Purpose
Robot-assisted radical prostatectomy (RARP) is associated with poorer post-operative urinary continence in older men. However, published studies reporting conflicting results have design limitations with insufficient data at the extremes of age. The purpose of this study was to assess the effect of age on post-RARP urinary continence.
Materials and Methods
This study included 5648 patients from two prospective Australian databases who underwent a primary RARP for prostate cancer between 2008 and 2019. Significant urinary bother and pad-usage were evaluated 12 months post-RARP by Expanded Prostate Cancer Index Composite (EPIC-26) questionnaires, independently collected by third parties. Multivariable logistic regression was used to investigate the relationship between continence and age.
Results
Percentages of significant bother increased with age: 4.2%, 6.8% 9.1% and 12.9% at age groups <55, 55-64, 65-74 and ≥75 years, respectively. Compared with men aged 65-69 years the odds of significant bother in patients <55 years was significantly lower (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.32–0.75, p=0.001). Corresponding OR found no significant difference in bother in patients ≥70 (OR 1.24, 95% CI 0.94–1.63, p=0.13) or ≥75 years (OR 1.41, 95%CI 0.88–2.25, p=0.16). Pad-free rates markedly decreased with age: 86%, 79%, 68% and 50% at ages, <55, 55-64, 65-74 and ≥75 years, respectively. Corresponding social continence (0-1 pads/day) rates also decreased with age: 98%, 96%, 92% and 85%.
Conclusions
Urinary bother and pad-usage post-RARP are excellent in young men but worsen with age. Older patients were only slightly more likely to be “significantly bothered” by incontinence despite higher pad-usage.
All accepted therapies for localized prostate cancer bear a substantial risk of side effects and may thus have an impact on health-related quality of life.(1,2) The main well-known side effects are erectile dysfunction, lower urinary tract and bowel symptoms. When counselling patients on the available treatment options, different patterns and risks of side effects should be taken into account and combined with specific patients’ expectations and wishes.
Surgical techniques have evolved and improved over the past years, such as sparing of the urethral stump, resulting in low rates of severely incontinent men.(3) The impact on erectile function has however remained significant.(4) Different patient-specific factors such as age may predict post-prostatectomy functional outcomes.
Gondoputro et al show the importance of taking age into account when discussing different options for local prostate cancer therapy. The study found an excellent recovery of continence one year after prostatectomy in younger men, while these were significantly worse in elderly ones. Two clinical databases were combined, including 5648 patients from two prospective Australian databases who underwent a primary RARP for prostate cancer between 2008 and 2019. The EPIC-26 questionnaire was used to measure continence pad use and bother by urine loss. Patients were followed up to one year after surgery.
Multivariable logistic regression was used to investigate the relationship between continence and age. The percentage of men who did not use a pad at 12 mo. after surgery was strongly associated with age; 86% for men <55 and only 50% for men ≥75 years, respectively. Bother (moderate/big) with incontinence also increased with age (4.2%, 6.8% 9.1% and 12.9% at age groups <55, 55-64, 65-74 and ≥75 years), but the two associations were discrepant. Younger men did generally significantly better than median-aged men, but older men did NOT significantly worse than the median age group.
Different reasons for the discordance between pad use and bother are presented in the study (e.g. more a priori BPH symptoms, less physical activity, less stigma in older men). Another known psychological effect is a shift in how patients experience their symptoms. For example, a man may appreciate his urine loss as much more important before his diagnosis, than after he ‘survived’ his prostate cancer, accepting a certain pattern of side effects after therapy. This effect may be more likely in older men. Still, although older men have less bother of urine loss, this should not be a reason to ignore this side effect.
In an ideal world, centre-specific predictions on outcomes after radical therapy that are used during the decision-making process, are based on multiple relevant variables. Besides age, membraneous urethra length (MUL), body mass index, and others, are known factors impacting on post-operative continence rates. Although perfect projections are impossible, we should aim to provide patients with the best prediction of the potential scenarios after different treatment options for their specific situation.
References
1. Mottet et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol. 2021 Feb;79(2):243-262.
2. Hamdy et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med. 2016 Oct 13;375(15):1415-1424.
3. Schlomm et al. Full functional-length urethral sphincter preservation during radical prostatectomy. Eur Urol. 2011 Aug;60(2):320-9.
4. Capogrosso et al. Are We Improving Erectile Function Recovery After Radical Prostatectomy? Analysis of Patients Treated over the Last Decade. Eur Urol 2019 Feb;75(2):221-228.
5. Gondoputro et al. How Does Age Affect Urinary Continence following Robot-Assisted Radical Prostatectomy? A Prospective Multi-Institutional Study Using Independently Collected, Validated Questionnaires. J Urol. 2022 Jan 3:101097JU0000000000002391.