The gold standard treatment for localized prostate cancer (CaP) is radical prostatectomy. Despite its high cure rate, it can lead to complications in urinary and sexual function, significantly impacting quality of life. This study aimed to evaluate the impact of robot-assisted radical prostatectomy (RARP) on patients quality of life by characterizing their functioning before and after surgery.

A prospective cohort study was conducted in patients with localized or locally advanced prostate cancer who underwent robot-assisted radical prostatectomy (RARP) between June 2022 and September 2023. A preoperative assessment was conducted, followed by evaluations at 30 days, 3 months, and 6 months post-surgery. These assessments took place in a specialized pelvic floor clinic within the Department of Physical Medicine and Rehabilitation from a tertiary hospital. Patients with disseminated disease, a history of pelvic surgery/radiotherapy, or those who did not provide informed consent were excluded.

To assess quality of life, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Prostate Cancer Module (EORTC QLQ-PR25) was administered at 30 days, 3 and 6 months. Symptoms of stress urinary incontinence (SUI) and erectile dysfunction (ED) were identified in the patients evaluated.

The study collected comprehensive health data including: (a) Clinical History: included age, Body Mass Index (BMI), Self-reported activity level using the Duke Activity Status Index (DASI) and the 6-Minute Walk Test (6MWT) measured endurance and handgrip strength. (b) Surgical Data obtained through the International Society of Urological Pathology (ISUP) grade, and lymphadenectomy. (c) Pelvic floor muscle function was evaluated using the Oxford scale for muscle  strength and a digital exam for sensory function and proprioception. (d) Validated questionnaires as the Hospital Anxiety and Depression Scale (HADS), International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), International Index of Erectile Function – 5 (IIEF-5), Erection Hardness Score (EHS). 

A descriptive analysis was conducted to characterize the variables. Percentages, means, and standard deviations were calculated to summarize the data. The collected data were entered into a RedCAP database and analyzed using IBM SPSS v24.0 software.

A total of 68 patients with a mean age of 64.39 (DE 5.16 years were enrolled in the study. Average body mass index (BMI) was 27.90 (SD 3.31), with a quarter (25%) classified as obese. Preoperatively, aerobic capacity was assessed using the DASI scale, revealing a VO2max of 29.25 ± 5.06ml/min/kg equivalent to 8.36 METs (SD 1.45). Handgrip strength was 41.22kg (SD 7.56). Functional evaluation involved a 6-minute walk test (6MWT), with an average distance covered of 580.61 meters (SD 75.12).

In the EORTC QLQ-PR25 scale, a variation in the severity of urinary symptoms was observed during the 6-month follow-up. The baseline assessment yielded a mean score of 15.29 ± 8.60. The score at 30 days was 29.51 ± 15.33, followed by 26.70 ± 17.13 at 3 months and 21.75 ± 22.80 at 6 months. On the other hand, in the sexual dysfunction section, a greater impact on quality of life is observed throughout the 6-month follow-up. The baseline assessment obtained a mean score of 66.33 ± 20.70, with a gradual progressive decrease to 54.39 ± 15.23 at 30 days, 45.70 ± 19.69 at 3 months, and a slight increase to 52.77 ± 26.35 at 6 months (Figure 1).

Preoperative assessment revealed anxiety and depression scores of 4.56 ± 3.11 and 3.13 ± 3.22, respectively, on the HADS. Sexual function evaluation using the IIEF-5 scale yielded a mean score of 13.52 ± 8.67. Furthermore, 61% of patients exhibited ED grades 3-4 on the EHS scale.Pre-surgical prostate volume averaged 53.25 (SD 18.46 cc, with 84% of cases classified as ISUP 2-3. Lymphadenectomy was performed in 22% of patients.

At 30 days post-surgery, patients showed improvements in anxiety and depression (HADS scores: 2.98 ± 2.70 and 2.41 ± 3.02, respectively). Positive outcomes (Oxford score ≥ 3) were observed in 77.1% of patients. However, altered pelvic floor sensation was common (91.4%). The prevalence of SUI was 87.7% (ICIQ-SF 8.84±6.32). Only 9.1% of patients did not use pads. Sexual function also decreased (IIEF-5 7.10±8.36). Erectile function (EHS grades 3-4) dropped to 5.4%.

Three months after surgery, patients continued to experience improvements in anxiety and depression (HADS scores: 2.68 ± 2.14 and 2.14 ± 3.03). Positive outcomes (Oxford score ≥ 3) remained high at 81.8%. However, altered pelvic floor sensation persisted in 64.9%. Prevalence of SUI was 81.8% (average ICIQ-SF 7.375.35). 27.6% of patients did not use pads. Sexual function also showed a decrease (IIEF-5: 5.516.13), with only 7.2% of patients maintaining erectile function (EHS grades 3-4).

Six months after surgery, anxiety and depression scores remained stable (HADS scores: 3.05 ± 3.73 and 3.37 ± 4.66). Positive outcomes (Oxford score ≥ 3) stayed high at 92.3%. Altered pelvic floor sensation persisted in 54%. Prevalence of SUI was 65.1% (average ICIQ-SF 5.35±5.25). 54.7% of patients did not use pads. Sexual function continued to show a decrease (IIEF-5: 5.11±5.19), with only 21.1% of patients maintaining erectile function (EHS grades 3-4). The summary of the ICIQ-SF and IIEF-5 scores can be observed in Figures 2 and 3 respectively.

Patients with localized or locally advanced CaP have adequate preoperative cardiorespiratory function. SUI and ED are two common side effects that impact quality of life, especially in the sexual sphere.

An improvement in SUI is observed at 6 months postoperatively, with a reduction in the ICIQ-SF score and an increase in the percentage of patients without pads. This improvement is associated with pelvic floor recovery, in the course of the first 6 months. On the other hand, ED shows a progressive worsening during the first 6 months, with a slight stabilization at the end of the period. Sexual function is negatively affected, impacting the patient's quality of life, which coincides with the scientific literature.

Given these findings and the progressive nature of symptoms that negatively impact patients' quality of life over time, a pre- and post-operative rehabilitation assessment is important.. Rehabilitation programs, including hygienic-dietary measures, pelvic floor muscle training, and the possible combination with other conservative treatment modalities, can contribute to the improvement of urinary continence. Finally, one of the limitations of our study is the lack of long-term evaluation (12 months) after RARP

Postoperative improvement in stress urinary incontinence is associated with pelvic floor recovery during the first 6 months.  However, erectile dysfunction worsens during this period, having the greatest impact on quality of life for patients undergoing RARP. Pelvic floor rehabilitation programs can help improve SUI in these patients. Long-term follow-up studies are needed to assess the durability of these effects.

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