Title: Physical activity and rehabilitation of incontinence after open and robot radical prostatectomy.
Other Titles: Fysieke activiteit en de revalidatie van incontinentie na open en robot radicale prostatectomie.
Authors: Geraerts, Inge
Issue Date: 26-Jun-2013
Abstract: Worldwide, prostate cancer is the second most frequently diagnosed cancer and the sixth leading cause of cancer death in men. In Belgium one out of four new cancer victims among men is yearly diagnosed with prostate cancer. Since many years radical prostatectomy is considered the ‘gold standardÂ’ treatment for local eradication of the carcinoma. Given the excellent oncological results, functional outcomes, such as urinary continence gained increasing importance. Technical advances have expanded beyond open surgery and resulted in the use of robotically guided surgery to remove prostate carcinoma. Robot-assisted radical prostatectomy is expected to provide improved visualization, dexterity and precision, however the impact on long-term functional side effects remains unknown.Apart from urinary continence, patients are also interested in when they can resume their preoperative activities (work, sports, household and leisure activities) after surgery. Research concerning the recovery of these different aspects of physical activity after radical prostatectomy is unfortunately limited. Gaining further insights on the treatment of post-prostatectomy urinary incontinence, could vastly benefit from improved evaluation of the pelvic floor muscle function. A rather inexpensive technique with high patient acceptance is transperineal ultrasound. Furthermore it has the advantage of real-time scanning without radiation exposure. Literature concerning transperineal ultrasound of the male pelvic floor is however rather scarce. Its clinical utility in men depends on the reliability and the ease of interpretation of data obtained from the measurement. Furthermore, such evaluation would allow investigating differences in pelvic floor structures between continent and incontinent men. Different investigators have suggested the added value of preoperative pelvic floor muscle training. Patients receiving such additional treatment before radical prostatectomy reported a faster recovery of urinary incontinence. However, limitations in study designs and different definitions of urinary continence complicated the drawing of firm conclusions.The scope of this doctoral project was to broaden the knowledge concerning the differences in functional outcomes and the evolution of physical activity after open and robot radical prostatectomy. Additionally we aimed to gain more insights in the displacements in pelvic floor structures during voluntary pelvic floor muscle contraction in continent and incontinent men after radical prostatectomy using transperineal ultrasound. Furthermore we aimed to investigate the effect of preoperative pelvic floor muscle training for post-prostatectomy incontinence. The first aim was to compare functional outcomes (urinary incontinence, voiding symptoms and quality of life) of patients who underwent open versus robot-assisted surgery. Analyses revealed that patients after robot-assisted surgery tended to regain continence sooner compared to patients who had open surgery. However, differences between both groups at baseline hinder final conclusions. Nevertheless, patients after robot-assisted surgery also achieved lower voiding symptoms severity and higher quality of life scores. The second aim was to investigate the evolution of the different physical activity levels (total, work, sports, household) over time after radical prostatectomy and to find predictive factors for a decrease in physical activity. Two hundred forty patients filled in the Flemish Physical Activity Computerized Questionnaire preoperatively concerning their physical activities over the past year. At 6 weeks and 3, 6 and 12 months after radical prostatectomy patients reported their physical activities of the previous month. Chapter 3 of this project indicated that all aspects of physical activity decreased significantly at 6 weeks after surgery and recovered to approximately baseline level afterwards. Predictive factors for decreased activity levels at 6 weeks after surgery were a younger age (total physical activity level), being semi-/unskilled (occupational physical activity level) and being unemployed/retired (household physical activity level). Surgery type did not influence the different activity levels at any of the measurement moments. Importantly, this study showed that urinary incontinence had a significant effect on total and household physical activity level. The third aim was to gain further insights into the role of pelvic floor muscles in urinary continence using transperineal ultrasound images. We first assessed the reliability of the measurement of displacement of pelvic floor structures during voluntary contraction. Next, we compared the performance between continent and incontinent men after radical prostatectomy. For most points of interest good to high intra- and interobserver reliability was observed, providing a sound base for the clinical utility of transperineal ultrasound in men. Comparing the performance of continent and incontinent men only showed a difference between both groups for one specific pelvic floor structure. Future research will have to reveal if this point is also clinically relevant.The fourth aim was to determine whether patients who performed pelvic floor muscle training before and after surgery, regained urinary continence earlier than patients who only performed pelvic floor muscle training after surgery. One hundred eighty patients were randomized to the experimental group, who started pelvic floor muscle training 3 weeks before surgery or to the control group, who only started training after surgery. All patients recorded their urine loss 24 hours/day until continence was achieved. Results from this study showed that standard postoperative continence rehabilitation using a strict pelvic floor muscle training scheme could not be improved by adding 3 preoperative training sessions.This doctoral project has clarified some of the lingering uncertainties concerning the postoperative consequences of radical prostatectomy. In the long run, these insights will lead to an optimal delineation of the management of urinary incontinence of prostate cancer patients.
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Research Group for Neuromotor Rehabilitation
Organ Systems (+)
Screening, Diagnostics and Biomarkers (-)

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