Surgical management of incontinence after localized therapy
Posted Sep 28 2008 1:49pm
While large numbers of men will have immediate, short-term urinary incontinence following radical prostatectomy and other forms of treatment for localized prostate cancer, this will largely resolve in time for the majority of men. However, a small percentage of patients will suffer from significant long-term urinary incontinence.
At the recently completed 4th International Conference on Incontinence, Dr. Sender Herschorn reviewed current committee recommendations on surgical treatments for urinary incontinence in men, specifically including surgical interventions for post-prostatectomy incontinence (PPI). A complete report on Dr. Herschorn’s presentation is available on the UroToday web site ( free registration is required ).
Rates of incontinence after radical propstatectomy are highly variable and reported rates are significantly affected by data collection techniques and definitions of incontinence. Surgical risk factors for incontinence include patient age, preoperative continence, presence of bladder neck contracture, tumor stage, and nerve-sparing. No difference has been demonstrated between rates of incontinence following open, laparoscopic, and robotic surgical techniques.
Dr. Herschorn reviewed use of all the main treatments for post-prostatectomy incontinence, including injectable bulking agents, male slings, and the artificial urinary sphincter (AUS).
In terms of bulking agents, the committee looked at collagen, Macroplastique and Tegress (although it should be noted that Tegress has now been withdrawn from the market.) The committee’s conclusions were as follows:
There is no difference between specific techniques for injection, and no differences in outcome have been demonstrated among the different agents.
Complete cure rates are low (< 20 percent) and “improved” rates are variable (usually < 60 percent).
A history of radiation, bladder neck scar, and large-volume incontinence are associated with lower rates of success.
Overall there seems to be an approximately 40 percent short-term improvement rate and a 50 percent failure rate with injectables.
With respect to the use of AUS, based on data from multiple studies, Dr. Herschorn summarized success rates (defined as need for 0-1 pads per day) as follows:
Rates ranged from 59 to 90 percent with variable follow-up periods.
The current male sling technologies were reviewed: bone-anchored, composite grafts, retropubic suspensions, adjustable slings. The transobturator male sling (Advance, American Medical Systems) was not included as it is a relatively new introduction. Multiple studies were reviewed with different procedures and sling materials. (Dr. Herschorn also highlighted several historical urethral compression procedures that have been abandoned over the years.) Overall, the committee found:
A minimum success rate of 58 percent with acceptable complication rates.
Predictors of success were low to moderate leakage and no history of radiation (especially with bulbourethral slings).
Dr. Herschorn commented briefly on use of the ProACT balloon procedure:
Success rates of 0-1 pads per day are acceptable (at 60-70 percent).
Complication rates are relatively high.
In summary, the committee recommended a 6-12 month period of conservative management for PPI. The AUS was recommended as the preferred procedure for men with moderate to severe incontinence, while the sling is a good alternative for men with mild to moderate leakage. Injectables are a less effective option and do not preclude subsequent sling or AUS.
With respect to options for treatment of PPI associated with bladder neck contracture, treatments include visual internal urethrotomy or urethral stent placement combined with AUS, or other complex reconstructive procedures.
The committee also addressed issues with external beam radiation therapy (EBRT). The committee noted several well-known issues, including an increase risk of urinary incontinence with transurethral resection of the prostate before or after EBRT (5-11 percent), a high risk of urinary incontinence associated with salvage prostatectomy after EBRT, and an increased risk of urinary incontinence from adjuvant EBRT after radical prostatectomy. Issues with the AUS after radiation were addressed. Treatment success seems to be similar to those without radiation, although revision rates and complication rates are higher (~20-50 percent). There is a higher incidence of erosion, infection, and urethral atrophy.
Incontinence rates after cryotherapy (~3-15 percent), brachytherapy (~0-6 percent) and HIFU (~6-28 percent) were briefly discussed. Previous radiation was noted to be a risk factor for urinary incontinence with cryotherapy, and TURP has been associated with higher rates of incontinence with brachytherapy. With HIFU, incontinence rates seem to improve with experience.