Introduction:

Over the past decade, there have been continued advances in radical prostatectomy surgical technique, technology, and pre- and post-operative care pathways. Many techniques have emerged targeting an earlier return of continence, including modifications to bladder neck reconstruction, increased sparing of the bladder neck, and preservation or reconstruction of the puboprostatic arch, among others. Our objective was to determine if urinary function after radical prostatectomy has improved over time at a high-volume, referral center.

Methods:

We included all radical prostatectomies, excluding prior radiation or focal therapy, treated at our institution from 2008-2019 and with baseline survey data and at least one post-op response available at 6 or 12 months. Good urinary function was defined as a composite score of ≥17 on a validated institutional urinary function questionnaire. We also defined no incontinence (0 pads/day), social continence (≤1 pad/day), and severe incontinence (≥3 pads/incontinence diapers/day) based on patient reports from an item on the questionnaire. Multivariable generalized additive models were fit to determine the association of the date of surgery and good urinary function, no incontinence, social continence, and severe incontinence at 6 and 12 months post-operatively. The adjusted models were plotted to demonstrate changes over time (Figure).

Results:

A total of 3,946 patients met inclusion criteria. At baseline, 3,143 (80%) patients had good urinary function. Good urinary function was achieved by 2,207 (70%) patients by 12 months. Older age, higher BMI, and greater use of robotic surgery were associated with more recent year of surgery, but rates of nerve sparing did not change over time (p=0.14). In our adjusted models, including use of salvage radiation or androgen deprivation, there was no association between year of surgery and good urinary function at 6 (p=0.9) or 12 (p=0.4) months post-operatively (Table). While no significant differences were detected at 6 months, we found evidence of decreasing probability of no incontinence at 12 months (p<0.001). Probability of social continence at 12 months improved in recent years after a prior decrease around 2015 (p=0.01), and there was a trend towards improving severe incontinence rates over the same time period (p=0.06) (Figure).

Conclusion:

We did not find significant, large improvements in urinary function across varied measures of urinary functional outcomes over the past decade, despite advances in understanding of surgical anatomy, refinement of perioperative pathways, and surgeon experience in minimally invasive techniques. The adjusted probability of no incontinence appeared to be decreasing, but there was also evidence to suggest decreasing probability of severe incontinence and improving social continence probability in recent years. These findings may be explained by the already high level of refinement in contemporary techniques, as even at 6 months post-operatively, 61% percent of patients had good urinary function and only 5.7% experienced severe incontinence. Selection criteria are also evolving with time and may not be fully accounted for in our adjusted analysis. Despite constant effort at quality improvement, these data suggest that improvements in patient selection and post-operative rehabilitation are needed for incremental gain in radical prostatectomy urinary function/continence.

Funding: None