[Epidemiology and physiopathology of urinary incontinence after radical prostatectomy]

Abstract

Beginning in the 1980s, a series of anatomical discoveries were introduced to modify the classic retropubic radical prostatectomy proposed by Millin in 1942 in an effort to reduce intra and postoperative complications such as intraoperative bleeding and postoperative erectile dysfunction and incontinence. Urinary incontinence post retropubic "anatomical" radical prostatectomy remains a distressing problem for the patient and the physician rating from 6 to 20% even in the hands of experienced surgeons from high volume Academic Centers. The reason for the discrepancy in results is unclear and should be searched in surgical experience of the surgeon, volume of surgical activity of the Center, and selection of the patients undergoing the radical retropubic procedure. In the Literature we identified methodological factors which can bias the data on post radical retropubic prostatectomy such as 1) Consensus is lacking on definition of continence and/or incontinence following radical retropubic prostatectomy 2) Different surgical techniques are compared: sphincter damaging, versus repairing, versus preserving; bladder neck sparing versus non sparing; nerve sparing versus non sparing 3) Patients with preoperative urinary incontinence are included in the series and the preoperative continence status is not known. 4) Different timing in registration of incontinence. 5) Different methods in data collection. This latter seems to be the most important reason for discrepancy in the collection of the data. Self administered questionnaires oriented to evaluate incontinence analyzed by a third party seem to be the most powerful and objective tool for post prostatectomy incontinence rating. Post prostatectomy incontinence may be attributed to sphincter dysfunction as a result of surgical injury during prostatic surgery and/or to bladder dysfunction including detrusor instability and decreased compliance resulting in stress or urge or mixed stress/urge postoperative incontinence. In the Literature bladder dysfunction is considered to be responsible or jointly responsible for post RRP incontinence in a rate as high as 93%. More recently, a major role is considered to be played in post RRP incontinence pathophysiology by intrinsic sphincter insufficiency. Rarely bladder dysfunction is an isolated cause of incontinence. Moreover the symptom of stress incontinence accurately predicts the finding of intrinsic sphincter deficiency. The apical dissection and the preservation of the intrinsic sphincter remain the most complex parts of RRP and the keys to the maintenance of postoperative urinary continence.