Recovery of Continence

The quality of continence after any technique of radical prostatectomy (i.e., retropubic, perineal, laparoscopic) is difficult to assess, as reflected by the marked variability of incontinence rates reported in the literature. This is related to three main factors: definition of continence, modalities of evaluation, and follow-up.

The definition of continence varies considerably from one pad study to another: total absence of protection (i.e., no pad) or use of a maximum of one pad (i.e., safety pad). Others distinguish between diurnal and nocturnal continence. Geary et al. (49) reported that 80.1% of patients did not require any protection, while Eastham et al. (50), considering patients who required a maximum of one pad daily to be continent, reported a rate of 91%. It might not be extremely relevant for the quality of life of the patients to wear a safety pad (i.e., to be "socially dry"), and some patients may still use one despite having reached already complete continence.

In most laparoscopic and open studies (Table 13), full continence was defined as no need of any pads during normal daily activity (i.e., work, exercise, walking), no urine leak with cough or sneeze. Minimal stress incontinence was defined as occasional urine leak (i.e., when exercising, with cough or sneeze) necessitating no more than three pads per day and no urine leak during night. Moderate stress incontinence was defined as urine leak during the day under normal activity requiring more than three pads, and no urine leak during night. Severe stress incontinence was defined as urine leak during the day and night representing a serious problem for the patient.

The modalities of evaluation also differ considerably: clinical interview by the surgeon, interview by another doctor not involved in the surgery, self-administered questionnaire. The method of data collection is essential to obtain perfectly objective information. Again an increase by 10-15% of incontinence rates has to be calculated, when using a questionnaire (36,59,60). Evidently, the general application of a validated questionnaire (i.e., Interrehand Continence Society-Male Questionnaire) would facilitate comparison of the various results reported in the literature (61). It has to be emphasized that in most of the laparoscopic studies a questionnaire was applied. In our center, all patients who do not return the questionnaire are interviewed by colleagues not involved in the surgery. Additionally, the time to full continence is documented for each patient.

Finally, the follow-up frequently differs from one series to another. Although about half of the patients can achieve full continence within the first three months and

TABLE 13 ■ Laparoscopic versus Open Radical Prostatectomy: Recovery of Continence

Mean age

Follow-up

Continence

Author (Ref.)

N

(yr)

Evaluation

(mos)

(%)

Laparoscopic radical prostatectomy

Turk et al. (28)

275

60.2

Physician

12

94.0

Eden (51)

100

62.2

Physician

12

90.0

Guillonneau et al. (12)

567

63.0

Questionnaire

12

79.0

Salomon et al. (40)

100

65.1

Questionnaire

12

90.0

Roumeguere (52)

77

62.5

Physician

12

80.7

Rassweiler et al. (14)

500

64.0

Questionnaire

12

83.6

Rassweiler et al. (14)

310

64.0

Questionnaire

24

97.7

Total/mean

1929

63.0

13.7

87.8

Open radical prostatectomy

Catalona et al.(1999)

1325

63.0

Physician

50

92.0

Walsh et al. (2000)

64

57.0

Questionnaire

18

93.0

Steiner (2000)

593

34-76

Physician

22

94.5

Kao (2000)

1069

63.6

Questionnaire

>12

77.0

Sullivan (2000)

75

63.3

Questionnaire

12

87.0

Rassweiler et al. (2003)

219

65.0

Questionnaire

12

89.9

Roumeguere (2003)

77

63.9

Physician

12

83.9

Harris (2003)

439

65.8

Physician

12

96.0

Total/mean

3861

63.0

18.7

89.1

most are dry at one year, some patients can still recover for up to two years (Table 14) with significant impact on their quality of life. Thereafter, improvement of urinary function is unlikely to occur.

Furthermore, independently of the technique, the main predisposing factor for postoperative incontinence appears to be greater than 70 years (49,52,53,61). The respective roles of other factors, such as stage of disease, associated diseases (i.e. diabetes, polyneuropathia, smoking), postoperative extravasation, or anastomotic stricture are also discussed (49,50,63).

Apart from this, some authors, again independent from the approach, consider that certain technical modifications appear to facilitate preservation of continence: quality of apical dissection, preservation of puboprostatic ligaments, preservation of bladder neck or the neurovascular bundle (55,63-65). The impact of such surgical modifications on postoperative continence is evident but very difficult to evaluate.

There is no doubt that in this millennium every "radical prostatecomist"—be it an open surgeon or a laparoscopist—tries to perform a most delicate apical dissection with maximal preservation of the circumferential rhabdosphincter muscles and minimal damage to its surrounding structure. On the other hand, all further technical proposals, such as preservation of the bladder neck or puboprostatic ligaments, preservation of the intrapelvic branch of the pudendal nerve, reconstruction of the rectourethralis muscle or facial retrourethral structures are still under debate, mainly because the initially described quicker time to total continence turned out not to be constantly reproducible (55,63-65).

TABLE 14 ■ Laparoscopic Radical Prostatectomy: Development of Continence (Compared with Open Radical Prostatectomy)

Laparoscopic

Open

Follow-up (%)

Rassweiler et al.

Salomon et al.

Eden et al.

Eastham et al.

Henzer et al.

Harris

1 month

28

45

11

28

33

38

3 months

51

63

62

65

69

62

6 months

70

74

81

79

85

85

12 months

84

90

90

92

91

96

24 months

97

NA

92a

95

NA

NA

aFollow-up at 18 months.

Abbreviation: NA, not available.

In summary, there are no significant differences between the laparoscopic or open approach, neither with respect to overall 12 months continence (60-94% vs. 61-98%) nor regarding the three months continence (51-63% vs. 62-69%), as postulated by some authors.

Conclusively, it is not the approach but the experience of the surgeon that remains one of the most essential factors to improve the recovery of continence.

The most successful tool to evaluate erectile dysfunction proved to be the abridged, five-item version of the International Index of Erectile Function.

In summary, there are no significant differences between the laparoscopic or open approach, neither with respect to overall 12 months continence (60-94% vs. 61-98%) nor regarding the three months continence (51-63% vs. 62-69%), as postulated by some authors.

Based on the actual results, laparoscopic surgery enables the transformation of all technical variations proposed for open radical prostatectomy, but despite all efforts could not yet significantly improve early continence rates in comparison to open surgery (49,50,53-55,62-65).

Conclusively, it is not the approach but the experience of the surgeon that remains one of the most essential factors to improve the recovery of continence. The cases of later recovery of continence are mainly attributed to associated factors such as age or concomitant morbidity of the patient.

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