Abstract
Background/Aim: Postoperative urinary incontinence (UI) after robot-assisted radical prostatectomy (RARP) has a significant impact on patients’ quality of life (QOL). Several surgical techniques have been reported to improve postoperative UI. The aim of the study was to investigate the impact of advanced reconstruction of vesicourethral support (ARVUS) on urinary symptoms and QOL after non-nerve-sparing robot-assisted radical prostatectomy (RARP). Patients and Methods: Patients who underwent non-nerve-sparing RARP from October 2010 to October 2020 at the Division of Urology, Department of Surgery, Tottori University Faculty of Medicine were reviewed. Patients were divided into the ARVUS and non-ARVUS groups, and propensity score matching was performed. Patients were evaluated by the International Prostate Symptom Score (IPSS), Incontinence Modular Questionnaire Short Form (ICIQ-SF), QOL index, and number of pads used before and 1, 3, 6, and 12 months after RARP. Results: The number of patients in the ARVUS and non-ARVUS group were 41 and 41, respectively. On cystography, the distance of the symphysis pubis to the bladder neck was significantly shorter (p<0.001) and the posterior urethrovesical angle was significantly smaller in the AUVUS group (p<0.001). In the ICIQ-SF, the ARVUS group was significantly better at 6 and 12 months postoperatively. In the IPSS, the ARVUS group was significantly better than the non-ARVUS group at 3 months postoperatively. In a multivariable analysis, membranous urethral length [odds ratio (OR)=3.44, p=0.015] and ARVUS (OR=2.72, p=0.046) were significant factors in achieving 0 pads and total ICIQ-SF Question 1 and 2 scores of ≤2 at 12 months postoperatively. Conclusion: ARVUS improved urinary symptoms and QOL. ARVUS seems to be a useful surgical procedure for non- nerve-sparing RARP.
Radical prostatectomy is an important treatment for patients with localized prostate cancer (PC) for patients with a life expectancy of >10 years. Robot-assisted laparoscopic radical prostatectomy (RARP) is currently the standard surgical treatment for localized PC. The three-dimensional magnified field of view and multiple joints enable delicate surgery, and compared to conventional open surgery, it has lower complication rates and blood transfusion rates, and is considered minimally invasive (1, 2). However, urinary incontinence (UI) and sexual dysfunction, complications specific to radical prostatectomy, are also important problems in RARP. The impact of UI on the patient quality of life (QOL) has been reported to be greater than that of sexual dysfunction (3). Nakagawa et al. reported that urinary bother and Incontinence Modular Questionnaire Short Form (ICIQ-SF) scores were associated with satisfaction after RARP (4). Several studies have reported on factors affecting urinary continence (UC) after RARP. Preoperative patient factors include age, body mass index (BMI), preoperative International Prostate Symptom Score (IPSS), and prostate volume (PV) (2, 5). Regarding surgical techniques, nerve-sparing (6-8) and bladder neck preservation (9) have been reported to be useful in achieving UC. Recently, Retzius-sparing (10) and Hood technique (11) have also been reported to be effective in achieving UC. Advanced reconstruction of vesicourethral support (ARVUS) is a surgical technique reported in 2017 and is a new method of posterior reconstruction (12). The procedure is simple and easy, requiring only a hammock suture of the anorectal muscles at the time of the posterior reconstruction. Since 2019, we have been performing ARVUS during non-nerve sparing (NNS) procedures in patients undergoing RARP.
The purpose of this study was to evaluate the impact of ARVUS on urinary symptoms and QOL for NNS RARP. This was a retrospective study, and propensity score matching (PSM) was performed to examine the effects of ARVUS.
Patients and methods
Ethics statement. This study was conducted at the Department of Urology, Tottori University Hospital. The research protocol was approved by the Tottori University Ethics Committee (approval number 2545).
Study population. Patients who underwent RARP at the Division of Urology, Department of Surgery, Tottori University Faculty of Medicine from October 2010 to December 2020 were included. The exclusion criteria included patients with missing data, an observation period of less than 12 months, preoperative or postoperative hormone therapy, postoperative radiation therapy, or nerve-sparing (NS) surgery (bilateral and unilateral NS), and without postoperative cystography. Preoperative factors include age, BMI, clinical stage, prostate-specific antigen (PSA) level, Gleason score (GS), PV, and membranous urethral length (MUL) were recorded. The IPSS, QOL index, ICIQ-SF, and number of pads used were evaluated before and at 1, 3, 6, and 12 months after RARP. All data were examined retrospectively.
Surgical procedures. RARP was performed by five highly experienced urologists using similar techniques. NS was performed in four grades following the report of Tewari et al. (13). The NS technique was defined as Grade 1, intrafascial dissection; Grade 2, interfascial dissection; Grade 3, extrafascial dissection; and Grade 4, wide dissection. The patient’s PSA level, GS of biopsy, and clinical stage were used for patient risk stratification, and the surgeon determined the NS grade preoperatively and intraoperatively. NS was defined as bilateral or unilateral Grade 1 and 2, and NNS was defined as Grades 3 and 4.
ARVUS was performed on NNS cases. First, the Denonvillier’s fascia and median dorsal raphe were sutured with a 3-0 Vloc (Figure 1A). The needle was applied to the right levator ani muscle (pubococcygeus muscle) (Figure 1B, C), and then to the left side using the same method (Figure 1D), pulling the levator ani muscle into a hammock-like shape (Figure 1E). Then, using the same thread as the second layer, the needle was moved into the longitudinal muscle, and the median dorsal raphe was sutured together (Figure 1F). In the non-ARVUS group, the Denonvilliers fascia and median dorsal raphe were sutured as the first layer, followed by a 3-0 Vloc suture of the longitudinal muscle and median dorsal raphe as the second layer.
The Denonvillier’s fascia and median dorsal raphe were sutured with a 3-0 Vloc (A). The needle was applied to the right levator ani muscle (pubococcygeus muscle) (B, C), and then to the left side using the same method (D), pulling the levator ani muscle into a hammock-like shape (E). Then, using the same thread as the second layer, the needle was moved into the longitudinal muscle, and the median dorsal raphe was sutured together (F).
Cystography. Cystography was performed on postoperative day 7 to evaluate the distance from the pubic symphysis to the bladder neck and the posterior urethral bladder angle. The frontal and oblique views were also obtained. The distance from the symphysis pubis to the bladder neck in the frontal view and posterior urethrovesical angle in the oblique view were measured. The oblique image was taken at a position of 45°.
Assessment of UI and questionnaire. UI was evaluated using the ICIQ-SF and the number of pads used. The status of urinary symptom was evaluated using the IPSS and QOL index. The frequency of incontinence was evaluated using the ICIQ-SF Question 1, while the amount of incontinence was evaluated using the ICIQ-SF Question 2. In the present study, we added the PICOMB definition to the assessment of UI and QOL. The PICOMB definition is an assessment method combining pad and ICIQ-SF (0 pads and total ICIQ-SF Questions 1 and 2 scores of ≤2), as reported by Twiss et al. (14).
Statistical analyses. Data were described in median and interquartile range (IQR). This study was a retrospective study, and a 1:1 PSM was performed to prepare the patients’ characteristics and exclude any possible influence on UC after RARP other than ARVUS. Propensity scores were estimated by multivariate logistic regression using variables such as age, clinical stage, BMI, PV, and MUL (Figure 2). The presented data were evaluated by the Mann-Whitney U or Chi-square tests. Multivariate logistic regression analysis was performed to identify factors associated with UI by the PICOMB definition at 12 months postoperatively. Statistical significance was set at p<0.05. Statistical analyses were performed using EZR, which is a modified version of R Commander.
Flowchart of inclusion criteria of propensity score matching analysis in patients with prostate cancer who underwent RARP with or without ARVUS. RARP: Robot-assisted radical prostatectomy; ARVUS: advanced reconstruction of vesicourethral support; BMI: body mass index; PV: prostate volume; MUL: membranous urethral length.
Results
After PSM, the total number of patients was 82; 41 in the ARVUS and 41 in the non-ARVUS groups (Table I). The median age, BMI, PSA, PV, and MUL of the ARVUS and non-ARVUS groups were 70.5 and 69 years, 23.2 and 24.1 kg/m2, 8.6 and 8.4 ng/ml 24.2 and 26.6 ml, and 12.5 and 13.8 mm, respectively. Surgical time, console time, and estimated blood loss were not significantly different between the two groups (Table I). In the ARVUS group, the distance from the symphysis pubis to the bladder neck was significantly shorter (median 10.9 mm vs. 17.6 mm, p<0.001), and the posterior urethrovesical angle was significantly smaller (median, 129.6° vs. 145°, p<0.001). Table II shows the results of ICIQ-SF, IPSS, and QOL index. In the ICIQ-SF, the ARVUS group was significantly better than the non-ARVUS group at 6 and 12 months postoperatively for each question and total score. IPSS was also significantly better in the ARVUS group from 3 to 12 months postoperatively. The QOL index was significantly better in the ARVUS group only at 6 months postoperatively. The pad-free rates were 6.8% and 9.1% at 1 month, 15.9% and 20.5% at 3 months, 36.4% and 34.1% at 6 months, and 45.5% and 61.4% at 12 months in the non-ARVUS and ARVUS groups respectively, with no significant difference between the two groups. In a multivariable logistic regression analysis with age, BMI, PV, MUL, and ARVUS as factors, MUL [odds ratio (OR)=3.44, p=0.015] and ARVUS (OR=2.72, p=0.046) were significant factors in achieving 0 pads and total ICIQ-SF Question 1 and 2 scores of ≤2 at 12 months postoperatively (Table III).
Patient characteristics and perioperative outcomes of non-ARVUS and ARVUS groups.
Longitudinal outcomes for ICIQ-SF, IPSS, QOL index and pad free rate.
Multivariate analysis used to identify significant predictors in achieving 0 pads and total ICIQ-SF questions 1 and 2 score: ≤2 definition at 12 months after RARP.
Discussion
Preoperative factors associated with UI after RARP include age, BMI, preoperative IPSS score, preoperative PV (2), MUL (15), and intravesical prostatic protrusion (16) have been reported. In addition, surgeon experience and intraoperative surgical techniques such as NS (2), bladder neck preservation (8), treatment of the prostatic apex (2), Retzius sparing (10), and the Hood technique (11) have been reported to be useful in obtaining UC. In our previous studies, preoperative MUL (15), intravesical prostatic protrusion (16), and NS (6) were also factors related to postoperative UC. Nevertheless, there are certain cases in which NS is not possible due to the localization or GS of PC. We have been performing ARVUS since 2019, with the objective of obtaining UC in cases of NNS RARP.
ARVUS is a surgical technique used to obtain early postoperative UC, as reported by Student et al. (12). They reported that ARVUS can achieve better UC than standard posterior reconstruction and does not adversely affect the complication rates, erectile dysfunction, or oncological outcomes. In a report by Student et al., ARVUS was also performed in patients who had undergone NS; however, we did not perform it in NS cases to minimize damage to neurovascular bundles. The mechanisms of ARVUS include the ability to directly support the urethra from the dorsal side, as in urethral sling surgery, relieving tension at the vesicourethral anastomosis, and bringing the anatomy closer to the preoperative state. There are several reports of sling operations for RARP (17), and sling materials including the rectus fascia (18) and small intestinal submucosa (19). A systematic review by Lim et al. reported that intraoperative sling procedures were effective in gaining UC in the early postoperative period but had no long-term impact (17). Kojima et al. reported that early UC was achieved using the bladder neck sling suspension technique; however, they included approximately 20% of patients with NS (20). Other reports have also included NS cases, and the results may differ because they did not include NS cases, as in our study.
In our study, postoperative posterior urethrovesical angle was more acute in the ARVUS group. This finding was thought to be due to the urethra being supported by muscles formed in a hammock shape on the dorsal side. In women with stress urinary incontinence, the posterior urethrovesical angle is often enlarged, and ARVUS may be useful for the treatment of UI through the same mechanism as after urethral sling surgery. As for the distance from the symphysis pubis to the bladder neck, the ARVUS group was also shorter than non-ARVUS group. We found that the vesicourethral anastomosis was more firmly supported by suturing the levator ani muscle than the Rocco stitch alone, reducing the strong traction of the urethra in the caudal direction and making it possible to secure the length of the urethra.
In this study, we evaluated UI using the ICIQ-SF. The International Continence Society (ICS) recommends pad weight, not pad count, for the assessment of postoperative UI after radical prostatectomy (21). The ICIQ-SF was developed as a common international questionnaire for the assessment of UI (22). In the present study, both groups were NNS cases, and UC was somewhat poor. Complete UC was achieved in a few cases, but the ICIQ-SF score was better in the ARVUS group 6 months postoperatively. In the present study, only a few patients were able to achieve complete UC, because patients who underwent NNS RARP were eligible. Therefore, PICOMB definition was used to evaluate ARVUS for UC. The PICOMB definition was proposed by Twiss et al. (14). They reported that 0 pads and an ICIQ score of ≤2 were defined as having the least impact on QOL. In this study, we proposed a PICOMB definition for the evaluation of UC and QOL at 12 months postoperatively, and a significant factor in achieving 0 pads and an ICIQ score ≤2 was the ARVUS procedure, along with MUL.
Student et al. reported that ARVUS was significantly effective in achieving UC from early postoperative period to 12th month postoperative period (12). In contrast, Kováčik et al. reported that ARVUS was not effective in achieving UC (23). They reported that NS and time since surgery were factors in achieving UC; however, ARVUS was not a significant factor. In the study by Kováčik et al., ARVUS was also performed in NS cases, which differs from our study. In the present study, ARVUS was performed only in NNS cases, suggesting that the addition of ARVUS to NNS cases may have some effect on obtaining UC.
This study had certain limitations. First, it included a small number of cases. Second, there were five surgeons who performed the RARP, which means that there may be differences in surgical skill. Therefore, it would be desirable to conduct a prospective study including a larger number of patients for NNS cases.
Conclusion
ARVUS is a simple procedure, does not extend the operative time, and has no specific complications. Our study suggests that ARVUS is effective in obtaining UC in patients undergoing NNS RARP.
Acknowledgements
We would like to thank Editage (www.editage.com) for English language editing.
Footnotes
Authors’ Contributions
Study concept and design: Katsuya Hikita. Data acquisition: Masashi Honda, Ryutaro Shimizu, Hideto Iwamoto, Shuichi Morizane, Katsuya Hikita. Data analysis: Shogo Teraoka, Ryoma Nishikawa, Yusuke Kimura, Noriya Yamaguchi, Katsuya Hikita. Drafting of manuscript: Katsuya Hikita. Critical revision of the manuscript: Masashi Honda, Atsushi Takenaka
Conflicts of Interest
The Authors declare no competing interests for this study.
- Received October 7, 2022.
- Revision received November 8, 2022.
- Accepted November 28, 2022.
- Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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