| Objective:Prostate cancer is the second most common cancer in men.There are a large number of long-term survivors of prostate cancer.Radical prostatectomy(RP)is the main surgical treatment for localized prostate cancer.However,studies have confirmed that the diagnosis,treatment and follow-up management of prostate cancer will significantly affect the quality of life of patients.Based on the guidelines and expert consensus,improving the quality of life of patients with prostate cancer under the condition of ensuring the survival outcome has become one of the main goals of the treatment of prostate cancer,and also an important end point of clinical research.With the development of magnetic resonance imaging(MRI),the relationship between MRI parameters and quality of life has attracted much attention.However,prostate cancer is a whole course disease,and the current research has the following limitations:1.Most studies only focus on patients after RP,and pay less attention to the quality of life in other stages of the disease.The database of quality of life of patients with prostate cancer is lacking.2.In the current study of multiparametric MRI in predicting the quality of life of patients after RP,there are few parameters involved,which can not evaluate the quality of life by measuring other pelvic anatomical structures.3.Most of these studies focused on postoperative urinary incontinence,and other dimensions of quality of life were insufficient.The existing studies failed to comprehensively evaluate and measure the overall impact of RP surgery on the quality of life of patients.4.Preoperative MRI parameters related to postoperative quality of life have not been fully studied,and many potential anatomical factors have not been fully explored.5.The research on quality of life from preoperative diagnosis to postoperative prognosis is of great significance,but as far as we know,there is no research on the combination of multiparametric MRI and quality of life based on Chinese people at home and abroad,and the prediction of quality of life based on pre-operative multiparametric MRI is lacking.Therefore,the purpose of this study is:1.To establish the quality of life database of patients with prostate cancer.Objective to investigate the effect of prostate cancer on preoperative quality of life.2.By comparing the quality of life of patients with different RP operation status,comprehensively evaluate and measure the specific impact of RP operation on the quality of life of patients.3.Integrate more preoperative MRI parameters and predict more dimensions of life quality of patients after RP.To fill the shortcomings of single MRI parameters and narrow dimension of quality of life in existing studies.4.To make a meta-analysis of the literatures published at home and abroad on MRI parameters predicting the quality of life of patients after RP,and explore the future research direction.Materials and Methods:In this study,we established a database of patients’whole course quality of life,and included patients in West China Hospital of Sichuan University:(1)from October 2019 to December 2020 to receive prostate biopsy;(2)from January 2017 to December 2020 to receive RP treatment;(3)from May 2020 to October 2020 to receive RP postoperative follow-up.The exclusion criteria were(1)non acceptance of quality of life assessment;(2)lack of baseline information;(3)lack of relevant examination results.The quality of life of the above patients was evaluated by EPIC-26 and FACT-P scale,and the relevant information of the patients was collected through the hospital information system and big data retrieval platform.Multiple parameters of preoperative MRI of RP patients were measured and calculated:membranous urethra length(MUL),membranous urethra angle,prostaglandin length,pubic symphysis prostate apex length(PAL),left/right obturator internal muscle thickness,prostate gland thickness height,levator externus distance,levator internus distance,transverse membranous urethral thickness,anterior posterior membranous urethral thickness,left/right anal sphincter thickness,urethral wall thickness,left/right levator ani thickness,membranous urethral cross-sectional surface area,prostate volume and membranous urethral volume.In terms of statistical methods,we used cohort studies,evidence-based medicine and other methods:1.The correlation between the quality of life and the results of prostate biopsySmooth curve fitting analysis was used to draw the Age-Quality of Life score fitting chart.Kruskal Wallis rank and Fisher exact probability test were used to reveal the differences between groups.Univariate/multivariate logistic regression was used to analyze the correlation or predictability of baseline age,quality of life score and biopsy results.After adjusting the age,multiple regression equation was used to analyze the correlation between the quality of life and puncture results.All parameters were resampled 500 times by bootstrap method.The sensitivity and specificity of different values were calculated and receiver operating characteristics(ROC)was drawn.2.Study on the correlation between RP operation status and patients’quality of lifeThe specific effect of RP on patients’quality of life was determined by univariate/multivariate logistic regression analysis with RP operation status as exposure factor and quality of life score as outcome index.Hierarchical analysis and interaction test were used to analyze the sensitivity of the results.In addition,propensity score matching(PSM)was performed in the non-operation group and the operation group to reduce the impact of selection bias on the results.Then,baseline comparison,univariate logistic regression analysis and multivariate logistic regression analysis were performed after PSM.3.The predictive study of preoperative multiparametric MRI on postoperative short-term urinary controlThe predictive value of preoperative MRI parameters on the outcome of urinary incontinence was studied by using preoperative MRI parameters as independent variables and urinary incontinence as dependent variables.LASSO regression analysis was used to screen the predictive effect of preoperative MRI parameters on patients’quality of life.The preoperative MRI parameters and clinicopathological parameters(including age,BMI,T stage,Gleason score and Charlson score)screened by LASSO regression analysis were analyzed by univariate/multivariate logistic regression analysis to determine the predictors of urinary control outcome.Diagnostic test and ROC modeling analysis were carried out for the predictive factors.ROC curve was calculated and drawn by BS method,and clinical decision curve analysis curve was drawn at the same time.At the same time,taking the upper variables into account,the stepwise regression method was used to build the prediction model and draw the corresponding ROC curve and nomogram.The model was verified and calibrated by BS method.Finally,the model constructed by LASSO regression screening variables and the prediction model constructed by stepwise regression method were compared to establish the best combination of predictive indicators for postoperative urinary control.In addition,the evaluation records of multiple follow-up patients were analyzed by generalized additive mixed model(GAMM)to study the effect of preoperative MRI parameters and time on urinary control.4.Predictive study of preoperative multiparametric MRI on postoperative quality of lifeLASSO regression analysis was used to analyze preoperative MRI parameters and screen potential predictors.Univariate/multivariate logistic regression analysis or multiple regression equation modeling analysis were used to determine the predictors.Smooth curve fitting analysis and(or)threshold effect analysis,hierarchical analysis and interaction test were carried out.For patients with multiple follow-up,multiple evaluation records and other data entered the repeated measurement data GAMM analysis.Random intercept was selected to fit the relationship between preoperative MRI parameters and quality of life scores and time.5.Meta analysis of urinary control after RP based on preoperative MULPub Med,EMBASE,Scopus and Cochrane library were searched.The Dersimonian and Laird random effect model was used for meta-analysis,and the odds ratio(OR)values of preoperative MRI MUL and postoperative urinary control were collected at each time point.Finally,multiple meta regression analysis of OR was performed.At the same time,by adjusting the intercept and the slope of random time,the results of different research reports and multiple time points were overlapped.Results:A total of 988 patients and 1391 quality of life follow-up records were included in the quality of life database.In this database,535 patients received prostate biopsy(mean age 67.84 years,mean time for quality of life assessment 15.02 minutes per person),453 patients received RP surgery(mean age 69.55 years,mean follow-up27.34 months,mean time for quality of life assessment 23.35 minutes per person).1.The correlation between the quality of life and the results of prostate biopsyAmong 535 patients(mean age 67.84 years,mean time for quality of life assessment 15.02 minutes per person)who underwent prostate biopsy,the higher scores of urethral stimulation and urethral obstruction symptoms(OR 1.01,95%CI1.00-1.02,p=0.0238)and functional status(OR 1.03,1.00-1.06,p=0.0446)in the quality of life were correlated with the results of prostate biopsy for prostate cancer.2.Study on the correlation between RP operation status and patients’quality of life703 patients(mean age 69.40 years,mean time for quality of life assessment20.23 minutes per person)were analyzed.By comparing the quality of life of patients who received RP with those who did not receive surgical treatment(Mean follow-up time:before propensity score matching(PSM)27.34 months;after PSM 28.87months),the incontinence score and(before PSMβ-14.95,95%-18.88--11.03,p<0.0001;after PSMβ-16.29,95%-21.62--10.95,p<0.0001)sexual function score(before PSMβ-18.08,95%CI-20.98--15.18,p<0.0001;after PSMβ-14.17,95%CI-18.10--10.24,p<0.0001)of patients after RP decreased,while the symptoms score of urethral stimulation and obstruction(before PSMβ6.79,95%CI 4.31-9.27,p<0.0001;after PSMβ8.54,95%CI 4.65-12.42,p<0.0001),bowel function score(before PSMβ3.78,95%CI 1.91-5.64,p<0.0001;after PSMβ4.91,95%CI2.04-7.78,p=0.0009),hormone level score(before PSMβ2.26,95%CI 0.17-4.34,p=0.0346;after PSMβ4.25,95%CI 1.09-7.41,p=0.0088),physical condition score(before PSMβ1.12,95%CI 0.54-1.70,p=0.0002;after PSMβ1.50,95%CI0.59-2.41,p=0.0012),social/family status score(before PSMβ2.10,95%CI1.18-3.02,p<0.0001;after PSMβ2.49,95%CI 1.07-3.92,p=0.0007),emotional condition score(before PSMβ2.23,95%CI 1.66-2.80,p<0.0001;after PSMβ2.39,95%CI 1.58-3.20,p<0.0001),functional condition score(before PSMβ3.73,95%CI 2.76-4.70,p<0.0001;after PSMβ3.67,95%CI 2.22-5.11,p<0.0001),addiction scores(before PSMβ2.73,95%CI 1.75-3.72,p<0.0001;after PSMβ3.72,95%CI2.25-5.19,p<0.0001)and the total score(before PSMβ11.92,95%CI 8.96-14.88,p<0.0001;after PSMβ13.77,95%CI 9.36-18.18,p<0.0001)of quality of life increased.3.The predictive study of preoperative multiparametric MRI on postoperative short-term urinary controlRobot assisted radical prostatectomy(RARP)is accepted for all patients with less than 12 months after RP.Age,MUL and PAL were independent predictors of the recovery of urinary incontinence after RP.Younger age(6 months group,OR0.87,95%CI 0.77-0.99,p=0.0398),longer MUL(6 months group,OR 1.50,95%CI1.10-2.05,p=0.0101;12 months group,OR 1.29,95%CI 1.06-1.56,p=0.0094)and shorter PAL(6 months group,OR 0.59,95%CI 0.38-0.93,p=0.0238;12 months group,OR 0.87,95%CI 0.77-0.97,p=0.0141)were associated with the improvement of urinary incontinence after RP.4.Predictive study of preoperative multiparametric MRI on postoperative quality of lifeFor each dimension of quality of life of patients after RP,249 patients were included:In terms of short-term quality of life after RP,94 patients(mean age 67.12 years,mean BMI 24.06 kg/m~2,mean Charlson score 2.57,mean follow-up 4.09 months)were studied.In patients with prostate cancer after RARP,the thicker levator muscle was related to the improvement of short-term overall quality of life(β1.71,95%CI0.12-3.29,p=0.0378)and hormone level score in short-term quality of life(β1.86,95%CI 0.53-3.18,p=0.0074).The longer MUL was related to the improvement of short-term quality of life and social and family status score(β0.38,95%CI0.07-0.70,p=0.0183).The higher age was negatively related to the improvement of short-term quality of life in functional status score(β-0.17,95%CI-0.33--0.01,p=0.0384).The lower preoperative MRI parameters the changes of short-term quality of life scores were correlated with the area of the middle membranous urethra(incontinence scoreβ-0.31,95%CI-0.57--0.05,p=0.021),the volume of the membranous urethra(incontinence scoreβ0.02,95%CI 0.00-0.04,p=0.022),the thickness of the anal sphincter(incontinence score-3.88,95%CI-6.73--1.04,p=0.009;addiction scoreβ0.80,95%CI 0.11-1.48,p=0.02;total scoreβ2.03,95%CI 0.22-3.85,p=0.031)and the thickness of the urethral wall(social/family status scoreβ-0.40,95%CI-0.78--0.01,p=0.046;functional status score-0.39,95%CI-0.77--0.01,p=0.048).In terms of long-term quality of life after RP,155 patients(mean age 69.55years,mean BMI 23.78 kg/m~2,mean Charlson score 2.00,mean follow-up 34.59months)were studied.The whole population includes two surgical methods,namely laparoscopic prostatectomy(LRP)and RARP.Therefore,this part is based on the whole population and different surgical methods.The preoperative MRI parameters included longer MUL(overallβ0.64,95%CI 0.04-1.24,p=0.0368;RARPβ0.98,95%CI 0.17-1.79,p=0.0198),younger age(overallβ-0.58,95%CI-0.83--0.33,p<0.0001;RARPβ-0.52,95%CI-0.85--0.18,p=0.0031;LRPβ-0.71,95%CI-1.08--0.34,p=0.0004)and higher BMI(overallβ0.82,95%CI 0.09-1.54,p=0.0284).The age(overallβ-0.73,95%CI 1.35--0.11,p=0.0221)and BMI(overallβ-2.65,95%CI-4.34--0.96,p=0.0025)were associated with the improvement of long-term quality of life and incontinence score.In addition,smaller membranous urethral cross-sectional area was associated with improved long-term quality of life scores in patients with prostate cancer undergoing LRP(β-0.03,95%CI-0.06--0.00,p=0.0419).In patients with prostate cancer after RARP,the shorter PAL in preoperative MRI parameters was associated with the improvement of long-term quality of life emotional status score(β-0.14,95%CI-0.25--0.03,p=0.0162).5.Meta analysis of urinary control after RP based on preoperative MULFinally,according to the meta-analysis of international published studies,the longer the MUL in preoperative MRI parameters of prostate cancer patients,the better the recovery of urinary incontinence at 1th month(OR 1.20,95%CI 1.03-1.39,p<0.05),3rd month(OR 1.16,95%CI 1.07-1.25,p<0.001),6th month(OR 1.20,95%CI 1.07-1.36,p<0.001)and 12th month(OR 1.24,95%CI 1.13-1.36,p<0.001)after RP.Conclusion:The quality of life of patients with prostate cancer can be analyzed through the establishment of quality of life database,which has potential reference value for clinical work.Patients with suspected prostate cancer had a higher quality of life than those in the group of benign prostatic hyperplasia because the tumor was more insidious at the initial stage than benign disease and caused fewer symptoms than benign prostatic hyperplasia.RP plays an important role in the treatment of prostate cancer.Its adverse effects can lead to urinary incontinence and sexual dysfunction,but it may also have the potential to improve quality of life in other ways,if lift a patient to obstruct a symptom,make the patient more be concerned by family member,affection condition is ameliorated.Therefore,clinical decision-making should be viewed dialectically and the best treatment method should be chosen for the patients.Based on preoperative MRI parameters,not only can MUL be used to predict and evaluate urinary incontinence after RP,it can also predict and evaluate the quality of life of the patients after RP by the parameters of MRI,such as PAL,levator muscle thickness,age and BMI.On the one hand,it is helpful to choose the most suitable treatment and prevent the possible adverse prognosis by fully evaluating the patients before operation.On the other hand,it is helpful to study the multi-parameter MRI combined with quality of life.It is helpful to improve the future RP surgery technology and improve the quality of life of patients. |
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