and 6
ered significant. Statistical analysis was carried out using
patients used 1 pad. However, 19 patients answered that
the Statistical Package for the Social Sciences, version
they leaked urine several times a day, but 5 of these pa19 (IBM, Armonk, NY).
tients did not use any pads and 8 of these patients used
only 1 pad (Table 3).
Twelve months after RARP,
Table 2. Continent rates after RARP according to the definition of nopads or 1 pad as an objective measure of continencein response to ICIQ-SF Question 2,
75 patients answered that they neverNo. of pads
1 month
3 month
6 month
9 month
12 monthleak urine, but 1 patient used 1 pad.
0 (%)
31.4
51.9
67.3
72.4
78.8
Of the 71 patients who answered that
0–1 (%)
58.3
81.4
90.1
94.2
94.9
they leaked a small amount of urine,

No., number; RARP, robot-assisted laparoscopic radical prostatectomy.

53

K. Hikita et al.
Table 3. Incontinent symptom scales based on ICIQSF and the number of pads used at 12 month after
RARP
ICIQ-SF / No. of pads

01

Table 4. QOL scores based on ICIQ-SF by the numberof pads used at 1, 3, 6, 12 month after RARP
Month

2 or more

No. of pads

ICIQ-SF Q3 score

n

* *
0
1.12 ± 1.34
49
1
1
3.54 ± 1.94
42*
2 or more
6.69 ± 2.96
62
* *00.93 ± 2.49
81
3
1
3.21 ± 2.49
46*
2 or more
6.34 ± 2.76
29
* *00.72 ± 1.10
105
6
1
3.14 ± 2.27
34*
2 or more
5.52 ± 2.96
17
* *00.85 ± 1.30122121
3.0 ± 2.19
26*
2 or more
7.5 ± 2.51
8
ICIQ-SF Question 3: “Overall, how much does leaking urine interfere with your everyday life?” Patients choice a number from 0
to 10, “Not at all” to “A great deal.” * P < 0.05.
ICIQ-SF, International Consultation on Incontinence Modular
Questionnaire Short Form; No., number; QOL, quality of life.

Q1 (How often does your urine leak?)
Never
72
1
0
About once a week or less30
40
Two or three times a week10
60
About once a day
5
70
Several times a day
5
8
6
All the time002Q2 (How much urine usually leaks?)
None
74
1
0
A small amount46
22
3
A moderate amount2
3
3
A large amount0
0
2
ICIQ-SF, International Consultation on Incontinence Modular
Questionnaire Short Form; No., number; Q, Question.

3 patients used ≥ 2 pads. Of the eight patients who answered that they leaked a moderate amount of urine, 2patients did not use any pads, 3 patients used 1 pad, and3 patients used ≥ 2 pads (Table 3).
In terms of QOL, 12 months after RARP in ICIQSF Q3, there were significant differences between nopad, 1 pad, and 2 or more pads at 1, 3, 6 and 12 months(Table 4).

ing to the definition of no pad use was 21.2%, lower thanreported in previous studies.11–13 Some studies have previously demonstrated age and nerve sparing as associated with continence after surgery.14–16 We suggested thatthe reasons for the lower continence rate in our study
were higher age and a lower nerve-sparing rate than inprevious studies.
In this study, 72 (59.0%) of the 122 patients that
did not use pads selected “Never” for Question 1 in the
ICIQ-SF at 12 months after RARP. Although ten (8.2%)of these 122 patients complained of leaking urine onceor more a day, the definition of no pad use seems relatively consistent with continence based on the ICIQ-SF.
On the other hand, only one (3.8%) of 26 patients using
one pad selected “Never” for Question 1 in the ICIQSF at 12 months after RARP. Fifteen (57.7%) of these 26
patients using 1 pad complained of leaking urine onceor more a day, although leaked amounts were small. The
definition of using 1 pad was not consistent with continence based on the ICIQ-SF.
Haga et al. found little correlation between thenumber of pads used and severity of incontinence. One
possible reason was that patients wore various configurations and sizes of pads, unrelated to the actual volumeof urinary incontinence.7 Pad count was thus not usefulas an objective measure of incontinence after RARP.
Some reports have used the number of pads and scoreson various questionnaires including the ICIQ-SF andthe Expanded Prostate Cancer Index Composite (EPIC)
as definitions of continence after RARP.7, 17 Our findings support their definition of continence based on the

DISCUSSION
Urinary incontinence after RARP is influenced by the
preoperative characteristics of the patient, patient age,experience of the surgeon, and the surgical techniquesapplied, including nerve sparing.5 A systematic review
showed that according to the definition of continence
as using no pads, 12-month urinary incontinence rates
ranged from 4% to 31%, with a mean of 16%. Considering studies that considered no pads or one safety padas the definition of continence, 12-month urinary incontinence rates ranged from 8% to 11%, with a mean of
9%.1 However, an unambiguous definition of continence
after RARP has yet to be established. Many definitions
have been employed, including the number of pads used,
leak-free status, and questionnaire responses.6–8 Many
authors have used the definition of no pad or 1 safety
pad as an objective measure of continence.1 On the other
hand, some studies have reported pad count as an unreliable indicator in the severity of incontinence.8–10 We
examined the relationship between the number of pads
used and an incontinence symptom scale based on the
ICIQ-SF.
In this study, the 12-month continence rate accord54

Evaluation of incontinence after RARP

number of pads used together with questionnaire-based
symptom scales.
Concerning QOL, urinary incontinence after RARP
has been suggested to have a higher impact on QOL
than sexual functioning.18 Haga et al. reported that the
number of pad exchanges per day, pad wetness, and thetiming of pad exchanges were important factors affecting QOL.7 In our study, a significant difference in QOL
was seen between no pad and 1 pad. The definition ofusing 1 pad is not consistent with continence based on
ICIQ-SF. If we evaluate incontinence based solely on
only the number of pads used, no pad use is appropriate
as a definition of continence.
One study limitation was that we did not include avalidated objective measure of the pad test. Nitti et al.
reported that men with post-prostatectomy incontinence
accurately described the number, size, and degree of
wetness of pads that they collected during a 24-h pad
test.8 However, this approach seems impractical as a pad
test for every patient. A practical approach is to performthe pad test for those patients showing inconsistency
between the number of pads used and symptom scales
based on questionnaire responses.
In conclusion, we feel the number of pads used is aninsufficient indicator for evaluating incontinence after
RARP. Incontinence after RARP should be evaluatedusing a combination of noting the number of pads used,
questionnaires, and possibly a pad test.
Further studies are needed to establish a unified
definition of continence from clinical outcome evaluations of RARP and provisions for accurate information
to and from patients.

Bienz M, Alhathal N, et al. Predictors of early continence following robot-assisted radical prostatectomy. Can Urol Assoc J.
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6 Geraerts I, Van Poppel H, Devoogdt N, Van Cleynenbreugel
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Period After Robot-Assisted Laparoscopic Radical Prostatectomy. J Endourol. 2015;29:1044-51. PMID: 26176381.
8 Nitti VW, Mourtzinos A, Brucker BM; SUFU Pad Test Study
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11 Kim SC, Song C, Kim W, Kang T, Park J, Jeong IG, et al. Factors determining functional outcomes after radical prostatectomy: robot-assisted versus retropubic. Eur Urol. 2011;60:41319. PMID: 21612859.
12 Rocco B, Matei DV, Melegari S, Ospina JC, Mazzoleni F,
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The authors declare no conflict of interest.

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