Postprostatectomy incontinence (PPI) is a feared complication that leads to significant compromises in patient quality of life and serious psychosocial effects, regardless of oncologic and sexual function outcomes . The advent of robotic surgery heralded a new dawn in radical prostatectomy with claims of lower rates of erectile dysfunction and urinary incontinence. Robotic-assisted radical prostatectomy (RARP) surgeons have strived not just for overall return of continence but also for earlier return of continence. Despite these efforts, loss of urinary control following RARP remains a problem, with incidences ranging from 2 to 87%. [1,2] Unfortunately, variations in outcomes reporting, definitions of urinary continence, methodology of data collection and patient selection have led to confusion regarding the large variation in reported PPI rates following RARP . In addition, high expectations of men undergoing RARP may result in regret and PPI bother .
The wide range of incontinence outcomes despite the supposed finer dissection afforded by RARP has led RARP surgeons to try to better understand the cause of PPI. Although the physiologic mechanism of urinary continence following radical prostatectomy is not completely understood, both functional and anatomical changes associated with prostate removal lead to alterations in the urinary sphincter complex and pelvic floor musculature . Improving urinary continence has driven the development of refined surgical techniques aimed at avoiding PPI. Within this review, we summarize the anatomical basis and outcomes of current surgical techniques aimed at improving urinary continence following RARP.
BLADDER NECK PRESERVATION
Anatomically, the bladder neck serves as an internal sphincter with three distinct muscular layers: the inner longitudinal layer, the middle circular layer and the outer longitudinal layer . The longitudinal fibres of the bladder neck may be identified and isolated with meticulous dissection at the prostato-vesicual junction during RARP . The outer longitudinal layer contributes anterior fibres to the pubovesical muscle and may contribute to the opening of the bladder neck during micturition. Posteriorly, the outer longitudinal fibres interdigitate with deep trigonal fibres and may aid in bladder neck closure. Therefore, although the bladder neck may not contribute to voluntary continence, it is intuitive that bladder neck preservation (BNP) may contribute to earlier return of urinary continence. However, published series analyzing outcomes of BNP at the time of open radical retropubic prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP) have shown conflicting results, with some showing little benefit on continence and potential compromise of oncologic outcomes [8–12].
However, more recent studies show that BNP during RARP hastens continence without compromise on cancer control. Curto et al.  reported a series of 425 men undergoing LRP with BNP, with complete urinary continence achieved in 95% at 6 months. However, this study is limited by not evaluating the direct effect of BNP on urinary continence. However, Freire et al.  retrospectively compared 348 men undergoing BNP with 271 undergoing standard technique during RARP and noted significantly improved urinary function with BNP at 4 and 24 months (Table 1) [7,14–16]. Urinary continence was also significantly improved at 4 months (65.6 vs. 26.5%, P < 0.001). Importantly, there was no compromise in surgical margins when performing BNP, as suggested by RRP and LRP series . Moreover, recent updates of this series demonstrate earlier recovery of continence throughout the 2-year follow-up interval, and no differences in PSA recurrence-free survival up to 5 years following RARP [17▪]. Even more recently, You et al.  confirmed improved early urinary continence with BNP compared with the standard technique, while Friedlander et al. noted improved time to continence and fewer urine leaks with BNP without compromising cancer control.
BLADDER NECK RECONSTRUCTION
BNP may not be possible in all patients . In these circumstances, some have shown improved urinary continence with bladder neck reconstruction (Table 1). Lin et al.  published a series of 74 men undergoing RARP who did not undergo BNP for various reasons. In these men, plication of the bladder neck was performed, and 12.7% of men undergoing plication had urinary continence following catheter removal and 97.3% had urinary continence at 12 months, although results were not compared with a control group . Similarly, Lee et al.  described a single bladder neck plication stitch to improve urinary continence. Following a change in technique to perform bladder plication, they noted shorter times to urinary continence with significantly increased odds of urinary continence at 1 month and 12 months in multivariate analysis .
URETHRAL LENGTH PRESERVATION
Urinary continence following radical prostatectomy may be directly correlated to postoperative urethral length . Hammerer and Huland  used urodynamic evaluation to confirm significantly longer urethral length in continent than in incontinent men following RRP. More recently, von Bodman et al. [22▪▪] performed an anatomic study measuring preoperative urethral length, urethral volume and proximity of levator muscle and membranous urethra following MRI in 967 men undergoing RRP. They found that urethral length, urethral volume and an anatomically close relationship between the levator muscle and membranous urethral were all significantly associated with recovery of urinary continence at 6 and 12 months [22▪▪].
Hakimi et al.  studied preoperative and intraoperative urethral length and its effect on postoperative urinary continence and quality of life in 75 men undergoing RARP. Unlike von Bodman et al.[22▪▪], they found no relationship between preoperative MRI urethral length and postoperative continence. However, on multivariate analysis, stretched and cut urethral length correlated with decreased time to urinary continence (P = 0.03 and P = 0.04, respectively). This implies that RARP techniques aimed at preserving urethral length as well as avoiding disturbance of the levator muscles can hasten urinary continence.
Using intraoperative transrectal ultrasound in 53 men undergoing LRP, Mizutani et al.  found that longer membranous urethral length had significantly higher continence rates at 1, 3 and 6 months following LRP, with no difference in positive surgical margin rates. Although there have not been any reports of utilizing intraoperative ultrasound during RARP to preserve urethral length, Hung et al.[25▪] recently described the feasibility of a robotically manipulated transrectal ultrasound system during RARP, which may aid surgeons in properly identifying the membranous urethra and maximizing urethral length.
PERIURETHRAL SUSPENSION STITCH
During his initial description of anatomic RRP, Walsh  described reversal of the dorsal venous complex (DVC) suture through the symphysis pubis perichondrium to control venous bleeding and provide rhabdosphincter support. This periurethral suspension stitch (PSS) was subsequently found to hasten continence recovery [27,28]. The PSS has been applied to RARP by Patel et al.  (Fig. 1), who describe this technique in a prospective, nonrandomized trial of 237 RARP with PSS vs. 94 without PSS (Table 1). Urinary continence in men undergoing PSS was significantly improved 3 months postoperatively, whereas urinary continence at 1, 6 and 12 months remained similar. Therefore, it appears that although PSS may hasten urinary continence recovery, it does not affect long-term urinary continence. More studies are needed to evaluate the effect of PSS alone on the recovery of urinary continence following RARP.
Rocco et al.  popularized posterior rhabdosphincter reconstruction (PR) during RRP. This technique reconstructs the posterior musculofascial plate by suturing the median raphe of the urethra to the remnants of Denonvillier's fascia posterior to the bladder. Theoretically, this restores anatomical length of the rhabdosphincter and posterior support by fixing the structure into its natural position. Rocco et al.  eventually applied this technique to LRP, and it was quickly adapted by multiple RARP surgeons with varying results (Table 2) [32–41,42▪]. Coelho et al.  and Brien et al.  found improvement in urinary continence at 1 and 3 months, respectively, without differences in long-term urinary continence. However, results of most remaining studies do not show a significant improvement in urinary continence following PR. In two retrospective studies, both Krane et al.  and Kim et al.  found no improvement in urinary continence and an increased risk in postoperative urinary retention in men undergoing PR. In a prospective, nonrandomized trial, Joshi et al. also found no benefit of PR. Furthermore, two randomized control trials showed no statistical improvement in men undergoing PR alone  and in conjunction with PSS .
A recent systematic review by Rocco et al. [43▪▪] sought to clarify the effect of PR on urinary continence following RARP. Cumulative analysis showed that PR results in earlier return of urinary continence within 1 week [relative risk (RR) 1.79, P = 0.03] and 30–45 days (RR 1.57, P = 0.004), however there were no differences in urinary continence 90 days postoperatively. Cumulative analysis also suggested lower rates of postoperative urine leak (RR 0.45, P = 0.05). Although Kim et al.  found significantly higher rates of postoperative urinary retention following PR, the remaining studies found no differences in postoperative complications. Therefore, although PR may have little if any effect on continence, it may improve postoperative urinary leakage as well as facilitate the vesico-urethral anastomosis by attenuating tension during RARP with a few drawbacks. However, evidence from randomized controlled trials does not support its effectiveness in improving postoperative urinary continence rates.
COMBINED ANTERIOR AND POSTERIOR RECONSTRUCTION
Many RARP surgeons perform a combination of anterior and posterior reconstruction by performing a PSS in conjunction with posterior reconstruction (Table 2). Kalisvaart et al.  retrospectively noted improved urinary continence at 3 months with modified combined anterior and posterior reconstruction. However, this study suffers from small sample size, lack of correction for learning curve effect, as well as lack of long-term follow-up. Tan retrospectively studied urinary continence in 1900 men undergoing various techniques, including combined anterior and posterior reconstruction, along a single surgeon's learning curve. The first 214 underwent conventional anastomosis without reconstruction, the next 303 underwent anterior reconstruction, while the final 1383 underwent combined anterior andposterior reconstruction . Bladder neck contracture rates were lower in men undergoing anterior reconstruction and combined anterior and posterior reconstruction vs. conventional anastomosis, whereas urinary continence was improved at all time points in men undergoing combined anterior and posterior reconstruction. However, differences in continence rates in this single-surgeon series do not account for likely learning curve effect over the study period.
Randomized controlled trials of combined anterior and posterior reconstruction vs. a standard anastomosis have been performed with conflicting results (Table 2). The same cohort studied by Menon et al.  and Sammon et al.  found no significant differences in early or late urinary continence in men undergoing combined anterior and posterior reconstruction vs. conventional anastomosis. Koliakos et al. , however, found improved urinary continence at 7 weeks in men undergoing combined anterior and posterior reconstruction, although long-term outcomes were not reported. Similarly, Hurtes et al. [42▪] noted significant urinary continence improvement in men undergoing combined anterior and posterior reconstruction vs. standard anastomosis at 1 and 3 months following RARP. However, there were no differences in continence at 6 months. In a recent meta-analysis, Ficarra et al. [45▪▪] found a small but significantly lower risk of urinary continence in men undergoing combined anterior and posterior reconstruction vs. standard anastomosis [odds ratio (OR) 0.4, P = 0.040]. In summary, similar to posterior reconstruction, it appears that combined anterior and posterior reconstruction may have a small impact urinary continence recovery; however, long-term outcomes are unknown and randomized controlled trials have not shown universal benefit. In addition, it is unknown whether the anterior or posterior support contributes to improved urinary continence in these studies, although it is the opinion of the authors that it is likely to be the PSS component that leads to improved urinary continence.
ENDOPELVIC FASCIA PRESERVATION
Following cadaveric dissection identifying components of smooth muscle and pudendal nerve branches within the endopelvic fascia leading to the rhabdosphincter, Takenaka et al.  described a novel technique of endopelvic fascia preservation during RRP to improve urinary continence. van der Poel et al.  have subsequently applied this technique to RARP. In a prospective study of 151 men, they found that the extent of lateral fascial preservation was the strongest predictor of urinary continence at 6 and 12 months postoperatively . These results have subsequently been replicated during RRP by Khoder et al. . Further studies are needed to confirm the benefit of this technique in RARP. However, similar to BNP as well as urethral length preservation, it is likely that techniques that aim to maintain native continence mechanism are more important to preservation of urinary continence than reconstructive techniques.
COMPLETE ANTERIOR PRESERVATION
Asimakopoulos et al. describe the feasibility of complete periprostatic anatomy preservation during RARP. They hypothesize that due to continuity of the puboprostatic ligaments to the detrusor apron, it is not feasible to preserve the puboprostatic support structure unless the entire pubovesical complex (DVC, puboprostatic ligaments and detrusor apron) remains intact. The technique was performed on 30 men, all less than 60 years old and with good preoperative continence and potency. Urinary continence was 80% at catheter removal and 100% at 3 months. Future comparative studies are needed, especially given the demanding nature of this technique, particularly with a larger prostate size.
DORSAL VENOUS COMPLEX CONTROL
Selective suture ligation (SSL) of the DVC was first described by Walsh . By selectively ligating the open venous channels of the DVC rather than taking the structure whole, surgeons can avoid damage to the surrounding levator muscle. Application of this technique during RRP is limited, given concerns of increased blood loss. However, pneumoperitoneum provided by laparoscopy makes this technique feasible. Porpiglia et al.  first described SSL during LRP in a prospective randomized study of 30 patients undergoing SSL vs. 30 patients undergoing complete ligation. SSL was associated with improved urinary continence at 3 months, although there were no differences at 1, 6 and 12 months. Lei et al. [17▪] first described SSL during RARP (Fig. 2). They retrospectively compared outcomes between 303 men undergoing standard DVC ligation and 240 men undergoing SSL. On a multivariate analysis, they found that SSL improved both overall urinary function scores and urinary continence at 5 months, although there were no differences at 12 months. Although men undergoing SSL experienced greater estimated blood loss (EBL), EBL remained low and there was no difference in transfusion rates. Thus, it appears that avoiding surrounding levator damage during DVC control by performing SSL may lead to earlier return to continence, although long-term continence remains unchanged. Again, further prospective studies are needed to confirm these results.
Although the rhabdosphincter receives direct innervation from the pudendal nerve , authors have noted an association between nerve-sparing approach and urinary continence. In a series of 602 RARP, Choi et al. [52▪] noted improved urinary continence and urinary function scores at 4 months in men undergoing bilateral nerve-sparing vs. non-nerve-sparing RARP. Urinary function scores remained higher in men undergoing bilateral nerve-sparing at 12 and 24 months, although urinary continence was similar [52▪]. Similarly, in a randomized trial of 200 men undergoing interfascial nerve-sparing vs. 200 men undergoing intrafascial nerve-sparing, Stolzenburg et al.  noted that intrafascial nerve-sparing was associated with improved urinary continence at 3 and 6 months, although with no difference at 12 months. Most recently, Suardi et al.  noted that bilateral nerve-sparing was an independent predictor associated with continence recovery in 1249 men undergoing RRP and with those undergoing bilateral nerve-sparing having a 1.8-fold higher chance of full continence recovery at 2 years of follow-up. Unlike previous studies reviewed, this is the only technique to show durable improved urinary continence at long-term follow-up.
However, some authors have not noted such an association between urinary continence and nerve-sparing approach. Marien and Lepor  concluded that bilateral nerve-sparing was not associated with continence in 1100 men undergoing RRP. They noted although 60% of men regained potency, 97% regained continence at 24 months. However, all men in the study underwent either bilateral or unilateral nerve-sparing, and results were not compared with men undergoing non-nerve-sparing. In addition, the direct effect of nerve-sparing approach on urinary outcomes was not addressed. Similarly, Pick et al.  retrospectively reviewed outcomes in 592 men undergoing RARP and found that there was no significant difference in continence rates between nerve-sparing approaches at 1, 3 and 12 months. However, the retrospective nature and relatively smaller sample size than studies showing nerve-sparing benefit limit these conclusions.
These authors have previously noted improved potency in men undergoing nerve-sparing with limited traction and delicate dissection of the neurovascular bundle [57,58]. In this same cohort of patients, we also noted improved urinary continence, with men undergoing nerve-sparing without traction having better urinary function at 5 months. In a multivariate analysis, bilateral nerve-sparing vs. nonlateral/unilateral nerve-sparing was associated with improved overall urinary function scores as well as continence 12 months postoperatively (both P ≤ 0.035) . Therefore, we believe it is likely a combination of neural preservation as well as delicate tissue handling during nerve-sparing that preserves urinary continence.
Urinary incontinence remains a feared complication following radical prostatectomy regardless of approach. Numerous surgical techniques based on the anatomy and physiology of the urinary tract have been proposed in order to improve these outcomes, although further multi-institutional studies with more patients and longer follow-up are needed to confirm the benefit of these techniques. Techniques aimed at preservation and nondistortion of the natural anatomy, such as BNP, urethral length preservation, endopelvic fascia preservation, and selective ligation of the DVC, seem to improve short-term urinary continence rates in most studies without conflicting evidence. Other techniques aimed at reconstruction of the pelvic anatomy, such as PR and combined anterior and posterior reconstruction, have had conflicting results and have largely not been supported by randomized controlled trials. We believe that a meticulous surgical technique and avoiding disruption of the natural continence mechanism remains the most important variable in the preservation of postoperative urinary function. Although reconstructive techniques may hasten urinary recovery in some patients, and are relatively easy to perform and are associated with few complications, there is no substitute for a meticulous surgical technique that obviates the need for such reconstructive procedures.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 101–102).
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