Yonsei Med J.  2016 Sep;57(5):1145-1151. 10.3349/ymj.2016.57.5.1145.

Urinary Continence after Robot-Assisted Laparoscopic Radical Prostatectomy: The Impact of Intravesical Prostatic Protrusion

• Jo JK
• Hong SK
• Byun SS
• Zargar H
• Autorino R
• Lee SE

• KMID: 2374159
• DOI: http://doi.org/10.3349/ymj.2016.57.5.1145

Abstract

PURPOSE
To assess the impact of intravesical prostatic protrusion (IPP) on the outcomes of robot-assisted laparoscopic prostatectomy (RALP).
MATERIALS AND METHODS
The medical records of 1094 men who underwent RALP from January 2007 to March 2013 were analyzed using our database to identify 641 additional men without IPP (non-IPP group). We excluded 259 patients who presented insufficient data and 14 patients who did not have an MRI image. We compared the following parameters: preoperative transrectal ultrasound, prostate specific antigen (PSA), clinicopathologic characteristics, intraoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, and continence until postoperative 1 year. IPP grade was stratified by grade into three groups: Grade 1 (IPP≤5 mm), Grade 2 (5 mm10 mm).
RESULTS
Of the 821 patients who underwent RALP, 557 (67.8%) experienced continence at postoperative 3 months, 681 (82.9%) at 6 months, and 757 (92.2%) at 12 months. According to IPP grade, there were significant differences in recovering full continence at postoperative 3 months, 6 months, and 12 months (p<0.001). On multivariate analysis, IPP was the most powerful predictor of postoperative continence in patients who underwent RALP (p<0.001). Using a generalized estimating equation model, IPP also was shown to be the most powerful independent variable for postoperative continence in patients who underwent RALP (p<0.001).
CONCLUSION
Patients with low-grade IPP have significantly higher chances of recovering full continence. Therefore, the known IPP grade will be helpful during consultations with patients before RALP.

Keyword

Continence; intravesical prostatic protrusion; robot assisted radical prostatectomy; transrectal ultrasonography

MeSH Terms

Aged, 80 and over
Humans
Laparoscopy/methods
Magnetic Resonance Imaging
Male
Middle Aged
Multivariate Analysis
Postoperative Complications/etiology
Prostatectomy/*methods
Prostatic Neoplasms/complications/*surgery
*Recovery of Function
*Robotic Surgical Procedures
Urinary Bladder Neck Obstruction/*diagnostic imaging/etiology
*Urination

Figure

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  Fig. 1 Intravesical prostatic protrusion (IPP) under transrectal ultrasound. (A) IPP (Grade 3). (B) No-IPP.

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  Fig. 2 IPP grade: Grade I (A), Grade II (B), Grade III (C), Grade III (transverse plane) (D); C and D are images of same patient. White line shows IPP. IPP, intravesical prostatic protrusion.

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  Fig. 3 GEE model for postoperative incontinence rates. GEE, generalized estimating equation.

Reference

1. Heidenreich A, Bastian PJ, Bellmunt J, Bolla M, Joniau S, van der Kwast T, et al. EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013. Eur Urol. 2014; 65:124–137.

2. Montorsi F, Wilson TG, Rosen RC, Ahlering TE, Artibani W, Carroll PR, et al. Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. Eur Urol. 2012; 62:368–381.

3. Walz J, Burnett AL, Costello AJ, Eastham JA, Graefen M, Guillonneau B, et al. A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Eur Urol. 2010; 57:179–192.

4. Jenkins LC, Nogueira M, Wilding GE, Tan W, Kim HL, Mohler JL, et al. Median lobe in robot-assisted radical prostatectomy: evaluation and management. Urology. 2008; 71:810–813.

5. Jeong CW, Lee S, Oh JJ, Lee BK, Lee JK, Jeong SJ, et al. Quantification of median lobe protrusion and its impact on the base surgical margin status during robot-assisted laparoscopic prostatectomy. World J Urol. 2014; 32:419–423.

6. Coelho RF, Chauhan S, Guglielmetti GB, Orvieto MA, Sivaraman A, Palmer KJ, et al. Does the presence of median lobe affect outcomes of robot-assisted laparoscopic radical prostatectomy. J Endourol. 2012; 26:264–270.

7. Jung H, Ngor E, Slezak JM, Chang A, Chien GW. Impact of median lobe anatomy: does its presence affect surgical margin rates during robot-assisted laparoscopic prostatectomy. J Endourol. 2012; 26:457–460.

8. Meeks JJ, Zhao L, Greco KA, Macejko A, Nadler RB. Impact of prostate median lobe anatomy on robotic-assisted laparoscopic prostatectomy. Urology. 2009; 73:323–327.

9. Nose H, Foo KT, Lim KB, Yokoyama T, Ozawa H, Kumon H. Accuracy of two noninvasive methods of diagnosing bladder outlet obstruction using ultrasonography: intravesical prostatic protrusion and velocity-flow video urodynamics. Urology. 2005; 65:493–497.

10. Mariappan P, Brown DJ, McNeill AS. Intravesical prostatic protrusion is better than prostate volume in predicting the outcome of trial without catheter in white men presenting with acute urinary retention: a prospective clinical study. J Urol. 2007; 178:573–577.

11. Kojima Y, Takahashi N, Haga N, Nomiya M, Yanagida T, Ishibashi K, et al. Urinary incontinence after robot-assisted radical prostatectomy: pathophysiology and intraoperative techniques to improve surgical outcome. Int J Urol. 2013; 20:1052–1063.

12. Mohler JL, Kantoff PW, Armstrong AJ, Bahnson RR, Cohen M, D'Amico AV, et al. Prostate cancer, version 2.2014. J Natl Compr Canc Netw. 2014; 12:686–718.

13. Srivastava A, Chopra S, Pham A, Sooriakumaran P, Durand M, Chughtai B, et al. Effect of a risk-stratified grade of nerve-sparing technique on early return of continence after robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2013; 63:438–444.

14. Xu D, Yu Y, Zhu Y, Huang T, Chen Y, Qi J. A new model consists of intravesical prostatic protrusion, prostate volume and serum prostatic-specific antigen in the evaluation of prostate cancer. Pathol Oncol Res. 2014; 20:439–443.

15. Lim KB, Ho H, Foo KT, Wong MY, Fook-Chong S. Comparison of intravesical prostatic protrusion, prostate volume and serum prostatic-specific antigen in the evaluation of bladder outlet obstruction. Int J Urol. 2006; 13:1509–1513.

16. Konety BR, Sadetsky N, Carroll PR. CaPSURE Investigators. Recovery of urinary continence following radical prostatectomy: the impact of prostate volume--analysis of data from the CaPSURE Database. J Urol. 2007; 177:1423–1425.

17. Kim KH, Kim YS. Correlation of male overactive bladder with intravesical prostatic protrusion. Korean J Urol. 2010; 51:843–846.

18. Park YJ, Bae KH, Jin BS, Jung HJ, Park JS. Is increased prostatic urethral angle related to lower urinary tract symptoms in males with benign prostatic hyperplasia/lower urinary tract symptoms. Korean J Urol. 2012; 53:410–413.

19. Lee JW, Ryu JH, Yoo TK, Byun SS, Jeong YJ, Jung TY. Relationship between intravesical prostatic protrusion and postoperative outcomes in patients with benign prostatic hyperplasia. Korean J Urol. 2012; 53:478–482.

20. Brunocilla E, Pultrone C, Pernetti R, Schiavina R, Martorana G. Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra during retropubic radical prostatectomy: description of the technique. Int J Urol. 2012; 19:783–785.

21. Gacci M, Carini M, Simonato A, Imbimbo C, Gontero P, Briganti A, et al. Factors predicting continence recovery 1 month after radical prostatectomy: results of a multicenter survey. Int J Urol. 2011; 18:700–708.

22. Stolzenburg JU, Kallidonis P, Hicks J, Do M, Dietel A, Sakellaropoulos G, et al. Effect of bladder neck preservation during endoscopic extraperitoneal radical prostatectomy on urinary continence. Urol Int. 2010; 85:135–138.

23. Lowe BA. Comparison of bladder neck preservation to bladder neck resection in maintaining postrostatectomy urinary continence. Urology. 1996; 48:889–893.

24. Asimakopoulos AD, Miano R, Di Lorenzo N, Spera E, Vespasiani G, Mugnier C. Laparoscopic versus robot-assisted bilateral nervesparing radical prostatectomy: comparison of pentafecta rates for a single surgeon. Surg Endosc. 2013; 27:4297–4304.

25. Wei JT, Dunn RL, Litwin MS, Sandler HM, Sanda MG. Development and validation of the expanded prostate cancer index composite (EPIC) for comprehensive assessment of health-related quality of life in men with prostate cancer. Urology. 2000; 56:899–905.