short - term urinary incontinence is a major cause of morbidity associated with both the open and standard robotic / laparoscopic radical prostatectomy .
although fewer than 510% of patients have long - term effects after one year , the incidence of early post - operative incontinence varies widely , with 4476% of patients requiring two or more pads per day at three months [ 13 ] . despite the transient nature in most cases ,
quality - of - life studies have revealed that short - term incontinence is severely bothersome to most men .
recent studies have attempted to preserve early continence by anatomically restoring the urethral  vesical junction [ 59 ] .
although early data suggests that some of these techniques may improve early urinary control , some are technically demanding and may prolong operative times for less experienced surgeons . the most effective and efficient method to improve early return of urinary control following ralp remains to be established . in an effort to improve short - term urinary control
we developed a simplified approach to combined posterior reconstruction and anterior suspension using a single anastomotic stitch ( prass ) .
herein , we prospectively evaluated recovery of urinary control in a single - surgeon - series of patients undergoing prass and compared them with a cohort who underwent standard ralp .
following approval from the uci internal review board , data were collected prospectively by patient reported self - administered questionnaires obtained during preoperative and three month post - operative visits following ralp .
all cases were performed by a single surgeon ( dko ) between november 2003 and may 2008 . in the first 231 procedures the urethral  vesical anastomosis was completed using the standard van velthovan stitch as previously described   without any additional anti - incontinence procedures . in july of 2007 ,
fifty consecutive patients were evaluated ( case # 275324 ) and compared with 50 consecutive patients who underwent standard ralp ( control group ; case # 182231 ) .
baseline patient characteristics are shown in table  1 . at three months , follow - up data were available for 39 patients ( 78% ) in the control group and 35 patients ( 70% ) in the prass group .
follow - up data were not available for 11 control and 15 prass patients because these patients had returned to their local urologist for follow - up care .
there was no significant difference in baseline characteristics of the patients with and without three month follow - up data.table  1baseline characteristic of ( a ) patients with and without three months follow - up data and ( b ) patients in the control and prass groupspatient with 3  month follow - up datapatients without 3  month follow - up data 
 p - value 
 n 
 mean 
 n 
 mean(a ) age ( years)7263.52862.30.45bmi6628.22728.40.79prostate volume ( cc)5852.92150.40.66shim  pre - surgery7119.72818.60.64aua ss  pre - surgery719.72811.60.32epic  sum at baseline727.6246.90.36controlprass 
 p value(b ) age ( years)63.862.60.41bmi29.828.60.53prostate volume ( cc)53.051.40.75pre - surgery shim20.518.30.32pre - surgery auass10.79.80.57pre - surgery epic sum7.67.30.64nerve sparing ( % ) 70701.0positive margins ( % ) 11.612.50.9 baseline characteristic of ( a ) patients with and without three months follow - up data and ( b ) patients in the control and prass groups baseline patient characteristics ( age , aua symptom score , shim score , nerve sparing procedure , bmi , prostate weight , positive surgical margin rate ) were analyzed to assess for preoperative differences between groups ( table  1 ) .
post - operative continence was evaluated by using questions 15 from the epic-26 questionnaire :  over the past 4  weeks how often have you leaked urine?which of the following best describes your urinary control during the last 4  weeks?how many pads or adult diapers per day did you usually use to control leakage?how big a problem if any has dripping or leaking urine been for you during the last 4  weeks?overall , how big a problem has urinary function been for you during the last 4  weeks ?   over the past 4  weeks how often have you leaked urine ?   which of the following best describes your urinary control during the last 4  weeks ?   how many pads or adult diapers per day did you usually use to control leakage ?   how big a problem if any has dripping or leaking urine been for you during the last 4  weeks ?
  overall , how big a problem has urinary function been for you during the last 4  weeks ? 
all responses were scored from a low of one for a favorable response ( e.g. , no problem ) to a high of four or five for an unfavorable response ( e.g. , significant problem ) .
response codes were thus reversed for questions 1 and 2 and modified to range from 14 and 15 for questions 3 and 4a , respectively , rather than 03 or 4 .
a weighted sum of all responses was calculated so that the highest score ( 4 or 5 ) received equal weight for each question .
data were compared between groups at baseline and at three month follow - up using two - group t - tests for continuous variables and pearson s chi - squared tests for categorical variables .
unadjusted epic summary scores were compared between groups using two - group t - tests . to adjust for possible baseline differences in individuals and to adjust for co - variables
independently associated with return to continence , repeated measures analysis of variance model was used .
epic summary score at baseline and at three month follow - up were used as the within - group repeated measure .
independent covariates which are constant across trials included age , nerve sparing , baseline aua symptom scores , and shim scores . a significant difference between surgical groups in the time by group interaction reflects a difference in the change in continence over time between the two groups . using a repeated measures analysis of variance model , we tested for differences between surgical groups in change in continence from baseline to the three month follow - up time point .
epic summary score was the within - group repeated measure and surgical procedure was the grouping factor .
age , pre - surgery aua symptoms scores , and pre - surgery shim scores were found to be significantly correlated with continence at three months as assessed using the epic summary score .
thus these covariates were included in the final repeated measures model to increase precision and adjust for any initial imbalances between groups related to these factors .
nerve sparing , bmi , and prostate volume were not significantly correlated with continence at three months and were excluded from the multivariate and repeated measures model .
baseline patient characteristics ( age , aua symptom score , shim score , nerve sparing procedure , bmi , prostate weight , positive surgical margin rate ) were analyzed to assess for preoperative differences between groups ( table  1 ) .
post - operative continence was evaluated by using questions 15 from the epic-26 questionnaire :  over the past 4  weeks how often have you leaked urine?which of the following best describes your urinary control during the last 4  weeks?how many pads or adult diapers per day did you usually use to control leakage?how big a problem if any has dripping or leaking urine been for you during the last 4  weeks?overall , how big a problem has urinary function been for you during the last 4  weeks ?   over the past 4  weeks how often have you leaked urine ?   which of the following best describes your urinary control during the last 4  weeks ?   how many pads or adult diapers per day did you usually use to control leakage ?   how big a problem if any has dripping or leaking urine been for you during the last 4  weeks ?   overall , how big a problem has urinary function been for you during the last 4  weeks ? 
all responses were scored from a low of one for a favorable response ( e.g. , no problem ) to a high of four or five for an unfavorable response ( e.g. , significant problem ) .
response codes were thus reversed for questions 1 and 2 and modified to range from 14 and 15 for questions 3 and 4a , respectively , rather than 03 or 4 .
a weighted sum of all responses was calculated so that the highest score ( 4 or 5 ) received equal weight for each question .
data were compared between groups at baseline and at three month follow - up using two - group t - tests for continuous variables and pearson s chi - squared tests for categorical variables .
unadjusted epic summary scores were compared between groups using two - group t - tests . to adjust for possible baseline differences in individuals and to adjust for co - variables
independently associated with return to continence , repeated measures analysis of variance model was used .
epic summary score at baseline and at three month follow - up were used as the within - group repeated measure .
independent covariates which are constant across trials included age , nerve sparing , baseline aua symptom scores , and shim scores . a significant difference between surgical groups in the time by group interaction reflects a difference in the change in continence over time between the two groups . using a repeated measures analysis of variance model , we tested for differences between surgical groups in change in continence from baseline to the three month follow - up time point .
epic summary score was the within - group repeated measure and surgical procedure was the grouping factor .
age , pre - surgery aua symptoms scores , and pre - surgery shim scores were found to be significantly correlated with continence at three months as assessed using the epic summary score .
thus these covariates were included in the final repeated measures model to increase precision and adjust for any initial imbalances between groups related to these factors .
nerve sparing , bmi , and prostate volume were not significantly correlated with continence at three months and were excluded from the multivariate and repeated measures model .
baseline patient characteristics ( age , aua symptom score , shim score , nerve sparing procedure , bmi , prostate weight , positive surgical margin rate ) were analyzed to assess for preoperative differences between groups ( table  1 ) .
post - operative continence was evaluated by using questions 15 from the epic-26 questionnaire :  over the past 4  weeks how often have you leaked urine?which of the following best describes your urinary control during the last 4  weeks?how many pads or adult diapers per day did you usually use to control leakage?how big a problem if any has dripping or leaking urine been for you during the last 4  weeks?overall , how big a problem has urinary function been for you during the last 4  weeks ?   over the past 4  weeks how often have you leaked urine ?   which of the following best describes your urinary control during the last 4  weeks ?   how many pads or adult diapers per day did you usually use to control leakage ?   how big a problem if any has dripping or leaking urine been for you during the last 4  weeks ?   overall , how big a problem has urinary function been for you during the last 4  weeks ? 
all responses were scored from a low of one for a favorable response ( e.g. , no problem ) to a high of four or five for an unfavorable response ( e.g. , significant problem ) .
response codes were thus reversed for questions 1 and 2 and modified to range from 14 and 15 for questions 3 and 4a , respectively , rather than 03 or 4 .
a weighted sum of all responses was calculated so that the highest score ( 4 or 5 ) received equal weight for each question .
data were compared between groups at baseline and at three month follow - up using two - group t - tests for continuous variables and pearson s chi - squared tests for categorical variables .
unadjusted epic summary scores were compared between groups using two - group t - tests . to adjust for possible baseline differences in individuals and to adjust for co - variables
independently associated with return to continence , repeated measures analysis of variance model was used .
epic summary score at baseline and at three month follow - up were used as the within - group repeated measure .
independent covariates which are constant across trials included age , nerve sparing , baseline aua symptom scores , and shim scores . a significant difference between surgical groups in the time by group interaction reflects a difference in the change in continence over time between the two groups . using a repeated measures analysis of variance model , we tested for differences between surgical groups in change in continence from baseline to the three month follow - up time point .
epic summary score was the within - group repeated measure and surgical procedure was the grouping factor .
age , pre - surgery aua symptoms scores , and pre - surgery shim scores were found to be significantly correlated with continence at three months as assessed using the epic summary score .
thus these covariates were included in the final repeated measures model to increase precision and adjust for any initial imbalances between groups related to these factors .
nerve sparing , bmi , and prostate volume were not significantly correlated with continence at three months and were excluded from the multivariate and repeated measures model .
after adjusting for age and baseline aua symptom score and shim score , subjects who received the prass procedure had significantly better urinary control at three months .
90.9% of patients in the prass group required one or fewer pads per day compared with 48.2% in the control group ( p  =  0.014 , table  2 ) . of patients undergoing ralp with the prass procedure 42% were pad - free at three months compared with only 20.6% of patients undergoing standard ralp ( p  =  042).table  2multivariate analysis results comparing ( a ) 01 pads per day and 0 pads per day ( epic question 3 ) in prass and control ( ralp ) groups at three months post - prostatectomy after controlling for age , and baseline aua and shim scores , and ( b ) epic sum score results adjusted for baseline epic score , age , baseline aua symptom score , and baseline shim scorepercent using 01 pads ( % ) 
 p - value(a ) control42.80.014prass90.9percent using 0 pads ( % ) control20.60.042prass42.0group 
 n 
 meanse 
 p - value(b ) standard group ( control)3416.00.890.013prass3712.80.85 multivariate analysis results comparing ( a ) 01 pads per day and 0 pads per day ( epic question 3 ) in prass and control ( ralp ) groups at three months post - prostatectomy after controlling for age , and baseline aua and shim scores , and ( b ) epic sum score results adjusted for baseline epic score , age , baseline aua symptom score , and baseline shim score the unadjusted epic score at three months was not statistically different between the prass and ralp groups ( p - value 0.96 )
however , when adjusted for baseline epic score , age , aua symptom score at baseline , and shim at baseline the difference was statistically different ( p - value 0.013 ; table  2b )
. there were no clinically significant urine leaks or early bladder neck contractures in either of the groups . in all patients
two patients ( 4% ) in the prass group developed urinary retention that resolved after reinsertion of the foley catheter for one week .
urinary incontinence is a major health related quality - of - life concern for patients undergoing open or robotic / laparoscopic radical prostatectomy . immediately following a radical prostatectomy estimates of patients experiencing
incontinence vary widely from 8 to 47% [ 2 , 3 ] . after approximately 1218  months
the majority of these patients will have regained urinary continence [ 1 , 11 ] . despite favorable long - term outcomes , the duration until full recovery of continence is a significant concern to patients .
quality - of - life studies suggest that even early transient incontinence itself is more bothersome to patients than impotence .
urodynamic studies have demonstrated post - prostatectomy incontinence to be primarily because of intrinsic sphincteric deficiency [ 1216 ] .
multiple attempts have been made to modify walsh s anatomic radical prostatectomy to prevent injury to , or to repair , the rhabdo - urinary sphincter .
rocco and coworkers described a technique for reconstruction of the posterior musculofascial plate and recreation of the pre - existing continuity between the denonvilliers fascia and the posterior rhabdosphincter .
the rationale for this maneuver is to provide support to the urethra and restore it to a more anatomic position . in follow - up
, the group undergoing the posterior reconstruction had a significantly higher continence rate , defined as 01 pads per day , compared with a historical group undergoing a standard walsh prostatectomy at 3  days ( 62.4 vs. 14% ) , 30  days ( 74 vs. 30% ) , and 90  days ( 85.2 vs. 46% ) , p  <  0.001 .
a follow - up report in 2007 also showed that this technique is feasible by a laparoscopic approach , demonstrating improvements in urinary control at 30  days , with 83.8% of patients with reconstruction having control versus 32.3% of those undergoing a standard laparoscopic prostatectomy ( p  =  0.0001 ) . in 2008 , nguyen et al .
obtained similar good results for patients undergoing either laparoscopic or robotic prostatectomy . in this series ,
urethral length was restored to 89% of its baseline compared with 78% without the posterior reconstruction , providing objective data to explain the improvement in continence rates . in 2008 tewari and
coworkers evaluated a group of patients undergoing anterior reconstruction alone versus anterior and posterior reconstruction versus a historical control group and found that both types of reconstruction were significantly better than no reconstruction in terms of time to continence , defined as 0 pads per day or a single pad for security reasons only . at three months ,
the control group had a continence rate of 50% whereas the anterior reconstruction group and the combined anterior and posterior reconstruction groups had a continence rate of 77 and 91% , respectively , at three months .
a much more extensive reconstruction was used in this study than that described here , with multiple interrupted sutures used to reapproximate the posterior urethral plate and a running suture used to reapproximate the arcus tendineus and puboprostatic plate to the bladder neck .
interestingly , a prospective randomized study by menon et al . in 2008 found there was no difference in early continence ( < 30  days ) between patients undergoing ralp with periprostatic tissue reconstruction and those undergoing a standard single - layer anastamosis . in this study
we compared the continence rates at three months in two groups of patients undergoing ralp 
one with a posterior reconstruction and anterior suspension with single anastomotic suture ( prass ) and a cohort without these modifications . unlike previous studies with anterior and/or posterior repairs requiring extensive reconstruction and multiple sutures
the posterior repair was performed by using the initial passes of the van velthoven suture consisting of 2 3 - 0 monocryl sutures   to reapproximate the posterior rhabodosphincter of the urethra ( fig . 
the anterior suspension stitch was performed at the end of the urethral  vesical anastomosis .
after the anastomosis was completed and tied , one of the two arms of the van velthoven suture was used to suspend the urethra from the posterior side of the pubic symphysis .
the stitch was secured with a single lapra - ty ( ethicon ) clip ( fig .  1b).fig . 
a the posterior repair is performed by using the initial passes of the van velthoven suture to reapproximate the posterior rhabodosphincter of the urethra .
b the anterior reconstruction is performed by using one of the two arms of the van velthoven suture to suspend the urethra from the posterior side of the pubic symphysis .
the stitch was secured with a single lapra - ty ( ethicon ) clip illustrations showing the prass reconstruction .
a the posterior repair is performed by using the initial passes of the van velthoven suture to reapproximate the posterior rhabodosphincter of the urethra .
b the anterior reconstruction is performed by using one of the two arms of the van velthoven suture to suspend the urethra from the posterior side of the pubic symphysis .
the stitch was secured with a single lapra - ty ( ethicon ) clip in our study , multivariate analysis demonstrated that , after adjusting for age and baseline aua symptoms scores and shim scores , subjects who underwent prass repair had significantly improved urinary control at three months compared with those undergoing a standard ralp .
ninety - one percent ( 90.9% ) of the patients undergoing the prass repair were using 01 pad per day at three months versus 48.2% in the control group ( p  =  0.014 ) .
this continence rate is comparable with that described by other groups using more extensive reconstructions , both posterior alone   and anterior and posterior .
the mechanism of improved continence with our technique is restoration of the anatomic configuration of the urethra created with the anterior and posterior reinforcement , as has been successfully done with other , more extensive reconstructions .
this eliminates multiple knots making it simpler and therefore potentially quicker and more available to less experienced surgeons compared with similar , previously described , techniques .
a potential limitation of our study is that it is a case - controlled study rather than a prospective randomized trial .
we believe that three months is a relevant time point and that longer follow - up will not alter the conclusions of this report because , in general , once men regain continence following surgery they do not lose it again .
of course longer term follow - up is needed to determine the true , long term continence rate .
in addition , all the men in the prass group underwent both an anterior and a posterior repair , making it hard to determine the impact of either the anterior or posterior stitch alone .
this is similar to findings in other studies in which reconstruction of any kind was superior to no reconstruction .
men in our study have not undergone urodynamic studies which could be an objective method to measure continence , avoiding the problems inherent to any questionnaire .
last , imaging studies such as mri could be used to evaluate the impact of our repair on factors such as urethral length . despite these potential limitations ,
this technique does show considerable promise for improving the time to continence in men undergoing robot - assisted laparoscopic prostatectomy .
our technique is simple and easy to perform and has resulted in a significant improvement in continence three months following ralp .
we have developed a novel , simplified technique for reconstruction of the anterior and posterior support of the urethra to improve time to continence in men undergoing robotic - assisted laparoscopic prostatectomy .
patients who had posterior reconstruction and anterior suspension with single anastomotic suture ( prass ) had higher continence rates at three months using this procedure .
 post - prostatectomy urinary incontinence is a major cause of morbidity from radical prostatectomy . 
 efforts have been made to develop techniques to hasten return of urinary control . 
 several authors have demonstrated improved early continence with anterior , posterior , or combined reconstruction of the urethral  pelvic attachments . in this study , we compare three - month urinary function and continence data for patients who underwent ralp with posterior reconstruction and anterior suspension with single anastomotic suture ( prass ) . 
 a prospective cohort of 50 patients underwent ralp with prass reconstruction and were compared to 50 control patients who underwent standard ralp . 
 continence was defined as use of 01 urinary pads and was evaluated at each follow - up visit using the epic-26 questionnaire . 
 a weighted summary score was created and group differences were compared using a repeated measures analysis of variance model . after adjusting for age , baseline aua symptom score , and shim scores , which were found to correlate with continence , patients who underwent the prass reconstruction had significantly improved urinary control at three months compared with the control group ; 90.9% of the patients in the prass group wore 01 pads per day versus 48.2% in the control group ( p  =  0.014 ) . of the patients undergoing the standard 
 prostatectomy 20.6% were totally pad - free compared with 42% of the patients undergoing the prass procedure ( p  =  0.042 ) . in conclusion , the prass technique resulted in statistically significant improvement in urinary control three months post - operation . 
 the prass reconstruction is technically straightforward , requires no additional sutures , and is a simple technique that is easily learned and adaptable to other robotic surgery . 
Introduction
Materials and methods
Statistical analysis
EPIC summary score
Results
Comments
Conclusion