Neumann Patricia Briar, O'Callaghan Michael
School of Health Sciences, University of South Australia, Adelaide, Australia.
Urology Unit, Flinders Medical Centre, Bedford Park, Australia.
Int Neurourol J. 2018 Jun;22(2):114-122. doi: 10.5213/inj.1836026.013. Epub 2018 Jun 30.
The efficacy of pelvic floor muscle training (PFMT) for men with postprostatectomy incontinence (PPI) after robotic-assisted radical prostatectomy (RARP) is controversial and the mechanism for its possible effect remains unclear. The aim of this study was to investigate the relationship between bladder neck (BN) displacement, as a proxy for puborectal muscle activation, and continence outcomes after RARP.
Data were extracted from the South Australian Prostate Cancer Clinical Outcomes Collaborative database for men undergoing RARP by high volume surgeons who attended preoperative pelvic floor physiotherapy for pelvic floor muscle (PFM) training between 2012 and 2015. Instructions were to contract the PFM as if stopping the flow of urine. BN displacement was measured with 2-dimensional transperineal ultrasound, without digital rectal examination. Urinary continence status was assessed preoperatively and at 3, 6, and 12 months using the Expanded Prostate Cancer Index Composite 26. Data were analysed using logistic regression and mixed effects linear modelling. Confounding variables considered were baseline continence, age at diagnosis, margin status, nerve sparing procedures and pathological stage.
Of 671 eligible men, 358 met the inclusion criteria and were available for analysis, with 136 complete datasets at 12-month follow-up. While BN movement was associated with preoperative continence, there was no significant effect of BN displacement on the change in urinary continence at 12 months postprostatectomy (P=0.81) or on the influence of time on continence over 3-12 months.
Continence outcomes were not associated with BN displacement, produced by activity of the puborectal portion of the levator ani muscle, at 3, 6, or 12 months after RARP. These results suggest that the puborectal muscle does not play a role in the recovery of continence after RARP and may help to explain the negative findings of many studies of PFMT for PPI.
对于接受机器人辅助根治性前列腺切除术（RARP）后出现前列腺切除术后尿失禁（PPI）的男性，盆底肌训练（PFMT）的疗效存在争议，其可能产生效果的机制仍不清楚。本研究的目的是探讨作为耻骨直肠肌激活指标的膀胱颈（BN）移位与RARP术后控尿结果之间的关系。
数据取自南澳大利亚前列腺癌临床结果协作数据库，研究对象为2012年至2015年间由大量外科医生进行RARP手术且术前接受盆底物理治疗以进行盆底肌（PFM）训练的男性。指导语是像停止排尿一样收缩PFM。使用二维经会阴超声测量BN移位，无需进行直肠指检操作。术前以及术后3、6和12个月使用扩展前列腺癌指数综合26评估尿失禁状态。采用逻辑回归和混合效应线性模型分析数据。考虑的混杂变量包括基线控尿情况、诊断时年龄、切缘状态、神经保留手术和病理分期。
在671名符合条件的男性中，358名符合纳入标准并可用于分析，其中136名在12个月随访时有完整数据集。虽然BN移动与术前控尿有关，但前列腺切除术后12个月时BN移位对尿失禁变化（P = 0.81）或3至12个月期间时间对控尿的影响均无显著作用。
RARP术后3、6或12个月时，由肛提肌耻骨直肠部分活动产生的BN移位与控尿结果无关。这些结果表明，耻骨直肠肌在RARP术后控尿恢复中不起作用，这可能有助于解释许多关于PFMT治疗PPI的研究的阴性结果。
