Current Management of Post-radical Prostatectomy Urinary Incontinence

Abstract

Prostate cancer is the second most common cancer in men worldwide. Radical prostatectomy and radiation beam therapy are the most common treatment options for localized prostate cancer and have different associated complications. The etiology of post prostatectomy incontinence is multifactorial. There is evidence in the literature that anatomic support and pelvic innervation are important factors in the etiology of post-prostatectomy incontinence. Among the many surgical and technical factors proposed in the literature, extensive dissection during surgery, damage to the neurovascular bundle and the development of postoperative fibrosis have a substantial negative impact on the continence status of men undergoing RP. Sparing of the bladder neck and anterior, and possibly posterior, fixation of the bladder-urethra anastomosis are associated with better continence rates. Overactive bladder syndrome (OAB) is multifactorial and the exact role of prostate surgery in the development of OAB is still under debate. There are several variables that could contribute to detrusor overactivity. Detrusor overactivity in patients after radical prostatectomy has been mainly attributed to a partial denervation of the bladder during surgery. However, together with bladder denervation, other hypotheses, such as the urethrovesical mechanism, have been described. Although there is conflicting evidence regarding the importance of conservative treatment after post-prostatectomy urinary incontinence, pelvic floor muscle training (PFMT) is still considered as the first treatment choice. Duloxetin, either alone or in combination with PFMT, may hasten recovery of urinary incontinence but is often associated with severe gastrointestinal and central nervous side effects. However, neither PFMT nor duloxetine may cure male stress urinary incontinence. The therapeutic decision and the chosen treatment option must be individualized for each patient according to clinical and social factors. During the recent years, the development of new therapeutic choices such as male sling techniques provided a more acceptable management pathway for less severe forms of urinary incontinence related to radical prostatectomy. Following this perspective, technological improvements and the emergence of new dedicated devices currently create the premises for a continuously positive evolution of clinical outcomes in this particular category of patients.

Keywords: detrusor activity; incontinence (male); prostate cancer; prostatectomy; stress incontinence.

Figure 1

Nomogram for the preoperative prediction of the 12-month ICIQ-UI-SF score among patients diagnosed with prostate cancer and treated with robotic-assisted prostatectomy. Instructions: locate the patient's values for age, EAU risk classification, baseline EORCT QLQ-C30/QoL and baseline ICIQ-UI-SF on the corresponding axes. Draw a straight line up to the Points axis for each value to determine the number of points for that value. Calculate the sum of the values on the Points axis and locate this sum score on the Total Points axis. Draw a straight line down to find the patient's predicted ICIQ-UI-SF score at 12 months. From Tutolo et al. (44). EORCT QLQ-C30/QoL, European Organization for Research and Treatment for Cancer Quality of Life Questionnaire of Prostate Cancer; ICIQ-UI-SF, International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form; EAU, European Association of Urology.

Figure 2

Nomogram for the postoperative prediction of the 12-month ICIQ-UI-SF score among patients diagnosed with prostate cancer and treated with robotic-assisted laparoscopic prostatectomy. Instructions: locate the patient's values for age, 3-month EORCT QLQ-C30/QoL, intraoperative complications, preoperative ICIQ-UI-SF and 3-month ICIQ-UI-SF on the corresponding axes. Draw a straight line up to the Points axis for each value to determine the number of points for that value. Calculate the sum of the values on the Points axis and locate this sum score on the Total Points axis. Draw a straight line down to find the patient's predicted ICIQ-UI-SF score at 12 months. Taken From Tutolo et al. (44). EORCT QLQ-C30/QoL, European Organization for Research and Treatment for Cancer Quality of Life Questionnaire of Prostate Cancer; ICIQ-UI-SF, International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form.

Figure 3

Surgical devices for the treatment of male stress urinary incontinence. (a) Circumferential compressive three-piece artificial urinary sphincter AMS800 (Boston scientific, USA). (b) Non-circumferential compressive device ProACT (UroMedica, USA). (c) Fixed male sling AdVanceXP (Boston Scientific, USA). (d) Adjustable male sling ATOMS (A.M.I., Austria). (e) Adjustable male sling Argus (Promedon, Argentina). (f) Adjustable male sling Remeex (Neomedic, Spain).