Using preoperative pelvic floor assessment to predict early return of continence after robotic radical prostatectomy
Alison Levy, MD1, Aaron Fleishman, MPH2, Max Jackson, MD4, Kyle McAnally, BA2, Jenna Leader, PT, DPT2, Marysa Warnhoff, PT2, Adrian Waisman, MD2, Marianne Chan, MD4, Allison Kleeman, MD4, Catrina Crociani, MPH2, Andrew Wagner, MD2, Peter Chang, MD, MPH2.
1Lahey Hospital and Medical Center, Burlington, MA, 2Beth Israel Deaconess Medical Center, Boston, MA.
BACKGROUND: While long-term urinary continence is eventually achieved in most patients who undergo radical prostatectomy, predicting when patients will become continent is challenging. The period of incontinence can be a source of uncertainty and distress for patients and may negatively impact quality of life. Prior studies aiming to predict return of post-operative continence have not evaluated patient-specific pelvic floor strength parameters. We evaluated the association of pre-operative pelvic floor physical therapy (PFPT) parameters with early return of urinary continence after robotic radical prostatectomy (RP).
METHODS: We reviewed a prospectively maintained database of all patients undergoing RP. Patients were included if they underwent pre-operative PFPT consultation and completed 3-month patient-reported quality of life evaluation using EPIC-CP. All patients were evaluated by one of two therapists specializing in PFPT with biofeedback, who documented pelvic floor resting tone, pelvic floor working tone, pelvic floor endurance (defined as the ability to hold a 10-second pelvic floor muscle contraction), and dominant hand grip strength. We defined urinary continence as using 0 or 1 pad per day. We used multivariable logistic regression to evaluate the association of PFPT parameters with urinary continence at 3 months. We adjusted for other factors that could affect continence, including age, BMI, D'Amico risk classification, nerve sparing, and prostate volume
RESULTS: 144 men met inclusion criteria. Nerve-sparing was performed in 92.4% of patients. 89% of men had intermediate- or high-risk prostate cancer. At 3 months, 90/144 (62.5%) were continent, while 54/144 (37.5%) were not. On multivariable analysis, prostate volume (OR 0.98, 95% CI 0.96-1.00) and pelvic floor endurance (OR 2.70, 95% CI 1.23-6.25) were significantly associated with being continent at 3 months. Pelvic floor resting tone, working tone, and dominant hand grip strength were not associated with continence at 3 months. 56/76 (74%) men with good pelvic floor endurance were continent at 3 months, while only 34/68 (50%) men with poor endurance were continent (p = 0.006).
CONCLUSIONS: Pre-operative assessment of pelvic floor endurance is an objective measure that may allow more accurate prediction of early continence return after radical prostatectomy. Improved patient counseling could positively impact patient satisfaction and quality of life.
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