Total anatomical reconstruction during robot-assisted radical prostatectomy: focus on urinary continence recovery and related complications after 1000 procedures

Objectives • To present the functional and oncological outcomes after one-year minimum follow-up, after an experience of more than 1000 robot-assisted radical prostatectomies (RARP) with our standardized total anatomic reconstruction (TAR) technique. • To evaluate which factor could influence the postoperative continence recovery in order to obtain a nomogram to predict the risk of post-operative incontinence. Materials and methods The enrolment phase began in June 2013 and ended in May 2017. Patients were prospectively included in the study with the following inclusion criteria: (1) localized PCa (clinical stages cT1-3, cN0, cM0); (2) indication for radical prostatectomy; (3) preoperative multiparametric prostate magnetic resonance imaging. All patients underwent RARP with a TAR technique done at the end of the demolitive phase. The continence rates were assessed at 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal. Patients were defined as continent if they answered ‘‘zero pad’’ or ‘‘one safety pad’’ per day. A logistic regression model was performed to evaluate the potential impact of some pre- and intra-operative factors on the postoperative urinary continence recovery. Model discrimination was assessed using an area under (AUC) the receiver operating characteristic (ROC) curve. A nomogram to predict the risk of post-operative incontinence after RARP with TAR technique was generated based on the logistic model. Results 1008 patients were enrolled in our study. At 24 h, and 1, 4, 12, 24 and 48 weeks after catheter removal, 621 (61.61%), 594 (58.93%), 803 (79.66%), 912 (90.48%), 950 (94.25%) and 956 (94.84%) patients were continent, respectively. In the logistic regression model, the variables analysed had a higher impact on continence recovery at 4 and 12 weeks. At 4 weeks, the post-operative odds of urinary continence recovery increased with the absence of diabetes (OR 2.76, 95% CI 1.41-5.41) and D’Amico low v. high risk (OR 2.01, 95% CI 1.01-3.99). At 12 weeks, increased with the absence of diabetes (OR 3.01, 95% CI 1.23-7.35), D’Amico low v. high risk (OR 4.04, 95% CI 1.56-10.47), and D’Amico intermediate v. high risk (OR 3.33, 95% CI 1.66-6.70). ROC curves were drawn and an AUC value of 61.9% (95% CI 57.49 – 66.36) at 4 weeks and 63.8% (95% CI 58.03 – 69.65) at 12 weeks were computed. Based on these parameters, two nomograms (at 4 and 12 post-operative weeks) were generated. Conclusion The TAR technique confirmed excellent results in the early recovery of urinary continence. Two nomograms were created, to predict pre-operatively the post-operative odds of urinary continence recovery at 4 and 12 weeks after RARP by integrating the presence of diabetes and the D’Amico risk classification.