Continence Recovery After Radical Prostatectomy: Personalized Rehabilitation and Predictors of Treatment Outcome

Abstract

Background/Objectives: Urinary incontinence (UI) remains a common and distressing complication following radical prostatectomy (RP). This prospective observational study aimed to assess the effectiveness of structured pelvic floor rehabilitation and to identify clinical and surgical predictors of continence recovery. Methods: A total of 182 patients undergoing RP received standardized physiotherapist-guided pelvic floor muscle training (PFMT), including supervised sessions before and after surgery, as well as individualized home exercise programs. UI severity was evaluated using a 1 h pad test and a four-level UI stage classification at three time points. The primary outcomes were changes in UI stage and the achievement of full continence, defined as a pad test result ≤2 g. Results: Following three rehabilitation sessions, 80.2% of patients regained full continence. Preoperative PFMT (β = -1.27, p = 0.0061) and shorter time to rehabilitation (β = -0.04, p = 0.0026) were associated with greater improvement in continence outcomes. Patients treated with robot-assisted RP showed a higher probability of continence recovery compared to those undergoing laparoscopic RP, particularly in the presence of moderate to severe baseline incontinence. Higher baseline urinary leakage significantly decreased the odds of treatment success (β = -0.01, p = 0.0001). ISUP grade and extraprostatic extension were not independently associated with outcomes. Conclusions: Despite the absence of a control group, this study demonstrates the effectiveness of structured and personalized pelvic floor rehabilitation in improving post-RP continence. Early initiation and preoperative training should be prioritized to optimize recovery in routine clinical practice.

Keywords: continence recovery; pad test; pelvic floor muscle training; physiotherapy; predictive factors; radical prostatectomy; robot-assisted radical prostatectomy; urinary incontinence.

Figure 1

Predicted Probabilities of UI Stage (0–3) by ISUP Grade, Type of Surgery, and EPE Status. Caption: Predicted probabilities of each UI stage (0–3) are shown for combinations of ISUP grade (2–5), surgery type (LRP vs. RARP), and presence of extraprostatic extension (EPE), assuming average patient age. RARP is associated with lower probabilities of more severe urinary incontinence compared with LRP. Presence of EPE increases the probability of more severe UI stages. ISUP grades 2–4 are associated with lower probabilities of severe UI compared with ISUP 1, whereas ISUP 5 does not differ significantly. Abbreviations: UI, urinary incontinence; ISUP, International Society of Urological Pathology; LRP, laparoscopic radical prostatectomy; RARP, robot-assisted radical prostatectomy; EPE, extraprostatic extension.

Figure 2

Distribution of improvement in UI stage between baseline and final assessment. The chart shows the distribution of patients according to the number of UI stage levels improved between Examination 1 and Examination 3. Only patients with a pad test result > 2 g at either time point were included in the analysis. Note: The most common improvement was by one UI stage (33.9%), followed by improvements of two (30.6%) and three stages (20.7%). Very few patients showed no change (13.2%) or deterioration (1.6%). Abbreviations: UI.

Figure 3

Predicted probability of full continence after Examination 3 by type of surgery and baseline pad test result. Caption: Predicted probabilities of achieving full continence (pad test ≤2 g) at the final assessment are shown as a function of baseline pad test result, stratified by surgical approach: RARP and LRP. Note: The solid line represents RARP; the dashed line represents LRP. Predictions are based on a multivariable logistic regression model adjusted for baseline pad test result, age, BMI, preoperative PSA, preoperative rehabilitation, time to rehabilitation, and pathological features (ISUP grade, EPE, and SVI).