Prostate cancer surgery is intended to be curative. The aim is to remove the prostate and seminal vesicles in men with localised disease, while preserving the surrounding structures, to leave the patient cancer free while trying to maintain quality of life. With the potential risks including incontinence and impotence, ensuring that patient follow up takes a holistic approach and includes these aspects, with timely referral to sub-specialties where required, is essential.

In the UK patients are routinely counselled preoperatively that 10-20% of men will have mild incontinence requiring the use of pads 1 year following radical prostatectomy. 3-5% will suffer severe incontinence that may require further surgical intervention, such as insertion of an artificial urinary sphincter (AUS) (1). The Prostate Cancer Outcomes Study parallels this, concluding 28% of men were using pads 2 years after radical prostatectomy (2).

Given the rising numbers of prostatectomies being performed, this means a significant number of patients will require assessment and management under our functional urology teams. This study aimed to evaluate the time interval between primary prostate surgery to first assessment and surgical management of urinary incontinence. The time period covered also allows for an assessment of the impact of the Covid-19 pandemic on these outcomes.

All patients who underwent primary AUS insertion between 13th January 2007 and 26th October 2022 for post prostatectomy incontinence (PPI) were included for retrospective cohort analysis. Patients underwent urodynamic assessment to confirm the diagnosis. Patients were identified by operative coding, and data collection performed from electronic patient records. Procedures were by one of three surgeons within a single centre, and all patients underwent implantation of an AMS 800TM system.

We evaluated the following outcomes: 

1) Time to first assessment by functional urologist following primary prostate surgery 
2) Time to surgical intervention (AUS) for incontinence from first assessment 
3) Impact of the Covid-19 pandemic on waiting times for surgical management 

Secondary outcomes included: post-operative continence, rates of infection, erosion, device failure and explanation/renewal of the device, with follow up time extending until 31st March 2023.

Primary outcomes 
A total of 160 patients with post prostatectomy incontinence underwent AUS insertion over a time period of 16 years – see table 1. 

Secondary outcomes 
Patients were followed up and assessed for secondary outcomes over period of up to 16 years, until 31st March 2023 - see table 2. Post-operative incontinence was assessed comparing urine collection methods. Pre-operatively pad use ranged from 1-10 per day with 77.5% of patients using this method. The remaining patients used a combination of intermittent self-catheterisation, catheters, modified underwear or sheath drainage. Post-operatively, one patient had device failure resulting in 12 pads per day usage, the remaining patients using pads had a maximum 4 pads per day, with 79.4% of patients achieving social continence (0-1 pads) following AUS surgery.

Patients are waiting an average time of 30.4 months (2.5 years) to be first assessed by a Functional Urologist and 11.6 months to undergo their AUS insertion following assessment. 
Between 2006-2019 the mean wait time from specialist assessment to insertion of AUS was 11 months. During 2020, this doubled to a mean of 22 months until the patient underwent surgical intervention. There has been a drive to reduce the time, with the mean 2021-2022 being only 8.5 months until surgery.
Secondary outcome results have demonstrated that over a follow up period of up to 16 years, insertion of AUS shows good continence outcomes with a low complication rate.

Despite a drive to improve functional outcomes for men with prostate cancer there remains a long interval period for men to be referred on for specialist assessment of their post prostatectomy incontinence. Men can be waiting a number of years, despite a consensus that improvements are unlikely to be seen past 12 months post-operatively. Once assessed, the average wait until AUS surgery is less than a year. Outcomes post AUS insertion are favourable with low complication rates.

The Covid-19 pandemic had a significant impact on the wait times for patients awaiting incontinence surgery, doubling the wait time, and during the pandemic recovery phase there remains pressure on healthcare services to avoid further delays for these patients.

BAUS robotic assisted laparoscopic radical prostatectomy. Information about your procedure. Patient information leaflet. The British Association of Urological Surgeons 2021 July; 5-6
Potosky AL et al. Health outcomes after prostatectomy or radiotherapy for prostate cancer: results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2000 Oct;92(19):1582-92