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Abstract
The advent of prostate-specific antigen screening has changed the global epidemiology of prostate cancer, with men being diagnosed with organ-confined cancer at a younger age. Radical prostatectomy with curative intent for these patients, while delivering excellent long-term survival outcomes, still has significant side effects, chiefly postprostatectomy incontinence. Increasing age, shorter pre- and post-operative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations of surgical technique and previous prostate surgery have been reported as negative risk factors for delayed continence recovery and/or permanent incontinence following radical prostatectomy. Significant progress in elucidating the functional anatomy and physiology of the male continence mechanism from cadaveric and videourodynamic studies have enabled surgeons to propose innovative surgical techniques during radical prostatectomy for augmenting continence preservation and early return. These have included optimizing the preservation of urethral rhabdosphincter length; avoiding rhabdosphincter injury; posterior reconstruction of Denonvilliers’ musculofascial plate; preservation of the bladder neck and internal sphincter; bladder neck intussusception; bladder neck mucosal eversion; preservation of the puboprostatic ligaments and arcus tendineus; and preservation of putative nerves supplying the continence mechanism. We review the scientific and technical advances in continence recovery following radical prostatectomy, identify the key principles undergirding early return of continence, highlight various treatment strategies for early and refractory postprostatectomy incontinence and describe our experience with a paradigm of these unified key principles. Increasing application of these principles in computer-aided (robotic), minimally invasive and minimal-access (i.e., single-port or natural orifice transluminal) approaches will hopefully enable patients to derive maximal benefit from curative prostatectomy while experiencing early return of continence in the not too distant future.
Financial & competing interests disclosure
Gerald Tan receives financial support from the Ferdinand C Valentine Fellowship in Urologic Research, New York Academy of Medicine; the Medical Research Fellowship, National Medical Research Council (Singapore); and the John Steyn Travelling Fellowship in Urology, Royal College of Surgeons of Edinburgh. Alexis Te is an investigator and consultant for Sanofi-Aventis, Inc.; an investigator for Pfizer, Inc.; and an investigator for American Medical Systems, Inc. Ashutosh Tewari has received a research grant from Intuitive Surgical, Inc. (Sunnyvale, CA, USA). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.