Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
Cancer. 2022 Mar 1;128(5):1066-1073. doi: 10.1002/cncr.33994. Epub 2021 Nov 1.
Changes in surgical technique and postoperative care that target improvements in functional outcomes are widespread in the literature. Radical prostatectomy (RP) is one such procedure that has seen multiple advances over the past decade. The objective of this study was to leverage RP as an index case to determine whether practice changes over time produced observable improvements in patient-reported outcomes.
This study analyzed patients undergoing RP by experienced surgeons at a tertiary care center with prospectively maintained patient-reported outcome data from 2008 to 2019. Four patient-reported urinary function outcomes at 6 and 12 months after RP were defined with a validated instrument: good urinary function (domain score ≥ 17), no incontinence (0 pads per day), social continence (≤1 pad per day), and severe incontinence (≥3 pads per day). Multivariable logistic regressions evaluated changes in outcomes based on the surgical date.
Among 3945 patients meeting the inclusion criteria, excellent urinary outcomes were reported throughout the decade but without consistent observable improvements over time. Specifically, there were no improvements in good urinary function at 12 months (P = .087) based on the surgical date, and there were countervailing effects on no incontinence (worsening; P = .005) versus severe incontinence (improving; P = .003). Neither approach (open, laparoscopic, or robotic), nor nerve sparing, nor membranous urethral length mediated changes in outcomes.
In a decade with multiple advances in surgical and postoperative care, there was evidence of improvements in severe incontinence, but no measurable improvements across 3 other urinary outcomes. Although worsening disease factors could contribute to the stable observed outcomes, a more systematic approach to evaluating techniques and implementing patient selection and postoperative care advances is needed.
Although there have been advances in radical prostatectomy over the past decade, consistent observable improvements in postoperative incontinence were not reported by patients. To improve urinary function outcomes beyond the current high standard, the approach to studying innovations in surgical technique needs to be changed, and further development of other aspects of prostatectomy care is needed.
旨在改善功能结果的手术技术和术后护理的变化在文献中广泛存在。根治性前列腺切除术（RP）就是这样一种手术，在过去十年中经历了多次改进。本研究的目的是利用 RP 作为一个指标病例，以确定随着时间的推移，实践的变化是否在患者报告的结果方面产生了可观察到的改善。
本研究分析了在一家三级护理中心由经验丰富的外科医生进行的 RP 手术，这些患者具有从 2008 年到 2019 年前瞻性维护的患者报告的结果数据。使用经过验证的工具定义了 RP 后 6 个月和 12 个月的四个患者报告的尿功能结果：良好的尿功能（域评分≥17）、无尿失禁（每天 0 片）、社交尿失禁（每天≤1 片）和严重尿失禁（每天≥3 片）。多变量逻辑回归评估了基于手术日期的结果变化。
在符合纳入标准的 3945 名患者中，整个十年报告了极好的尿功能结果，但没有随着时间的推移而出现一致的可观察到的改善。具体来说，根据手术日期，12 个月时良好的尿功能没有改善（P=0.087），无尿失禁（恶化；P=0.005）与严重尿失禁（改善；P=0.003）之间存在相互矛盾的影响。无论是开放、腹腔镜还是机器人手术方法，还是神经保留术，还是膜状尿道长度都没有改变结果。
在过去十年中，手术和术后护理方面取得了多项进展，但在其他 3 个尿功能结果方面没有证据表明有可衡量的改善。尽管疾病因素的恶化可能导致观察到的结果稳定，但需要采用更系统的方法来评估技术，并实施患者选择和术后护理的进展。
患者报告的术后尿失禁并没有得到改善。为了改善除目前高标准之外的尿功能结果，需要改变研究手术技术创新的方法，进一步发展前列腺切除术护理的其他方面。
