Ippoliti Simona, Colalillo Gaia, Egbury Gerald, Orecchia Luca, Fletcher Peter, Piechaud Thierry, Gaston Richard, Finazzi-Agrò Enrico, Miano Roberto, Asimakopoulos Anastasios D
Department of Urology, Hull University Teaching Hospitals, Hull, United Kingdom.
Department of Urology, Fondazione PTV Policlinico Tor Vergata University Hospital, Rome, Italy.
J Endourol. 2023 Oct;37(10):1088-1104. doi: 10.1089/end.2023.0188. Epub 2023 Sep 11.
Numerous continence-sparing radical prostatectomy techniques have been developed to enhance postoperative early continence (EC) recovery; however, evidence regarding the best approach remains controversial. The objectives are to provide a critical appraisal of various prostatectomy techniques, based on the evidence of quality-assessed randomized control trials (RCTs); to summarize the immediate continence and the EC reported; and to propose a new standardization for continence outcomes reporting. Data acquired from five medical registries were reported to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Evidence from published, English, full-text RCTs reporting postoperative urinary continence outcomes within 6 months from surgery was included. The heterogeneity of surgical techniques and continence definitions did not allow a meta-analysis. All RCTs were critically appraised, and quality assessed. In total, 39 RCTs were included: 19 of 39 studies were low-quality RCTs, presenting small cohort, monocentric, or single-surgeon data. The best RCT-supported evidence is in favor of robot-assisted radical prostatectomy (RARP) compared with laparoscopic radical prostatectomy (LRP) and of the Retzius-sparing (RS) technique over the traditional prostatectomy. Other techniques such as bladder neck and puboprostatic ligament (PPL) preservation, posterior reconstruction with or without combination of anterior suspension technique, and nerve-sparing (NS) approach seem to enhance EC. Oppositely, the endopelvic fascia preservation, bladder neck mucosa eversion/plication/slings, and the selective ligature of dorsal venous complex (DVC) were not significantly associated with EC improvements. RCTs are lacking on pubovesical complex-sparing, seminal vesicle preservation, anterior reconstruction of the puboprostatic collar, musculofascial reconstruction, and DVC suspension to the periosteum of the pubic bone techniques. RARP and RS have high-quality evidence supporting their ability to enhance postoperative EC recovery. NS, bladder neck, and PPL preservation may contribute to better EC recovery, although the evidence level is low. Further multicenter RCTs are needed to establish the optimal combination of standard surgical techniques. A new continence outcome-reporting standardization was proposed.
为提高术后早期控尿（EC）恢复率，人们已开发出多种保留控尿功能的根治性前列腺切除术技术；然而，关于最佳手术方法的证据仍存在争议。目的是基于质量评估随机对照试验（RCT）的证据，对各种前列腺切除术技术进行批判性评价；总结报告的即时控尿情况和早期控尿情况；并提出控尿结果报告的新标准化方法。从五个医学登记处获取的数据按照系统评价和Meta分析的首选报告项目（PRISMA）标准进行报告。纳入了已发表的、英文的、全文RCT中关于术后6个月内尿控结果的证据。手术技术和控尿定义的异质性使得无法进行Meta分析。对所有RCT进行了批判性评价和质量评估。总共纳入了39项RCT：39项研究中有19项是低质量RCT，呈现的是小队列、单中心或单术者的数据。与腹腔镜根治性前列腺切除术（LRP）相比，最佳的RCT支持证据表明机器人辅助根治性前列腺切除术（RARP）更具优势，与传统前列腺切除术相比，保留Retzius间隙（RS）技术更具优势。其他技术，如保留膀胱颈和耻骨前列腺韧带（PPL）、采用或不采用前悬吊技术联合的后重建以及保留神经（NS）方法似乎可提高早期控尿。相反，保留盆腔内筋膜、膀胱颈黏膜外翻/折叠/悬吊以及选择性结扎背静脉复合体（DVC）与早期控尿改善无显著相关性。关于保留耻骨膀胱复合体、保留精囊、耻骨前列腺环的前重建、肌筋膜重建以及将DVC悬吊至耻骨骨膜的技术，缺乏RCT研究。RARP和RS有高质量证据支持其提高术后早期控尿恢复的能力。保留神经、膀胱颈和PPL可能有助于更好地恢复早期控尿，尽管证据水平较低。需要进一步开展多中心RCT来确定标准手术技术的最佳组合。提出了一种新的控尿结果报告标准化方法。
