NC.com

Normal 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

• Self-reported hx SUI: 95% PPV, 100% NPV
• Hx: prostatectomy: 5% will have persistent SUI 2yrs after surgery
• Hx TURP: SUI 0-8%, up to 70% have reported some urge incontinence
• Confirm UUI vs SUI - 29-48% report OAB symptoms
• Severity: pads per day

Further Workup

• Cystoscopy: 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
• Repair BNC prior to any incontinence treatment, and confirm success with cystoscopy

Artificial Urinary Sphincter

Preop Evaluation

• Consider surgery at 12mo if persistent SUI, but can offer as early as 6mo
• Confirm mental and manual ability to operate AUS - assess grip strength
• If history of XRT, AUS has better results than sling (continence 56% vs 89%) but increased revision rate overall (HR=1.56)

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

Complications

• Failure: 24% at 5yrs, 50% at 10yrs
• Infection: 1-5%, explant then wait 3-6mo for reimplant
• Erosion: 1-10%, presents with hematuria, dysuria, or retention
• 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: 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
• If sling fails, AUS has lower failure rate than repeat sling (6% vs 55%)
• Short term complications: urinary retention (resolves within 1 week), pelvic/perineal pain (resolves within 12 weeks)

Bulking agents

• 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

• 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.