Minimising postoperative incontinence following radical prostatectomy: considerations and evidence

To review evidence regarding perioperative predictors of incontinence after radical prostatectomy (RP), related anatomic and patient factors, and surgical techniques used to minimise incontinence. A search of the Pubmed, Cancerlit, Cochrane, and ISI Web of Science databases was performed for the key words prostatectomy, incontinence, and continence. Relevant articles were reviewed, summarised, and analysed. Enhanced understanding of pelvic anatomy applied to surgical approaches has improved continence rates following RP; however, incontinence remains a potential adverse outcome. Evidence suggests that increasing patient body weight and prostate volume are not associated with continence outcomes, but increasing patient age may be predictive. Behavioural therapy may aid in early return to continence although the timing of therapy and benefit of biofeedback assistance are unclear. Various surgical techniques are used to improve continence, but no evidence overwhelmingly supports any specific technique. At best, evidence supports early return to continence with some techniques. No technique significantly increased margin positivity solely at the experimental anatomic site. Despite enhanced knowledge of anatomy and improved surgical approach, incontinence persists as a potential adverse outcome of RP. Urologists may not find an evidence-based rationalisation for any particular surgical technique due to the nature of surgical series, variability in the definition of incontinence, and individual surgical skills, preferences, and techniques. Giving careful consideration to the trial design can potentially improve the resulting level of evidence.