"I've worked in 3 different countries, I've seen dozens of people doing robotic radical prostatectomy...so my current practice is kind of a “best of” what I have seen and learned," says Ricardo Soares, MD.
In this article, Ricardo Soares, MD, discusses the techniques he and other experts employ to minimize incontinence after radical prostatectomy. Dr. Soares is a urologist with Northwestern Medicine in Chicago (Western suburbs), Illinois.
When I'm discussing surgery, or any kind of treatment for prostate cancer, with patients, I always talk about the “trifecta”—the 3 factors to define a successful treatment, by order of priority:
1. Oncological outcome by getting all the cancer out, resulting in undetectable [prostate-specific antigen level] after surgery.
2. Continence. And when I say "be continent," I mean being pad free, because [there are] articles that define continence as wearing 0-1 pads.
3. Maintain their erectile function. Many patients already have issues before surgery, so they mostly worry about the first 2 factors.
Given the concerns about post-operative incontinence, I'm always trying to improve my technique and try to prepare patients better and better to minimize side effects from the surgery.
In about 80% of the cases of incontinence after surgery, there is a sphincter insufficiency problem. That's because when the prostate is removed, you lose all the smooth muscle in the prostatic urethra and sometimes the bladder neck. Also, the striated muscle of the sphincter, although it is still saved, gets impacted by the surgery. It is impacted because of 4 factors: shortened membranous urethra; direct trauma to the sphincter; innervation of the pelvic muscles (particularly with more advanced cancer when you need to remove part of the neurovascular bundle); hypoperfusion (due to removal of small blood vessels that are supplying blood to the sphincter).
There are different factors that increase the risk of incontinence after surgery, and I always discuss them with my patients: older age; comorbidities / worse performance status ( higher [American Society of Anesthesiology] score); obesity; large prostate size; and previous prostate surgery.
Obviously, in the US, obesity is a big problem. Sometimes, it may be difficult to extrapolate the results from Europe and Asia to the American population, because the bodies are not the same. That's why it's important to know your own results. I know my results over the past 5 years here in the US, and those are what I quote to my patients. Whenever you're talking about the risk of incontinence, you should know your own data. Citing the results of someone who has more experience than you may be misleading and patients should be made aware of that.
Prostate size is another factor. Patients with larger prostates are going to have a slightly higher risk of incontinence. The bladder neck is going to be bigger, there's more difficulty in sparing the surrounding structures and having a good view of the apex to spare that membranous urethra. It's easier with small prostates to get a good sparing of the urethra.
Patients who have a higher score on questionnaires such as the International Consultation on Incontinence Questionnaire and International Prostate Symptom Score tend to have more problems, particularly [if they have] overactive bladder, because obviously that is not going to be resolved with a prostatectomy.
Another factor is the stage of the cancer. If the cancer is more advanced, you need to remove more surrounding tissues around the prostate. To get extra safety margin, you remove more nerves and more arteries, and therefore the sphincter innervation and blood supply are going to be more compromised, increasing the risk of incontinence. Even if the patient eventually becomes continent, they tend to have a slower recovery.
In terms of imaging, there have been studies showing that the length of the membranous urethra length (evaluated on either MRI or transperineal ultrasound) is a predictor of continence after surgery. For someone who has a very long urethra, the reconstruction is probably going to be easier. It has been shown that for each extra millimeter that you have in the urethra, there is a 5% increase of recovery of continence, and that's predictive at 6 and 12 months.
Another parameter is the thickness of the levator ani muscle. That is obviously is a surrogate for the patient's fitness, and it has been shown to weave in with other types of cancer surgery; the thicker it is, the faster recovery the patient is going to have.
There have been studies [looking at whether] the bladder neck shape of the apex is overlapping the urethra makes a difference, but there was nothing conclusive in regards to those parameters.
There are things that you can do to prepare the patient for when they get to the surgery date. Obviously, weight loss is number 1. With most cases, from the time of diagnosis until the surgery, you're probably going to have maybe 6 weeks to 3 months. That's not a long time to lose a lot of weight, but it still can be significant. I have a patient with a [body mass index] of 49, but his cancer is not too aggressive. We decided to give him some extra time to become fitter, because this is going to help him in the long run. There are several studies showing that doing aerobic exercise and resistance training can also help with recovery.
For me, what is most important is doing pelvic floor muscle therapy. Upon diagnosis, I send all of my patients to see one of our physical therapists here at Northwestern. You can really see the difference with the patients who go for physical therapy and the ones who don't. This has been studied for over 20 years; there have been randomized controlled trials, initially all [evaluating] postop physical therapy. Then, in 2001, there was the first trial of preop and postop physical therapy showing that you can increase the chances of quicker recovery of continence at 3 months by up to 4 times.1 Even at 1 year, it can be 1.2 times compared with someone who doesn't do physical therapy. Therefore, I have this in my normal protocol for every single patient.
Then you get to the actual surgery. Since the time of open surgery, there have been multiple maneuvers to try to improve continence: preservation of the membranous urethra, preservation of the bladder neck, nerve sparing (if the cancer allows you to), [and] preservation of the puboprostatic ligaments that attach the anterior side of the prostate to the pubic bone.
Regarding neurovascular bundle sparing, there are good data from [Ashutosh K. Tewari, MD] showing that with grade 1 interfascial nerve sparing surgery, 71% of patients are continent at 3 months compared to 50% in the overall cohort.
There have been studies trying to link lymph node dissection to incontinence; the results are inconsistent.
I think the preservation of puboprostatic ligaments is probably one of the first things that was done on a regular basis. There are some studies from laparoscopic surgery in Germany from [Jens-Uwe Stolzenberg, MD], back in the early 2000s, showing that if you preserve the puboprostatic ligaments in extraperitoneal laparoscopic prostatectomy, you can really improve continence at 3 months.
Usually, there's a lot of preservation anterior to the prostate but also posteriorly. But anteriorly, where we have the dorsal vascular complex (DVC), I think generally people would put a stitch on the DVC and then cut it. But there are studies showing that if you cut first, you're able to visualize better the urethra. If you cut and stitch, you can improve continence right there. A study from [Vipul Patel, MD], showed that if you suspend that stitch through the pubic periosteum, you have a small improvement of continence results. Some of these things by themselves are not going to make a huge difference, but if you add them all together, they really make an impact for the patient.
Posteriorly, the Rocco stitch is very widespread. It was actually developed in 2006 for open surgery, and 1 year later, applied to laparoscopic surgery. I mostly do Retzius sparing surgery, but when I do an anterior approach, I always do a Rocco stitch, because although the data is inconsistent, a meta-analysis show that it may improve continence at 3 months, with no difference at 6 months. Anyway, I think it helps achieve a tension-free anastomosis, so when I do an anterior approach, I do a Rocco stitch.
In 2007, [Richard Gaston, MD], from Bordeaux, France, developed a pubovesical complex-sparing technique, also called lateral approach. I actually saw him do this in a live course at the Martini-Klinik in Germany and it is a really outstanding surgery. [Dr Gaston] takes down only the right half of the bladder, leaving all the connective tissue anterior to the left side of the bladder and anterior to the prostate still attached to the anterior abdominal wall. He then finds the angle between the prostate and the bladder, and goes directly into the tip of the right seminal vesicle. And that's how he'll start the dissection of the neurovascular bundle. Then he goes anteriorly under the pubovaginal complex, also called the detrusor apron, which has striated muscles, smooth muscle fascia, connective tissue, that gives an extra support. He will go under that tissue, and then remove the prostate. This was first reported in 30 patients, of whom 80% were immediately continent and 100% were continent at 1 month. There were some concerns about positive margins, [which were observed in] only about 10% of patients. More recently he presented a series of 300 patients, of which 90% were continent at 1 month and 98.5% at 1 year. [That is] outstanding, and the technique is really fascinating in his hands.2,3
Then in 2010, [Aldo Bocciardi, MD], in Milan, Italy, developed what is known as Retzius-sparing technique, in which the whole surgery is done through the Douglas pouch. Due to the complete preservation of the connective tissue anterior to the prostate and bladder, 75% of patients were continent at 1 week, and 90% at 1 month, so pretty similar results to the results by Dr Gaston. I learned this technique in 2016 back in England during Fellowship. I had the pleasure to be the bedside assistant to my mentor [Christopher Eden, MD] as he performed the first Retzius-sparing surgery in England. As in any new technique, there were some initial struggles because of dissection being done from posterior to anterior, but we published our data and even in the beginning of the learning curve, 90% of patients were pad free at 1 month. For experienced surgeons, there's going to be maybe 20 cases of a learning curve to get good results. Also, because you leave the bladder attached to the anterior wall, instead of using a Foley catheter, you can use a suprapubic catheter, which means that the patient is more comfortable and they can start doing their pelvic floor exercises right after surgery. This technique has fortunately now gone across the ocean, and there are a lot of people in the US doing it, including myself.
More recently, Dr Tewari developed a variation of Dr. Gaston’s lateral approach called “hood-sparing” technique. It's an anterior approach, but leaves all the tissue of the detrusor apron (or “hood”), attached to the anterior wall. At the end, while Dr Gaston would go laterally (and wouldn't have to reconstruct the detrusor apron), with Dr Tewari's technique there is a need to reconnect the detrusor apron to the bladder. Again, the results are really good: 83% continence at 1 month, 95% after 1 year, with positive margins in only 6% of patients.
Now, more recently, the latest innovation is the single-port robot system that allows for transvesical prostatectomy. There are some data, mainly from [Jihad Kaouk, MD], from Cleveland Clinic, where there's only 1 port and the prostate is removed through the bladder. With this approach, everything that surrounds the bladder and prostate from above and below is preserved. The results are good with 72% continence at 6 weeks, but seem to fall short of the outcomes for Retzius-sparing, lateral approach, or hood-sparing techniques, in which 90% are continent at 1 month. Perhaps the difference lies on removing the prostate through the bladder neck. We know that the bladder neck has some role in postop continence, but to allow removal of the prostate the bladder neck is going to need to be wider.
I've worked in 3 different countries, I've seen dozens of people doing robotic radical prostatectomy, including visits to the Martini-Klinik (Germany) and OLV (Belgium), so my current practice is kind of a “best of” what I have seen and learned.
Whenever I get someone who comes to my office with a diagnosis of prostate cancer, we discuss surgery, and I usually send them to see a radiation oncologist to discuss radiotherapy options. Right away, I send them to physical therapy. Even if the patient does not choose to undergo surgery, physical therapy may be beneficial. It's better to start early because it's easier if you start when you're healthy and are not recovering from surgery. If you already know all the exercises before, you're going to do better in the postoperative period.
By default, I do a Retzius-sparing robotic prostatectomy and the continence results are excellent without jeopardizing cancer control. However, when the MRI shows tumor in the anterior base with abutment of the capsule or anterior fibromuscular stroma, I may proceed with a more traditional anterior approach of taking down the bladder. In this case, I will cut and stitch the DVC and perform a Rocco stitch. Sometimes do an anterior reconstruction of the detrusor apron. But in more than 90% of cases, Retzius-sparing is my chosen technique given the quicker recovery of continence.
1. Sueppel C, Kreder K, See W. Improved continence outcomes with preoperative pelvic floor muscle strengthening exercises. Urol Nurs. 2001;21(3):201-210
2. Asimakopoulos AD, Annino F, D’Orazio A, et al. Complete periprostatic anatomy preservation during robot-assisted laparoscopic radical prostatectomy (RALP): the new pubovesical complex-sparing technique. Eur Urol. 2010;58(3):407-17. doi:10.1016/j.eururo.2010.04.032
3. Elbers JR, Socarras MR, Llanes L, Rivas JG. Feasibility and clinical outcomes of robot-assisted radical prostatectomy by lateral approach. J Urol. 2022;207(suppl 5):e661. doi:10.1097/JU.0000000000002598.08