Nurse-Led Enhanced Recovery Care and Early Continence Outcomes after Robot-Assisted Radical Prostatectomy: A Retrospective Cohort Study
To evaluate rehabilitation adherence and early continence recovery within a standardized nurse-led enhanced recovery care pathway after robot-assisted radical prostatectomy (RARP), and to develop an interpretable model for identifying patients at risk of poor 3-month rehabilitation adherence. This single-center retrospective cohort analysis used a prospectively maintained perioperative nursing database comprising 168 men aged ≥50 years who underwent RARP between June and December 2023 and completed follow-up through June 2024. The nurse-led pathway included preoperative education, pelvic floor muscle training (PFMT), catheter and urinary symptom management, psychological support, discharge planning, home rehabilitation recording, and structured follow-up. Assessments were available before surgery, at discharge or catheter removal, and at 1, 3, and 6 months. Poor adherence at 3 months was defined as a composite score <80/100. Logistic regression, least absolute shrinkage and selection operator regression, random forest, support vector machine, and extreme gradient boosting (XGBoost) were internally evaluated using repeated stratified fivefold cross-validation. Shapley additive explanations (SHAP) were used to interpret the final model. At 3 months, 112 patients (66.7%) had adequate adherence and 56 (33.3%) had poor adherence. At 6 months, the adequate-adherence group had lower urinary symptom burden (ICIQ-UI SF, 3.4 ± 2.5 vs 7.2 ± 3.4), higher EPIC-26 urinary function (83.1 ± 9.5 vs 67.5 ± 12.2), and a higher no-pad rate (78% vs 35%). Patients with poor adherence also had lower baseline PFMT self-efficacy (26.8 ± 5.4 vs 32.6 ± 4.7), higher anxiety (8.2 ± 3.7 vs 4.9 ± 3.1), and less frequent completion of a home rehabilitation diary at 1 month (46.4% vs 85.7%; all P<0.001). XGBoost showed the best internal performance for poor adherence (area under the receiver operating characteristic curve, 0.89; accuracy, 0.84; sensitivity, 0.79; specificity, 0.87; F1-score, 0.77; Brier score, 0.12). Within a standardized nurse-led enhanced recovery care pathway, adequate rehabilitation adherence was associated with faster early continence recovery and better prostate cancer–specific quality of life. The interpretable landmark model identified modifiable nursing-related factors that may support risk-stratified follow-up, although external validation and prospective impact evaluation are required before clinical implementation.