Urinary incontinence after robot‐assisted radical prostatectomy: Pathophysiology and intraoperative techniques to improve surgical outcome

Abstract

Abbreviations & AcronymsAbstract: Robot-assisted radical prostatectomy has been shown to have comparable and possibly improved postoperative continent rates compared with retropubic and laparoscopic radical prostatectomy. However, postoperative urinary incontinence has remained one of the most bothersome postoperative complications. The basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. Therefore, improved knowledge of the normal structure in the pelvis should lead to a greater understanding of the pathophysiology of urinary incontinence, and further development of intraoperative techniques to improve the outcomes of urinary continence. It might be necessary to carry out three steps to realize improvement of the early return of urinary continence after robot-assisted radical prostatectomy: (i) preservation (bladder neck, neurovascular bundle, puboprostatic ligament, pubovesical complex, and/or urethral length, etc.); (ii) reconstruction (posterior and/or anterior reconstruction, and/or reattachment of the arcus tendineus to the bladder neck, etc.); and (iii) reinforcement (bladder neck plication and/or sling suspension, etc.). On the basis of these steps, further modifications during robot-assisted radical prostatectomy should be developed to improve urinary continence and quality of life after robot-assisted radical prostatectomy.

Impact of preoperative and postoperative membranous urethral length measured by 3 Tesla magnetic resonance imaging on urinary continence recovery after robotic-assisted radical prostatectomy

“…Recent advances in knowledge of pelvic structure have led to increased understanding of the urinary continence mechanism. 15 In brief, the urethral sphincter system and periurethral support system are two main mechanisms of preserving urinary continence. The external striated sphincter is the main structure maintaining urethral closure pressure greater than bladder pressure.…”

“…4,[6][7][8][9] Recent studies reported that preoperative clinical factors, anatomical characteristics, and surgical techniques are significantly associated with urinary incontinence after RARP. 1,7,[10][11][12][13][14][15] Of these factors, membranous urethral length (MUL) is an important factor that directly correlates with the functional sphincter mechanism. The urethral sphincter mechanism is composed of an external striated sphincter and an internal smooth muscle layer that are both crucial to maintaining urethral closure pressure.…”

“…The urethral sphincter mechanism is composed of an external striated sphincter and an internal smooth muscle layer that are both crucial to maintaining urethral closure pressure. 15 Preservation of maximal MUL is necessary to regain urinary continence, but it is affected by clinical factors, surgeon experience, and surgical technique.…”

Current Techniques to Improve Outcomes for Early Return of Urinary Continence Following Robot-Assisted Radical Prostatectomy

“…The basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible 7) . It may be necessary to conduct three steps to realize improvement of the early return of urinary continence after 2 T. YANAGIDA et al…”

“…and reinforcement (bladder neck plication and/ or sling suspension, etc.). On the basis of these steps, further modifications during RARP should be developed to improve urinary continence and quality of life (QOL) after RARP 7) . In this review, we discuss the intraoperative techniques to improve outcomes for early return of urinary continence following RARP, and provide a critical summary of current knowledge on its outcome in the literature.…”