Hypothesis / aims of study
Incontinence after radical prostatectomy (PRPi) affects the patient’s quality of life. Adequate selection of treatment depends on correct diagnosis. The prevalence of sphincter deficiency in this group of patients is high. Pelvic floor training (PFT) is effective in many patients and is usually first line management. In a proportion of patients however, bothersome incontinence remains after 6 months of conservative measures and PFT. Many of these patients request further treatment. In one (US-cancer) outcomes surveillance 1,057 out of 16,348 men (6%) had undergone at least 1 incontinence procedure. In 34% of these, artificial urinary sphincter placement was the only procedure performed. PMID: 230175282013. In a more recent study, based on insurance data, 1,068 out of 29,287 men (3.6%) were treated with incontinence surgery. PMID: 31642741. Predicting success of surgical treatment for male incontinence , based on severity of incontinence (symptoms or volume loss) or urodynamic parameters (leak point pressure, detrusor overactivity or compliance), has not been very succesful.1,2 In an analysis of PRPi in combination with frequent voiding and or small bladder capacity, detrusor overactivity was not found to have an impact on the overall outcome although small capacity predicted frequent voiding after implantation. PMID: 21497853 Various methods have been published for PRPi urodynamic assessment, but standardization is lacking.3 We are a tertiary referral center for artificial sphincter implantations and designed a standardized urodynamic workup to evaluate PRPi. From our pool of patients with uniform diagnostic data and management follow-up, we aimed to analyze the value of individualized specific and objective diagnosis of dysfunction and its role in treatment outcome.
Study design, materials and methods
237 Patients referred between Jan 2006 and July 2019 with PRPi or post prostatectomy were mean age 68.7 (43-86) years at the time of urodynamic investigation; 49.7 months after the index-surgery (4-218 months). Of all patients 12% had treatment for (neo-bladder-neck) strictures, 8% had failed sling(s) or failed cuff(s) (4%) or bulking (2%). Pelvic floor exercise programs according to local protocols were completed by 58% of patients with moderate or positive effects in 29% of the patients. 61% had no urine loss while asleep. 58% of the patients voided on the toilet more than once a day and 74% used condom catheter or diapers. The other patients ‘only’ used pads. When referred to our hospital for further investigation 50% was on (or had tried) anticholinergic treatment. Two patients died during the recruitment period. Subtraction urodynamic studies were done in sitting position with 9F transurethral catheter with room temperature saline with medium fill-rate. All studies were performed according to (ICS) standard urodynamic practice and have concentrated on the demonstration of incontinence. We used a treatment simulating urodynamic investigation technique (TSUIT) allowing focus on the storage and emptying capacity of the bladder while preventing leakage, to simulate the situation after incontinence surgery. We have done so by simply (self-) squeezing of the penis during cystometry up to a tolerable volume. We report cystoscopy, PAD-test results and urodynamic results.
The urodynamic technique was well accepted and apprehended by the patients. Table 1 shows; that the mean bladder capacity using the TSUIT was 355 ml (range 150-1000 ml) in these patients (who usually continuously leak while physically active). 62% had a normal bladder storage phase, without detrusor-overactivity and with a normal sensation of bladder filling. In 31%, the storage phase was abnormal because of detrusor overactivity and in 27% patients because of reduced compliance. Four patients (7%) had obstructed voiding on pressure flow analysis. Purely based on TSUIT, we advised a sphincter prosthesis to 148 patientsand 90 patients were advised against; Two patients ultimately did not undergo the surgery. The table shows significantly different urodynamic results in the patients with a negative advise, specifically a severely reduced bladder capacity, detrusor overactivity or other filling phase abnormalities. Bladder outlet obstruction was a voiding phase marker leading to advize against an artificial sphincter. In 28 patients (19%) the prosthesis was revised. Their pretreatment results did not differ from the implanted group in total.
Interpretation of results
This analysis shows that rational selection of patients for a sphincter prosthesis has ensured optimal outcome. Only 6% of patients were incontinent after prosthesis placement and only 4% needed auxiliary medical management. Only 19% of these had device failure, unrelated to their lower urinary tract dysfunction. 37% of patients had clinically significant LUT dysfunction when filling was allowed above the incontinence volume up to 400mL or earlier when limited by strong desire to void or pain. Only a small proportion had urethral of neo-bladder neck stenosis. The feedback of the urodynamic results has been helpful in counselling these patients. Patients who were advised against an artificial sphincter were managed conservatively or (strictures) surgically. A proportion of patients received a prosthesis after secondary successful individualized conservative management.