Недержание мочи после радикальной простатэктомии: факторы прогноза

Рак предстательной железы — наиболее распространенное онкоурологическое заболевание у мужчин. Радикальная простатэктомия (РПЭ) обеспечивает высокие показатели безрецидивной выживаемости. Частым осложнением РПЭ является недержание мочи, приводящее к значительному снижению качества жизни и социальной дезадаптации пациентов. Благодаря научному прогрессу в области анатомии таза, оптимизации хирургической техники, внедрению лапароскопической и робот-ассистированной хирургии улучшились функциональные результаты РПЭ. Однако существующая в мире устойчивая тенденция роста заболеваемости раком предстательной железы несомненно ведет к увеличению числа пациентов, подвергнутых РПЭ, и как следствие, к увеличению числа мужчин с недержанием мочи. В связи с этим вопросы, касающиеся этиологии, патогенеза и профилактики недержания мочи после РПЭ остаются крайне актуальными. Согласно многочисленным публикациям этиология недержания мочи после РПЭ является многофакторной.

В настоящем обзоре представлен анализ результатов исследований, посвященных недержанию мочи после РПЭ. Рассматриваются Доказательства роли предоперационных и интраоперационных параметров в качестве возможных факторов развития недержания мочи.

1. Злокачественные новообразования в России в 2018 году (заболеваемость и смертность). Под ред. А.Д. Каприна, В.В. Старинского, Г.В. Петровой. М.: МНИОИ им. П.А. Герцена - филиал ФГБУ «НМИЦ радиологии» Минздрава России, 2019. 250 с.

2. Абоян И.А., Абоян В.Э., Орлов Ю.Н. и др. Комплексное уродинамическое исследование у пациентов с недержанием мочи после оперативного лечения локализованного рака предстательной железы. Урология 2018;(6):14-8. DOI: 10.18565/urology.2018.6.14-18.

3. Ficarra V., Novara G., Rosen R.C. et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012;62:405-17. DOI: 10.1016/j.eururo.2012.05.045.

4. Lepor H., Kaci L., Xue X. Continence following radical retropubic prostatectomy using self-reporting instruments. J Urol 2004;171:1212-5. DOI: 10.1097/01.ju.0000113964.68020.a7.

5. Loughlin K.R., Prasad M.M. Post-prostatectomy urinary incontinence: a confluence of 3 factors. J Urol 2010;183:871-7. DOI: 10.1016/j.juro.2009.11.011.

6. Koraitim M.M. The male urethral sphincter complex revisited: an anatomical concept and its physiological correlate. J Urol 2008;179:1683-9. DOI: 10.1016/j.juro.2008.01.010.

7. Stolzenburg J.U., Kallidonis P., Hicks J. et al. Effect of bladder neck preservation during endoscopic extraperitoneal radical prostatectomy on urinary continence. Urol Int 2010;85:135-8. DOI: 10.1159/000314842.

8. Soljanik I., Bauer R.M., Becker A.J. et al. Is a wider angle of the membranous urethra associated with incontinence after radical prostatectomy? World J Urol 2014;32:1375-83. DOI: 10.1007/s00345-014-1241-5.

9. Selli C., De Antoni P., Moro U. et al. Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy. Scand J Urol Nephrol 2004;38:32-7. DOI: 10.1080/00365590310017280.

10. Steiner M.S. The puboprostatic ligament and the male urethral suspensory mechanism: an anatomic study. Urology 1994;44:530-4. DOI: 10.1016/s0090-4295(94)80052-9.

11. Zhang C., Ding Z.H., Li G.X. et al. Perirectal fascia and spaces: annular distribution pattern around the mesorectum. Dis Colon Rectum 2010;53:1315-22. DOI: 10.1007/DCR.0b013e3181e74525.

12. Richardson A.C. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976-83. DOI: 10.1097/00003081-199312000-00022.

13. Kirschner-Hermanns R., Wein B., Niehaus S. et al. The contribution of magnetic resonance imaging of the pelvic floor to the understanding of urinary incontinence. Br J Urol 1993;72:715-8. DOI: 10.1111/j.1464-410x.1993.tb16254.x.

14. Gosling J.A., Dixon J.S., Critchley H.O., Thompson S.A. A comparative study of the human external sphincter and periurethral levator ani muscles. Br J Urol 1981;53:35-41. DOI: 10.1111/j.1464-410x.1981.tb03125.x.

15. Tan G., El Douaihy Y., Te A.E., Tewari A.K. Scientific and technical advances in continence recovery following radical prostatectomy. Exp Rev Med Dev 2009;6:431-53. DOI: 10.1586/erd.09.19.

16. De Ridder D., Rehder P. The advance male sling: anatomic features in relation to mode of action. Eur Urol Suppl 2011;10:383-9. DOI: 10.1016/j.eursup.2011.04.001.

17. Tan G.Y., Jhaveri J.K., Tewari A.K. Anatomic restoration technique: a biomechanics-based approach for early continence recovery after minimally invasive radical prostatectomy. Urology 2009;74:492-6. DOI: 10.1016/j.urology.2009.02.005.

18. Hurtes X., Roupret M., Vaessen C. et al. Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial. BJU Int 2012;110:875-83. DOI: 10.1111/j.1464-410X.2011.10849.x.

19. Stolzenburg J.U., Liatsikos E.N., Rabenalt R. et al. Nerve sparing endoscopic extraperitoneal radical prostatectomy -effect of puboprostatic ligament preservation on early continence and positive margins. Eur Urol 2006;49:103-11. DOI: 10.1016/j.eururo.2005.10.002.

20. Schlomm T., Heinzer H., Steuber T. et al. Full functional-length urethral sphincter preservation during radical prostatectomy. Eur Urol 2011;60:320-9. DOI: 10.1016/j.eururo.2011.02.040.

21. 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;52:376-83. DOI: 10.1016/j.eururo.2007.01.109.

22. Nguyen M.M., Kamoi K., Stein R.J. et al. Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int 2008;101:1135-9. DOI: 10.1111/j.1464-410X.2007.07425.x.

23. Kim I.Y., Hwang E.A., Mmeje C. et al. Impact of posterior urethral plate repair on continence following robot-assisted laparoscopic radical prostatectomy. Yonsei Med J 2010;51:427-31. DOI: 10.3349/ymj.2010.51.3.427.

24. DeLancey J.O. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 1994;170:1713-20. DOI: 10.1016/s0002-9378(94)70346-9.

25. Burnett A.L., Mostwin J.L. In situ anatomical study of the male urethral sphincteric complex: relevance to continence preservation following major pelvic surgery. J Urol 1998;160:1301-6. DOI: 10.1016/S0022-5347(01)62521-7.

26. Rehder P., Gozzi C. Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. Eur Urol 2007;52:860-6. DOI: 10.1016/j.eururo.2007.01.110.

27. Gozzi C., Becker A.J., Bauer R., Bastian P.J. Early results of transobturator sling suspension for male urinary incontinence following radical prostatectomy. Eur Urol 2008;54:960-1. DOI: 10.1016/j.eururo.2008.04.096.

28. Rehder P., Haab F., Cornu J.N. et al. Treatment of postprostatectomy male urinary incontinence with the transobturator retroluminal repositioning sling suspension: 3-year follow-up. Eur Urol 2012;62:140-5. DOI: 10.1016/j.eururo.2012.02.038.

29. Suskind A.M., DeLancey J.O., Hussain H.K. et al. Dynamic MRI evaluation of urethral hypermobility post-radical prostatectomy. Neurourol Urodynam 2014;33:312-5. DOI: 10.1002/nau.22408.

30. Tuygun C., Imamoglu A., Keyik B. et al. Significance of fibrosis around and/or at external urinary sphincter on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence. Urology 2006;68:1308-12. DOI: 10.1016/j.urology.2006.08.1080.

31. Sacco E., Prayer-Galetti T., Pinto F. 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;97:1234-41. DOI: 10.1111/j.1464-410X.2006.06185.x.

32. Tanagho E.A., Schmidt R.A., de Araujo C.G. Urinary striated sphincter: what is its nerve supply? Urology 1982;20:415-7. DOI: 10.1016/0090-4295(82)90468-x.

33. Karam I., Droupy S., Abd-Alsamad I. et al. The precise location and nature of the nerves to the male human urethra: histological and immunohistochemical studies with three-dimensional reconstruction. Eur Urol 2005;48:858-64. DOI: 10.1016/j.eururo.2005.03.016.

34. Karam I., Moudouni S., Droupy S. et al. The structure and innervation of the male urethra: histological and immunohistochemical studies with three-dimensional reconstruction. J Anat 2005;206:395-403. DOI: 10.1111/j.1469-7580.2005.00402.x.

35. Akita K., Sakamoto H., Sato T. Origins and courses of the nervous branches to the male urethral sphincter. Surg Radiol Anat 2003;25:387-92. DOI: 10.1007/s00276-003-0151-9.

36. Murphy D.G., Costello A.J. How can the autonomic nervous system contribute to urinary continence following radical prostatectomy? A “boson-like” conundrum. Eur Urol 2013;63:445-7. DOI: 10.1016/j.eururo.2012.09.021.

37. Gosling J.A., Dixon J.S. The structure and innervation of smooth muscle in the wall of the bladder neck and proximal urethra. Br J Urol 1975;47:549-58. DOI: 10.1111/j.1464-410x.1975.tb06260.x.

38. Strasser H., Bartsch G. Anatomic basis for the innervation of the male pelvis. Urologe A 2004;43:128-32. DOI: 10.1007/s00120-003-0500-7.

39. Catarin M.V., Manzano G.M., Nobrega J.A. et al. The role of membranous urethral afferent autonomic innervation in the continence mechanism after nerve sparing radical prostatectomy: a clinical and prospective study. J Urol 2008;180:2527-31. DOI: 10.1016/j.juro.2008.08.020.

40. Ozdemir M.B., Eskicorapci S.Y., Baydar D.E. et al. A cadaveric histological investigation of the prostate with three-dimensional reconstruction for better results in continence and erectile function after radical prostatectomy. Prostate Cancer Prostatic Dis 2007;10:77-81. DOI: 10.1038/sj.pcan.4500917.

41. Kaye D.R., Hyndman M.E., Segal R.L. et al. Urinary outcomes are significantly affected by nerve sparing quality during radical prostatectomy. Urology 2013;82:1348-53. DOI: 10.1016/j.urology.2013.06.067.

42. Burkhard F.C., Kessler T.M., Fleischmann A. et al. Nerve sparing open radical retropubic prostatectomy - does it have an impact on urinary continence? J Urol 2006;176:189-95. DOI: 10.1016/S0022-5347(06)00574-X.

43. Marien T.P., Lepor H. Does a nervesparing technique or potency affect continence after open radical retropubic prostatectomy? BJU Int 2008;102:1581-4. DOI: 10.1111/j.1464-410x.2008.07921.x.

44. Costello A.J., Brooks M., Cole O.J. Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU Int 2004;94:1071-6. DOI: 10.1111/j.1464-410X.2004.05106.x.

45. Takenaka A., Murakami G., Matsubara A. et al. Variation in course of cavernous nerve with special reference to details of topographic relationships near prostatic apex: histologic study using male cadavers. Urology 2005;65:136-42. DOI: 10.1016/j.urology.2004.08.028.

46. Nelson C.P., Montie J.E., McGuire E.J. et al. Intraoperative nerve stimulation with measurement of urethral sphincter pressure changes during radical retropubic prostatectomy: a feasibility study. J Urol 2003;169:2225-8. DOI: 10.1097/01.ju.0000058213.15524.90.

47. 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;48:938-45. DOI: 10.1016/j.eururo.2005.09.004.

48. Park J.M., Bloom D.A., McGuire E.J. The guarding reflex revisited. Br J Urol 1997;80:940-5. DOI: 10.1046/j.1464-410x.1997.00488.x.

49. Song C., Lee J., Hong J.H. et al. Urodynamic interpretation of changing bladder function and voiding pattern after radical prostatectomy: a long-term follow-up. BJU Int 2010;106:681-6. DOI: 10.1111/j.1464-410X.2009.09189.x.

50. Lee H., Kim K.B., Lee S. et al. Urodynamic assessment of bladder and urethral function among men with lower urinary tract symptoms after radical prostatectomy: a comparison between men with and without urinary incontinence. Korean J Urol 2015;56:803-10. DOI: 10.4111/kju.2015.56.12.803.

51. Hoyland K., Vasdev N., Abrof A., Boustead G. Post-radical prostatectomy incontinence: etiology and prevention. Rev Urol 2014;16(4):181-8.

52. Novara G., Ficarra V., D'Elia C. et al. Evaluating urinary continence and preoperative predictors of urinary continence after robot assisted laparoscopic radical prostatectomy. J Urol 2010;184:1028-33. DOI: 10.1016/j.juro.2010.04.069.

53. Karakiewicz P.I., Tanguay S., Kattan M.W. et al. Erectile and urinary dysfunction after radical prostatectomy for prostate cancer in Quebec: a population-based study of 2415 men. Eur Urol 2004;46:188-94. DOI: 10.1016/j.eururo.2004.04.020.

54. Matsushita K., Kent M.T., Vickers A.J. et al. Preoperative predictive model of recovery of urinary continence after radical prostatectomy. BJU Int 2015;116:577-83. DOI: 10.1111/bju.13087.

55. Kadono Y., Ueno S., Kadomoto S. et al. Use of preoperative factors including urodynamic evaluations and nerve-sparing status for predicting urinary continence recovery after robot-assisted radical prostatectomy: nerve-sparing technique contributes to the reduction of postprostatectomy incontinence. Neurourol Urodynam 2016;35:1034-9. DOI: 10.1002/nau.22877.

56. Catalona W.J., Basler J.W. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J Urol 1993;150:905-7. DOI: 10.1016/s0022-5347(17)35645-8.

57. Wolin K.Y., Luly J., Sutcliffe S. et al. Risk of urinary incontinence following prostatectomy: the role of physical activity and obesity. J Urol 2010;183:629-33. DOI: 10.1016/j.juro.2009.09.082.

58. Wiltz A.L., Shikanov S., Eggener S.E. et al. Robotic radical prostatectomy in overweight and obese patients: oncological and validated functional outcomes. Urology 2009;73:316-22. DOI: 10.1016/j.urology.2008.08.493.

59. Hsu E.I., Hong E.K., Lepor H. Influence of body weight and prostate volume on intraoperative, perioperative, and postoperative outcomes after radical retropubic prostatectomy. Urology 2003;61:601-6. DOI: 10.1016/s0090-4295(02)02422-6.

60. Elder J.S., Gibbons R.P., Correa Jr R.J., Brannen G.E. Morbidity of radical perineal prostatectomy following transurethral resection of the prostate. J Urol 1984;132:55-7. DOI: 10.1016/s0022-5347(17)49462-6.

61. Palisaar J.R., Wenske S., Sommerer F. et al. Open radical retropubic prostatectomy gives favourable surgical and functional outcomes after transurethral resection of the prostate. BJU Int 2009;104:611-5. DOI: 10.1111/j.1464-410X.2009.08474.x.

62. Rodriguez Jr E., Skarecky D.W., Ahlering T.E. Post-robotic prostatectomy urinary continence: characterization of perfect continence versus occasional dribbling in pad-free men. Urology 2006;67:785-8. DOI: 10.1016/j.urology.2005.10.006.

63. Wei J.T., Dunn R.L., Marcovich R. et al. Prospective assessment of patient reported urinary continence after radical prostatectomy. J Urol 2000;164:744-8. DOI: 10.1097/00005392-200009010-00029.

64. Van Randenborgh H., Paul R., Kubler H. et al. 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;7:253-7. DOI: 10.1038/sj.pcan.4500726.

65. Cambio A.J., Evans C.P. Minimising postoperative incontinence following radical prostatectomy: considerations and evidence. Eur Urol 2006;50:903-13. DOI: 10.1016/j.eururo.2006.08.009.

66. Boczko J., Erturk E., Golijanin D. et al. Impact of prostate size in robot-assisted radical prostatectomy. J Endourol 2007;21:184-8. DOI: 10.1089/end.2006.0163.

67. Konety B.R., Sadetsky N., Carroll P.R. Recovery of urinary continence following radical prostatectomy: the impact of prostate volume - analysis of data from the CaPSURE database. J Urol 2007;177:1423-5. DOI: 10.1016/j.juro.2006.11.089.

68. Pettus J.A., Masterson T., Sokol A. et al. Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy. J Urol 2009;182:949-55. DOI: 10.1016/j.juro.2009.05.029.

69. 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;179:1907-11. DOI: 10.1016/j.juro.2008.01.036.

70. Paparel P., Akin O., Sandhu J.S. 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;55:629-37. DOI: 10.1016/j.eururo.2008.08.057.

71. Borin J.F., Skarecky D.W., Narula N., Ahlering T.E. Impact of urethral stump length on continence and positive surgical margins in robot-assisted laparoscopic prostatectomy. Urology 2007;70:173-7. DOI: 10.1016/j.urology.2007.03.050.

72. Аль-Харири М.Ф. Анатомо-клинические критерии недержания мочи после радикальной позадилонной простатэктомии. Дис. ... канд. мед. наук: 14.01.23. М., 2016, 119 с.

73. Мосоян М.С., Ильин Д.М. Раннее восстановление функции удержания мочи после робот-ассистированной радикальной простатэктомии. Трансляционная медицина 2017;4(6):53-61.

74. Абоян И.А., Орлов Ю.Н., Пакус С.М. и др. Оптимизация функциональных результатов радикальной простатэктомии. Программы реабилитации пациентов. Экспериментальная и клиническая урология 2018;(3):20-7.