Surgery and radiation are the gold standard treatments for localized prostate cancer. However, complications such as urinary incontinence and erectile dysfunction in the immediate postoperative period can occur. Various attempts have been made to improve postoperative urinary incontinence. In recent years, the effect of advanced reconstruction of vesicourethral support (ARVUS) on early postoperative urinary incontinence has been reported [1], but the number of reports is still limited. In this study, we examined the effects of ARVUS after robotic-assisted radical prostatectomy (RARP) on incontinence with adjustment by propensity score matching (PSM).

A total of 588 patients who underwent RARP from October 2010 to October 2020 in our department were included in the study. After May 2019, ARVUS was performed in principle in non-nerve sparing (NS) cases. Cystography was performed at the time of urethral catheter removal to measure the posterior urethrovesical angles (PUVA) and the distance from the upper margin of the pubis to the neck of the bladder. Urinary incontinence was measured on the day after catheter removal and evaluated at 1 and 3 months after surgery using question 1 of the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). We performed univariate and multivariate analyses using age, BMI, prostate volume, membranous urethral length, levator thickness, distance from the upper margin of the pubis to the neck of the bladder, PUVA, NS (bil non-NS or others), and ARVUS (with or without) to investigate the factors affecting the amount of incontinence on the day after catheter removal.

A total of 118 validly analyzed cases were obtained after PSM, which were split equally into the ARVUS group (mean age 68.9 ± 5.6 years) and non-ARVUS group (mean age 68.6 ± 5.2 years). In the ARVUS group, the distance from the upper margin of the pubis to the neck of the bladder during cystography was significantly shorter (p < 0.001) and PUVA was significantly smaller (p < 0.001). Although no obvious difference was observed in the amount of urinary incontinence on the day after catheter removal (Fig. 1A), the percentage of patients with urinary incontinence of 500 ml or less on the day after catheter removal (Fig. 1B) was significantly higher in the ARVUS group (p = 0.011). No significant difference was found in the percentage of patients with an ICIQ-SF score below 1 at 1 and 3 months after surgery between the ARVUS and non-ARVUS groups (p = 0.489 and p = 0.360, respectively). In univariate analysis, the distance from the upper margin of the pubis to the neck of the bladder, PUVA, and ARVUS varied significantly (p < 0.001, p = 0.015, and p = 0.041, respectively), and in multivariate analysis, the distance from the upper margin of the pubis to the neck of the bladder was identified as a predictor of urinary incontinence below 500 ml on the day after catheter removal (p = 0.003).

Before PSM, the patient tended to be younger in the non-ARVUS group, and a significant difference was found in clinical T stage. After PSM, no significant difference was observed, and patient background factors were adjusted by performing PSM. In the case of urinary incontinence, no significant difference was found between patients with and without ARVUS in the ICIQ-SF evaluation at 1 and 3 months after surgery. However, when the cutoff value for incontinence volume on the day after catheter removal was set at 500 ml, the percentage of incontinence volume below 500 ml was significantly higher in the ARVUS group. Multivariate analysis showed that the distance from the upper margin of the pubis to the neck of the bladder was a predictor of urinary incontinence below 500 ml on the day after catheter removal. In the ARVUS group, the distance from the upper margin of the pubis to the neck of the bladder was significantly shortened, suggesting that ARVUS moved the urethra ventrally and increased urethral resistance, resulting in early postoperative urinary incontinence.

ARVUS was found to be effective in early postoperative urinary incontinence. The distance from the upper margin of the pubis to the neck of the bladder on cystography was significantly shorter in the ARVUS group, suggesting that it may be a predictor of early postoperative urinary incontinence.

Vladimir Student Jr, et al. Eur Urol 2017