european urology 55 (2009)

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1 european urology 55 (2009) available at journal homepage: Prostate Cancer Recovery of Urinary Continence after Radical Prostatectomy: Association with Urethral Length and Urethral Fibrosis Measured by Preoperative and Postoperative Endorectal Magnetic Resonance Imaging Philippe Paparel a, Oguz Akin b, Jaspreet S. Sandhu a, Javier Romero Otero a, Angel M. Serio c, Peter T. Scardino a, Hedvig Hricak b, Bertrand Guillonneau a, * a Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York, United States b Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York, United States c Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York, United States Article info Article history: Accepted August 22, 2008 Published online ahead of print on September 2, 2008 Keywords: Urethral length Urinary continence Endorectal MRI Radical prostatectomy Abstract Background: Limited data on endorectal magnetic resonance imaging (MRI) features and urinary continence after radical prostatectomy (RP) are available. Objective: To assess whether recovery of urinary continence after RP is associated with endorectal MRI findings regarding preoperative and postoperative membranous urethral length (MUL), percent change in MUL, and postoperative urethral and periurethral fibrosis. Design, setting, and participants: Sixty-four patientswho received anmri scan before and after RP for localized prostate cancer were evaluated in a retrospective study at a single institution. Intervention: All patients underwent RP. Measurements: The postoperative scan was performed to detect local recurrence in patients with rising levels of prostate-specific antigen. Urinary continence was graded on a five-point scale. MUL was measured on T2-weighted images. Urethral and periurethral fibrosis was graded from 0 to III based on axial T2-weighted images. Univariate Cox proportional hazards regression was performed to assess variables associated with continence. Results and limitations: Forty-eight patients regained continence following surgery. The median follow-up for patient who were incontinent at their last assessment was 7 mo. The median interval from RP to postoperative endorectal MRI was 10 mo. A longer preoperative or postoperative MUL was associated with superior continence (both p < 0.01). The MUL loss ratio was significantly associated with postoperative continence ( p = 0.02). Patients with a high grade of postoperative periurethral fibrosis tended to have worse postoperative continence; nevertheless a statistical correlation was not reached (hazard ratio: 0.64, p = 0.16). This is a retrospective study. Conclusions: Preoperative and postoperative MUL and the MUL loss ratio are related to the recovery time and level of urinary continence after RP. Therefore, preservation of urethral length during surgery is recommended. Periurethral fibrosis might impede the recovery of continence after RP by altering the elasticity of the external sphincter. # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Memorial Sloan-Kettering Cancer Center, Sidney Kimmel Center for Prostate Cancer and Urologic Cancers, 353 East 68th Street, New York, NY 10021, USA. Tel ; Fax: address: guillonb@mskcc.org (B. Guillonneau) /$ see back matter # 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 630 european urology 55 (2009) Introduction The reported percentages of patients with urinary incontinence after radical prostatectomy (RP) range from 6% to 20% [1 3]. Cambio and Evans [4] recently published an exhaustive analysis of the literature identifying the risk factors for urinary incontinence after RP. They analyzed the influence of perioperative factors (body weight, prostate volume, patient age, and pelvic floor exercise), anatomic factors (puboperinealis muscle-sparing dissection, trigonal denervation, and preservation of endopelvic fascia), and technical factors (bladder neck preservation, urethral length preservation, mucosal eversion, neurovascular bundle [5], and puboprostatic ligament preservation). Preservation of urethral length by far did not reach level III on the rating scale of the American Society of Clinical Oncology (ie, evidence from well-designed, nonexperimental studies such as comparative and correlational descriptive and case studies) and was inferior to the above parameters. Postoperative urethral fibrosis was not cited in this review due to the paucity of relevant data in the literature. The development of magnetic resonance imaging (MRI) has led to improved anatomical understanding of the structures that affect urinary continence after RP [6 8]. The objective of our study is to use endorectal MRI to evaluate the roles of preoperative and postoperative membranous urethral length (MUL) and urethral and periurethral fibrosis in the recovery of urinary continence after RP. 2. Methods 2.1. Patients Our institutional review board approved and issued a waiver of informed consent for our Health Insurance Portability and Accountability Act (HIPAA) compliant retrospective study. From among 1622 consecutive patients who underwent endorectal MRI before open or laparoscopic RP for prostate cancer at our institution between February 1999 and May 2006, we identified 71 patients who also underwent postoperative endorectal MRI. Three of these patients were excluded from our study because of prior irradiation (two had salvage RP after radiation failure, and one had adjuvant external-beam radiotherapy before the postoperative endorectal MRI), and four were excluded because they had local recurrence preventing assessment of features related to continence on postoperative endorectal MRI. Thus the study cohort included 64 patients, none of whom had salvage radiotherapy during the period of postoperative evaluation for continence. Nine surgeons performed these 64 prostatectomies, with 64% (41/64) performed by three surgeons. The median interval from RP to postoperative endorectal MRI was 10 mo. In these patients, postoperative endorectal MRI was performed due to rising Table 1 The level of stable continence graded on a fivepoint scale Level of urinary continence levels of prostate-specific antigen (PSA) or other suspicion of local recurrence. Two of these patients had previously undergone transurethral resection of the prostate. One patient who was postoperatively incontinent developed a pelvic hematoma on postoperative day 2, requiring a blood transfusion; one patient who was postoperatively continent developed a bladder-neck contracture requiring two endoscopic sections of the bladder neck. There were no urinary fistulae in either group Continence evaluation After surgery the time to stable postoperative continence was assessed and recorded by validated self-questionnaire inclinic interviews. The first consultation took place 6 wk after surgery. Continence was graded on a five-point scale (Table 1). Patients were considered continent when they remained at level 1 (using no pad or protection) for 6 wk. All patients were assessed for continence before any subsequent adjuvant radiotherapy Magnetic resonance imaging technique Clinical meaning 1 Complete continence 2 One pad daily 3 Two to three pads daily 4 Four or more pads daily 5 Complete incontinence MRI was performed on a 1.5 Tesla whole-body magnetic resonance (MR) scanner (Signa, GE Medical Systems, Milwaukee, WI). We instructed each patient to empty his bladder before MRI and to empty his rectum; if he could not, we gave him a Fleet enema. Patients were examined in the supine position, using the body coil for excitation and a pelvic phased array coil (GE Medical Systems, Milwaukee, WI) in combination with an expandable endorectal coil (Medrad, Pittsburg, PA) for signal reception. Axial spin-echo T1-weighted images were obtained with the following parameters: TR/TE, / 8 10 ms; slice thickness, 5 mm; interslice gap, 1 mm; field of view, 24 cm; matrix, ; and two excitations. Thinsection, high-spatial-resolution axial, coronal and sagittal T2-weighted, fast spin-echo images were obtained with the following parameters: TR/TE, / ms; echo train length, 12 16; slice thickness, 3 mm; interslice gap, 0 mm; field of view, cm; matrix, ; and four excitations. T2-weighted images were postprocessed to correct for the reception profile of the endorectal coil Magnetic resonance imaging interpretation Images were retrospectively interpreted in consensus by a radiologist dedicated to prostate endorectal MRI and a urologist. The readers were aware that patients had prostate cancer but were blinded to all other clinical and pathological findings. MRI variables evaluated were preoperative and

3 european urology 55 (2009) Fig. 1 (a) Preoperative T2-weighted endorectal magnetic resonance images from a 64-yr-old incontinent patient. The preoperative membranous urethral length is measured in the (a) coronal and (b) sagittal planes and is considered to be the distance from the prostatic apex to the level of the urethra at the penile bulb. (b) Preoperative T2-weighted endorectal magnetic resonance images from a 64-yr-old incontinent patient. The preoperative membranous urethral length is measured in the (a) coronal and (b) sagittal planes and is considered to be the distance from the prostatic apex to the level of the urethra at the penile bulb. postoperative MUL, percent change in MUL during RP, and postoperative fibrosis of the urethral wall and periurethral structures Measurement of membranous urethral length MUL was measured in the midline sagittal plane as crossreferenced to the coronal plane on T2-weighted endorectal MR images (Fig. 1 and 2). On preoperative endorectal MRI, MUL was considered to be the distance from the prostatic apex to the level of the urethra at the penile bulb (Fig. 1a and b); on postoperative endorectal MRI, MUL was considered to be the distance from the bladder neck to the level of the urethra at the penile bulb (Fig. 2a and b). The percent change in MUL was defined as [(preoperative MUL postoperative MUL) 100]/ preoperative MUL. Fig. 2 (a) Postoperative T2-weighted endorectal magnetic resonance images from a 62-yr-old incontinent patient. The postoperative membranous urethral length is measured in the (a) coronal and (b) sagittal planes and is considered to be the distance from the bladder neck to the level of the urethra at the penile bulb. (b) Postoperative T2-weighted endorectal magnetic resonance images from a 62-yr-old incontinent patient. The postoperative membranous urethral length is measured in the (a) coronal and (b) sagittal planes and is considered to be the distance from the bladder neck to the level of the urethra at the penile bulb.

4 632 european urology 55 (2009) Fig. 3 Grading of urethral and periurethral fibrosis Evaluation of postoperative fibrosis This evaluation was performed on axial T2-weighted images from postoperative endorectal MRI (always before any adjuvant radiotherapy). On axial T2-weighted images, the normal membranous urethra appears as a low signal intensity ring, and normal periurethral tissue appears as a high signal intensity around the membranous urethra. Urethralwall fibrosis appears as a change in signal intensity or as focal thinning in the urethral wall. Periurethral fibrosis appears as ill-defined, low signal intensity within normally high signal intensity periurethral tissue Classification of fibrosis The urethral wall and the periurethral tissue were each divided into thirds in the axial plane to quantify fibrosis (Fig. 3). This classification has been created by our team. Fibrosis was graded as follows: Grade 0: No fibrosis (Fig. 4) Grade I: Fibrosis involving one-third of the circumference (Fig. 5) Grade II: Fibrosis involving two-thirds of the circumference Grade III: Circumferential fibrosis (Fig. 5) Statistical analysis Fig. 4 Postoperative axial T2-weighted image from a 61-yr-old continent patient showing no postoperative fibrosis; grade 0 for the urethral wall (arrow) and for the periurethral tissue (dashed arrows). Cox proportional hazards regression was used to determine variables associated with time to continence following prostatectomy. Patients incontinent at their last continence evaluation were censored at that time. All variables were entered as continuous except for postoperative fibrosis, which was categorized as either low grade (Grade 0 or I) or high grade (Grade II or III). We did not perform a multivariable analysis including all MRI features in a single model due to multicollinearity (eg, the correlation between preoperative and

5 european urology 55 (2009) Table 2 Patient characteristics Clinical characteristics Median (interquartile range) Age at surgery (yr) 61 (55, 66) Preoperative PSA (ng/ml) 8.3 (5.89, 14.0) Number (%) Clinical stage T1 16 (26%) T2 45 (74%) Biopsy Gleason score 6 5 (8%) 7 32 (50%) 8 18 (28%) Fig. 5 Postoperative axial T2-weighted endorectal magnetic resonance image from a 56-yr-old patient showing grade I urethral fibrosis (arrow) and grade III circumferential periurethral fibrosis (dashed arrows). postoperative MUL was 0.61). However, we did perform multivariate analyses to evaluate each variable adjusted for age at RP, since age is known to be associated with continence. The cumulative incidence of continence following RP was estimated using the Kaplan-Meier method. For illustrative purposes, we present the cumulative incidence, stratifying patients at the median level of the predictor. All statistical analyses were conducted using Stata 9.0 (Stata Corporation, College Station, TX). 3. Results 3.1. Magnetic resonance imaging results Operative characteristics Type of surgery Open 57 (89%) Laparoscopic 7 (11%) Nerve preservation (n = 47) None 7 (15%) Unilateral 15 (32%) Bilateral 25 (53%) Pathological characteristics Pathologic Gleason score 6 2 (3%) 7 38 (59%) 8 19 (30%) Extracapsular extension No 12 (19%) Yes 52 (81%) Lymph node involvement (n = 63) No 48 (76%) Yes 15 (23%) Seminal vesicle invasion (n = 63) No 39 (62%) Yes 24 (38%) Positive surgical margin No 40 (63%) Yes 24 (38%) PSA = prostate-specific antigen. Clinical and pathological characteristics of our 64 patients are summarized in Table 2, and MRI findings are summarized in Table 3. The median preoperative MUL and the median postoperative MUL were similar (14 mm and 13 mm, respectively). The median percent change in MUL between preoperative and postoperative endorectal MRI was 6% (interquartile range, 9% 14%). Postoperative fibrosis of the urethral wall was low grade in 86% of the patients, and postoperative fibrosis of the periurethral tissue was low grade in 62% of the patients Continence results In total, 48 patients regained continence following surgery (Fig. 6). The median follow-up period for patients incontinent at their last assessment was 7 mo. Sixteen patients remained incontinent (13 level 2 patients, 2 level 3 patients, and 1 level 5 patient). The results of the univariate analyses are summarized in Table 4. Both preoperative and postoperative MUL were significantly associated with time to recovery of continence (Figs. 7 and 8). As expected, patients with longer preoperative and postoperative membranous urethras had superior postoperative continence with a hazard ratio (HR) of 1.15/mm increase in preoperative length (95% confidence interval [CI], ) and 1.18/mm increase in postoperative length (95% CI, ). The percent change in MUL between preoperative and postoperative endorectal MRI was also associated with postoperative continence (HR, 0.89 for each 10% increase in length removed; p =0.02; Fig. 9). We hypothesize that this association was largely driven by the postoperative MUL: Patients with longer postoperative membranous urethras had a smaller proportion removed. However, due to the correlation between the percent change and the postoperative

6 634 european urology 55 (2009) Table 3 Magnetic resonance imaging (MRI) results (n = 64) MRI results Median Interquartile range Range Prostate volume (n = 61) 32 22, 41 13, 147 Preoperative membranous urethral length (mm) 14 11, 15 6, 21 Postoperative membranous urethral length (mm) 13 11, 15 4, 24 Percent change in membranous urethral length 6 9, 13 90, 57 Number Percentage Grade of postoperative fibrosis on the urethral wall (n = 63) 0 or I 54 86% II or III 9 14% Grade of postoperative fibrosis on the periurethral tissue (n = 63) 0 or I 39 62% II or III 24 38% Table 4 Evaluation of magnetic resonance imaging (MRI) variables for prediction of time to continence after radical prostatectomy MRI variable Unadjusted Age-adjusted HR 95% CI p value HR 95% CI p value Preoperative membranous urethral length (mm) , , Postoperative membranous urethral length (mm) , 1.27 < , 1.26 < Fraction of membranous urethral length removed * , , Grade of postoperative urethral fibrosis (n = 63) or I II or III , , 2.41 Grade of postoperative periurethral fibrosis (n = 63) or I II or III , , 1.11 HR = hazard ratio. * Hazard ratio estimate given in units of 10%. The higher the fraction of membranous urethra removed, the longer the time to recovery of continence. length (r = 0.53), as well as the small sample size, we were unable to formally test this hypothesis. Postoperative continence was not significantly associated with the grade of postoperative fibrosis of the urethral wall (HR: 1.28 for high grade vs low grade; 95% CI, ; p = 0.6), or the grade of postoperative fibrosis of periurethral tissue (HR: 0.64 for high grade vs low grade; 95% CI, ; p = 0.16). Because of the wide confidence intervals around these estimates, we are unable to rule out an association between postoperative fibrosis and recovery of continence following RP. Additional analyses adjusting for age produced no substantial change in the results (Table 4). 4. Discussion 4.1. Urethral length Fig. 6 Overall cumulative incidence of continence (time until the patient wears no pads) following radical prostatectomy. Several authors have used urodynamic assessment to study changes in the length of the functional

7 european urology 55 (2009) Fig. 7 Cumulative incidence of continence following radical prostatectomy, stratified by the median preoperative membranous urethral length (MUL). Red line: patients with preoperative MUL = 14 mm; blue line: patients with preoperative MUL > 14 mm ( p = 0.011). Fig. 9 Cumulative incidence of continence following radical prostatectomy (RP), stratified by the median percent change in membranous urethral length (MUL) after RP. Red line: patients with percent change in the MUL = 6%; blue line: patients with percent change in the MUL > 6% ( p = 0.02). Fig. 8 Cumulative incidence of continence following radical prostatectomy, stratified by the median postoperative membranous urethral length (MUL). Red line: patients with postoperative MUL = 13 mm; blue line: patients with postoperative MUL > 13 mm ( p < ). urethra, defined as the posterior section of the urethra where high pressure is focused after RP. They have noted a decrease in functional urethral length after RP and a longer functional urethra in continent patients compared to incontinent patients [9 12]. Urethral length can also be evaluated anatomically by endorectal MRI. Coakley et al [7] published the first study to use endorectal MRI to measure preoperative MUL and to correlate it with urinary continence after RP. The study demonstrated that a longer preoperative membranous urethra was associated with a faster recovery of continence ( p = 0.02); 1 yr after surgery, 120 of 134 patients (89%) with a preoperative MUL >12 mm were completely continent, as opposed to just 35 of 46 patients (76%) with a preoperative MUL 12 mm [7]. Not surprisingly, our study confirms their findings, since our data also show that patients with a longer preoperative membranous urethras experienced faster recovery of urinary continence ( p = 0.011). Other studies have shown that the relationship between the membranous urethra and the prostatic parenchyma at the apex, as observed on pelvic MRI, might also affect postoperative continence [13 14]. Lee et al [13] demonstrated that when the prostatic parenchyma covered the membranous urethra on the anterior and/or posterior side there was a greater risk of excessive shortening of the urethra and therefore an increased risk of urinary incontinence. MUL after RP can be measured with endorectal MRI and corresponds to the distance between the bladder neck and the entrance of the urethra in the penile bulb. Unlike Kordan et al, who used pelvic MRI to measure postoperative MUL [15], we have demonstrated that postoperative MUL has a significant influence on postsurgical recovery of continence and that patients with longer postoperative membranous urethras recover continence more quickly ( p < ). Thus, our results show that the residual urethral length after surgery, and not

8 636 european urology 55 (2009) only the preoperative length, affects the recovery of continence after RP. The use of both preoperative and postoperative endorectal MRI allowed us to assess the role of changes in urethral length in postoperative urinary continence. The median MUL was similar before and after RP (14 mm vs 13 mm, respectively). There was more variability in postoperative measurement; this is likely related to differences in anatomic landmarks. Other authors have noted the importance of urethral preservation for postoperative continence. For example, van Randenborgh et al [16] reported that recovery of urinary continence was faster in patients in whom a urethral stump was preserved by intraprostatic dissection during RP. Rocco et al underlined the role of the posterior restoration of the rhabdosphincter fibers (to recreate its original length) to improve urinary continence after RP [17]. Our results lend additional support to the argument for preserving MUL during RP Fibrosis Tuygun et al [18] used pelvic MRI to evaluate postoperative fibrosis in patients who had undergone RP. Fibrosis was classified as mild, moderate, or severe. According to this classification, moderate fibrosis concerns only the urethra, while severe fibrosis extends concentrically to periurethral tissue. We did not use this classification in our study for two reasons: First, we think that urethral fibrosis should be differentiated from periurethral tissue fibrosis since the two are not necessarily concurrent. We observed high-grade fibrosis in periurethral tissue when there was no fibrosis in the urethra and vice versa. Second, fibrosis is not always circumferential, which is why we divided the urethra and periurethral tissue into three areas in order to quantify the fibrosis in each area as precisely as possible. Whereas, Tuygun et al used pelvic MRIs, we performed endorectal MRI, which allowed a different evaluation of the fibrosis. Kordan et al [15] estimated the volume of periurethral fibrosis on pelvic MRIs by measuring the length in the three spatial planes. Tuygun et al [18] described eight severe cases and two moderate cases of periurethral fibrosis in ten incontinent patients and no severe fibrosis and only one case of moderate fibrosis in the control group. Kordan et al reported that periurethral fibrosis was twice as severe in patients who were incontinent as in those who were continent after radical prostatectomy (means: mm 3 vs mm 3 ), but the results were not statistically significant ( p > 0.05) [15]. We found a tendency for high-grade periurethral fibrosis to be associated with slower recovery of continence after RP. Nevertheless, statistical correlation between a high grade of periurethral fibrosis and worse postoperative continence was not reached (HR: 0.64; p = 0.16). In incontinent patients, urethral or periurethral fibrosis apparently changed the normal functioning of the external urinary sphincter and decreased its elasticity. Several hypotheses have been advanced to explain the development of postoperative fibrosis Study limitations Our study has a number of limitations. The size of the cohort was small, making it difficult to statistically identify variables, such as urethral fibrosis, that may have a small but clinically significant effect on continence. Postoperative urethral and periurethral fibrosis measured with endorectal MRI and assessed with our personal definition still cannot be considered as a standard diagnostic modality. Further studies with a larger cohort will be useful to confirm this classification. The cohort of patients evaluated is small and superselected: all patients had evidence of recurrent disease shortly, and they might not represent the total cohort of men having undergone nerve-sparing prostatectomy for organ-confined disease. This retrospective study also included patients who presented with recurrent cancer after RP and who, therefore, had initially poor oncologic prognoses. Thus, 47% of the patients underwent RP without preservation of the neurovascular bundles, which may have had a negative impact on urinary continence [2]. The follow-up period of the cohort is short. This study suggests that urethral length should be preserved. However, this should not be at the expense of oncologic efficacy. Oncologic efficacy could not be evaluated in this study because every patient had a biochemical recurrence for which they underwent a postoperative MRI. 5. Conclusions In conclusion, preoperative and postoperative MUL and the percent change in MUL are related to recovery of urinary continence after RP both time-to-recovery and degree of recovery. Periurethral fibrosis might impede the recovery of continence after RP by altering the elasticity of the external sphincter. These results reinforce the importance of minimizing intraoperative trauma and preserving membranous urethral length

9 european urology 55 (2009) through accurate dissection of the prostatic apex during radical prostatectomy. Author contributions: Bertrand Guillonneau had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Guillonneau, Paparel, Hricak, Cronin, Sandhu. Acquisition of data: Paparel, Akin, Cronin, Romero Otero. Analysis and interpretation of data: Paparel, Cronin, Guillonneau, Sandhu. Drafting of the manuscript: Paparel, Guillonneau, Cronin, Sandhu. Critical revision of the manuscript for important intellectual content: Scardino, Guillonneau, Sandhu. Statistical analysis: Cronin. Obtaining funding: None. Administrative, technical, or material support: Paparel, Cronin. Supervision: Guillonneau. Other (specify): None. Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None. References [1] Steiner MS, Morton RA, Walsh PC. Impact of anatomical radical prostatectomy on urinary continence. J Urol 1991;145: [2] Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol 1996;156: [3] Majoros A, Bach D, Keszthelyi A, et al. Analysis of risk factors for urinary incontinence after radical prostatectomy. Urol Int 2007;78: [4] Cambio AJ, Evans CP. Minimising postoperative incontinence following radical prostatectomy: considerations and evidence. Eur Urol 2006;50: [5] Mattei A, Naspro R, Annino F, Burke D, Guida Jr R, Gaston R. Tension and energy-free robotic-assisted laparoscopic radical prostatectomy with interfascial dissection of the neurovascular bundles. Eur Urol 2007;52: [6] Hricak H. MR imaging and MR spectroscopic imaging in the pretreatment evaluation of prostate cancer. Br J Radiol 2005;78: [7] Coakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 2002;168: [8] Myers RP, Cahill DR, Devine RM, King BF. Anatomy of radical prostatectomy as defined by magnetic resonance imaging. J Urol 1998;159: [9] Hammerer P, Huland H. Urodynamic evaluation of changes in urinary control after radical retropubic prostatectomy. J Urol 1997;157: [10] Kielb SJ, Clemens JQ. Comprehensive urodynamics evaluation of 146 men with incontinence after radical prostatectomy. Urology 2005;66: [11] Presti Jr JC, Schmidt RA, Narayan PA, Carroll PR, Tanagho EA. Pathophysiology of urinary incontinence after radical prostatectomy. J Urol 1990;143: [12] Constantinou CE, Freiha FS. Impact of radical prostatectomy on the characteristics of bladder and urethra. J Urol 1992;148: [13] Lee SE, Byun SS, Lee HJ, et al. Impact of variations in prostatic apex shape on early recovery of urinary continence after radical retropubic prostatectomy. Urology 2006;68: [14] Myers RP. Practical surgical anatomy for radical prostatectomy. Urol Clin North Am 2001;28: [15] Kordan Y, Alkibay T, Sozen S, et al. Is there an impact of postoperative urethral and periurethral anatomical features in post-radical retropubic prostatectomy incontinence? Urol Int 2007;78: [16] Van Randenborgh H, Paul R, Kubler H, Breul J, Hartung R. Improved urinary continence after radical retropubic prostatectomy with preparation of a long, partially intraprostatic portion of the membraneous urethra: an analysis of 1013 consecutive cases. Prostate Cancer Prostatic Dis 2004;7: [17] Rocco F, Carmignani L, Acquati P, et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol 2007;52: [18] Tuygun C, Imamoglu A, Keyik B, Alisir I, Yorubulut M. Significance of fibrosis around and/or at external urinary sphincter on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence. Urology 2006;68:

10 638 european urology 55 (2009) Editorial Comment on: Recovery of Urinary Continence after Radical Prostatectomy: Association with Urethral Length and Urethral Fibrosis Measured by Preoperative and Postoperative Endorectal Magnetic Resonance Imaging Markus Graefen Martini-Clinic, Prostate Cancer Center, University Medical Center Eppendorf, Martinistr. 52, Hamburg, Germany In modern radical prostatectomy series, the vast majority of patients finally achieve urinary continence [1 4]. As we all know, there is variability in time to continence despite standardisation of surgical approach and technique. The presented study by Paparel et al nicely explains one of the factors that influence this variability and which cannot be influenced by the surgical technique: the preoperative membranous urethral length (MUL) [5]. Interestingly, the final continence status was almost independent of preoperative MUL (see Fig. 7 in reference [5]), yet the time to recovery was strongly associated with preoperative MUL. In daily practice, this allows us to explain to the patient why it might take some time to finally achieve urinary continence. Furthermore, this study underscores that prostate surgeons should strive to preserve every millimetre of the MUL: a postoperative MUL >13 mm approached a 100% continence rate, whereas a postoperative length of <13 mm resulted in a final continence rate of only about 70%! This difference emphasizes the responsibility of the surgeon, not only for the time to continence but, more important, for the final continence result. The meticulous preparation of the sphincter muscle, restoration of the rhabdosphincter, and sphincterpreserving anastomotic techniques are important aspects of preserving functional tissue, and every surgeon that offers radical prostatectomy to a patient today must be aware of these techniques [1 4]. Besides the important discussion of potency preservation, we should never forget that urinary incontinence following radical prostatectomy is a far larger disaster for the patient s quality of life. References [1] Barré C. Open radical retropubic prostatectomy. Eur Urol 2007;52: [2] Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51: (discussion 657 8). [3] Kessler TM, Burkhard FC, Studer UE. Nerve-sparing open radical retropubic prostatectomy. Eur Urol 2007; 51:90 7. [4] Graefen M, Walz J, Huland H. Open retropubic nervesparing radical prostatectomy. Eur Urol 2006;49: [5] Paparel P, Akin O, Sandhu JS, 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: DOI: /j.eururo DOI of original article: /j.eururo Editorial Comment on: Recovery of Urinary Continence after Radical Prostatectomy: Association with Urethral Length and Urethral Fibrosis Measured by Endorectal Magnetic Resonance Imaging Luigi Da Pozzo Vita-Salute University, Via Olgettina 60, Milan, Italy dapozzo.luigi@hsr.it In a study aimed at evaluating endorectal magnetic resonance imaging (MRI) findings related to urinary continence prior to and after radical prostatectomy, membranous urethral length (MUL) and periurethral fibrosis were the two investigated radiologic parameters [1]. The positive correlation reported between preoperative MUL and postoperative urinary continence recovery is certainly not a new finding and has also been recently advocated in literature in larger series [2]. The original message of this study is represented by the demonstration that postoperative MUL and percent change in MUL, analyzed by a comparison of preoperative and postoperative endorectal MRI, are also related to urinary continence recovery. Of course, this finding does not suggest that endorectal MRI should be introduced in clinical practice before and after surgery, even in incontinent patients. I wonder, in fact, what the practical utility of these radiologic findings could be. Yet, in my opinion, this study [1] is a very elegant demonstration of the usefulness of accurately

11 european urology 55 (2009) dissecting the prostatic apex and preserving as much membranous urethra as possible during radical prostatectomy [3 5]. This is the right message to take from this study [1], and the authors have properly discussed their results in such a manner. I quite disagree with the message related to postoperative urethral fibrosis as evidenced by postoperative MRI. The authors have presented a personal definition of this radiologic feature [1]. It must be very clearly remembered that postoperative urethral fibrosis measured with endorectal MRI, as reported in the article, cannot be considered as a standard diagnostic modality. I wonder whether this complicated definition of urethral fibrosis could be demonstrated in clinical practice. Moreover, statistical correlation between high grade of postoperative periurethral fibrosis and worse postoperative continence was not reached. Although the authors have reported this in the results, they also claim that a tendency for highgrade periurethral fibrosis was associated with slower recovery of continence after radical prostatectomy. This definition is ambiguous and potentially misleading. Finally, this study is retrospective and was conducted in a small and extremely selected cohort of patients who were submitted to endorectal MRI postoperatively based on biochemical evidence of recurrence. These are two major biases that might influence interpretation of data that need to be confirmed in larger series in the future. References [1] Paparel P, Akin O, Sandhu JS, 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: [2] Nguyen L, Jhaveri J, Tewari A. Surgical technique to overcome anatomical shortcoming: balancing postprostatectomy continence outcomes of urethral sphincter lengths on preoperative magnetic resonance imaging. J Urol 2008;179: [3] Harris MJ. The anatomic radical perineal prostatectomy: an outcomes-based evolution. Eur Urol 2007;52:81 8. [4] Kessler TM, Burkhard FC, Studer UE. Nerve-sparing open radical retropubic prostatectomy. Eur Urol 2007;51:90 7. [5] Montorsi F, Salonia A, Suardi N, et al. Improving the preservation of the urethral sphincter and neurovascular bundles during open radical retropubic prostatectomy. Eur Urol 2005;48: DOI: /j.eururo DOI of original article: /j.eururo