NC.com

Post-Prostatectomy Expectations

Incontinence

• Continence: 90% by 6mo, 94% by 12mo, 95% by 24mo
• Kegels: start 3-4 weeks prior to surgery for best results
• XRT worsens incontinence rates
• Salvage prostatectomy: 20-70% incontinence rate

Climacturia

• Rate: ~30% (range 20-93%)
• 50% report as bothersome, 33% avoid sexual situations
• 70% SUI also report climacturia...and 70% climacturia report SUI
• Robotic surgery decreases time to no climacturia
• Risk factors: prior TURP, shorter urethral length
• Treatments: pre-sex urination, condoms, PFPT

Workup + Evaluation

History

• Assess duration, frequency, severity (PPD, pad type), precipitating factors
• Self-reported hx SUI: 95% PPV, 100% NPV
• Prior prostatectomy: 5% will have persistent SUI 2yrs after surgery
• Prior TURP: SUI 0-8%, up to 70% have reported some urge incontinence
• Medications: a-blockers, diuretics, anticholinergics
• Assess sexual, erectile, and bowel function
• Confirm UUI vs SUI - 29-48% with SUI also report OAB symptoms

Further Workup

• Exam: assess cognitive function and manual dexterity, inguinal hernias, prior surgical scars, neuro exam
• DRE: check prostate (if present), rectal tone, and pelvic floor dysfunction
• Post-void residual: check to ensure patient does not have overflow incontinence
• Bladder diary: 3-days is adequate, can use for UUI or unclear symptoms
• Pad weight: assess severity, < 200g mild, 200-400g moderate, > 400g severe
• UA/UCx: treat UTI prior to surgery
• Cystoscopy: required preop or intraop, assess for stricture, bladder neck contracture
• Urodynamics: use only if it would affect treatment options
• 35% patients will not demonstrate SUI while UDS catheter is in place - bladder neck contracture may be present

Artificial Urinary Sphincter

Preoperative planning

• Consider anti-incontinence surgery at 12mo, but can offer as early as 6mo
• Assess: BMI, prior surgery/XRT, SUI severity
• Contraindications: poor manual dexterity or cognitive function, high surgical risk, bladder neck contracture, poor compliance, VUR at low pressures, bladder cancer (relative)
• Repair BNC prior to any incontinence treatment, and confirm success with cystoscopy

Surgical tips

• Single cuff via perineal approach is preferred
• Tandem cuff has increased explant rates (17% vs 4%)
• Abort procedure if urethral injury noted

Success

• PPD: preop (median 4) -> postop (median 0.6)
• Leakage quantity: full continence (20%), few drops of leakage (55%), less than a teaspoon leakage (22%)
• 92% would undergo again, 96% would recommend to a friend
• If history of XRT, AUS has better results than sling (continence 56% vs 89%) but increased revision rate overall (HR=1.56)

Complications

• Failure: normal life expectancy 7-10yrs, 24% at 5yrs, 50% at 10yrs
• Retention: rare, more common with smaller cuffs, place temporary catheter for 1-2 days, consider SPT to avoid urethral erosion
• Infection: 1-5%, explant immediately, can perform immediate or delayed (3-6mo) reimplant
• Erosion: 1-10%, risks include prior XRT, DM, CAD, and prior revisions, presents with hematuria, dysuria, or retention, explant and place catheter with possible intraop urethral repair, delay reimplant by 3-6mo
• Urethral atrophy: slowly worsening incontinence, manage with downsizing, repositioning, transcorporal placement or tandem placement, do not increase reservoir pressure
• Persistence incontinence: accidental deactivation, fluid loss, or improper cuff sizing
• Recurrent incontinence: fluid loss, urethral atrophy, or cuff erosion
• Fluid loss: assess for balloon leak with CT or US imaging
• Consider cystoscopy to assess erosion or atrophy, cycle cuff
• Revision: 25%, consider cuff resizing, adjusting position, tandem cuff, or transcorporal approach
• Urinary diversion: multiple AUS failures, intractable BNC, detrusor instability

Non-AUS Therapies

Conservative therapies

• Kegels: can start before prostatectomy, decrease time to regaining continence but do not improve overall chances of regaining continence
• Pelvic Floor PT: consider as adjunct if mild SUI
• Catheters: useful for high volume leakage and skin breakdown but should be last resort, SPT will not work if patient has sphincteric incompetence
• Condom catheter: may provide improved quality of life but require proper sizing
• Clamps: release every 2 hours to prevent erosion and do not wear overnight, do not use if patient has memory deficits, poor manual dexterity, impaired sensation, or OAB symptoms
• Pads: variety of options for patient preferences, but even 1 PPD may be bothersome

Sling

• Reasonable option for mild/moderate incontinence (24hr pad weight < 150-400g)
• Not recommended for prior XRT or urethral erosion
• All else being equal, most men ((2%)) prefer sling placement due to AUS complication risk
• If sling fails, AUS has lower failure rate than repeat sling (6% vs 55%)
• Short term complications: urinary retention (0-44%, resolves within 1 week), pelvic/perineal pain (12-17%, most resolve within 12 weeks)
• Erosion/infection complications 1-2%

Bulking agents

• Agents: bovine collagen, macroplastique
• May require repeat injections
• Efficacy: full continence (17%), improvement (50%), increased leakage (1.5%)
• Complications: retention, frequency, dysuria, UTI

Balloon

• Option for mild incontinence
• Efficacy: 60-81% report 0-1 PPD
• Explant rates: 4-20%

Sources

• AUA Core Curriculum
• Al-Mousa, R. and H. Hashim. "Evaluation and Management of Men with Urinary Incontinence." Campbell-Walsh Urology 12 (2020).
• Boone, T., J. Stewart, and L. Martinez. "Additional Therapies for Storage and Emptying Failure." Campbell-Walsh Urology 12 (2020).
• Cameron, A. "Complications Related to the Use of Mesh and Their Repair." Campbell-Walsh Urology 12 (2020).
• Matsushita, Kazuhito, et al. "Preoperative predictive model of recovery of urinary continence after radical prostatectomy." BJU international 116.4 (2015): 577-583.
• Sandhu, Jaspreet S., et al. "Incontinence after prostate treatment: AUA/SUFU Guideline." The Journal of urology 202.2 (2019): 369-378.
• Wessells, H. and A. Vanni. "Surgical Procedures for Sphincteric Incontinence in the Male." Campbell-Walsh Urology 12 (2020).