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