Вестник урологии (Jan 2023)
Influence of vesicourethral segment reconstruction techniques in radical prostatectomy on urinary continence: evaluation of immediate and long-term outcomes
Abstract
Introduction. Currently, various methods and modifications of radical prostatectomy (RP) have been developed and tested, aimed at preventing and minimizing the development of urinary incontinence (UI). However, UI remains an urgent problem in patients who undergo RP, especially at the early follow-up stages.Objective. To evaluate and compare the effectiveness of modified reconstructive techniques for vesicourethral anastomosis in radical prostatectomy for the prevention of urinary incontinence with respect to the standard technique at different follow-up periods.Materials and methods. Design: single-centre, clinical, simple, comparative, parallel-group study with retrospective and prospective material evaluation, conducted in 2017 – 2022. Patients: men with verified prostate cancer cT1a – 2cN0 – xM0 without decompensated comorbidities. Age: 45 – 78 years. Retrospective part — group (G) 1: 90 patients who underwent non-nerve-sparing open retropubic RP with a "classic" vesicourethral anastomosis (VUA). Prospective part — G2: 46 patients who underwent similar surgery with modified VUA in two variations: without and with prostatic urethra-sparing — G2a (n = 25) and G2b (n = 21), respectively. Initial examination: standard preoperative laboratory and instrumental examination, assessment of lower urinary tract symptoms (LUTS) using the IPSS-QoL questionnaire. Follow-up examination: objective evaluation of UI according to established criteria and subjective assessment using the ICIQ-SF questionnaire, tracking the dynamics of LUTS using IPSS-QoL. Follow-up periods: 0-point (after catheter removal), 1, 3, 6, and 12 months (exit-point); the dynamics of recovery of urinary continence (UC) was determined monthly. Statistical analysis: Statistica ver.10.0 (StatSoft Inc., Tulsa, OK, USA) using non-parametric methods (CL p < 0.05 at a = 0.05)Results. Preoperative demographic, questionnaire and instrumental statistics did not differ (p > 0.05) between the groups, confirming the homogeneity of the samples. After RP, the urethral catheter was removed in a period of 7 to 21 days. There was no difference (p > 0.05) in the duration of drainage between the groups. Total urinary continence (TUC) immediately after catheter removal was detected in G1, G2a and G2b in 20.0%, 44.0% and 57.1% of cases, respectively. Subsequent objective monitoring of UC recovery from 1 month showed differences (p < 0.001) between the groups in the dynamics of rehabilitation during the year. The improvement in UC over the one-year follow-up period was cumulatively achieved in G1, G2a and G2b in 48.9%, 44.0% and 33.3% of cases, respectively. Total UI persisted in G1 and G2a by month 12 in 22.2% and 8.0% of patients, respectively, and was not detected in G2b. The severity of UI by the end of the follow-up according to the ICIQ-SF data was the most pronounced (p < 0.001) in patients from G1. TUC-patients in all groups from 1 month showed a marked decrease in the severity of obstructive and irritative LUTS and improved quality of life, with no differences (0.157 < p < 0.390) in IPSS-QoL values between groups.Conclusions. The use of modified VUA reconstruction techniques made it possible, compared with the standard one, to achieve high continence rates in patients both immediately after the removal of the urethral catheter and at subsequent follow-up periods, without the formation of severe iatrogenic obstruction. Prostatic urethra-sparing modification is the most effective technique that provided the rehabilitation of UI to a complete and/or social level in all patients within a year after surgery.
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