Post‐prostatectomy urinary incontinence

Abstract

Post‐prostatectomy incontinence is an increasing problem that can have a devastating impact on men's lives. In this article the authors consider some of the options for management and discuss the efficacy as well as advantages and disadvantages of the different approaches to management that are currently available.

Full text

trendsinmenshealth.com
28 ❙ Trends in Urology & Men’s Health ❘ March/April 2019
● Lower urinary tract symptoms
Post-prostatectomy incontinence
(PPI) has a signicant impact on
all aspects of quality of life.1 As the
population ages, and with increasing
use of prostate-specic antigen
(PSA) testing, the number of men
undergoing radical prostatectomy to
treat prostate cancer is rising.
Hence, the timely and effective
management of
its complications is
of great importance.
The prevalence of PPI is difcult
to establish as it varies depending
on how and when it is measured,
and the surgical procedure
performed. A recent meta-analysis
looked at the prevalence of
incontinence following radical
prostatectomy at different intervals
and found that at three months post-
surgery 35% of the participants
were incontinent.2 However, the
numbers decreased over time and at
24 to 36 months post-surgery rates
of PPI were 5%.2
The reported rates of PPI also
vary depending upon how they are
measured. For example, when
questionnaire-derived incontinence
rates were compared with video
urodynamic data, the latter showed
much higher rates of PPI.3 Also,
prostate surgeons are more likely to
report lower rates of incontinence
compared with patients.3
In order to accurately assess
a patient’s level of continence
and quality of life following
prostatectomy, it is therefore
recommended that patient-reported
outcome measures be used
alongside objective measurements.
When this approach was applied just
over half of the patients reported
recovering to the baseline level of
bothersome symptoms at 12 months
post-prostatectomy.3 A recent study
of all men who underwent radical
prostatectomy in the UK between
2008 and 2012 reported a rate of
incontinence requiring surgical
treatment of 0.8%, although the true
rates of incontinence are likely to be
higher than this due to the limitations
of the study.4 As there were almost
21 000 radical prostatectomies
performed in England from 2014 to
2016, a considerable number of men
are likely to suffer from this signicant
complication.5
What causes PPI?
The male urethral sphincter complex
consists of two distinct parts: the
internal urethral sphincter, which is
located proximal to the bladder neck;
and the external urethral sphincter,
which is located more distally.
The internal sphincter is
responsible for passive continence
during normal daily activities. Its
smooth muscle contracts to keep
the bladder outlet in the closed
position. The external sphincter, on
the other hand, is made of skeletal
muscle. When performing strenuous
activities, abdominal pressure
increases and puts pressure on the
bladder. The weak smooth muscle of
Post-prostatectomy urinary
incontinence
Eliza Gimson, Medical Student; Daniel Majidian, Medical Student; Anvarjon Mukhammadaminov, Medical Student, King’s
College School of Medical Education, London; Claire Taylor, Consultant Urologist; Sachin Malde; Consultant Urologist; Arun
Sahai, Consultant Urologist, Pelvic Floor Unit, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London
Post-prostatectomy
incontinence is an increasing
problem that can have a
devastating impact on men’s
lives. In this article the
authors consider some of the
options for management and
discuss the efcacy as well
as advantages and
disadvantages of the
different approaches to
management that are
currently available.
(A) (B)
Os pubis
Urethra Prostate
Sphincter
Figure 1. Urethral sphincter complex before and after prostatectomy6

trendsinmenshealth.com Trends in Urology & Men’s Health ❘ March/April 2019 ❙ 29
Lower urinary tract symptoms ●
the internal sphincter alone cannot
cope with this increased pressure,
hence the external sphincter
contracts to prevent leakage. During
radical prostatectomy the majority
of the internal sphincter complex is
removed alongside the prostate
gland (see Figure 1). The remaining
external sphincter, which may also
have been damaged during surgery,
might not be strong enough to
prevent urine leakage.7
Urinary incontinence following
prostatectomy can be related to
sphincteric weakness or detrusor
overactivity, resulting in stress or
urge incontinence, respectively, or
could be related to a combination of
the two. Stress urinary incontinence
is the most common situation,
resulting from an inability of the
urinary sphincter complex to
withstand an increase in intra-
abdominal pressure.
Several factors have been shown
to be associated with developing
PPI (see Box 1). These include
biological factors such as increased
age, prostate size and BMI; as well
as pre-existing lower urinary tract
symptoms, functional bladder
changes, previous transurethral
resection of the prostate and
previous radiotherapy. Surgical
factors have also been identied and
include: brosis, urethral stricture,
technique of prostatectomy, laxity of
posterior support, neurovascular
bundle damage and devascularisation.
These should all be kept in mind to
ensure patients are appropriately
counselled about their risk of
developing PPI.7
Investigations and work-up
for surgery
Initial clinical assessment begins
with a thorough history review to
establish the type, timing and
severity of the leak. Patients will
also be asked if they require
containment devices, such as pads
or a convene, and will be requested
to complete a 24-hour pad test to
gain an objective measure of the
volume of leak. A exible cystoscopy
will also be performed to exclude
urethral stricture and anastomotic
stenosis and the sphincter can be
assessed for its ability for coaptation
and for any defects. Urodynamics
are performed to conrm the
diagnosis, assess for evidence of
detrusor overactivity and to
understand factors that may
inuence future surgery – such as
bladder capacity and compliance
(particularly in those who have had
radiation treatment).
Initial management
Pelvic oor muscle training
Pelvic oor muscle training remains
the primary conservative
intervention for PPI. A recent
Cochrane systematic review
evaluating the conservative
management of PPI found that
pelvic oor muscle training may help
speed the recovery of men’s
continence status.8 A meta-analysis
included in the review found that
pelvic oor muscle training led to
improved continence rates between
three and 12 months post-
operatively, compared with controls.
However, by 12 months there was
no overall difference in levels of
continence between the control or
intervention groups. A recent
meta-analysis suggested the use of
pre-operative pelvic oor training did
not improve the resolution of
incontinence at 3, 6 or 12 months
following on from surgery when
compared with post-operative pelvic
oor exercises alone.9
Duloxetine
Duloxetine is a noradrenaline-
serotonin reuptake inhibitor that
works by increasing tone in the
external urethral sphincter muscle,
and may be offered to patients
alongside pelvic oor muscle
training. The evidence base is larger
in women, where it is licensed as a
treatment for stress urinary
incontinence. It is not currently
licensed for use in men post-
prostatectomy, although evidence
suggests it may help hasten the
recovery of continence10 and the
European Association of Urology
recommend considering duloxetine
for this purpose.11 However, adverse
effects such as nausea and fatigue
are commonly reported,10 and so it
is important that the patient is
informed about its side-effect prole.
Surgery
Urethral bulking
The injection of bulking agents into
the submucosal tissue of the urethra
to aid coaptation of the damaged
sphincter has been well studied in
female stress urinary incontinence.
In post-prostatectomy cases there is
limited evidence on bulking agents,
but temporary improvement in
quality of life in milder cases of
incontinence have been reported.
Despite the availability of many
different agents there is no evidence
for any one being superior to
another, and according to the 2012
EAU guidelines bulking agents can
be considered for men with mild
Box 1. Factors that may contribute to the
development of urinary incontinence after
prostate surgery6
Biological factors
● BMI
● Age
● Prostate size
● Membranous urethral length
● Pre-existing LUTS
● Previous TURP
● Functional bladder changes
● Previous radiotherapy
Surgical factors
● Fibrosis
● Urethral stricture
● Technique of prostatectomy
● Laxity of posterior support
● Neurovascular bundle damage
● Devascularisation

trendsinmenshealth.com
30 ❙ Trends in Urology & Men’s Health ❘ March/April 2019
● Lower urinary tract symptoms
post-prostatectomy incontinence
who understand this will provide
temporary improvement of their
incontinence symptoms.11
Male sling
Generally, there are two types of
male sling – xed and adjustable.
Among the xed slings there are
several variations and two different
mechanisms of action. One works
by compressing the urethra. The
other, commercially known as the
AdVance XP sling (see Figure 2),
works by repositioning the bulb of the
urethra to a retrourethral position,
providing additional support to the
existing sphincter and (in theory)
without causing obstruction. Slings
are generally recommended for men
with mild-to-moderate incontinence
and are a less invasive alternative to
the articial urinary sphincter.
Although there are several types
of male sling, the AdVance XP sling
has the most evidence for use. A
2012 multicentre prospective study
evaluating the AdVance XP male sling
followed 156 men for three years and
reported a 42.3% cure rate (dened
as no pads or one dry for security
reasons) and a 25% improvement
rate (dened as one or two pads per
day with a 50% reduction in daily pad
use). The AdVance XP sling has also
been found to improve quality of life;
although outcomes are worse for
patients with severe incontinence,
those who have undergone urethral
stricture surgery, or those who have
had prior radiotherapy.13 Adequate
patient selection and careful
counselling is therefore important.
More recently, adjustable slings such
as the adjustable trans-obturator
male system sling have been
designed with the idea that they
would provide the added benet of
being able to adjust sling tension
post-operatively. Although promising,
randomised trials to determine
whether adjustable slings provide
any benet over xed slings are yet
to be carried out.14
Articial urinary sphincter
The articial urinary sphincter (AUS)
has been considered the gold
standard for treating post-
prostatectomy stress urinary
incontinence since the conception
of the current popular model, the
AMS 800 (see Figure 3), in 1983.
This model has three main
components: a pressure-regulating
balloon, an inatable cuff that is
placed around the bulbar urethra,
and a control pump that is placed in
a subdartos pouch in the scrotum.
It works to provide circumferential
occlusion of the bulbar urethra
at rest. When the patient wishes to
urinate, the cuff can be deated by
pressing the control pump. The cuff
then re-inates over a period of
about two minutes, thereby
restoring continence.15–17
The AUS is recommended for
men with moderate-to-severe
incontinence with good mental
capacity and manual dexterity in order
to operate the pump. Also, success
rates are better than with male slings
in patients with prior prostate or
salvage radiotherapy. Follow up data
from many sources collected in a
2013 systematic review highlight
Figure 2. AdVance XP sling mechanism12
Figure 3. The AMS 80018
AdVance
Sling

trendsinmenshealth.com Trends in Urology & Men’s Health ❘ March/April 2019 ❙ 31
Lower urinary tract symptoms ●
variation in results for success rates
of this procedure, with rates of
improvement at 61% to 100% (79%
on average) and dry continence
ranging from 4.3% to 85.7%.18
However, these high success
rates need to be balanced against
the potential complications. As with
any mechanical device there is a risk
of failure of the components
requiring revision surgery. More
common is the risk of infection or
erosion. Furthermore, urethral
instrumentation (eg catheterisation)
must be avoided as this can increase
the risk of urethral erosion, and
patients should seek urgent
specialist urological advice if any
such intervention is required. Table 1
above, adapted from a 2013
systematic review, summarises
AMS 800 outcomes.
There are currently no published
data that directly compare the AMS
800 with the AdVance XP male
sling. The MASTER trial is a UK
randomised controlled trial directly
comparing these two procedures in
men with PPI, and has recently
completed recruitment. The results
are eagerly awaited.20
Conclusions
PPI is an increasing problem that
can have a devastating impact on
men’s lives. Early management
largely consists of pelvic oor
muscle training that evidence
suggests can help speed the
recovery of continence. If
incontinence is still bothersome
one year post-surgery then further
improvement in urinary control is
unlikely. It is at this point that more
invasive options should be
considered and appropriate
investigations instigated. Male
slings can be considered for
mild-to-moderate incontinence,
while the AUS remains the gold
standard treatment for patients with
moderate-to-severe incontinence or
a history of radiotherapy.
Declaration of interests
Sachin Malde and Arun Sahai have
both received funding from
Medtronic for involvement in a
promotional event. Arun Sahai is
also an advisor for Allergan Ltd. and
has received speaker fees and an
educational grant from them.
References
1. Powel LL. Quality of life in men with
urinary incontinence after prostate
cancer surgery. J Wound Ostomy
Continence Nurs 2000;27(3):174–8.
2. Ficarra V, Novara G, Rosen RC, et al.
Systematic review and meta-analysis of
studies reporting urinary continence
recovery after robot-assisted radical
prostatectomy. Eur Urol 2012;62(3):
405–17.
3. Tromenko V, Myers JB, Brant WO.
Post-Prostatectomy Incontinence: How
Common and Bothersome Is It Really?
Sex Med Rev 2017;5(4):536–43.
4. Sujenthiran A, Charman SC, Parry M,
et al. Quantifying severe urinary
complications after radical
prostatectomy: the development and
validation of a surgical performance
indicator using hospital administrative
data. BJU Int 2017;120(2):219–25.
5. The British Association of Urological
Surgeons. Radical Prostatectomy
Outcomes Data. (www.baus.org.uk/
patients/surgical_outcomes/radical_
prostatectomy/timescales.aspx;
accessed 10 December 2018).
6. Bauer RM, Bastian PJ, Gozzi C, Stief
CG. Postprostatectomy incontinence: all
about diagnosis and management. Eur
Urol 2009;55(2):322–33.
7. Heesakkers J, Farag F, Bauer RM, et al.
Pathophysiology and Contributing Factors
in Postprostatectomy Incontinence: A
Review. Eur Urol 2017;71(6):936–44.
8. Anderson CA, Omar MI, Campbell SE,
et al. Conservative management for
postprostatectomy urinary incontinence.
Cochrane Database Syst Rev
2015;1:CD001843. DOI:
10.1002/14651858.CD001843.pub5.
9. Wang W, Huang QM, Liu FP, Mao QQ.
Effectiveness of preoperative pelvic oor
muscle training for urinary incontinence
after radical prostatectomy: a meta-
analysis. BMC Urol 2014;14:99.
10. Alan C, Eren AE, Ersay AR, et al.
Efcacy of Duloxetine in the Early
Management of Urinary Continence after
Radical Prostatectomy. Curr Urol
2015;8(1):43–8.
11. Burkhard (Chair) FC, Bosch JL,
Cruz F, et al. Urinary Incontinence
Guidelines: European Association of
Urology. (http://uroweb.org/guideline/
urinary-incontinence/#4; accessed 10
December 2018).
12. Boston Scientic Corporation.
AdVance Male Sling System. (www.
xincontinence.com/treatment-options/
advance-male-sling; accessed 10
December 2018).
13. Rehder P, Haab F, Cornu JN, et al.
Treatment of postprostatectomy male
urinary incontinence with the
transobturator retroluminal repositioning
sling suspension: 3-year follow-up. Eur
Urol 2012;62(1):140–5.
Outcomes Results % (range) Number of
participants included
(number of studies)
Infection/erosion 8.5 (3.3–27.8) 562 (10)
Mechanical failure 6.2 (2.0–13.8) 562 (10)
Urethral atrophy 7.9 (1.9–28.6) 456 (6)
Reintervention (for any reason) 26.0 (14.8–44.8) 549 (10)
Number of patients socially
continent (≤1 pad/24 h)
79.0 (60.9–100) 262 (7)
Number of patients completely
dry (0 pads/24 h)
43.5 (4.3–85.7) 336 (7)
Table 1. AMS 800 outcomes (adapted from a 2013 systematic review)19

trendsinmenshealth.com
32 ❙ Trends in Urology & Men’s Health ❘ March/April 2019
● Lower urinary tract symptoms
14. Sahai A, Abrams P, Dmochowski R,
Anding R. The role of male slings in post
prostatectomy incontinence: ICI-RS
2015. Neurourol Urodyn 2017;36(4):
927–34.
15. Boston Scientic Corporation. AMS
800 Urinary Control System For Male
Patients. Operating Room Manual.
Minnetonka: American Medical Systems;
2016. (www.bostonscientic.com/
content/dam/Manuals/us/current-rev-
en/92116964-01A_AMS_800_ORM_en_s.
pdf; accessed 10 December 2018).
16. Walsh PC, Retik AB, Darracott
Vaughan E, Jr., et al. Implantation Of
The Genitourinary Sphincter. In:
Campbell’s Urology 8th ed. Philadelphia:
Saunders; 2002.
17. Sajadi KP, Kim ED. Articial Urinary
Sphincter Placement. MedScape; 2016.
(https://emedicine.medscape.com/
article/443737-overview; accessed 10
December 2018).
18. Boston Scientic Corporation. AMS
800 Urinary Control System. (www.
bostonscientic.com/en-EU/products/
articial-urinary-sphincter/ams-800-
urinary-control-system.html; accessed
10 December 2018).
19. Van der Aa F, Drake MJ, Kasyan GR,
et al. The articial urinary sphincter after
a quarter of a century: a critical
systematic review of its use in male
non-neurogenic incontinence. Eur Urol
2013;63(4):681–9.
20. Abrams P, Shearer K. The MASTER
trial: articial urinary sphincter versus
male sling. Trends in Urology & Men’s
Health 2015;6:(2):37–8.