The Role of Preoperative Puborectal Muscle Function Assessed by Transperineal Ultrasound in Urinary Continence Outcomes at 3, 6, and 12 Months After Robotic-Assisted Radical Prostatectomy

Abstract

PurposeThe efficacy of pelvic floor muscle training (PFMT) for men with postprostatectomy incontinence (PPI) after robotic-assisted radical prostatectomy (RARP) is controversial and the mechanism for its possible effect remains unclear. The aim of this study was to investigate the relationship between bladder neck (BN) displacement, as a proxy for puborectal muscle activation, and continence outcomes after RARP.MethodsData were extracted from the South Australian Prostate Cancer Clinical Outcomes Collaborative database for men undergoing RARP by high volume surgeons who attended preoperative pelvic floor physiotherapy for pelvic floor muscle (PFM) training between 2012 and 2015. Instructions were to contract the PFM as if stopping the flow of urine. BN displacement was measured with 2-dimensional transperineal ultrasound, without digital rectal examination. Urinary continence status was assessed preoperatively and at 3, 6, and 12 months using the Expanded Prostate Cancer Index Composite 26. Data were analysed using logistic regression and mixed effects linear modelling. Confounding variables considered were baseline continence, age at diagnosis, margin status, nerve sparing procedures and pathological stage.ResultsOf 671 eligible men, 358 met the inclusion criteria and were available for analysis, with 136 complete datasets at 12-month follow-up. While BN movement was associated with preoperative continence, there was no significant effect of BN displacement on the change in urinary continence at 12 months postprostatectomy (P=0.81) or on the influence of time on continence over 3–12 months.ConclusionsContinence outcomes were not associated with BN displacement, produced by activity of the puborectal portion of the levator ani muscle, at 3, 6, or 12 months after RARP. These results suggest that the puborectal muscle does not play a role in the recovery of continence after RARP and may help to explain the negative findings of many studies of PFMT for PPI.

The Effectiveness of Cystography-Measured Bladder Neck Elevation at Predicting the Return of Continence After Robot-Assisted Radical Prostatectomy

“…As they have been reported, many static cystographic findings could estimate the postoperative urinary continence. In addition to that, some researchers the similar results were reported using preoperative magnetic resonance imaging [10,11]. However, we believed that dynamic evaluation of cystography is needed.…”

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction

“…Correct movement occurs with the PFM only: the shaft of the penis draws in and the testes lift in a cephalad direction. These movements may be better visualized in standing than supine position . (NEW) 2.6.1.2 Perineal descent : This is the outward (dorso‐caudal) movement of the perineum and anus. Examinations PFM state at rest ; aspects to assess.…”

“…Correct movement occurs with the PFM only: the shaft of the penis draws in and the testes lift in a cephalad direction. These movements may be better visualized in standing than supine position . (NEW)…”

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

“… Present Uncertain Absent Response can be further described according to perineal movement observed: 2.1.7.1 Perineal elevation : Inward (ventrocephalad) movement of the vulva ( f ), perineum, and anus 11,24 = normal finding No change Sex‐specific changes on perineal elevation: f : closure of the urethral meatus (“wink”); a clitoral “nod” m : Closure of the anus, cephalad testicular lift and penile retraction (the shaft of the penis draws inc) 25–27 2.1.7.2 Perineal descent : Dorsocaudal movement of the perineum, or anus 1 cm or greater beyond resting level (CHANGED) 24 …”