The continence status of patients with very large prostates after radical retropubic prostatectomy
Artykuł opublikowany w Urologii Polskiej 2006/59/1.
Dmitry Y. Pushkar 1, Alexander V. Govorov 1, John W. Kosko 2
- 1 MSMSU, Department of Urology, Moscow, Russia
2 Newman Regional Health, Emporia KS, United States of America
stercz, rak stercza, prostatektomia radykalna załonowa, stan trzymania moczu
- The aim of the study. The aim of our study was to assess the continence status of patients with very large glands (>100 cc) at 3, 6, 12 and 18 months after radical retropubic prostatectomy (RRP) and compare it with contemporaneous control patients with smaller prostates undergoing RRP at our institution.
- Material and methods. 369 patients underwent radical retropubic prostatectomy after determining the prostate volume by means of transrectal ultrasound at the time of prostate biopsy. The continence status was assessed using a self-reported validated questionnaire at 3, 6, 12 and 18 months after operation. The patients were stratified into four groups according to their prostate volumes (Group I: <60 cc - 106 patients; Group II: 60-80 cc - 103 patients; Group III: 80-100 cc - 82 pts; Group IV: >100 cc - 78 patients).
- Results. The continence rates of the four groups at 3, 6, 12 and 18 months postoperatively are shown in the table. Patients in group IV had significantly lower continence rates at 3, 6 and even 12 months postoperatively as compared with groups I, II and III (p<0,05). Interestingly, it took Group IV patients twice as long to achieve continence rates at 3 months as compared with those patients with prostate volume <80 cc. Among patients with prostates volume more than 100 cc, our results differ from some previously published data by showing a longer period of time to obtain the same continence rate as those with low prostate volumes.
- Conclusions. Patients with large size prostates (>100 cc) need more time (up to 18 months) to have the same continence rate as those with smaller prostates after radical retropubic prostatectomy. While an enlarged prostate may contraindicate other potentially curative cancer treatments (external beam radiotherapy or brachytherapy), it is necessary to keep in mind the fact of postponed continence in discussing the treatment strategy with patients pre-operatively
Introduction and objectives
Prostate cancer is the most commonly diagnosed malignancy in men, with 232 090 presumable new cases and 30 350 deaths in the United States in 2005 . Currently, 57% of prostate carcinomas are diagnosed while still localized, with crude and cancer-specific 10-year survival rates of 67% and 93%, respectively .
Radical retropubic prostatectomy (RRP) is a curative surgical treatment for most men with localized prostate cancer, but may result in urinary incontinence and / or impotence with a significant long-term impact on quality of life. Urinary incontinence remains one of the most troubling side effects of radical prostatectomy. Studies based on questionnaires completed by the patient at home reveal high rates of emotional distress related to incontinence . The reported risk of incontinence after RRP varies widely. These variations result from different definitions of continence, different patient populations and different times of assessment after the operation. After RRP the overall incidence of permanent incontinence is 5-25%, with 70-90% of patients dry with no pads at 1 year after surgery, and 80-95% free of nocturnal leakage .
Some authors have evaluated the continence status in patients with different prostate sizes after RRP. Horninger et al.  concluded that one year after radical prostatectomy prostate cancer patients with prostates >60 cc have the same continence rate as those with low prostate volumes, however, it takes longer for them to become continent. The largest mean prostate size we found in the literature was 86.5 (76-182) cc in a subgroup of 44 patients: Foley C.L. et al.  found that prostate size at RRP does not affect the risk of impotence or incontinence afterward.
It has been suggested that benign prostatic hyperplasia (BPH) increases the width of the avascular plane overlying the apex of the prostate, potentially allowing easier vascular control and reducing the risk of damage to the urethral sphincter and pelvic floor musculature . Conversely, in the presence of BPH the neurovascular bundles are displaced posteriorly and may be obscured by the prostate . All the above have potential implications for urinary continence and erectile function after RRP .
The aim of our study was to assess the continence status of patients with very large glands (>100 cc) at 3, 6, 12 and 18 months after RRP and to compare them to contemporaneous control patients with smaller prostates undergoing RRP at our institutions.
Material and methods
Retrospective information was obtained from a database of 369 patients treated with RRP after determining the prostate volume by means of transrectal ultrasound (B&K Medical 2101 Falcon and 2102 Hawk) at the time of prostate biopsy. Some patients with prostates more than 80 cc underwent transrectal ultrasound-guided prostate biopsy by 18 gauge needle using extended 30 mm cutting length .
All RRPs were performed by two urologists (D.Y.P. and J.W.K.), all biopsies – by two urologists (A.V.G. and J.W.K.). The continence status was assessed at 3, 6, 12 and 18 months after operation.
The patients were stratified into four groups according to their prostate volumes (Group I: <60 cc – 106 patients; Group II: 60-80 cc – 103 patients; Group III: 80-100 cc – 82 pts; Group IV: >100 cc – 78 patients). These four groups were compared for age, preoperative PSA value, cancer volume, grade and stage, surgical margin status, presence of clinically significant and insignificant tumours, biochemical relapse rates and urinary continence (table 1). Information on the site of positive surgical margins was not available. Data concerning potency are under evaluation now and final results are not obtained yet.
„Clinically insignificant” prostate cancer was defined as tumour confined to the prostate with a tumour volume of Ł0.5 cc and a Gleason score of Ł3 +3 . Biochemical recurrence was defined as a consistent rise in serum PSA for two consecutive tests of >0,2 ng/ml.
Urinary continence was defined as no need for pads and was evaluated using a validated self-completed patient questionnaire, complied from questions on the Short Form-36 and International Continence Society male questionnaires. Patients who did not respond to the questionnaire are not shown and not included in this paper.
Results and discussion
Patients with prostates of >100 cc were older, with a median (range) age of 69 (59-74) years, than patients from the other groups and had higher initial PSA level of 11.2 (4.8-40,4) ng/ml. Tumours within larger prostates were of a lower stage, lower Gleason grade, of smaller volume and more often „clinically insignificant”. There was no difference in the number of positive surgical margins. For a limited median follow-up of 21-25 months, patients with prostates of > 100 cc were less likely to have biochemical recurrence (5% versus 13-23%; p<0,05).
The continence rates of the four groups at 3, 6, 12 and 18 months postoperatively are shown in the table 2. Patients in group IV had significantly lower continence rates at 3, 6 and even 12 months postoperatively compared to groups I, II and III (p<0.05).
Interestingly, it took Group IV patients twice as long to obtain continence rates equivalent to those achieved by patients in Groups I and II (<80 cc) at 3 months. Among patients with prostates more than 100 cc, our results differ from some previously published data by showing a longer period of time to obtain the same continence rate as those with low prostate volumes.
As progress has been made toward minimizing the invasiveness, hospitalization and recovery associated with RRP, patient expectations have increased. As noted, most men regain adequate continence in a matter of weeks or months after prostatectomy. However, tolerance of even temporary incontinence varies among patients and may be the greatest source of short-term morbidity and concern. Therefore, efforts to minimize the time of return to continence continue .
It can be supposed, that placement of absorbable bulbourethral sling immediately after RRP beneath the anastomosis under slight tension, as described by Jones et al. , may be beneficial for hastening recovery of urinary continence, especially in patients with large prostates.
Patients with large size prostates (>100 cc) need more time (up to 18 months) to have the same continence rate as those with smaller prostates after radical retropubic prostatectomy. While an enlarged prostate may contraindicate other potentially curative cancer treatments (external beam radiotherapy or brachytherapy), it is necessary to keep in mind the fact of postponed continence in discussing the treatment strategy with patients pre-operatively.
While such patients with glands of >100 cc still represent only a minority of those undergoing RRP, this population seems likely to increase in the future. In other words due to increasing life expectancy, it is possible that in the future the mean age of patients undergoing RRP may increase and since prostate size increases with increasing age, we may face this problem more often and these patients can be reassured accordingly.
Because many patients tolerate even short-term incontinence poorly, the efforts to decrease the time to continence should continue.
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Dmitry Y. Pushkar
Department of Urology of MSMSU
Vucheticha street, 21
127206 Moscow, Russia
tel./fax +7 095 611 31 29, +7 499 760 75 89