Predictor of Early Recovery on Urinary Continence After Laparoscopic Radical Prostatectomy
Condition: Urinary Incontinence
MeSH terms: Urinary Incontinence; Enuresis
Study type: Observational

Summary: 
      To investigate the relationship between post-operative bladder neck levels and urodynamic
      parameters and their effect on urinary incontinence after laparoscopic radical prostatectomy
      (LRP). Forty-eight consecutive patients undergoing LRP were retrospectively reviewed. All
      patients had investigated by retrograde cystography after LRP and were grouped according
      their bladder neck position: Level 0: bladder neck at or above the superior margin of the
      symphysis pubis (SMSP), Level -1: bladder neck at <2 cm below SMSP, and Level -2: bladder
      neck at >2 cm below SMSP. Urodynamic studies were carried out at baseline, 3 and 6 months
      post-operatively. Early recovery of urinary continence was defined as no urine leakage or
      only one pad/day used within 3 months after surgery. Demographic characteristics, changes of
      urodynamic parameters and continence outcomes were analyzed.
    

Detailed description: 
      Laparoscopic radical prostatectomy (LRP) is effective in treating localized prostate cancer
      with good long-term oncological outcomes. Urinary incontinence, which is a bothersome
      complication with a negative effect on the patient's quality of life, remains a relevant
      problem after LRP, despite the improvements in the surgical technique. More than 80% of
      patients undergoing radical prostatectomy encounter urinary incontinence immediately after
      catheter removal, but the bladder condition can generally stabilize within two years after
      operation. Among the patients undergoing LRP, persistent urinary incontinence has been
      reported in 4-30% of patients, and further treatment is often required.

      Definite evaluation for the voiding function has been recommended for patients with prolonged
      post-prostatectomy urinary incontinence (PPI). To improve quality of life after LRP, early
      recovery of urinary continence is an important concern for patients. Several studies have
      investigated the predictive factors of early recovery of urinary continence after
      prostatectomy, including the amount of urine loss after catheter removal, pelvic floor muscle
      function, a nerve-sparing technique, and the membranous urethral length loss ratio.

      Other factors relating to the early recovery of urinary continence include post-operative
      anatomy of the lower urinary tract, such as the length of the membranous urethra and the
      level of the vesicourethral junction. However, there has been no consensus on the standard
      criteria that should be used to measure the structural changes, and the relationship between
      the urodynamic change and the anatomical morphology remains unclear. In this study,
      investigators study the relationship between the urodynamic parameters and the bladder neck
      levels after LRP, and their effects on the early recovery of urinary incontinence.

      This study was a retrospective analysis. From 2011 to 2014, a total of 48 consecutive
      patients with localized prostatic cancer underwent LRP in single medical center by two
      experienced surgeons. Videourodynamic study was performed before operation (baseline) and at
      3 and 6 months after operation. The Ethics Committee of the hospital approved this study and
      written informed consent was waived because the study was a retrospective analysis. The
      principles of Helsinki Declaration were followed throughout the study.

      The urodynamic parameters were measured and recorded including first sensation of filling
      (FSF), maximum flow rate (Qmax), detrusor pressure at Qmax (PdetQmax), voided volume,
      cystometric bladder capacity (CBC), bladder compliance, post-void residual (PVR) volume,
      maximal urethral closure pressure (MUCP) and functional profile length (FPL). The urodynamic
      parameters were compared between baseline and different time-points after LRP.

      The BN level was evaluated by retrograde cystography, which was routinely performed 7 to 14
      days after LRP to evaluate the condition of anastomosis. The image was obtained
      anteroposteriorly after infusing 100-150 mL of contrast solution into the bladder while the
      patient was in standing position. The distance between the bladder neck and the superior
      margin of the symphysis pubis (SMSP) was then measured by the same urologist. The bladder
      neck level was graded on a three-point scale: a bladder neck level at or above the SMSP was
      marked as level 0, a bladder neck level with a distance less than 2 cm below the SMSP was
      marked as level -1, and bladder neck levels 2 or more cm below the SMSP was labeled as level
      -2.

      The patient's urinary continence status was evaluated on direct visits and via questionnaires
      during follow-up periods at 3, 6, and 12 months post-operatively. Patients without urine
      leakage in their daily life and those who used only one pad per day for safety reasons
      without limitation in their daily activities were defined as "urinary continent". Otherwise,
      the patients were defined as "urinary incontinent". Regaining continence within 3 months
      after LRP was considered early recovery of urinary continence.

      The data was collected retrospectively by chart review. The variables among continent and
      incontinent patients were evaluated by univariate analysis (t-test for continuous variables
      and Chi-square for categorical variables ). The ANOVA test was use to compare the urodynamic
      parameters between different BN levels. Statistical analysis was performed using SPSS 20.0
      statistical software.
    

Intervention name(s): bladder neck level on cystography
Intervention type(s): Diagnostic Test
Intervention description(s): All patients had investigated by retrograde cystography after LRP and were grouped according their bladder neck position: Level 0: bladder neck at or above the superior margin of the symphysis pubis (SMSP), Level -1: bladder neck at <2 cm below SMSP, and Level -2: bladder neck at >2 cm below SMSP.
Other intervention name(s): BN level
Observational model: Case-Only
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Consecutive patients with localized prostate cancer underwent laparoscopic radical
        prostatectomy
      
Keywords: laparoscopic radical prostatectomy; urinary incontinence; prostate cancer; bladder neck level; urodynamics