Elsevier

European Urology

Volume 62, Issue 3, September 2012, Pages 405-417
European Urology

Platinum Priority – Review – Prostate Cancer
Editorial by Peter C. Albertsen on pp. 365–367 of this issue
Systematic Review and Meta-analysis of Studies Reporting Urinary Continence Recovery After Robot-assisted Radical Prostatectomy

https://doi.org/10.1016/j.eururo.2012.05.045Get rights and content

Abstract

Context

Robot-assisted radical prostatectomy (RARP) was proposed to improve functional outcomes in comparison with retropubic radical prostatectomy (RRP) or laparoscopic radical prostatectomy (LRP). In the initial RARP series, 12-mo urinary continence recovery rates ranged from 84% to 97%. However, the few available studies comparing RARP with RRP or LRP published before 2008 did not permit any definitive conclusions about the superiority of any one of these techniques in terms of urinary continence recovery.

Objective

The aims of this systematic review were (1) to evaluate the prevalence and risk factors for urinary incontinence after RARP, (2) to identify surgical techniques able to improve urinary continence recovery after RARP, and (3) to perform a cumulative analysis of all available studies comparing RARP versus RRP or LRP in terms of the urinary continence recovery rate.

Evidence acquisition

A literature search was performed in August 2011 using the Medline, Embase, and Web of Science databases. The Medline search included only a free-text protocol using the term radical prostatectomy across the title and abstract fields of the records. The following limits were used: humans; gender (male); and publication date from January 1, 2008. Searches of the Embase and Web of Science databases used the same free-text protocol, keywords, and search period. Only comparative studies or clinical series including >100 cases reporting urinary continence outcomes were included in this review. Cumulative analysis was conducted using the Review Manager v.4.2 software designed for composing Cochrane Reviews (Cochrane Collaboration, Oxford, UK).

Evidence synthesis

We analyzed 51 articles reporting urinary continence rates after RARP: 17 case series, 17 studies comparing different techniques in the context of RARP, 9 studies comparing RARP with RRP, and 8 studies comparing RARP with LRP. The 12-mo urinary incontinence rates ranged from 4% to 31%, with a mean value of 16% using a no pad definition. Considering a no pad or safety pad definition, the incidence ranged from 8% to 11%, with a mean value of 9%. Age, body mass index, comorbidity index, lower urinary tract symptoms, and prostate volume were the most relevant preoperative predictors of urinary incontinence after RARP. Only a few comparative studies evaluated the impact of different surgical techniques on urinary continence recovery after RARP. Posterior musculofascial reconstruction with or without anterior reconstruction was associated with a small advantage in urinary continence recovery 1 mo after RARP. Only complete reconstruction was associated with a significant advantage in urinary continence 3 mo after RARP (odds ratio [OR]: 0.76; p = 0.04).

Cumulative analyses showed a better 12-mo urinary continence recovery after RARP in comparison with RRP (OR: 1.53; p = 0.03) or LRP (OR: 2.39; p = 0.006).

Conclusions

The prevalence of urinary incontinence after RARP is influenced by preoperative patient characteristics, surgeon experience, surgical technique, and methods used to collect and report data. Posterior musculofascial reconstruction seems to offer a slight advantage in terms of 1-mo urinary continence recovery. Update of a previous systematic review of literature shows, for the first time, a statistically significant advantage in favor of RARP in comparison with both RRP and LRP in terms of 12-mo urinary continence recovery.

Introduction

Postoperative urinary incontinence has a relevant negative effect on the satisfaction and health-related quality of life of patients who undergo radical prostatectomy for prostate cancer.

Historically, significant updates in the surgical techniques used in anatomic retropubic radical prostatectomy (RRP) derived from improvements in the knowledge of the anatomy of the dorsal venous complex [1], [2], the puboprostatic ligaments [3], prostate shape, urinary sphincter [2], and posterior rhabdosphincter [4] as well as the description of the intrapelvic branch of the pudendal nerve and putative continence enabling intrapelvic branches of the pelvic plexus [5]. The most important recent RRP series showed a 12-mo urinary continence recovery rate ranging from 60% to 93% according to the different methods used to evaluate this parameter [6].

Since 1999, some surgeons have proposed using the laparoscopic approach [7] with the intent of minimizing damage to the anatomic structure involved in the urinary continence mechanism. Mature laparoscopic radical prostatectomy (LRP) series showed 12-mo urinary continence recovery ranging from 66% to 95%, and a cumulative analysis of available comparative studies showed overlapping results in comparison with RRP [6].

Robotic technology combining optical magnification, three-dimensional vision, and instruments with 7 degrees of freedom allows surgeons to perform meticulous, precise, and accurate movements that are fundamental to preserve the key anatomic structures for urinary continence and potency and to minimize perioperative complications. In a previous systematic review of the literature, the 12-mo urinary recovery after RARP in referral centers ranged from 84% to 97%. However, the few comparative studies between RARP and other approaches (RRP and LRP) published before 2008 did not permit any definitive conclusion about the superiority of one of these techniques in terms of urinary continence recovery [6].

The aims of this systematic review were to evaluate the prevalence of and the risk factors for urinary incontinence after RARP, to identify surgical techniques able to improve urinary continence recovery after RARP, and to perform a cumulative analysis of all studies comparing RARP versus RRP or LRP in terms of urinary continence recovery.

Section snippets

Evidence acquisition

To update our previous systematic reviews [6], [8], a literature search was performed in August 2011 using the Medline, Embase, and Web of Science databases. The Medline search included only a free-text protocol using the term radical prostatectomy across the title and abstract fields of the records. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. The searches of the Embase and Web of Science databases used the same free-text protocol,

Quality of the studies and level of evidence

Figure 1 shows the flowchart of this systematic review of the literature (Fig. 1). We selected 76 records reporting urinary continence rates after RARP. One further randomized controlled trial (RCT) comparing different techniques in the context of RARP published after the search period [10] and a prospective nonrandomized study comparing RARP and RRP [11] and one retrospective study comparing RARP and LRP [12] published before the search period were also included in the present analyses.

Discussion

The prevalence of urinary incontinence after RARP is influenced by preoperative patient characteristics, surgeon experience, surgical techniques, and methodological aspects such as continence definitions, tools used for data collection, and different follow-up intervals. Specifically, 12-mo urinary incontinence rates ranged from 4% to 31% of cases using a no pad definition and from 8% to 11% when also including as successful those patients using a safety pad. Currently, few data are available

Conclusions

The prevalence of urinary incontinence after RARP ranged from 4% to 31%. These outcomes can be influenced by preoperative patient characteristics, surgeon experience, surgical technique, and methods used to collect and report data. Similar to RRP and LRP, increasing age, the presence of comorbidities, high BMI, and the presence of LUTS also seem to be correlated with a higher risk of urinary incontinence in patients who underwent RARP. Only a few comparative studies have evaluated the impact of

References (65)

  • V.R. Patel et al.

    Pentafecta: a new concept for reporting outcomes of robot-assisted laparoscopic radical prostatectomy

    Eur Urol

    (2011)
  • B.A. Link et al.

    The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy

    J Urol

    (2008)
  • D.G. Murphy et al.

    Operative details and oncological and functional outcome of robotic-assisted laparoscopic radical prostatectomy: 400 cases with a minimum of 12 months follow-up

    Eur Urol

    (2009)
  • T.A. Skolarus et al.

    Does robotic technology mitigate the challenges of large prostate size?

    Urology

    (2010)
  • A.L. Wiltz et al.

    Robotic radical prostatectomy in overweight and obese patients: oncological and validated-functional outcomes

    Urology

    (2009)
  • Y. Lei et al.

    Athermal division and selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy: description of technique and outcomes

    Eur Urol

    (2011)
  • M.P. Freire et al.

    Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes

    Eur Urol

    (2009)
  • J. Sammon et al.

    Anastomosis during robot-assisted radical prostatectomy: randomized controlled trial comparing barbed and standard monofilament suture

    Urology

    (2011)
  • N. Joshi et al.

    Impact of posterior musculofascial reconstruction on early continence after robot-assisted laparoscopic radical prostatectomy: results of a prospective parallel group trial

    Eur Urol

    (2010)
  • R.F. Coelho et al.

    Influence of modified posterior reconstruction of the rhabdosphincter on early recovery of continence and anastomotic leakage rates after robot-assisted radical prostatectomy

    Eur Urol

    (2011)
  • D.E. Sutherland et al.

    Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: results from a phase II randomized clinical trial

    J Urol

    (2011)
  • M. Menon et al.

    Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial

    J Urol

    (2008)
  • J.D. Sammon et al.

    Long-term functional urinary outcomes comparing single- vs double-layer urethrovesical anastomosis: two-year follow-up of a two-group parallel randomized controlled trial

    Urology

    (2010)
  • G.B. Di Pierro et al.

    A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload

    Eur Urol

    (2011)
  • S.C. Kim et al.

    Factors determining functional outcomes after radical prostatectomy: robot-assisted versus retropubic

    Eur Urol

    (2011)
  • J.P. Caballero Romeu et al.

    Radical prostatectomy: evaluation of learning curve outcomes laparoscopic and robotic-assisted laparoscopic techniques with radical retropubic prostatectomy [in Spanish]

    Actas Urol Esp

    (2008)
  • A.D. Asimakopoulos et al.

    Randomized comparison between laparoscopic and robot-assisted nerve-sparing radical prostatectomy

    J Sex Med

    (2011)
  • A.A. Hakimi et al.

    Direct comparison of surgical and functional outcomes of robotic-assisted versus pure laparoscopic radical prostatectomy: single-surgeon experience

    Urology

    (2009)
  • E.J. Trabulsi et al.

    Transition from pure laparoscopic to robotic-assisted radical prostatectomy: a single surgeon institutional evolution

    Urol Oncol

    (2010)
  • D.G. Murphy et al.

    Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications

    Eur Urol

    (2010)
  • G. Gautam et al.

    Posterior rhabdosphincter reconstruction during robot-assisted radical prostatectomy: critical analysis of techniques and outcomes

    Urology

    (2010)
  • V.R. Patel et al.

    Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes

    Eur Urol

    (2009)
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