










































Key Words Competing Interests Article Information

Urinary incontinence, robotic radical 
prostatectomy, conservative management

None declared. Received on July 28, 2021 
Accepted on August 27, 2021 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(2):88–100

DOI: 10.48083/DPRH8648

88 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

REVIEW

Postoperative Non-Surgical Interventions  
to Improve Urinary Continence After  
Robot-Assisted Radical Prostatectomy:  
A Systematic Review
Luigi Candela,1,2 Giancarlo Marra,2,3,4 Manuela Tutolo,1 Lara Rodríguez-Sánchez,2 Petr Macek,2  
Xavier Cathelineau,2 Francesco Montorsi,1 Andrea Salonia,1 Rafael Sanchez Salas2

1 Division of Experimental Oncology/Unit of Urology; URI; IRCCS Ospedale San Raffaele, Milan, Italy 2 Urology Department, Institut Mutualiste Montsouris, Paris, France  
3 Department of Surgical Sciences, San Giovanni Battista Hospital and University of Turin, Italy 4 Department of Urology and Clinical Research Group on Predictive Onco-
Urology, APHP, Sorbonne University, Paris, France

Abstract

Background The occurrence of postoperative urinary incontinence (UI) remains a problem for patients undergoing 
robot-assisted radical prostatectomy (RARP). Non-surgical interventions (NSI) in addition to intraoperative 
techniques and patient behavioral changes have been proposed to improve urinary continence (UC) recovery after 
RARP. However, to date, the real clinical impact of postoperative NSI remains not well characterized.

Materials and Methods We performed a Systematic Review in April 2021, using Allied and Complementary 
Medicine (AMED), Embase, and MEDLINE according to the PRISMA recommendations and using the Population, 
Intervention, Comparator and Outcome (PICO) criteria. Primary outcome of interest was the impact of NSI on UC 
recovery rate and time to achieve UC after RARP. Secondary outcomes of interest were the assessment of patient 
adherence to NSI, risk factors associated with UI, and correlation between postoperative NSI and sexual activity 
recovery.

Results A total of 2758 articles were screened, and 8 full texts including 1146 patients were identified (3 randomized 
controlled trials, 3 prospective single-arm trials, and 2 retrospective series). Postoperative NSI of interest included 
pelvic floor muscle training (PFMT) (n = 6 studies) and administration of oral medications (solifenacin) (n = 2 
studies). PFMT appeared to increase UC rates and to accelerate time to achieve UC in the early postoperative period. 
Similarly, solifenacin provided higher rates of UC recovery and contributed to a certain degree of symptomatic relief. 
There was a great variability regarding NSI features and data reporting among studies. Major limitations were the 
small sample sizes and the short follow-up.

Conclusion Postoperative NSI to manage UI after RARP include PFMT and solifenacin administration. Both seem 
to modestly improve early UC recovery. Nonetheless, evidence supporting their routinely use is still weak and lacks 
appropriate follow-up to evaluate possible benefits on long-term UC recovery.

Introduction

Radical prostatectomy (RP), together with radiotherapy, represents the gold standard of care for patients with inter-
mediate- to high-risk clinically localized prostate cancer (PCa)[1]. Minimally invasive approaches have demonstrated 
non-inferior functional outcomes compared with open surgery and have a good safety profile[2–4]. In this context, 

http://SIUJ.org
mailto:candela.luigi%40hsr.it?subject=SIUJ


robot-assisted radical prostatectomy (RARP) is increas-
ingly used in urological centers as the approach of choice 
for RP[5]. Nevertheless, the rate of postoperative urinary 
incontinence (UI) remains consistent. UI rates at 1 year 
after RARP range from 4% to 31% in different studies, 
decreasing patient quality of life (QoL) especially when 
associated with a new onset of erectile disfunction in 
previously sexually active men[6].

In the last decade, many intraoperative surgi-
cal strategies have been proposed to improve func-
tional outcomes, demonstrating satisfactory urinary 
continence (UC) recovery rates[7–9]. Preservation of 
bladder neck, endopelvic fascia, pubo-prostatic liga-
ments, neuro-vascular bundles, and urethral length 
together with anterior and posterior reconstructions 
are commonly used to maximize continence recovery. 
Postoperative non-surgical interventions (NSI) in addi-
tion to patients’ behavioral changes have been proposed 
to improve UC after RP[10]. Specifically, pelvic f loor 
muscle training (PFMT) and oral medication including 
duloxetine and muscarinic receptor antagonists repre-
sent the most used NSI[11–13]. Therefore, NSI could 
represent a valuable tool to improve post-RARP UC 
recovery, especially in the setting of mild UI. However, 
to date, the real clinical impact of NSI on postoperative 
UC recovery after RARP has not been well character-
ized[14]. We therefore thought this the optimal time to 
perform a systematic review of the literature with the 
aim of summarizing the current evidence on postopera-
tive NSI to improve UC recovery after RARP.

Materials and Methods
Study Population and Aims 
The current systematic review was registered with 
the International Prospective Registry of Systematic 
Reviews (PROSPERO).

The Population, Intervention, Comparator and 
Outcome (PICO) criteria were used to frame the aims of 
the current systematic review. The population of inter-
est consisted of patients who had undergone RARP for 
PCa (P). Postoperative NSI for the management of post-

RARP UI were the evaluated interventions (I). A no-NSI 
comparator was considered mandatory for the specific 
purpose of the current review (C). The primary aim was 
to evaluate the impact of NSI strategies in UC recovery 
after RARP in terms of UC rate and/or time to achieve 
UC. Secondary aims were to identify patient compli-
ance with these treatments, risk factors associated with 
UI, and correlation between UC restoration and sexual 
activity recovery (O).

The treatment options of interest included postopera-
tive non-surgical strategies to manage UI and to improve 
UC recovery. Stress, urgency, and mixed UI were taken 
into consideration, and UC was defined according to 
urinary pads/day used and/or according to validated 
questionnaires.

Literature Search 
A systematic web search was performed according to 
the Preferred Reporting Items for Systematic Reviews 
and Meta-Analyses (PRISMA) guidelines on April 
19, 2021, through the Ovid platform with no time 
restrictions, using Allied and Complementary Medicine 
(AMED), Embase, and MEDLINE databases. The terms 
“continence’’ and “incontinence’’ were pooled together 
with the Boolean operator “OR.” The terms “RARP’’ and 
“robot radical prostatectomy’’ were pooled together with 
the Boolean operator “OR.” The results were then pooled 
together with the Boolean operator “AND.” The web 
search was supplemented by a manual search (authors 
consultation and references of included articles). Two 
authors (L.C. and G.M.) independently screened all 
items. Disagreements were resolved through discussion 
or by consultation with a third and senior author (R.S.S.). 
Only full-text publications in English were considered.

We included all randomized controlled trials (RCTs) 
and prospective and retrospective series without restric-
tions. We excluded studies not providing (1) details on 
UI rate before and after RARP; (2) details on NSI; (3) 
continence rates after surgery; (4) appropriate definitions 
to categorize type and severity of UI including either the 
number of pads used/day or pre-defined validated ques-
tionnaires. Case reports, editorials, letters, reviews, and 
meeting abstracts were excluded.

Risk of bias and study quality were assessed according 
to European Association of Urology recommendations 
for performing systematic reviews and meta-analy-
sis[15]. The Cochrane Risk of Bias assessment tool was 
used for RCTs and the quality appraisal tool for case 
series using a modified Delphi technique for retrospec-
tive studies[16] (Table 1).

Results
Figure 1 details the literature search strategy and the 

included/excluded studies. Of 2758 identified abstracts, 

Abbreviations 
NSI  non-surgical interventions
PCa  prostate cancer
PFMT pelvic floor muscle training
RARP  robot-assisted radical prostatectomy
RCT randomized controlled trial
RP radical prostatectomy
UC  urinary continence
UI urinary incontinence

89SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Postoperative Non-Surgical Interventions to Improve Urinary Continence After Robot-Assisted Radical Prostatectomy: A Systematic Review

http://SIUJ.org


we included 8 studies (3 RCTs, 3 prospective single-
arm trials, and 2 retrospective series) reporting results 
of UC recovery following postoperative NSI of 1146 
patients who had undergone RARP for PCa. Overall, 
2 NSI strategies to improve UC recovery after RARP 
were found: pelvic floor muscle training (PFMT) (n = 6 
studies) and solifenacin oral administration (n = 2 stud-
ies). Only 1 RCT was a multicenter study[17]. Popula-
tion sizes ranged between 39 and 623 patients. Among 
the studies on PFMT efficacy, 4 out of 6 had a control 
group[18–21]. More precisely, the study by Sayilan et al. 
compared PFMT with no intervention[20], while the 
other included studies compared modified PFMT strat-
egy, including ultrasound-guided, biofeedback and visu-
al-feedback PFMT, with the conventional one[18,19,21]. 
Among the studies on solifenacin oral administration 
safety and efficacy, Liss and colleagues conducted a 
single-arm prospective clinical trial[22], while Bianco et 
al. performed a multicenter RCT with a placebo arm as 
control group[17].

Overall, NSI duration of treatments ranged from 
1 to 3 months after surgery. Primary endpoints were 
UC recovery rate and time to UC in the majority of the 
studies. Follow-up periods ranged from 1 month to 9 
months, with most of studies reporting 3 months post 
bladder catheter removal urinary outcomes.

TABLE 1A. 

Quality / Risk of Bias of the Included Studies 

Retrospective series (n = 2 studies)  

Quality Appraisal tool for case series using a  

modified Delphi technique

n  (%)

S
TU

D
Y

 P
O

P
U

LA
TI

O
N

1. Hypothesis/aim/objective 
stated clearly

2 100

2. Characteristics of the  
study participants described

2 100

3. Multicentre study 0 0

4. Inclusion and exclusion criteria 
explicit and appropriate

1 50

5. Participants recruited 
consecutively

2 100

6. Participants entering at a  
similar disease point

2 100

IN
TE

R
V

EN
TI

O
N

S

7. Intervention clearly described 2 100

8. Cointerventions clearly reported 0 0

O
U

TC
O

M
ES

9. Outcome measures clearly 
defined

2 100

10. Relevant outcomes 
appropriately measured

2 100

11. Outcomes measured before and 
after the intervention

0 0

S
TA

TS 12. Statistical tests appropriate to 
assess outcomes

1 50

R
ES

U
LT

S 
/  

C
O

N
C

LU
SI

O
N

S

13. Length of follow-up reported 2 100

14. Loss to follow-up reported 2 100

15. Estimates of the random 
variability in  data analysis

1 50

16. Adverse events reported? 0 0

17. Conclusions of the study 
supported

2 100

C
I 18. Competing interests and 

sources of support reported
2 100

TABLE 1B. 

Quality / Risk of Bias of the Included Studies 

Randomized controlled trials (n = 3 studies)

The Cochrane risk of bias assessment tool 

+ – ?

1. Random sequence generation 2 0 1

2. Allocation concealment 1 2 0

3. Blinding of participants 1 2 0

4. Blinding of outcomes 0 3 0

5. Incomplete outcome data 0 3 0

6. Selective reporting 0 3 0

7. Other bias 1 0 2

90 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org


Reported rates of UC varied between a minimum of 
29.1% at 3 months in patients treated with solifenacin[17] 
to a maximum of 100% at 6 months in patients who have 
performed PFMT[21].

Overall, 3 out of 5 studies comparing NSI group with 
a control group showed a statistically significant advan-
tage of NSI in UC recovery rate[17,20,21] whereas 2 stud-
ies did not find significant differences among groups 
within the follow-up period[18,19]. Regarding the time 
to achieve UC after RARP, PFMT has shown to decrease 
time to UC recovery in 2 studies with mean time rang-
ing from 32 to 75±100 days[18,21]. Similarly, in the study 
by Liss et al., mean time to achieve UC was 95 days in 
patients treated with solifenacin[22].

Tables 2A, 2B, 3A, and 3B show patient characteris-
tics and general information for the included studies.

Among studies reporting urinary outcomes after 
PFMT, we found 100% adherence to treatment: no 
patient with complete follow-up dropped out the exer-
cises for any reason. The rate of adherence to NSI among 
patients receiving pharmacological treatment was 85% 
to 100%, demonstrating its good tolerability and safety 
profile. Overall, 2 studies reported post-RARP UI risk 

factors[21,23] and 1 reported data on patients’ sexual 
activity recovery[19].

Tables 4A and 4B show secondary outcomes of the 
current systematic review.

Studies on Pelvic Floor Muscle Training 
Yoshida et al. conducted a prospective cohort study 
of 116 men undergoing RARP to examine whether 
transperineal ultrasound-guided PFMT promoted 
early UC recovery after surgery[16]. Overall, 36 men 
received US-guided PFMT (interventional group), and 
80 received only verbal instructions for PFMT (control 
group). Continence was defined as time in days needed 
to require a small pad (20g) per day by patient self-report. 
Mean time for UC recovery was significantly shorter 
in the intervention group than in the control group 
(75±100 versus 121.8±132 days; P = 0.037). Moreover, UC 
rates were higher in the intervention group at 30 days 
(52.8% versus 35.4%; P = 0.081); however, at 9 months no 
statistically significant differences were found between 
the 2 groups in terms of continence status (P = 0.558).

Oh et al. performed an RCT with 84 patients who 
had undergone RARP to investigate the effectiveness 
of an extracorporeal biofeedback device (Anykegel) for 
PFMT on UC recovery[19]. Overall, 42 patients received 
biofeedback PFMT using the Anykegel device, and 
42 patients received PFMT with only oral and written 
instructions. UC was defined as a loss of 0 g of urine on 
a 24-hour pad test. In addition, patients were also asked 
to complete the International Prostatic Symptoms Score 
(IPSS) with QoL and International Index of Erectile 
Function (IIEF) questionnaires to identify differences 
from the baseline during the follow-up period (second-
ary outcomes). The follow-up duration of the study was 
3 months, with control visits at 1, 2, and 3 months after 
catheter removal. In the intervention group, the authors 
found a statistically significant smaller volume of urine 
loss at 1 month than in the control group (71 g versus 
120.8 g; P = 0.028). However, at 2 and 3 months no differ-
ences were reported between the 2 groups. Likewise, 
the rate of continent patients was similar between the 
intervention and control groups throughout the study 
follow-up. At the end of the study, 67.5% and 61.9% of 
patients were continent, in the intervention and control 
groups, respectively. Similarly, no differences were 
found among groups in terms of IPPS, QoL, and IIEF, 
despite the intervention group demonstrating a favor-
able change from the baseline to the 1-month follow-up 
visit in IPSS score.

Sayilan and colleagues conducted an RCT to deter-
mine the effect of PFMT after RARP in UC recovery [20]. 
The 30 patients of the intervention group were taught 
to perform Kegel exercises 3 times a day for 6 months 
after surgery, while the control group of 30 patients did 

Web and manual 
search n = 2758

Id
en

ti�
ca

tio
n

Sc
re

en
in

g
El

ig
ib

ili
ty

In
cl

ud
ed

After de-duplication 
n = 2067

Screened
 n = 276

Full-text assessed 
for eligibility

 n = 31

Excluded
 n = 2045

Excluded n = 23
Reasons:
No RARP
No post-RARP NSI
Other outcomes

Full-text included
 n = 8

FIGURE 1. 

PRISMA flowchart

91SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Postoperative Non-Surgical Interventions to Improve Urinary Continence After Robot-Assisted Radical Prostatectomy: A Systematic Review

http://SIUJ.org


TABLE 2A. 

General features of included studies on PFMT to improve UC recovery after RARP

Authors Accrual, year Center Study type Intervention
Duration of  
treatment

Primary  
endpoint

Exclution criteria
n of  

patients
UC  rate (% 

pts)

Mean time 
to UC  

recovery
Definition of UC

Questionnaries /  
urodynamic evaluation

Yoshida et al. 2018 Japan
Prospective 
cohort study

US-guided PFMT 
vs. verbal-PFMT

Preoperatively 
and 1 month after 

RARP
Time to UC recovery

Severe mental disease or cognitive 
impairment, neurological disorder 
affecting urinary tract, inability to 

understand Japanese

36 vs. 80
88.9% vs. 84.7%  

at 9 months  
(P = 0.558)

75±100 vs. 
121.8±132 days 

(P = 0.037)

1 small pad 
(20g)/day

None / None

Oh et al. 2020 Korea RCT
Biofeedback-PFMT 

vs. verbal-PFMT
3 month after 

RARP
Time to UC recovery

Neurologic deficiency, previous pelvic 
radiation therapy or urological surgery, 
total incontinence at catheter removal

42 vs. 42
67.5% vs. 61.9%  

at 3 months  
(P = 0.649)

not reported
loss of 0g  
on a 24h  
pad test

IPSS, IIEF-5 / None

Sayilan et al. 2018 Turkey RCT
PFMT vs.  

no intervention

Preoperatively to 
6 months after 

RARP

Self-reported UC recovery at  
6 months

Urinary incontinence before RARP, 
BMI>30, age<30 or >75 years, 

absence of elementary school level of 
education

30 vs. 30
50% vs. 3.3% 
at 6 months  
(P = 0.001)

not reported
ICIQ-UI score of 

zero
ICIQ-SF / None

Pan et al. 2019 Taiwan Prospective
Resistance band 

PFMT
3 month after 

RARP

Improvement in UC recovery, 
QoL, anxiety and depression 

after RARP

age < 40 years, patients uncapable of 
verbal communication or of getting out 
of bed and moving without assistance, 
UI before surgery, UTI before surgery, 

patients not able to lie in supine 
position

43
34.9% at  
3 months

not reported

Using Urinary 
Incontinence 

Scale after RP 
(UISRP)

UISRP, IIQ, HADS / None

Manley et al. 2016 Australia Retrospective PFMT
Preoperatively 

to 1 month after 
RARP

PFM stength Not reported 98
49.4% at  
1 month

not reported
The requirement 
of no continence 

aids
None / None

Kim et al. 2021 Korea Retrospective

Visual feedback 
PFMT vs 

conventional  
PFMT

1 month Time to UC recovery

Previous pelvic RT, poor compliance 
due to psychiatric or medical problems, 
previous prostate surgery, < 3 months 

FU

41 vs. 42
100% vs. 88.1% 

at 6 months  
(P = 0.023)

32.4 vs. 95.3 
days (P < 0.001)

Cessation of pad 
use

None / None

TABLE 2B. 
General features of included studies on solifenacin administration to improve UC recovery after RARP 

Authors Accrual, year Center Study type Intervention
Duration of  
treatment

Primary endpoint Exclution criteria
n of 

patients
UC  rate (% pts)

Mean time 
to UC  

recovery
Definition of UC

Questionnaries / 
urodynamic evaluation

Liss et al. 2014 United States
Prospective 
clinical trial

Solifenacin 5mg 
daily

3 months
Safety and 3 months UC 

recovery
< 3 pads/day 39

53.8% at  
3 months

95 (61–202) 
days

0 pads/ day AUA symptom score / Yes

Bianco F. et al. 2015 United States RCT
Solifenacin vs. 

placebo
3 months Time to UC recovery < 2 pads/day 7 to 21 days after RARP 313 vs. 310

29.1% vs. 21.4% 
at 3 months  

(P = 0.04)
not reported

0 pads/ day or  
1 dry safety pad/ 

day
None / None

92 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org


TABLE 2A. 

General features of included studies on PFMT to improve UC recovery after RARP

Authors Accrual, year Center Study type Intervention
Duration of  
treatment

Primary  
endpoint

Exclution criteria
n of  

patients
UC  rate (% 

pts)

Mean time 
to UC  

recovery
Definition of UC

Questionnaries /  
urodynamic evaluation

Yoshida et al. 2018 Japan
Prospective 
cohort study

US-guided PFMT 
vs. verbal-PFMT

Preoperatively 
and 1 month after 

RARP
Time to UC recovery

Severe mental disease or cognitive 
impairment, neurological disorder 
affecting urinary tract, inability to 

understand Japanese

36 vs. 80
88.9% vs. 84.7%  

at 9 months  
(P = 0.558)

75±100 vs. 
121.8±132 days 

(P = 0.037)

1 small pad 
(20g)/day

None / None

Oh et al. 2020 Korea RCT
Biofeedback-PFMT 

vs. verbal-PFMT
3 month after 

RARP
Time to UC recovery

Neurologic deficiency, previous pelvic 
radiation therapy or urological surgery, 
total incontinence at catheter removal

42 vs. 42
67.5% vs. 61.9%  

at 3 months  
(P = 0.649)

not reported
loss of 0g  
on a 24h  
pad test

IPSS, IIEF-5 / None

Sayilan et al. 2018 Turkey RCT
PFMT vs.  

no intervention

Preoperatively to 
6 months after 

RARP

Self-reported UC recovery at  
6 months

Urinary incontinence before RARP, 
BMI>30, age<30 or >75 years, 

absence of elementary school level of 
education

30 vs. 30
50% vs. 3.3% 
at 6 months  
(P = 0.001)

not reported
ICIQ-UI score of 

zero
ICIQ-SF / None

Pan et al. 2019 Taiwan Prospective
Resistance band 

PFMT
3 month after 

RARP

Improvement in UC recovery, 
QoL, anxiety and depression 

after RARP

age < 40 years, patients uncapable of 
verbal communication or of getting out 
of bed and moving without assistance, 
UI before surgery, UTI before surgery, 

patients not able to lie in supine 
position

43
34.9% at  
3 months

not reported

Using Urinary 
Incontinence 

Scale after RP 
(UISRP)

UISRP, IIQ, HADS / None

Manley et al. 2016 Australia Retrospective PFMT
Preoperatively 

to 1 month after 
RARP

PFM stength Not reported 98
49.4% at  
1 month

not reported
The requirement 
of no continence 

aids
None / None

Kim et al. 2021 Korea Retrospective

Visual feedback 
PFMT vs 

conventional  
PFMT

1 month Time to UC recovery

Previous pelvic RT, poor compliance 
due to psychiatric or medical problems, 
previous prostate surgery, < 3 months 

FU

41 vs. 42
100% vs. 88.1% 

at 6 months  
(P = 0.023)

32.4 vs. 95.3 
days (P < 0.001)

Cessation of pad 
use

None / None

TABLE 2B. 
General features of included studies on solifenacin administration to improve UC recovery after RARP 

Authors Accrual, year Center Study type Intervention
Duration of  
treatment

Primary endpoint Exclution criteria
n of 

patients
UC  rate (% pts)

Mean time 
to UC  

recovery
Definition of UC

Questionnaries / 
urodynamic evaluation

Liss et al. 2014 United States
Prospective 
clinical trial

Solifenacin 5mg 
daily

3 months
Safety and 3 months UC 

recovery
< 3 pads/day 39

53.8% at  
3 months

95 (61–202) 
days

0 pads/ day AUA symptom score / Yes

Bianco F. et al. 2015 United States RCT
Solifenacin vs. 

placebo
3 months Time to UC recovery < 2 pads/day 7 to 21 days after RARP 313 vs. 310

29.1% vs. 21.4% 
at 3 months  

(P = 0.04)
not reported

0 pads/ day or  
1 dry safety pad/ 

day
None / None

93SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Postoperative Non-Surgical Interventions to Improve Urinary Continence After Robot-Assisted Radical Prostatectomy: A Systematic Review

http://SIUJ.org


TABLE 3A. 
Patient baseline and pathological features (PFMT cohorts) 
 

Authors n of patients Age (years) BMI (Kg/m2) PSA (ng/mL)
Prostate volume 

(mL)
Nerve sparing 
procedures (%)

Gleason score (n) or (%) pT stage (n) or (%) Positive surgical margins (%)

Yoshida et al. 36 vs. 80
66.5 (±6.2) vs.  

66.6  (±5.8)
24.4 (±3.2) vs. 24 (±2.9)

11.3 (±11.8) vs.  
10.3 (±8.5)

48.3 (±15.7) vs.  
47.6 (±20.4)

16.7% vs. 21.3% – >pT3a=13.9%  vs. >pT3a=15.2% –

Oh et al. 40 vs. 42
67.5 (±6.9) vs.  

65.9  (±6.8)
24.8 (±2.6) vs.  

24.6 (±2.7)
19.7 (±28.1) vs.  

15 (±16.3)
33.7 (±10.6) vs.  

36.9 (±11.9)
100% vs. 100%

G6=0, G3+4=10, G4+3=17, G≥8=13 vs. G6=1, 
G3+4=20, G4+3=10, G≥8=11

≤pT2=55%, ≥pT3=45% vs. 
≤pT2=61.9%, ≥pT3=38.1%

20% vs. 19%

Sayilan et al. 30 vs. 30
63 (±8.61) vs.  
59.93  (±6.98)

26.4 vs. 25.8 – – – – – 30% vs. 13.3%

Pan et al. 43 65 25 9.7 47 – – – –

Manley et al. 98 64 (49 - 77) – 5.2 (4.5 - 7.1) – – G6=9, G3+4=60, G4+3=19, G≥8=10 pT2=63, pT3a=28, pT3b=6 17%

Kim et al. 41 vs. 42
68.4 (±5.98) vs.  

67.7  (±4.9)
–

45.4 (±78.7) vs.  
16.8 (±20.5)

33.8 (±15.2) vs.  
36.2 (±13.8)

19.5% vs. 16.7%
G<8=56.1%,G≥8=43.9% vs. G<8=73.8%, 

G≥8=26.2%
≤pT2=46.3%, ≥pT3=53.7% vs. 

≤pT2=57.1%, ≥pT3=42.9%
–

TABLE 3B. 

Patient baseline and pathological features (solifenacin cohorts)

Authors n of patients Age (years) BMI (Kg/m2) PSA (ng/mL)
Prostate volume 

(mL)
Nerve sparing 
procedures (%)

Gleason score (n) or (%) pT stage (n) or (%)
Positive surgical margins 

(%)

Liss et al. 39 65 (57–70) 25.9 (24.6–28.7) 5.8 (4.1–7.4) 51 (43–65) – G6=8, G7= 26, G>7=5 pT2=26, pT3a=12, pT3b=1 –

Bianco et al. 313 vs. 310 60.5 vs. 61.2 28.4 vs. 28.66 – – – – – –

not receive any instruction for PFMT. UC was defined 
as International Consultation on Incontinence Ques-
tionnaire Short Form (ICIQ-SF) score of 0. The primary 
outcome of this study was the patients’ self-reported UC 
recovery at 6 months after bladder catheter removal, and 
the secondary outcomes were the score of incontinence 
scale and the number of pads/week used. The follow-up 
schedule consisted of interviews at 10 days and 1, 3, and 
6 months after catheter removal. The authors found 
a significant difference between the 2 groups in pads/
week at 1 and 6 months after surgery (P < 0.01); likewise, 
ICIQ-SF scores were higher in the control group than in 
the intervention group at 3 and 6 months, but there were 
no differences at 10 days and 1 month. At 6 months after 
surgery, 50% of patients in the intervention group, but 
only 3.3% of patients in the control group, reported the 
use of 0 pads/week. Pan et al. conducted a pre-experi-
mental single-group study in 43 men undergoing RARP 
in order to examine the effects of resistance band PFMT 
(modified PFMT) on patients’ UC recovery, life impact, 
anxiety and depression after surgery[24]. Patients were 
evaluated at 2 weeks, 1, 2, and 3 months after catheter 

removal via the Urinary Incontinence Scale after Radi-
cal Prostatectomy (UISRP), Incontinence Impact Ques-
tionnaire (IIQ), Hospital Anxiety and Depression Scale 
(HADS). Authors showed that UI severity significantly 
decreased with the study period; at 2 weeks 88.4% of 
patients suffered from any degree of UI versus 65.1% at 
3 months.

In a retrospective study, Manley et al. evaluated the 
effect of PFMT in improving pelvic floor strength and 
UC recovery[23]. A trained pelvic floor physiotherapist 
gave a daily PFMT program to each man undergoing 
RARP and graded patient pelvic floor muscle strength 
(PFMS) before and 4 days and 4 weeks after catheter 
removal. UC was defined as the requirement for no pads, 
and it was assessed at the 4-week control visit. Complete 
data were available for 98 patients, and the majority of 
them increased their pelvic floor strength during the 
study period. Preoperatively, PFMS was strong in 79% 
of patients, moderate in 12%, and weak in 9%. Postop-
eratively, the majority of those with previous moderate 
and weak PFMS improved to strong PFMS; younger age 

94 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org


TABLE 3A. 
Patient baseline and pathological features (PFMT cohorts) 
 

Authors n of patients Age (years) BMI (Kg/m2) PSA (ng/mL)
Prostate volume 

(mL)
Nerve sparing 
procedures (%)

Gleason score (n) or (%) pT stage (n) or (%) Positive surgical margins (%)

Yoshida et al. 36 vs. 80
66.5 (±6.2) vs.  

66.6  (±5.8)
24.4 (±3.2) vs. 24 (±2.9)

11.3 (±11.8) vs.  
10.3 (±8.5)

48.3 (±15.7) vs.  
47.6 (±20.4)

16.7% vs. 21.3% – >pT3a=13.9%  vs. >pT3a=15.2% –

Oh et al. 40 vs. 42
67.5 (±6.9) vs.  

65.9  (±6.8)
24.8 (±2.6) vs.  

24.6 (±2.7)
19.7 (±28.1) vs.  

15 (±16.3)
33.7 (±10.6) vs.  

36.9 (±11.9)
100% vs. 100%

G6=0, G3+4=10, G4+3=17, G≥8=13 vs. G6=1, 
G3+4=20, G4+3=10, G≥8=11

≤pT2=55%, ≥pT3=45% vs. 
≤pT2=61.9%, ≥pT3=38.1%

20% vs. 19%

Sayilan et al. 30 vs. 30
63 (±8.61) vs.  
59.93  (±6.98)

26.4 vs. 25.8 – – – – – 30% vs. 13.3%

Pan et al. 43 65 25 9.7 47 – – – –

Manley et al. 98 64 (49 - 77) – 5.2 (4.5 - 7.1) – – G6=9, G3+4=60, G4+3=19, G≥8=10 pT2=63, pT3a=28, pT3b=6 17%

Kim et al. 41 vs. 42
68.4 (±5.98) vs.  

67.7  (±4.9)
–

45.4 (±78.7) vs.  
16.8 (±20.5)

33.8 (±15.2) vs.  
36.2 (±13.8)

19.5% vs. 16.7%
G<8=56.1%,G≥8=43.9% vs. G<8=73.8%, 

G≥8=26.2%
≤pT2=46.3%, ≥pT3=53.7% vs. 

≤pT2=57.1%, ≥pT3=42.9%
–

TABLE 3B. 

Patient baseline and pathological features (solifenacin cohorts)

Authors n of patients Age (years) BMI (Kg/m2) PSA (ng/mL)
Prostate volume 

(mL)
Nerve sparing 
procedures (%)

Gleason score (n) or (%) pT stage (n) or (%)
Positive surgical margins 

(%)

Liss et al. 39 65 (57–70) 25.9 (24.6–28.7) 5.8 (4.1–7.4) 51 (43–65) – G6=8, G7= 26, G>7=5 pT2=26, pT3a=12, pT3b=1 –

Bianco et al. 313 vs. 310 60.5 vs. 61.2 28.4 vs. 28.66 – – – – – –

was the only predictor of PFMS improvement. Overall, 
at 4 weeks after catheter removal 49.4% of patients were 
incontinent, and PFMS correlated with UI (P < 0.01); 
however, preoperatively PFMS was not associated with 
UC rate after RARP. Older men with baseline moder-
ate and weak PFMS were more likely to experience UI at  
4 weeks after RARP (P = 0.07).

Kim et al. performed another retrospective study 
to determine the benefit of PFMT with visual biofeed-
back compared with conventional PFMT in improving 
UC recovery after RARP[21]. Forty-one patients formed 
the intervention group in which PFMT was performed 
with visual biofeedback under the supervision of a 
physiotherapist, while 42 patients in the control group 
performed Kegel exercises at home after only verbal 
instructions were given by the treating urologist. UC 
was defined as the cessation of urinary pad use. The 
follow-up schedule consisted of outpatient office visits at 
1 week and at 1, 3, and 6 months after catheter removal. 
Overall, UC rates were 18.1%, 49.4%, 77.1%, and 94% at 
1 week and 1, 3, and 6 months, respectively. In the inter-

vention group, the rates of UC restoration were higher at 
1 (P = 0.037), 3 (P < 0.001), and 6 (P = 0.023) months than 
in the control group. Likewise, the mean time to achieve 
UC was shorter in the exercise group (32.4 versus 95.3 
days, P < 0.001). At multivariate analysis, patients < 65 
years old were found to have no benefit from the exer-
cises while patients ≥ 65 years old benefited significantly 
from PFMT, thus suggesting that PFMT with biofeed-
back is an effective treatment for promoting early UC 
recovery and that it is more effective in elderly patients.

Studies on Oral Medical Treatment 
(Solifenacin) 
Liss a nd col leag ues per formed a n ex plorator y 
investigator-initiated phase 1 clinical trial to assess 
safety and efficacy of solifenacin (Vesicare) in men 
with UI after RARP[22]. The authors hypothesized that 
anticholinergic agents can reduce UI because of their 
effect in reducing detrusor overactivity. Men using ≥ 
3 pads/day 7 days after catheter removal were enrolled 
in the study and were prescribed a daily dose of 5mg 
solifenacin for 3 months. Continence was defined as the 

95SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Postoperative Non-Surgical Interventions to Improve Urinary Continence After Robot-Assisted Radical Prostatectomy: A Systematic Review

http://SIUJ.org


usage of 0 pads/day; moreover, AUA and QoL symptom 
scores were submitted preoperatively and 3 months after 
surgery to measure the effectiveness of the treatment. 
Complete data were available for 39 patients. Overall, 6 
patients withdrew from the study because of side effects 
or adverse events, and 16 men achieved UC before 90 
days of treatment. At 3 months, 21 patients (53.8%) were 
fully continent with a median time to achieve UC of 95 
days. The AUA symptom score improved during the 
study period, but the QoL score worsened.

Bianco et al. conducted a multicentric double-
blind RCT evaluating the efficacy and safety profile of 
solifenacin versus placebo in UC recovery in men who 
had undergone RARP and were still incontinent 7 to 
21 days after catheter removal[17]. Patients requiring 
2 to 10 pads/day for 7 consecutive days were enrolled 
in the study and randomized 1:1 to solifenacin 5 mg 
daily versus placebo during the 12-week study period. 
Continence was defined as zero pads/day or a dry secu-
rity pad for 3 consecutive days, and QoL was assessed 

TABLE 4A. 

Secondary outcomes of the systematic review (PFMT cohorts) 

Authors Intervention
Duration of  
treatment

n of 
patients

Patient 
adherence to 
treatment, %

UI risk 
factors

Erectile 
dysfunction 

rate

Sexual  
activity  

recovery

Yoshida et al
US-guided PFMT vs.  

verbal-PFMT

Preoperatively and  
1 month after 

RARP
36 vs. 80 100 not reported not reported not reported

Oh et al
Biofeedback-PFMT 

vs. verbal-PFMT
3 month after 

RARP
42 vs. 42 100 not reported not reported

No differences 
in IIEF-5 scores 

among the  
2 groups

Sayilan et al.
PFMT vs. no  
intervention

Preoperatively to 
6 months after 

RARP
30 vs. 30 100 not reported not reported not reported

Pan et al.
Resistance band 

PFMT
3 month after 

RARP
43 100 not reported not reported not reported

Manley et al.
PFMT vs. no inter-

vention

Preoperatively 
to 1 month after 

RARP
98 100 age not reported not reported

Kim et al.
Visual feedback 

PFMT vs.  
conventional PFMT

1 month 41 vs. 42 100
Gleason 

score, PSA, 
PFMT

not reported not reported

TABLE 4B. 

Secondary outcomes of the systematic review (solifenacin cohorts) 

Authors Intervention
Duration of  
treatment

n of 
patients

Patient 
adherence to 
treatment, %

UI risk 
factors

Erectile 
dysfunction 

rate

Sexual  
activity  

recovery

Liss et al. Solifenacin 5mg daily 3 months 39 85% not reported not reported not reported

Bianco et al.
Solifenacin vs. 

placebo
3 months 313 vs. 310 100% not reported not reported not reported

96 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org


by AUA symptom score and ICIQ-SF questionnaires. 
Overall, 623 patients completed the study and no differ-
ences in time to achieve UC were found between the  
2 groups (P = 0.17). However, UC rate by the end of the 
observation period was 29% versus 21% (P = 0.04) in 
the intervention and control group, respectively. More-
over, patients in both groups had a statistically signifi-
cant decrease in the number of pads/day from baseline 
to the end of the study that was greater in the solifenacin 
arm at 12 weeks (P = 0.01). QoL measures significantly 
improved by the end of the study (P < 0.001) without 
differences between groups. Among patients on solifena-
cin, 33.2% reported at least 1 adverse event, dry mouth 
being the most common.

Discussion
We performed a systematic review investigating 
postoperative NSI role in early UC recovery after 
RARP. Our interest was motivated by the need for 
conservative interventions to manage mild UI in order 
to improve patient satisfaction and QoL in the early 
postoperative period[25]. In this context, it is important 
to underline that surgery (eg, male slings) is not always 
recommended for patients who experience post-RARP 
UI[26]. Overall, we focused our research on NSI carried 
out only in patients who have undergone RARP because 
of the wide availability of the robotic prostatectomy 
procedure and its technical advantages that can 
lead to optimal functional outcomes[27,28]. Several 
findings are of interest. To date, PFMT and orally 
administered solifenacin have been proposed as the 
only available NSI to improve UC recovery after RARP. 
These NSI are carried out in the early postoperative 
period with a limited duration of treatment of 1 to 
6 months, theoretically in all patients submitted to 
RARP. Recently, Marchioni et al. reviewed 6 articles, 
concluding that PFMT has the advantage of shortening 
the time to recovery of UC, while the use of solifenacin 
does not offer any significant advantages in post-RARP 
UI management[10].

Studies included in our systematic review showed a 
possible association between PFMT and oral solifenacin 
administration and an early improvement in urinary 
functional outcomes after RARP. Yoshida et al. found 
that the mean time for UC recovery was significantly 
shorter in the intervention group (ultrasound-guided 
PFMT) than in the control group (conventional PFMT) 
(75±100 versus 121.8±132 days; P = 0.037). Moreover, UC 
rates were higher in the intervention group at 30 days 
(52.8% versus 35.4%; P = 0.08); however, at 9 months no 
statistically significant differences were found between 
the 2 groups in terms of continence status (88.9% versus 
84.7%, P = 0.558)[18]. Oh et al. found similar UC rates 
at 3 months in the intervention and control groups 

(67.5% and 61.9%, respectively; P = 0.649)[19]. Sayilan 
et al. found a significant difference in pads/day at 1 and 
6 months after surgery between PFMT and no-NSI 
cohorts (P < 0.01); at 6 months after surgery, 50% of 
patients in the intervention group but only 3.3% of 
patients in the control group reported the use of 0 pads/
day[20]. Kim et al. found that in the interventional group 
(visual-feedback PFMT) the rates of UC restoration were 
higher at 1 (P = 0.037), 3 (P < 0.001), and 6 (P = 0.023) 
months than in the control group (conventional PFMT). 
Likewise, the mean time to achieve UC was shorter in 
intervention group (32.4 versus 95.3 days; P < 0.001)[21]. 
Pan et al. and Manley et al. reported UC rates of 34.9% 
at 3 months and 49.4% at 1 month after bladder cathe-
ter removal, respectively[23,24]. Regarding solifenacin 
administration, Liss et al. reported that at 3 months, 21 
patients (53.8%) were fully continent with a median time 
to achieve UC of 95 days[22] while Bianco et al. reported 
3 months UC rate of 29% versus 21% (P = 0.04) in the 
intervention group and placebo group, respectively; 
however, no differences in time to achieve UC was found 
between the 2 groups (P = 0.17)[17]. Of note, among 
included studies, only Bianco et al. provided level 1B 
clinical evidence supporting the use of NSI (solifenacin) 
to improve UC recovery after RARP[17]. Nevertheless, 
Liss et al. failed to demonstrate an obvious benefit of 
solifenacin administration in urinary outcomes except 
a potential symptomatic relief[22]. Previously, other oral 
medications such as duloxetine showed a good efficacy 
profile in the UI following RP[29]. However, to the best 
of our knowledge, there are no studies exploring post-
RARP duloxetine administration since current evidence 
is available only for open or laparoscopic RP[30].

A variability in UC definition exists among stud-
ies reporting functional outcomes after prostatectomy, 
thus making difficult a standardized interpretation of 
the results[31]. In the literature, UC is mainly defined as 
the use of no pad or the use of 1 safety pad/day, and 5 
out of 8 reviewed studies adopted this method. In this 
context, Kuehhas et al. recommend adding the use of 
validated questionnaires to assess UC after prostatec-
tomy[32]; however, in 4 studies of the current systematic 
review, the authors did not distribute questionnaires 
to patients[17,18,21,23]. In general, a comprehensive 
evaluation of both subjective and objective functional 
outcomes combined with assessment of satisfaction has 
not been conducted systematically. Yoshida et al. defined 
UC as the need to require a small pad (20g) per day 
by patient self-report[18]; Oh et al. used a loss of 0 g of 
urine on a 24-hour pad test to define UC[19]; Sayilan et 
al. and Pan et al. used validated questionnaires to score 
UI[20,24]; in the remaining studies UC was defined as 
no need of urinary pad usage[17,21–23].

97SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Postoperative Non-Surgical Interventions to Improve Urinary Continence After Robot-Assisted Radical Prostatectomy: A Systematic Review

http://SIUJ.org


Importantly, among included studies only data on 
early urinary function outcomes are reported. There-
fore, follow-up is inadequate to evaluate medium- and 
long-term continence recovery rates in patients who 
performed PFMT or have been treated with solifenacin.

Several studies reported the natural history of urinary 
function in men who have undergone RARP and found 
that UC rates increase up to 90% to 95% especially 
during the first year after surgery, thus demonstrat-
ing a spontaneous improvement in UC rate with time 
[33–35]. Even though mild UI can spontaneously 
improve in the first year after surgery, we believe that 
conservative strategies to accelerate this process should 
be taken into account by urologists to ameliorate 
patients’ QoL in the early postoperative period.

Of note, we miss 2 of our secondary aims because of 
data insufficiency: to identify risk factors associated with 
UI after RARP and to find a correlation between post-
operative UC and sexual activity recovery in patients 
enrolled to NSI. Regrettably, the studies included in our 
review did not analyze the association among patient 
related characteristics such as age, BMI and comorbidi-
ties, PCa features and surgical variables that may impact 
on post-RARP UC before surgery given that UI is a 
multifactorial condition[36]. However, we found high 
compliance to PFMT and solifenacin administration, 
thus suggesting the feasibility of these interventions to 
manage UI.

From a research perspective our work highlights 
the gaps we should fill to improve evidence on NSI 
to manage mild UI after RARP. First, further multi-
center randomized studies are needed, including large 
population studies comparing NSI—even PFMT in 

combination with solifenacin—with no postoperative 
intervention with longer follow-up. Second, UI should 
be defined as the use of 0 pads/day or 1 safety pad/day 
and validated questionnaires should be submitted to 
patients. Third, UI risk factors and sexual activity recov-
ery might be reported to globally assess patients’ func-
tional outcomes.

The study has several limitations. First, there was great 
variability in the assessment and data reporting of UI 
and UC recovery among studies, thus making compari-
son between results difficult. Moreover, some studies did 
not use a control group against which to compare NSI. 
Second, all studies reported short-term follow-up func-
tional outcomes, with the majority of them reporting 
results only to 3 months. Third, the sample sizes of the 
studies were generally small and heterogeneous in terms 
of comorbidities and PCa features. Fourth, the differ-
ent PFMT schedules used in the studies could influence 
patient outcomes. For these reasons we were not able to 
perform a meta-analysis of the 8 selected studies in order 
to integrate their results.

Conclusions
Ea rly postoperat ive NSI—including PFMT a nd 
oral administration of solifenacin—to manage UI 
after RARP may improve UC recovery. Moreover, 
both interventions are safe and well tolerated, with 
high patient ad herence to treat ment. However, 
clinical evidence supporting their routine use is still 
weak. Further multicenter prospective studies with 
longer follow-up, adequate number of patients, and 
standardized functional outcomes assessment are 
needed to confirm the efficacy of the NSI on UC recovery 
after RARP.

98 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org


References

1. Mottet N, van den Bergh RCN, Briers E, Van den Broeck T, Cumberbatch 
MG, De Santis M, et al. EAU-EANM-ESTRO-ESUR-SIOG Guidelines 
on Prostate Cancer—2020 Update. Part 1: Screening, Diagnosis, and 
Local Treatment with Curative Intent. Eur Urol.2021 Feb;79(2):243–
262. doi: 10.1016/j.eururo.2020.09.042. Epub 2020 Nov 7.

2. Haglind E, Carlsson S, Stranne J, Wallerstedt A, Wilderäng U, 
Thorsteinsdottir T, et al. Urinary incontinence and erectile dysfunction 
after robotic versus open radical prostatectomy: a prospective, 
controlled, nonrandomised trial. Eur Urol.2015 Aug;68(2):216–225. 
doi: 10.1016/j.eururo.2015.02.029. Epub 2015 Mar 12.

3. Yaxley JW, Coughlin GD, Chambers SK, Occhipinti S, Samaratunga 
H, Zajdlewicz L, et al. Robot-assisted laparoscopic prostatectomy 
versus open radical retropubic prostatectomy: early outcomes 
from a randomised controlled phase 3 study. Lancet.2016 Sep 
10;388(10049):1057–1066. doi: 10.1016/S0140-6736(16)30592-X. 
Epub 2016 Jul 26.

4. Coughlin GD, Yaxley JW, Chambers SK, Occhipinti S, Samaratunga H, 
Zajdlewicz L, et al. Robot-assisted laparoscopic prostatectomy versus 
open radical retropubic prostatectomy: 24-month outcomes from a 
randomised controlled study. Lancet Oncol.2018 Aug;19(8):1051–1060. 
doi: 10.1016/S1470-2045(18)30357-7. Epub 2018 Jul 17.

5. Costello AJ. Considering the role of radical prostatectomy in 21st 
century prostate cancer care. Nat Rev Urol.2020 Mar;17(3):177–188. 
doi: 10.1038/s41585-020-0287-y. Epub 2020 Feb 21. 

6. Ficarra V, Novara G, Rosen RC, Artibani W, Carroll PR, Costello A, et 
al. Systematic review and meta-analysis of studies reporting urinary 
continence recovery after robot-assisted radical prostatectomy. Eur 
Urol.2012 Sep;62(3):405–417. doi: 10.1016/j.eururo.2012.05.045. Epub 
2012 Jun 1.

7. Capogrosso P, Sanchez-Salas R, Salonia A, Cathala N, Mombet A, 
Sivaraman A, et al. Recovery of urinary continence after radical 
prostatectomy. Expert Rev Anticancer Ther.2016 Oct;16(10):1039–
1052. doi: 10.1080/14737140.2016.1233818. Epub 2016 Sep 21. 

8. Sridhar AN, Abozaid M, Rajan P, Sooriakumaran P, Shaw G, Nathan S, 
et al. Surgical techniques to optimize early urinary continence recovery 
post robot assisted radical prostatectomy for prostate cancer. Curr Urol 
Rep.2017 Sep;18(9):71. doi: 10.1007/s11934-017-0717-4 

9. Zattoni F, Artibani W, Patel V, Montorsi F, Porpiglia F, Hampton LJ, 
et al. Technical innovations to optimize continence recovery after 
robotic assisted radical prostatectomy. Minerva Urol Nefrol.2019 
Aug;71(4):324–338. doi: 10.23736/S0393-2249.19.03395-2. Epub 
2019 Apr 5.

10. Marchioni M, Primiceri G, Castellan P, Schips L, Mantica G, Chapple 
C, et al. Conservative management of urinary incontinence following 
robot-assisted radical prostatectomy. Minerva Urol Nefrol.2020 
Oct;72(5):555–562. doi: 10.23736/S0393-2249.20.03782-0. Epub 
2020 May 20.

11. Bauer RM, Bastian PJ, Gozzi C, Stief CG. Postprostatectomy 
incontinence: all about diagnosis and management. Eur Urol.2009 
Feb;55(2):322–333. doi: 10.1016/j.eururo.2008.10.029. Epub 2008 
Oct 23.

12. Zahariou A, Papaioannou P, Kalogirou G. Is HCl duloxetine effective 
in the management of urinary stress incontinence after radical 
prostatectomy? Urol Int.2006;77(1):9–12. doi: 10.1159/000092927 

13. Cornu JN, Merlet B, Ciofu C, Mouly S, Peyrat L, Sbe P, et al. Duloxetine for 
mild to moderate postprostatectomy incontinence: preliminary results of 
a randomised, placebo-controlled trial. Eur Urol.2011 Jan;59(1):148–154. 
doi: 10.1016/j.eururo.2010.10.031. Epub 2010 Oct 27.

14. Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener 
CMA. Conservative management for postprostatectomy urinary 
incontinence. Cochrane Database Syst Rev.2015 Jan 20;1(1):CD001843. 
doi: 10.1002/14651858.CD001843.pub5

15. Knoll T, Omar MI, Maclennan S, Hernández V, Canfield S, Yuan Y, 
et al. Key steps in conducting systematic reviews for underpinning 
clinical practice guidelines: methodology of the European Association 
of Urology. Eur Urol. 2018 Feb;73(2):290 –300. doi: 10.1016/j.
eururo.2017.08.016. Epub 2017 Sep 13. 

16. Moga C, Guo B, Harstall C. Development of a quality appraisal 
tool for case series studies using a modified Delphi Technique. IHE 
Publications. 2012. 

17. Bianco FJ, Albala DM, Belkoff LH, Miles BJ, Peabody JO, He W, et 
al. A randomized, double-blind, solifenacin succinate versus placebo 
control, phase 4, multicenter study evaluating urinary continence after 
robotic assisted radical prostatectomy. J Urol.2015 Apr;193(4):1305–
1310. doi: 10.1016/j.juro.2014.09.106. Epub 2014 Oct 2. 

18. Yoshida M, Matsunaga A, Igawa Y, Fujimura T, Shinoda Y, Aizawa N, 
et al. May perioperative ultrasound-guided pelvic floor muscle training 
promote early recovery of urinary continence after robot-assisted 
radical prostatectomy? Neurourol Urodyn.2019 Jan;38(1):158–164. 
doi: 10.1002/nau.23811. Epub 2018 Oct 30.  

99SIUJ.ORG SIUJ  •  Volume 3, Number 2  •  March 2022

Postoperative Non-Surgical Interventions to Improve Urinary Continence After Robot-Assisted Radical Prostatectomy: A Systematic Review

http://SIUJ.org


19. Oh JJ, Kim JK, Lee H, Lee S, Jin Jeong S, Kyu Hong S, et al. Effect 
of personalized extracorporeal biofeedback device for pelvic floor 
muscle training on urinary incontinence after robot-assisted radical 
prostatectomy: a randomized controlled trial. Neurourol Urodyn.2020 
Feb;39(2):674–681. doi: 10.1002/nau.24247. Epub 2019 Dec 2.

20. Aydın Sayılan A, Özbaş A. The effect of pelvic floor muscle training 
on incontinence problems after radical prostatectomy. Am J Mens 
Health.2018 Jul;12(4):1007–1015. doi: 10.1177/1557988318757242. 
Epub 2018 Mar 14. 

21. Kim YU, Lee DG, Ko YH. Pelvic floor muscle exercise with biofeedback 
helps regain urinar y continence af ter robot-assisted radical 
prostatectomy. Yeungnam Univ J Med.2021 Jan;38(1):39–46. doi: 
10.12701/yujm.2020.00276. Epub 2020 Jun 22.

22. Liss MA, Morales B, Skarecky D, Ahlering TE. Phase 1 clinical trial 
of vesicareTM (solifenacin) in the treatment of urinary incontinence 
after radical prostatectomy. J Endourol.2014 Oct;28(10):1241–1245. 
doi: 10.1089/end.2014.0342. Epub 2014 Jul 21. 

23. Manley L, Gibson L, Papa N, Beharry BK, Johnson L, Lawrentschuk 
N, et al. Evaluation of pelvic floor muscle strength before and after 
robotic-assisted radical prostatectomy and early outcomes on urinary 
continence. J Robot Surg.2016 Dec;10(4):331–335. doi: 10.1007/
s11701-016-0602-z. Epub 2016 May 9.

24. Pan LH, Lin MH, Pang ST, Wang J, Shih WM. Improvement of 
urinary incontinence, life impact, and depression and anxiety with 
modified pelvic floor muscle training after radical prostatectomy. 
Am J Mens Health.2019 May-Jun;13(3):1557988319851618. doi: 
10.1177/1557988319851618

25. Waller J, Pattison N. Men’s experiences of regaining urinar y 
continence following robotic-assisted laparoscopic prostatectomy 
(RALP) for localised prostate cancer: a qualitative phenomenological 
study. J Clin Nurs.2013 Feb;22(3-4):368–378. doi: 10.1111/jocn.12082 

26. Tutolo M, Briganti A, Montorsi F. Re: Kathrin Meisterhofer, Sereina 
Herzog, Karin A. Strini, Luca Sebastianelli, Ricarda Bauer, Orietta 
Dalpiaz. Male slings for postprostatectomy incontinence: a systematic 
review and meta-analysis. Eur Urol Focus.2020;6:575–92. 

27. Martini A, Falagario UG, Villers A, Dell’Oglio P, Mazzone E, Autorino 
R, et al. Contemporary techniques of prostate dissection for robot-
assisted prostatectomy. Eur Urol.2020 Oct;78(4):583–591. doi: 
10.1016/j.eururo.2020.07.017. Epub 2020 Aug 1 

28. Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, et al. 
Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a 
systematic review and cumulative analysis of comparative studies. Eur 
Urol.2009 May;55(5):1037–1063. doi: 10.1016/j.eururo.2009.01.036. 
Epub 2009 Jan 25.

29. Neff D, Guise A, Guralnick ML, Langenstroer P, See WA, Jacobsohn 
KM, et al. Duloxetine for the treatment of post-prostatectomy 
stress urinary incontinence. Can Urol Assoc J.2013 May-Jun;7(5–
6):E260–262. doi: 10.5489/cuaj.318.

30. Kotecha P, Sahai A, Malde S. Use of duloxetine for postprostatectomy 
stress urinary incontinence: a systematic review. Eur Urol Focus.2021 
May;7(3):618–628. doi: 10.1016/j.euf.2020.06.007. Epub 2020 Jun 27. 

31. Borregales LD, Berg WT, Tal O, Wambi C, Kaufman S, Gaya JM, et al. 
“Trifecta” after radical prostatectomy: is there a standard definition? 
BJU Int.2013 Jul;112(1):60–67. doi: 10.1111/bju.12002

32. Kuehhas FE, Naegele R, Eckersberger E, Margreiter M, Herwig R, 
Kazzazi A, et al. Urinary continence after radical prostatectomy: the 
patient perspective. Can J Urol.2011 Aug;18(4):5811–5818 

33. Wang L, Chung SFCM, Yip SKH, Lau WKO, Cheng CWS, Sim HG. The 
natural history of voiding function after robot-assisted laparoscopic 
radical prostatectomy. Urol Oncol.2011 Mar-Apr;29(2):177–182. doi: 
10.1016/j.urolonc.2009.01.030. Epub 2009 Apr 11.

34. Patel V R, Thaly R, Shah K. Robotic radical prostatectomy: 
outcomes of 500 cases. BJU Int.2007 May;99(5):1109–1112. doi: 
10.1111/j.1464-410X.2007.06762.x 

35. Menon M, Shrivastava A, Kaul S, Badani KK, Fumo M, Bhandari M, 
et al. Vattikuti Institute prostatectomy: contemporary technique and 
analysis of results. Eur Urol.2007 Mar;51(3):648–657; discussion 
657–658. doi: 10.1016/j.eururo.2006.10.055. Epub 2006 Nov 3.

36. Tutolo M, Bruyneel L, Van der Aa F, Van Damme N, Van Cleynenbreugel 
B, Joniau S, et al. A novel tool to predict functional outcomes after 
robot-assisted radical prostatectomy and the value of additional 
surgery for incontinence. BJU Int.2021 May;127(5):575–584. doi: 
10.1111/bju.15242. Epub 2020 Oct 1

100 SIUJ  •  Volume 3, Number 2  •  March 2022 SIUJ.ORG

 REVIEW

http://SIUJ.org

