1

Post-Prostatectomy

Incontinence

Daniel Rapoport

UBC Urology

Nov 14, 2007

It’s a roller-coaster!

Post Rad P:

Pathology

looks good

The day he

realizes he has

no erections.

Man walks into

your office with

prostate Ca

The day

Viagra works

for him!

The day he

realizes he

hasn’t dried up

Baverstock 2002

2

Not Just SUI

• Urge incontinence

• Mixed incontinence

• Overflow

• Climacturia…

• 42 patients, 39 “continent”

• 45% climacturia

– 50% bothered

• Coping mechanisms

– Voiding before intercourse

– Condom

• Due to relaxation of external sphincter during

orgasm

3

Incidence & Natural History

Incidence

Urol Clin NA 1991

– Literature varies widely

– Differences in definitions and reporting

– Differences in patients, techniques…

2.5 - 87%

4

Definitions

• Subjective

– Physician assessment vs Self-reporting

• Objective

– Any leakage?

– Pad weight?

– Pad number?

Physician Assessment

• 5-10% pad use

5

Self-Reporting

• Up to 74% pad use

Contemporary Data

• Likely reflect changes in technique

– Nerve-sparing RRP (Walsh)

– Bladder neck sparing/reconstruction

• Different patient populations??

– Younger

– Localized disease

• Definitions

– < 1 pad per day

– HRQOL questionnaires

6

• 500 men consecutive open RRP

• Filled out UCLA-PCI & AUASS at

baseline, 3, 6, 12 and 24 months post-

RRP

• All had localized disease

2004

Lepor and Kaci, J Urol: 2004

18.5%15.9%23.7%37%1 Pad Use

1.5%7.9%12.8%29.1%>2 Pad Use

80%76.2%63.5%33.7%No Pad Use

24 mo12 mo6 mo3 mo

7

Natural History

Eastham, Kattan, Rogers J Urol 1996

Lepor and Kaci, J Urol: 2004

18.5%15.9%23.7%37%1 Pad Use

1.5%7.9%12.8%29.1%>2 Pad Use

80%76.2%63.5%33.7%No Pad Use

24 mo12 mo6 mo3 mo

8

How much leakage is significant?

• 1 pad? 2 pads/day?

• Aren’t subjective outcomes more

important?

• Intervention for incontinence is usually

based on bother and patient goals

• Is there a difference in HRQOL between

patients who use no pads and 1 pad/day?

9

Cooperberg et al, 2003: J Urol

• 168 men consecutive open RRP

• Mailed UCLA-PCI and AUASI

• Mean 75 wks post-op (45-105 wks)

• Compared “no pad” vs “1 pad” goups in

– Functional scores

– Satisfaction/bother scores

• No Pad: n=146; 1 Pad: n=20

• No significant differences in

demographics, pathology, technical data

10

p < 0.0001

54%52%1 pad

86%81%No pad

Mean Urinary

Bother Score

Mean Urinary

Function Score

PPI Incidence: Summary

• Depends on definition and how you ask…

• Contemporary data

– Gets better with time

– Around 80% completely dry at 24 months

– < 20% need 1 pad/day

• Some of these will be bothered

– < 2% need 2 or more pads/day

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What about LRP and RALP?

What About *LRP & RALP?• Shalhav, Eur Urol: 2007 (n=300)

– 92% continent at 24 months (< 1 pad/day)

– No mention of bother

• Menon, BJU int: 2003 (n=200)– 50% faster recovery of continence

– Used physician assessment, not clearly defined

• Ahlering, Urology: 2004 (n=60)– 75% continence at 3 months same as RRP group

• *Rassweiller, J Urol: 2001 (n=180)– 97% continence at 1 yr

– No influence of learning curve

• *Guillioneau, J Urol: 2000 (n=120)– 72% continent at 6 months

12

What can we do to prevent post-RP

incontinence?

Proposed Risk Factors

• Age

• Stage

• Technique

– Nerve-sparing

– Bladder neck sparing

• Surgeon experience

• Previous TURP

• Previous Radiation

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The Bladder Neck

• Literature review

• Summarized evidence for relationship b/w

technique and continence outcomes

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Cambio & Evans, Eur Urol: 2006

• 11 randomized trials of PFMT

• Over 1000 men

• Earlier recovery of continence in PFMT

• No difference at 6 months

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The Bladder Neck

• Preservation

– Conflicting evidence

– No randomized control trials

– May lower BNC rate

– Appears not to compromise oncologic outcomes

– Patient selection important

• Intussusception

– May improve early return to continence (3 mo)

– Few studies

The Bladder Neck

• Mucosal Eversion

• (Strougi et al BJU int, 2005)

– Randomized trial of 95 men

– No difference in continence or contracture

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Nerve Sparing

• Several series showing better continence

in bilateral vs unilateral vs non-sparing

• Few series showing no relationship

• No correlation between potency and

continence established

• Retrospective review of 52 patients

• Functional outcomes measured with UCLA-PCI

• 54% incontinence (defined at > 1 pad/day)

• 40% required AUS implantation

• More insult to external urinary sphincter…

17

• Retrospective review of 753 RRPs

• 36 (4.8%) developed anastamotic stricture

• Stricture patients were 4x more likely to be

incontinent (46.5% vs 12.2%)

Anatomy of Male Continence and

Pathophysiology of Incontinence

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Anatomy of Male Continence

1. Proximal Urethral Sphincter

– BN, prostate, urethra to veru

– Removed by Rad P

2. Distal Urethral Sphincter

– Veru to proximal bulb

1. Urethral mucosal infoldings

2. Rhabdosphincter (s.m. &

skel)

3. Extrinsic skeletal (levators)

4. Supporting fascia

Anatomy of Male Continence

• Rhabdosphincter– Longitudinal s.m.

– Slow twitch (type I) skeletal

– Maintain resting tone and preserve continence

• Striated Skeletal Muscle– Levator ani

– Fast twitch (type II)

– Contract rapidly with ↑Pabdo

• Innervation:– Parasympathetic (pelvic

nerves)

– Somatic (pudendal nerves)

19

Pathophysiology

Post-prostatectomy

Incontinence

Bladder Dysfunction Obstruction Sphincter Dysfunction

Post-prostatectomy

Incontinence

Bladder Dysfunction Obstruction Sphincter Dysfunction

– Overactivity

• Detrusor Instability

• Impaired Compliance

– Underactivity

• Impaired contractility

(overflow)

20

Post-prostatectomy

Incontinence

Bladder Dysfunction Obstruction Sphincter Dysfunction

B.N. contracture

Post-prostatectomy

Incontinence

Bladder Dysfunction Obstruction Sphincter Dysfunction

– Injury to:

• Rhabdosphincter

• Neural Supply

• Supporting structures

21

Evaluation

Evaluation Overview

• History

• Physical Exam

• Ancillary Tests

• Urodynamics

• Cystoscopy

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History

• Type & severity of incontinence

• QOL/Bother

• Other LUTS

• Sexual Function

• Details of Prostate Ca therapy

– XRT

• Past Medical History

– DM, Neurologic disease, Pelvic Surgeries, Medications

History Adjuncts

• UCLA-PCI

• Voiding diary

• 24 hr pad test

23

Physical Examination

• Bladder

– r/o distension

• DRE

• Penis

– Assess excoriation, infection

• Neurourologic exam

• Examine the pads

– Type, how wet, last change, underwear stains

Ancillary Testing

• Urine• UA, C&S

• Blood• PSA, +/- Cr

• Non-invasive Urodynamics• PVR

• Uroflow

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Flexible Cystoscopy

• Urethra

– stricture

– Bladder neck contracture

• Bladder

– Stones, FB, tumor

• Fill bladder and perform

stress maneuvres

Urodynamics

• Defines the problem and guides therapy

• Assess bladder and outlet

– Filling: capacity, overactivity, compliance

– Storage: VLPP

– Emptying: contractility, obstruction

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Urodynamics

10%Bladder neck

contracture

60%90%Sphincter

Dysfunction

3%45%Bladder

Dysfunction

Alone (%)Total (%)

Nitti J Urol, 1998

Management Overview

Post-prostatectomy

Incontinence

Behavioural Medication Surgical

Fluid Restriction

Kegel Exercises

Biofeedback

Anticholinergics

Alpha-agonists

Injectables

Male sling

AUS

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Surgery

• Indication:

– Bothersome incontinence

– Due to sphincteric deficiency

– Persisting beyond 1 yr

– Refractory to pelvic floor exercises

Surgery

• Considerations:

– Patient goals/lifestyle

– Severity of incontinence

– Anatomy/radiation

– Bladder (compliance, stability)

– Comorbidites

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Injectables

• Pro

– Easy to perform

– Minimal morbidity

– Doesn’t burn any bridges

• Con

– Expensive, not cost-effective

– Not durable, requires multiple procedures

– Less efficacious

Injection Technique

• Local anesthetic

• Retrograde or antegrade

• Collagen, Macroplastique or Zuidex

• Inject material above sphincter at a few

sites circumferentially

• Goal is co-aptation of the urethral lumen

• Avoid passing scope into bladder or

catheterization

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Injectables

• Complications

– Retention 15 - 25%

– Irritative LUTS

– UTI

– Failure

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• Reviewed 322 men with ISD

– 199 men post RRP

– Others had EBRT, cryo, TURP

• Findings (40 months)

– Mean response 50% pad reduction

– Mean duration of response 6 months

– Mean of 4.5 injection sessions required

– Patients with EBRT did worse

– Good response (dry) tends to last longer (11 mo)

Westney et al. J Urol, 2005

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Injectables Summary

• Ideal candidate

– Mild incontinence

• < 3 pads/day

• VLPP > 60 cm H2O

– No radiation

– Adequate suprasphincteric urethra

– Patient ok with multiple sessions

Male Sling

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Male Slings

• The niche

– Don’t want or can’t use a mechanical device

– Mild incontinence

– Need repeated transurethral instrumentation

• Don’t preclude subsequent AUS

• Options

– Bone-anchored sling (InVance)

– Trans-obturator sling (AdVance)

Technique

• General or spinal anesthesia

• 3-4 cm perineal incision

• Leave bulbocavernosus intact

• Dissect pubic rami

• 2-3 titanium bone anchors

• Adjust sling tension**

• Foley overnight

32

Sling tension

• Retrograde LPP

– 14 fr foley (like doing a RUG)

– Raise water until flow starts

– Goal is 60 cm H2O RLPP

• Cough/Valsalva

– Requires spinal anesthesia

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• 48 patients

– 42 post-RP, 2 post-EBRT

• 24-60 month follow-up

• Success: leakage “no problem” or “small

problem” on UCLA-PCI

– 80% cured or much improved

• 1 infection, 1 erosion requiring explant

• 62 men with PPI, InVance sling

• All degrees of incontinence

• 15 month follow-up

• Success: subjective “much” or “very much”

improved

– 58% success

– 10% “a little better”

– 32% failed

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Fischer et al. J Urol, 2007

• Logistic regression analysis to determine

influence of several factors

– Age

– Time from surgery/radiation

– Length of follow-up

– Pre-operative pad weight

– ALPP

• Only pre-operative pad weight predicted success

• Radiation or BNC no effect

Fischer et al. J Urol 2007

• Chance of success 6x greater if pad weight < 423g

(< 150 g considered “mild”)

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Fischer et al. J Urol 2007

• 21% complication rate

– De novo urgency: 1

– Retention: 2

– Obstructive LUTS: 1

– Paresthesia: 5

– Infection: 3

– Erosion: 1

• 14% re-operation

Other Options

• AdVance

– Male TOT

• ProACT

– Adjustable balloons implanted under bladder

neck

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Artificial Sphincter

Artificial Urinary Sphincter

• Introduced by Scott in

1973

• Current model AMS

800 introduced in

1983

– cuff around bulb

– Pump in scrotum

– Reservior retropubic

• “Gold Standard”

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AUS Modifications

• Narrow-back cuff

introduced in 1987

– More even distrubution of

occlusive pressure

– Decreased mechanical

and non-mechanical

failure rates by > 50%

AUS Contraindications

• Inablility to use device (AUS)

• Bladder dysfunction

• Unstable urethral stricture

• Need for repeated trans-urethral surgery

• Infection

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Perineal vs Trans-scrotal

• Trans-scrotal technique described by

Wilson in 2003

• Pro’s

– Place all components through 1 incision

– Good for revision: tandem cuff or distal cuff

– Synchronous placement of a penile prosthesis

• Con’s

– More distal cuff placement

Additional Techniques

• Double cuff (Kowalcyk, J Urol; 1996)

– For severe incontinence

– Higher rate of erosion

• Transcorporal cuff (Webster, J Urol; 2002)

– Protects against erosion and allows for distal

placement

– Good for previous radiation and revisions

– Only perform in impotent men

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• Review of AUS from 1992-2005 (narrow back cuff)

• 218 men

– 60 RRP + EBRT

– 116 RRP

– 11 NGB

– 28 Secondary AUS placement

• Mean 36.5 mo follow-up

– 75% free of revision or removal at 5 yrs

– 69% using < 1 pad/day

– No QOL data

Lai et al. J Urol, 2007

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Summary of AUS Series

Montague & Angermeir. Urology, 2000

AUS Troubleshooting

• Infection

• Erosion

• Failure

– Mechanical

– Non-mechanical (atrophy)

• Urethral Strictures

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Evaluation of AUS Problems

• H&P

– Signs of infection

• X-ray (if contrast in AUS fluid)

• Cystoscopy

– Erosion? Stricture?

• Urodynamics

• Surgical exploration

– For device failure

– Intra-operative electrical testing

Mechanical Failure

• AMS 800: “7-10 yr life expectancy”

• Cuff leak is most common cause

• If device is < 3yrs � Replace component

• If older � Replace entire AUS

• Tie connectors should be used in revisions

– Lose biofilm in retained tubing

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Urethral Atrophy

• Most common reason for revision

• Options

– Downsize cuff (if cuff > 4.0 cm)

– Move cuff proximally

– Tandem cuff

– Transcorporal cuff

Urethral Erosion

• Immediate removal of all components

• Reimplantation 3 months later if:

– No infection

– Urethra patent

• Reimplant at different site

43

AUS Infection

• 3% incidence

• Due to seeding of device during

implantation

– S epidermidis or S aureus

– within 6 wks of implantation

• Delayed infection rare

– Usually associated with erosion

• Requires explantation and delayed reimp.

AUS Infection

• Immediate salvage has been reported

– 7 solution antibiotic irrigation protocol

– Only if non-eroded

• Relative contraindications

– Necrotizing infection

– Sepsis

– Ketoacidosis

– Immunosuppression

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Urethral Stricture

• May represent impending erosion

• Transurethral management

– Dilation

– DVIU, laser

– Consider surgical uncoupling of cuff

• Removal of device, urethroplasty and

delayed reimplantation at a remote site

Summary

• PPI continues to occur despite surgical

advances in radical prostatectomy

• May have a profound impact on QoL

• Evaluation should include UDS, endoscopy,

and quantitative/subjective data

• Surgery is mainstay of therapy

• AUS is gold-standard, other options exist for

mild incontinence