Urinary Incontinence After Robot-Assisted Laparoscopic Radical Prostatectomy

  • Kevin G. Chan
  • Timothy G. Wilson


Urinary incontinence following radical prostatectomy continues to be a significant problem despite improving surgical techniques. Robotic surgical techniques have the potential to improve urinary outcome measurements even more than their open predecessors. Improved visualization and precision of dissection with robotic technology offer a truly anatomic approach. The main purpose of this chapter is to summarize the status of urinary outcomes following robotic-assisted laparoscopic radical prostatectomy as well as to discuss the most current therapies used in the treatment of post-prostatectomy urinary incontinence. We also discuss the etiology of post-prostatectomy urinary incontinence, contributing risk factors, and the evaluation for incontinence as they are intimately related to prostatic surgical technique and incontinence interventions.


  1. 1.
    Rocco F, et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007;52(2):376–83.PubMedGoogle Scholar
  2. 2.
    Marien TP, Lepor H. Does a nerve-sparing technique or potency affect continence after open radical retropubic prostatectomy? BJU Int. 2008;102(11):1581–4.PubMedGoogle Scholar
  3. 3.
    Harris MJ. The anatomic radical perineal prostatectomy: an outcomes-based evolution. Eur Urol. 2007;52(1):81–8.PubMedGoogle Scholar
  4. 4.
    Martis G, et al. Retropubic versus perineal radical prostatectomy in early prostate cancer: eight-year experience. J Surg Oncol. 2007;95(6):513–8.PubMedGoogle Scholar
  5. 5.
    Goeman L, et al. Long-term functional and oncological results after retroperitoneal laparoscopic prostatectomy according to a prospective evaluation of 550 patients. World J Urol. 2006;24(3):281–8.PubMedGoogle Scholar
  6. 6.
    Takenaka A, et al. Influence of nerve-sparing procedure on early recovery of urinary continence after laparoscopic radical prostatectomy. J Endourol. 2009;23(7):1115–9.PubMedGoogle Scholar
  7. 7.
    Stolzenburg JU, et al. Endoscopic extraperitoneal radical prostatectomy: evolution of the technique and experience with 2400 cases. J Endourol. 2009;23(9):1467–72.PubMedGoogle Scholar
  8. 8.
    Potdevin L, et al. Functional and oncologic outcomes comparing interfascial and intrafascial nerve sparing in robot-assisted laparoscopic radical prostatectomies. J Endourol. 2009;23(9):1479–84.PubMedGoogle Scholar
  9. 9.
    Reynolds WS, et al. Analysis of continence rates following robot-assisted radical prostatectomy: strict leak-free and pad-free continence. Urology. 2010;75(2):431–6.PubMedGoogle Scholar
  10. 10.
    Menon M, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol. 2007;51(3):648–57. discussion 657–658.PubMedGoogle Scholar
  11. 11.
    Lepor H, Kaci L. The impact of open radical retropubic prostatectomy on continence and lower urinary tract symptoms: a prospective assessment using validated self-administered outcome instruments. J Urol. 2004;171(3):1216–9.PubMedGoogle Scholar
  12. 12.
    Sacco E, et al. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU Int. 2006;97(6):1234–41.PubMedGoogle Scholar
  13. 13.
    Majoros A, et al. Urinary incontinence and voiding dysfunction after radical retropubic prostatectomy (prospective urodynamic study). Neurourol Urodyn. 2006;25(1):2–7.PubMedGoogle Scholar
  14. 14.
    Kleinhans B, et al. Changes of urodynamic findings after radical retropubic prostatectomy. Eur Urol. 1999;35(3):217–21. discussion 221–222.PubMedGoogle Scholar
  15. 15.
    Pfister C, et al. Assessment of the intrinsic urethral sphincter component function in postprostatectomy urinary incontinence. Neurourol Urodyn. 2002;21(3):194–7.PubMedGoogle Scholar
  16. 16.
    Ficazzola MA, Nitti VW. The etiology of post-radical prostatectomy incontinence and correlation of symptoms with urodynamic findings. J Urol. 1998;160(4):1317–20.PubMedGoogle Scholar
  17. 17.
    Narayan P, et al. Neuroanatomy of the external urethral sphincter: implications for urinary continence preservation during radical prostate surgery. J Urol. 1995;153(2):337–41.PubMedGoogle Scholar
  18. 18.
    Bader P, et al. Inefficient urethral milking secondary to urethral dysfunction as an additional risk factor for incontinence after radical prostatectomy. J Urol. 2001;166(6):2247–52.PubMedGoogle Scholar
  19. 19.
    Hollabaugh RS Jr, Dmochowski RR, Steiner MS. Neuroanatomy of the male rhabdosphincter. Urology. 1997;49(3):426–34.PubMedGoogle Scholar
  20. 20.
    John H, et al. Effect of radical prostatectomy on sensory threshold and pressure transmission. J Urol. 2000;163(6):1761–6.PubMedGoogle Scholar
  21. 21.
    Gomha MA, Boone TB. Artificial urinary sphincter for post-prostatectomy incontinence in men who had prior radiotherapy: a risk and outcome analysis. J Urol. 2002;167(2 Pt 1):591–6.PubMedGoogle Scholar
  22. 22.
    Oefelein MG. Prospective predictors of urinary continence after anatomical radical retropubic prostatectomy: a multivariate analysis. World J Urol. 2004;22(4):267–71.PubMedGoogle Scholar
  23. 23.
    Hu JC, et al. Perioperative complications of laparoscopic and robotic assisted laparoscopic radical prostatectomy. J Urol. 2006;175(2):541–6. discussion 546.PubMedGoogle Scholar
  24. 24.
    Eastham JA, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol. 1996;156(5):1707–13.PubMedGoogle Scholar
  25. 25.
    Wille S, et al. Impact of comorbidities on post-prostatectomy incontinence. Urol Int. 2006;76(3):223–6.PubMedGoogle Scholar
  26. 26.
    Burkhard FC, et al. Nerve sparing open radical retropubic prostatectomy—does it have an impact on urinary continence? J Urol. 2006;176(1):189–95.PubMedGoogle Scholar
  27. 27.
    Twiss C, Slova D, Lepor H. Outcomes for men younger than 50 years undergoing radical prostatectomy. Urology. 2005;66(1):141–6.PubMedGoogle Scholar
  28. 28.
    Novara G, et al. Evaluating urinary continence and preoperative predictors of urinary continence after robot assisted laparoscopic radical prostatectomy. J Urol. 2010;184(3):1028–33.PubMedGoogle Scholar
  29. 29.
    Kundu SD, et al. Potency, continence and complications in 3,477 consecutive radical retropubic prostatectomies. J Urol. 2004;172(6 Pt 1):2227–31.PubMedGoogle Scholar
  30. 30.
    Kubler HR, et al. Impact of nerve sparing technique on patient self-assessed outcomes after radical perineal prostatectomy. J Urol. 2007;178(2):488–92. discussion 492.PubMedGoogle Scholar
  31. 31.
    Berry T, et al. Is there correlation of nerve-sparing status and return to baseline urinary function after robot-assisted laparoscopic radical prostatectomy? J Endourol. 2009;23(3):489–93.PubMedGoogle Scholar
  32. 32.
    Coakley FV, et al. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol. 2002;168(3):1032–5.PubMedGoogle Scholar
  33. 33.
    Paparel P, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol. 2009;55(3):629–37.PubMedGoogle Scholar
  34. 34.
    Lee SE, et al. Impact of variations in prostatic apex shape on early recovery of urinary continence after radical retropubic prostatectomy. Urology. 2006;68(1):137–41.PubMedGoogle Scholar
  35. 35.
    Pettus JA, et al. Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy. J Urol. 2009;182(3):949–55.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Konety BR, Sadetsky N, Carroll PR. Recovery of urinary continence following radical prostatectomy: the impact of prostate volume-analysis of data from the CaPSURE database. J Urol. 2007;177(4):1423–5. discussion 1425–1426.PubMedGoogle Scholar
  37. 37.
    Milhoua PM, et al. Issue of prostate gland size, laparoscopic radical prostatectomy, and continence revisited. Urology. 2008;71(3):417–20.PubMedGoogle Scholar
  38. 38.
    Ahlering TE, et al. Impact of obesity on clinical outcomes in robotic prostatectomy. Urology. 2005;65(4):740–4.PubMedGoogle Scholar
  39. 39.
    Wolin KY, et al. Risk of urinary incontinence following prostatectomy: the role of physical activity and obesity. J Urol. 2010;183(2):629–33.PubMedGoogle Scholar
  40. 40.
    Mulholland TL, et al. Urinary incontinence after radical retropubic prostatectomy is not related to patient body mass index. Prostate Cancer Prostatic Dis. 2006;9(2):153–9.PubMedGoogle Scholar
  41. 41.
    Colombo R, et al. Radical prostatectomy after previous prostate surgery: clinical and functional outcomes. J Urol. 2006;176(6):2459–63.PubMedGoogle Scholar
  42. 42.
    Hu JC, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302(14):1557–64.PubMedGoogle Scholar
  43. 43.
    Webb DR, Sethi K, Gee K. An analysis of the causes of bladder neck contracture after open and robot-assisted laparoscopic radical prostatectomy. BJU Int. 2009;103(7):957–63.PubMedGoogle Scholar
  44. 44.
    Leach GE, et al. Post-prostatectomy incontinence: urodynamic findings and treatment outcomes. J Urol. 1996;155(4):1256–9.PubMedGoogle Scholar
  45. 45.
    Anger JT, et al. Anastomotic contracture and incontinence after radical prostatectomy: a graded approach to management. J Urol. 2005;173(4):1143–6.PubMedGoogle Scholar
  46. 46.
    Elliott DS, Boone TB. Combined stent and artificial urinary sphincter for management of severe recurrent bladder neck contracture and stress incontinence after prostatectomy: a long-term evaluation. J Urol. 2001;165(2):413–5.PubMedGoogle Scholar
  47. 47.
    Magera JS Jr, Inman BA, Elliott DS. Outcome analysis of urethral wall stent insertion with artificial urinary sphincter placement for severe recurrent bladder neck contracture following radical prostatectomy. J Urol. 2009;181(3):1236–41.PubMedGoogle Scholar
  48. 48.
    Wessells H, Morey AF, McAninch JW. Obliterative vesicourethral strictures following radical prostatectomy for prostate cancer: reconstructive armamentarium. J Urol. 1998;160(4):1373–5.PubMedGoogle Scholar
  49. 49.
    Schlossberg S, Jordan G, Schellhammer P. Repair of obliterative vesicourethral stricture after radical prostatectomy: a technique for preservation of continence. Urology. 1995;45(3):510–3.PubMedGoogle Scholar
  50. 50.
    Filocamo MT, et al. Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. Eur Urol. 2005;48(5):734–8.PubMedGoogle Scholar
  51. 51.
    Parekh AR, et al. The role of pelvic floor exercises on post-prostatectomy incontinence. J Urol. 2003;170(1):130–3.PubMedGoogle Scholar
  52. 52.
    MacDonald R, et al. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int. 2007;100(1):76–81.PubMedGoogle Scholar
  53. 53.
    Wille S, et al. Pelvic floor exercises, electrical stimulation and biofeedback after radical prostatectomy: results of a prospective randomized trial. J Urol. 2003;170(2 Pt 1):490–3.PubMedGoogle Scholar
  54. 54.
    Bales GT, et al. Effect of preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy. Urology. 2000;56(4):627–30.PubMedGoogle Scholar
  55. 55.
    Thor KB, Katofiasc MA. Effects of duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, on central neural control of lower urinary tract function in the chloralose-anesthetized female cat. J Pharmacol Exp Ther. 1995;274(2):1014–24.PubMedGoogle Scholar
  56. 56.
    Millard RJ, et al. Duloxetine vs placebo in the treatment of stress urinary incontinence: a four-continent randomized clinical trial. BJU Int. 2004;93(3):311–8.PubMedGoogle Scholar
  57. 57.
    Dmochowski RR, et al. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol. 2003;170(4 Pt 1):1259–63.PubMedGoogle Scholar
  58. 58.
    van Kerrebroeck P, et al. Duloxetine versus placebo in the treatment of European and Canadian women with stress urinary incontinence. BJOG. 2004;111(3):249–57.PubMedGoogle Scholar
  59. 59.
    Bianco FJ Jr, Scardino PT, Eastham JA. Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (“trifecta”). Urology. 2005;66(5 Suppl):83–94.PubMedGoogle Scholar
  60. 60.
    Filocamo MT, et al. Pharmacologic treatment in postprostatectomy stress urinary incontinence. Eur Urol. 2007;51(6):1559–64.PubMedGoogle Scholar
  61. 61.
    Cornu JN, et al. Duloxetine for mild to moderate postprostatectomy incontinence: preliminary results of a randomised, placebo-controlled trial. Eur Urol. 2010;59(1):148–54.PubMedGoogle Scholar
  62. 62.
    Malizia AA Jr, et al. Migration and granulomatous reaction after periurethral injection of polytef (Teflon). JAMA. 1984;251(24):3277–81.PubMedGoogle Scholar
  63. 63.
    Cummings JM, Boullier JA, Parra RO. Transurethral collagen injections in the therapy of post-radical prostatectomy stress incontinence. J Urol. 1996;155(3):1011–3.PubMedGoogle Scholar
  64. 64.
    Aboseif SR, et al. Collagen injection for intrinsic sphincteric deficiency in men. J Urol. 1996;155(1):10–3.PubMedGoogle Scholar
  65. 65.
    Faerber GJ, Richardson TD. Long-term results of transurethral collagen injection in men with intrinsic sphincter deficiency. J Endourol. 1997;11(4):273–7.PubMedGoogle Scholar
  66. 66.
    Smith DN, et al. Collagen injection therapy for post-prostatectomy incontinence. J Urol. 1998;160(2):364–7.PubMedGoogle Scholar
  67. 67.
    Westney OL, et al. Transurethral collagen injections for male intrinsic sphincter deficiency: the University of Texas-Houston experience. J Urol. 2005;174(3):994–7.PubMedGoogle Scholar
  68. 68.
    Kaufman JJ. Surgical treatment of post-prostatectomy incontinence: use of the penile crura to compress the bulbous urethra. J Urol. 1972;107:293–7.PubMedGoogle Scholar
  69. 69.
    Guimaraes M, et al. Intermediate-term results, up to 4 years, of a bone-anchored male perineal sling for treating male stress urinary incontinence after prostate surgery. BJU Int. 2009;103(4):500–4.PubMedGoogle Scholar
  70. 70.
    Cornu JN, et al. The AdVance transobturator male sling for postprostatectomy incontinence: clinical results of a prospective evaluation after a minimum follow-up of 6 months. Eur Urol. 2009;56(6):923–7.PubMedGoogle Scholar
  71. 71.
    Gregori A, et al. Transrectal ultrasound-guided implantation of adjustable continence therapy (ProACT): surgical technique and clinical results after a mean follow-up of 2 years. Eur Urol. 2010;57(3):430–3.PubMedGoogle Scholar
  72. 72.
    Schaeffer AJ, et al. The male bulbourethral sling procedure for post-radical prostatectomy incontinence. J Urol. 1998;159(5):1510–5.PubMedGoogle Scholar
  73. 73.
    Migliari R, Pistolesi D, De Angelis M. Polypropilene sling of the bulbar urethra for post-radical prostatectomy incontinence. Eur Urol. 2003;43(2):152–7.PubMedGoogle Scholar
  74. 74.
    John H. Bulbourethral composite suspension: a new operative technique for post-prostatectomy incontinence. J Urol. 2004;171(5):1866–70. discussion 1869–1870.PubMedGoogle Scholar
  75. 75.
    Stern JA, et al. Long-term results of the bulbourethral sling procedure. J Urol. 2005;173(5):1654–6.PubMedGoogle Scholar
  76. 76.
    Migliari R, et al. Male bulbourethral sling after radical prostatectomy: intermediate outcomes at 2 to 4-year followup. J Urol. 2006;176(5):2114–8. discussion 2118.PubMedGoogle Scholar
  77. 77.
    Comiter CV. The male sling for stress urinary incontinence: a prospective study. J Urol. 2002;167(2 Pt 1):597–601.PubMedGoogle Scholar
  78. 78.
    Fassi-Fehri H, et al. Efficacy of the InVancetrade mark male sling in men with stress urinary incontinence. Eur Urol. 2007;51:498–503.PubMedGoogle Scholar
  79. 79.
    Rajpurkar AD, Onur R, Singla A. Patient satisfaction and clinical efficacy of the new perineal bone-anchored male sling. Eur Urol. 2005;47(2):237–42. discussion 242.PubMedGoogle Scholar
  80. 80.
    Comiter CV. The male perineal sling: intermediate-term results. Neurourol Urodyn. 2005;24(7):648–53.PubMedGoogle Scholar
  81. 81.
    Castle EP, et al. The male sling for post-prostatectomy incontinence: mean followup of 18 months. J Urol. 2005;173(5):1657–60.PubMedGoogle Scholar
  82. 82.
    Giberti C, et al. The bone anchor suburethral synthetic sling for iatrogenic male incontinence: critical evaluation at a mean 3-year followup. J Urol. 2009;181(5):2204–8.PubMedGoogle Scholar
  83. 83.
    Rehder P, Gozzi C. Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol. 2007;52(3):860–6.PubMedGoogle Scholar
  84. 84.
    Bauer RM, et al. Complications of the AdVance transobturator male sling in the treatment of male stress urinary incontinence. Urology. 2010;75(6):1494–8.PubMedGoogle Scholar
  85. 85.
    Hubner WA, Schlarp OM. Treatment of incontinence after prostatectomy using a new minimally invasive device: adjustable continence therapy. BJU Int. 2005;96(4):587–94.PubMedGoogle Scholar
  86. 86.
    Gregori A, et al. Transrectal ultrasound guided implantation of the ProACT adjustable continence therapy system in patients with post-radical prostatectomy stress urinary incontinence: a pilot study. J Urol. 2006;176(5):2109–13. discussion 2113.PubMedGoogle Scholar
  87. 87.
    Gilling PJ, et al. An adjustable continence therapy device for treating incontinence after prostatectomy: a minimum 2-year follow-up. BJU Int. 2008;102(10):1426–30. discussion 1430–1431.PubMedGoogle Scholar
  88. 88.
    Sousa-Escandon A, et al. Adjustable suburethral sling (male remeex system) in the treatment of male stress urinary incontinence: a multicentric European study. Eur Urol. 2007;52(5):1473–9.PubMedGoogle Scholar
  89. 89.
    Dikranian AH, et al. The male perineal sling: comparison of sling materials. J Urol. 2004;172(2):608–10.PubMedGoogle Scholar
  90. 90.
    Bauer RM, et al. Mid-term results for the retroluminar transobturator sling suspension for stress urinary incontinence after prostatectomy. BJU Int. 2011;108(1):94–8.PubMedGoogle Scholar
  91. 91.
    Hubner WA, et al. Adjustable bulbourethral male sling: experience after 101 cases of moderate-to-severe male stress urinary incontinence. BJU Int. 2011;107(5):777–82.PubMedGoogle Scholar
  92. 92.
    Litwiller SE, et al. Post-prostatectomy incontinence and the artificial urinary sphincter: a long-term study of patient satisfaction and criteria for success. J Urol. 1996;156(6):1975–80.PubMedGoogle Scholar
  93. 93.
    Klijn AJ, et al. The artificial urinary sphincter in men incontinent after radical prostatectomy: 5 year actuarial adequate function rates. Br J Urol. 1998;82(4):530–3.PubMedGoogle Scholar
  94. 94.
    Walsh IK, et al. Artificial urinary sphincter implantation in the irradiated patient: safety, efficacy and satisfaction. BJU Int. 2002;89(4):364–8.PubMedGoogle Scholar
  95. 95.
    Clemens JQ, et al. Revision rate after artificial urinary sphincter implantation for incontinence after radical prostatectomy: actuarial analysis. J Urol. 2001;166(4):1372–5.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Division of UrologyCity of Hope National Medical CenterDuarteUSA

Personalised recommendations