Outcomes after surgical treatment of localized prostate cancer with focus on urinary incontinence and short term complications

Background: Urinary incontinence is a significant long-term complication after radical prostatectomy. The aim was to evaluate clinically significant definitions of urinary incontinence and to investigate its potential predictors. Robot-assisted radical prostatectomy has become a widespread surgical technique in prostate cancer despite the lack of randomised trials showing its superiority compared to open surgery. A further aim was to compare shortterm results three months after the two surgical techniques.

Material and methods: Data for this thesis derives from two sources. The first cohort is a consecutive series of 1411 men who underwent radical prostatectomy at Karolinska University Hospital from 2002 to 2006 and completed a study-specific validated questionnaire. The second cohort derives from the LAPPRO study, a multicentre, prospective controlled trial of men who underwent radical prostatectomy between 2008 and 2011 (n=4003). Data was collected prospectively with validated patient questionnaires and case report forms which were completed by health-care personnel.

Results: Urinary leakage as a long-term side effect after radical prostatectomy proved to cause the patient a lot of bother. Even a proportion of those who had occasional leakage reported significant bother. Increased age at surgery increases the risk of urinary incontinence one year after surgery and this increases exponentially with age. Furthermore patients with preoperative urinary leakage have an increased risk of postoperative incontinence. When evaluating short-term outcomes and comparing open radical prostatectomy to robot-assisted radical prostatectomy, re-operation during initial hospital stay was more frequent after open surgery. Men operated by open surgery also sought medical care more frequently compared to men operated by robot-assisted surgery within three months after surgery. Men who underwent lymph-node dissection proved to have an increased risk for readmission as well as a greatly increased risk for thromboembolic events, such as deep venous thrombosis and pulmonary embolism. Regardless of whether lymph-node dissection was preformed or not, men who underwent open prostatectomy appeared to have an increased risk of thromboembolic events compared to those who had robot-assisted surgery.

Conclusions: If the definition of continence consists of the use of pads, a certain number of men that are bothered significantly by urinary leakage will be defined as continent. When planning a patient for radical prostatectomy, one must take age and preoperative urinary leakage into consideration as risk factors for postoperative incontinence. The robot-assisted radical prostatectomy is a safe procedure and has some short-term advantages compared to open surgery. Lymph-node dissection during radical prostatectomy increases the risk for thromboembolic events, the risk is higher in open surgery compared to robot-assisted surgery.

List of scientific papers

I. Wallerstedt A, Carlsson S, Nilsson AE, Johansson E, Nyberg T, Steineck G, Wiklund N. P. Pad use and patient reported bother from urinary leakage after radical prostatectomy. The Journal of urology 2012;187:196-200.
https://doi.org/10.1016/j.juro.2011.09.030

II. Wallerstedt A, Carlsson S, Steineck G, Thorsteinsdottir T, Hugosson J, Stranne J, Wilderäng U, Haglind E, Wiklund N. P. Patient and tumour-related factors for prediction of urinary incontinence after radical prostatectomy. Scand J Urol 2013;47:272-81.
https://doi.org/10.3109/00365599.2012.733410

III. Wallerstedt A, Tyritzis S, Thorsteinsdottir T, Carlsson S, Stranne J, Gustafsson O, Hugosson J, Bjartell A, Wilderäng U, Wiklund N. P, Steineck G, Haglind E. Short term results after robot-assisted laparoscopic radical prostatectomy compared to open radical prostatectomy. European Urology 2014.
https://doi.org/10.1016/j.eururo.2014.09.036.

IV. Tyritzis SI, Wallerstedt A, Steineck G, Nyberg T, Hugosson J, Bjartell A, Wilderäng U, Thorsteinsdottir T, Carlsson S, Stranne J, Haglind E, Wiklund N. P. Thromboembolic complications in 3544 patients undergoing radical prostatectomy with or without lymph node dissection. The Journal of urology 2014.
https://doi.org/10.1016/j.juro.2014.08.091.