Dr. Soares on the effect of weight loss on postprostatectomy incontinence

In this video, Ricardo M. de Oliveira Soares, MD, discusses how physical therapy and weight loss can improve postprostatectomy incontinence. He also describes elements of his surgical approach. Soares is a urologist at Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Transcription:

There are things that you can do to prepare the patient for when they get to the surgery date. Obviously, weight loss is number 1. With most cases, from the time of diagnosis until the surgery, you're probably going to have maybe 6 weeks to 3 months. That's not a long time to lose a lot of weight, but it still can be significant. I have a patient with a [body mass index] of 49, but his cancer is not too bad. We decided to give him some extra time to become fitter, because this is going to help him in the long run. There are several studies showing that doing aerobic exercise and resistance training can also help with recovery. For me, what is most important is doing pelvic floor muscle therapy. Upon diagnosis, I send all of my patients to see one of our physical therapists here at Northwestern. I have been working here for 3 and a half years, and there was no male pelvic physical therapy program previously. But everyone in back in England, when I was working there, was doing this. You can really see the difference with the patients who go for physical therapy and the ones who don't. This has been studied for over 20 years; there have been randomized controlled trials, initially all [evaluating] postop physical therapy. Then, in 2001, there was the first trial of preop and postop physical therapy, which also showed good results. You can really increase your chances of continence at 3 months by up to 4 times. It's more about quicker recovery. Even at 1 year, it can be 1.2 times compared with someone who doesn't do physical therapy. So I have this in my normal protocol for every single patient.

Then you get to the actual surgery. Since the time of open surgery, there have been multiple maneuvers to try to improve continence. Number 1 is trying to preserve most of the urethra, trying to preserve the bladder neck, nerve sparing as well if the cancer allows you to, some preservation of the puboprostatic ligaments that attach the anterior side of the prostate to the pubic bone. Regarding neurovascular bundle sparing, there are some good data from [Ashutosh K. Tewari, MD], from New York. When he performs grade 1 interfascial nerve sparing, 71% of patients are continent at 3 months, when in general only half of them are. So it's like 50% vs 71. That's a significant improvement. There have some studies trying to link lymph node dissection to incontinence; the results are inconsistent. There's really no proof that one thing affects the other. I think the preservation of puboprostatic ligaments is probably one of the first things that was really done on a regular basis. There are some studies from laparoscopic surgery in Germany from [Jens-Uwe Stolzenberg, MD], back in the early 2000s, showing that if you preserve the puboprostatic ligaments in extraperitoneal laparoscopic prostatectomy, you can really improve continence at 3 months. Usually, there's a lot of preservation anterior to the prostate but also posteriorly. But anteriorly, in regards to the dorsal vascular complex (DVC), I think generally people would put a stitch on the DVC and then cut it. But there are a couple of studies showing that if you cut first, you're able to visualize better where you are cutting and therefore you're probably going to approach the apex in a better place. If you cut and stitch, you can improve continence right there. Also, a study from [Vip Patel, MD], from Florida showed if you suspend that stitch through the pubic periosteum, that is another little gain to get better results. Some of these things by themselves are not going to make a difference, but if you add them all together, they really make a difference for the patient. Posteriorly, the Rocco stitch is very, very widespread. It was actually developed in 2006 for open surgery, and 1 year later, was applied to laparoscopic surgery. I mostly do Retzius sparing, but when I do an anterior approach, I always do a Rocco stitch, because although the data are not very clear if that improves continence or not, some meta analyses show that it may improve continence at 3 months, but doesn't really make a difference at 6 months. But I think it helps achieve a tension-free anastomosis, so when I do an anterior approach, I just do a Rocco stitch.

This transcription was edited for clarity.