Home 
Prostate Cancer European Urology - Urinary Continence after Radical Prostatectomy: “Beauty is in the Eye of the Beholder”
Prostate Cancer European Urology - Urinary Continence after Radical Prostatectomy: “Beauty is in the Eye of the Beholder”
 |
| European Urology - Urinary Continence after Radical Prostatectomy: “Beauty is in the Eye of the Beholder” |
|
|
|
|
|
| Monday, 02 April 2007 | ||
|
Volume 51, Issue 4, Pages 879-880 (April 2007) Predicting the time to recovery of urinary continence after radical prostatectomy remains an impossible task. The causes for the challenge are the multifactorial nature of incontinence after postprostatectomy, involving preoperative, intraoperative, and postoperative factors, some of which have been studied at length and others not studied thoroughly [1], [2]. Preoperatively, the patient's age, urinary function, detrusor status, prostate size, bladder capacity, and compliance are either known or still hypothetical factors affecting postoperative urinary continence. Intraoperatively, the surgical technique and the degree of preservation of the neurovascular bundles have been shown as independent predictors of long-term urinary continence [2]. Postoperatively, the most striking factor is the literature's lack of uniformity in defining, assessing, and reporting urinary continence, which may explain in part the wide variability of results [3]. The definition of urinary continence used, the methodology by which the data are obtained and analyzed, and the time of assessment need to be considered when interpreting the results; otherwise any comparative analysis between series remains totally meaningless. This lack of standardization hinders the understanding of urinary incontinence after radical prostatectomy and adds to its complexity. The paper by Rocco and colleagues in this issue of European Urology reports on the impact of a surgical technique modification (posterior reconstruction of the rhabdosphincter) on recovery of continence in the short term after radical prostatectomy. Significant improvement over the control group was noted during the first few weeks, although this positive effect was no longer significant at 3 mo postoperatively and both groups had comparable recovery of continence [4]. This article does not explain the physiologic impact of such a reconstruction but certainly confirms two already known facts: (1) the outcome of radical prostatectomy is intimately related to the surgical technique, and (2) the assessment of postoperative continence is far from being standardized. The bias can be introduced at different levels: the patient, the method of measurement, the physician, the statistical analysis, and, finally, the interpretation of results. One can raise the question of how continent is “continent” according to the surgeon and how continent is “continent” according to the patient? The reported results in the prostatectomy literature oppose the findings of multicenter studies using patient self-reported questionnaires to those based on single-surgeon, single-institution experience, physician assessment, or third-party telephone caller (92–97% continence rate at 1 yr postoperatively, with a median time to recovery of continence of 14 d) [1], [5]. Multi-institutional, patient- completed questionnaire types of studies reflect lower continence rates (31% reported having total urinary control at 12 mo with the urinary incontinence representing a moderate to big problem in 14.3% of the patients at 1 yr [6], and in another study it represented 8% at 4 yr [7]). It is my experience that a patient having “no leak with complete control” of urination in the immediate postoperative period is exceptional; the majority of patients do experience different degrees of stress urinary incontinence, the duration of which nobody is yet able to predict. Fortunately, the majority of the patients “overcome” their urinary control issues. Some of them reach the “no leak” perfect stage, others still experience an occasional and minimal degree of stress urinary incontinence, and perhaps others have learned to live with it and have adapted to their new condition with less of a bother. All three scenarios, on one hand, are considered “continent” by the most stringent definition, that of no pads; on the other hand, the three scenarios clearly show the inadequacy of the questionnaires in assessing urinary continence. The findings in the Prostate Cancer Outcomes Study of 60.5% reporting a pad-free continence level at 12 mo, whereas only 31% reporting total control [6], bears witness to the fact that what we define as “continent” covers a wide spectrum of clinical scenarios. The questionnaire is the best tool we have so far that considers subjective symptoms, objective and measurable. To accomplish this it has to be reliable, easily readable, reproducible, and thorough, evaluating the patient's condition as well as its impact on the quality of life. It should offer multiple options to fit the patient's clinical scenario with as close accuracy as possible. For scientific “rigueur”, it is best to use appropriate and agreed-on questionnaires as tools to measure continence after radical prostatectomy and to avoid the physician's input, albeit in good faith, as a possible source of bias. Although, it may be interesting if the questionnaire included the question “Is your urinary control similar to what it was before treatment?” or if we reported on degrees of incontinence rather than continence rate after radical prostatectomy because the term “continent” remains a mosaic. Perhaps it is incumbent on the medical journal editors to set the acceptable standard of reporting on urinary continence and enforce it the same way other guidelines are. References . Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies. J Urol. 1999;162:433. 2. . Risk factors for urinary incontinence after radical prostatectomy. J Urol. 1996;156:1707. 3. . Laparoscopic radical prostatectomy: a critical analysis of surgical quality. Eur Urol. 2006;49:625–632. 4. . Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol. 2007;51:996–1003. 5. . Functional outcomes and oncological efficacy of Vattikuti Institute prostatectomy with veil of Aphrodite nerve-sparing: an analysis of 154 consecutive patients. BJU Int. 2006;97:46. 6. . Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000;283:354. 7. . Comprehensive comparison of health-related quality of life after contemporary therapies for localized prostate cancer. J Clin Oncol. 2002;20:557. Karim Touijer
Please log-in or register in order to submit comments. Powered by AkoComment! |
||
| < Prev | Next > |
|---|
|
UroToday, 1802 Fifth Street, Berkeley CA 94710 510.540.0930 (fax), info@urotoday.com ISSN 1939-4810
Privacy Policy | © 2009 UroToday ® All Rights Reserved |
