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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

Up to 30% of patients complain about urine leakage after radical prostatectomy, but persistent stress incontinence (beyond 1 year) affects <5% of them. This complication is mainly caused by sphincter dysfunction. Some preventive measures have been described to decrease the risk of incontinence after radical prostatectomy, but with conflicting results. The effectiveness of preoperative and early postoperative physiotherapy is controversial. Moreover, while meticulous apical dissection of the prostate significantly improves postoperative continence, the benefit of other surgical techniques, e.g. preserving the bladder neck and the neurovascular bundles, is under debate. The treatment of persistent stress urinary incontinence is mainly based on surgery, as this type of incontinence usually does not respond to physiotherapy and anticholinergic medication. While injection therapy is safe and well tolerated, its effect on postoperative continence is limited and decreases with time. The best results are achieved by implanting an artificial urinary sphincter, but with significant complication and revision rates.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

Postoperative urinary incontinence affects 5–30% of patients undergoing radical prostatectomy (RP), with a significant effect on their quality of life. In recent years many preventive measures have been described to decrease the risk of incontinence after RP, including preoperative physiotherapy and surgical techniques.

The treatment of postoperative incontinence depends on its mechanism, its importance and the delay after surgery. Patients with early incontinence caused by bladder instability are good candidates for physiotherapy, and usually achieve normal continence at 1 year. However, patients who have persistent stress incontinence will be more difficult to treat. The implantation of an AUS may achieve good functional results but with significant morbidity.

Incidence

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

The reported rates of urinary incontinence after RP depend on several factors, one of the most important, and which partly explains the variations among published data, being the definition of incontinence. Evaluating >1300 patients after radical prostatectomy, Mettlin et al.[1] reported an incontinence rate of 2% when only complete incontinence was considered. However, this rate increased to 47% when considering any daily urine leakage. Moreover, urinary continence gradually improves during the first years after surgery [2] and it is therefore necessary to distinguish early from delayed incontinence. For most authors, delayed incontinence is defined as the persistence of urine leakage 1 year after RP.

Another important point is the method of questioning patients; studies in which patients are personally interviewed report urinary incontinence rates after 1 year of 6–18.8% [2,3]. Nevertheless, this rate is higher when assessed by self-administered questionnaires [4].

In summary, there is a wide range in the reported rates of urinary incontinence after RP. From published reports it seems reasonable to assume that 5–30% of patients have some degree of postoperative urine leakage and that <5% require surgical treatment.

Pathophysiology

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

The mechanism of urinary incontinence after RP is complex. Most authors agree that sphincter deficiency may be the predominant factor in incontinence but the precise role of the external striated sphincter and that of the intrinsic sphincter are under debate. Many urodynamic studies, including the measurement of the maximal urethral closing pressure (MUCP) have led to conflicting results. The MUCP, measured with or without voluntary contraction of the sphincter, reflects the effectiveness of the sphincter mechanism. Based on studies of the MUCP, some authors indicated the role of extrinsic sphincter deficiency as the prime determining factor of in postoperative incontinence [5,6]. For example, Kleinhans et al.[6] noted a significant decrease in MUCP at voluntary sphincter contraction, from 137.7 to 90.7 cmH2O in patients complaining of urinary leakage after RP, and concluded that the incontinence was a result of external striated sphincter deficiency. However, others found no correlation between postoperative stress incontinence and MUCP measured at the level of the membranous urethra, and suggested that urinary control did not depend on the extrinsic sphincter [7]. In reality, it is probable that both extrinsic and intrinsic sphincters have an effect on postoperative continence status. The external striated sphincter (or distal sphincter) is tubular and has broad attachments over the fascia of the prostate near the apex [8]. Its innervation arises from the pudendal nerves, the autonomic nerves in the pelvic plexus, and nerve connections with the dorsal vein complex. The striated sphincter can therefore be injured at the time of transection of the dorsal vein complex, apical dissection, and reconstruction of the urethra either by myogenic damage or by denervation [8]. The internal sphincter (or proximal sphincter) is represented by the bladder neck and the urethral smooth muscle [8,9]. The urethral resistance, which is under sympathogenic control, may be partly responsible for urinary continence [8,9]. Myers [8] described five phenomena occurring after RP that may affect intrinsic sphincter function: reduction in functional urethral length, loss of vesico-urethral smooth muscle continuity, reduction of the investment of the membranous urethra by fascia and levator muscles, loss of elasticity of the vesico-urethral junction, and denervation of the urethra and bladder neck. Recently, John et al.[9] took biopsies of the superficial trigone before and after RP, finding that protein gene-product 9.5 immunoreactive nerve fibre density in the trigone was lower after RP. Furthermore, there was a strong correlation between the expression of this protein and the continence status. The authors concluded that trigonal denervation was a significant risk factor for incontinence.

There are connections between intrinsic and extrinsic sphincters. Indeed, it has been shown that an increased tension in the bladder neck as filling progresses or urine escapes into the proximal urethra induces a stimulation of the external striated sphincter [9]. Moreover, the role of bladder factors such as detrusor instability and reduced bladder capacity has been widely documented [10]. Nevertheless, a distinction between early and persistent incontinence should be emphasized. Although detrusor instability is very important in early postoperative incontinence, it is the explanation in only 4% of patients who have persistent incontinence [5]. Conversely, sphincter deficiency is present in 90–100% of patients with incontinence at any time after surgery [5,6]. Consequently, early incontinence partly depends on detrusor instability, whereas persistent stress incontinence is mainly a result of sphincter dysfunction.

Risk factors

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

Many factors have been suggested as risks for incontinence after RP; vesico-urethral anastomosis stricture is one of them. Recently, Park et al.[11] analysed the effect of anastomotic stricture on postoperative continence in 753 patients undergoing RP. The percentage of men who required pads 1 year after surgery was significantly higher in the stricture group than in the control group (46.2% vs 12.5%).

The predictive value of other factors on postoperative incontinence has been assessed, but with conflicting results. The role of the bladder neck denervation during RP has been emphasized by many, but in some studies bladder neck preservation was not shown to be as beneficial for postoperative continence status [12].

Another controversial risk factor for incontinence after RP is the resection of the neurovascular bundles. In some series neurovascular preservation was reported to improve continence [12,13], but this issue is debatable, as patients who are candidates for neurovascular preservation are more likely to be continent because of their overall health, age and stage of disease [14].

In most reports the patient's age and preoperative urine leakage are also predictive of postoperative urinary incontinence [12,15], whereas some come to the opposite conclusion. For example, in a series of 615 patients Goluboff et al.[16] found no correlation between postoperative continence status and patient's age or preoperative incontinence.

Considering that vesico-urethral stenosis, bladder neck denervation and neurovascular bundle injury may impair continence after RP, meticulous surgical technique appears to be essential for preventing postoperative urine leakage. Moreover, the approach used for RP has been reported to have an effect on incontinence. In a retrospective study in which the outcome of 100 patients undergoing retropubic RP was compared with that of 127 patients undergoing perineal prostatectomy, Bishoff et al.[17] reported lower rates of urinary incontinence with the latter approach. In that study, continence was evaluated by a telephone interview at least 1 year after surgery. A significantly higher proportion of patients after perineal rather than retropubic RP reported that all urinary leakage had ceased (70% vs 53%), and a smaller proportion of complained about the need to wear pads (39% vs 56%).

Prevention

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

Preoperative physiotherapy

The first step in prevention is informing the patient before surgery; the risk of early urine leakage, and the usual delay in return to continence, should be clearly stated to the patient, to minimize the psychological effects of such a complication.

Many authors advocate muscular exercises before surgery, reporting that preoperative pelvic floor training may not only improve the efficiency of postoperative physiotherapy but also reassure the patient that every aspect of postoperative care will be taken care of. Nevertheless, the benefit of preoperative physiotherapy has not been documented in a randomized study. Moreover, the addition of biofeedback with pelvic muscle exercises before RP remains a matter of debate. Although postoperative biofeedback has been reported to improve urinary continence after RP [18], the use of electrical stimulation before surgery seems to be ineffective [19]. Early postoperative pelvic floor biofeedback has also been advocated to prevent urinary incontinence, but with disappointing results [20].

Apical dissection of the prostate

Many authors have emphasized the benefit of a meticulous apical dissection of the prostate during retropubic RP. The control of the dorsal vein complex is one of the most important steps of the apical dissection. During the 1990s, connections between the dorsal vein complex and the striated sphincter fibres were described in anatomical studies. Cutting the dorsal veins at a distance from the pelvic floor is now admitted to reduce the risk of postoperative incontinence. Several procedures have been proposed to achieve an elective transection of the dorsal vein complex which preserves the urethra and the sphincteric system. To avoid injuring the anterior urethral wall, some authors recommend that no clamp is passed between the dorsal vein complex and the urethra [21]. Furthermore, various devices have been advocated to control the dorsal vein complex. Gould and Borer [22] recommended the use of an endoscopic gastrointestinal anastomosis stapler. In another report, Avant et al.[23] used a vein ligator consisting of a hollow steel shaft, a tip and a handle. Two straight needles are loaded 1 cm proximal to the tip of the device, and extrude when a drive-rod mechanism is activated. After inserting the device into the urethra, both needles are extruded transurethrally. The suture is tied down after removing the device.

Preserving the puboprostatic ligaments has also been proposed to give better continence rates, by preserving the maximum possible urethral length, but with conflicting results. In the study of Poore et al.[14] the puboprostatic sparing method improved the rapidity of return to continence but did not enhance the overall continence rate after 1 year.

In summary, although many techniques of meticulous apical dissection have been described and may not be convenient for all authors, two principles are important to consider; the dorsal vein complex should be transected and the urethra incised without damaging the striated sphincter, and the maximum urethral length should be preserved.

Preservation of the bladder neck

The effect of bladder neck preservation on continence after RP is controversial. For many authors, preserving the bladder neck does not compromise the safety of cancer surgery. Moreover, there was a benefit of bladder neck preservation on continence status in several studies. Comparing the bladder neck-sparing with the traditional technique, some reported an earlier return of continence with the former [24,25]. In the study of Lowe [24], the continence rate at 3 months was higher in the preservation than in the resection group (62% vs 44%). Nevertheless, continence rates at the long-term follow-up were not significantly different between the groups.

The benefit of bladder neck preservation on the continence rate after RP has not been documented in prospective studies. Recently, Wei et al.[12] prospectively evaluated 482 patients undergoing RP, with a median follow-up of 18 months, and found no benefit of bladder neck preservation on postoperative continence. In another prospective study, Srougi et al.[26] reported no significant differences in terms of early or delayed urinary continence rates between the sparing and the resection technique.

For others, bladder neck resection followed by reconstruction with tubularization may improve postoperative continence by preserving the functional urethral length [27]. The benefit of bladder neck preservation during RP is uncertain, and further data are mandatory to clarify its effect on continence.

Preservation of the neurovascular bundles

Although neurovascular bundle-sparing techniques have been shown to preserve sexual function without compromising cancer control [28], the effect of nerve-sparing methods on continence is not well known. Hollabaugh et al.[13] showed that both pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter, to enter at the 5 and 7 o'clock positions. The authors identified three factors that might damage these nerves: the blunt dissection of the posterior periurethral tissues using a right-angle clamp, placing the sutures at the 5 and 7 o'clock positions during vesico-urethral anastomosis, and dissecting the seminal vesicles. They also described technical modifications to avoid such nervous injury, and compared the outcome of 60 patients undergoing a nerve-sparing RP with those of 38 patients undergoing a standard RP. The authors found that nerve preservation decreased the time to achieve continence but did not significantly increase the continence rate at 9 months. Similarly, in the study of Wei et al.[12] the median time to continence recovery was significantly shorter in the nerve-sparing than in the control group (5.3 vs 10.9 months). Nevertheless, this issue is controversial, as patients who are candidates for neurovascular preservation are more likely to be continent because of their overall health, age and tumour stage [14]. Furthermore, no large study has shown that the incontinence rate in the long-term was significantly lower with such neurovascular bundle-sparing techniques.

Vesico-urethral anastomosis

Mucosa-to-mucosa apposition of the bladder neck to the urethra is advocated by most authors to reduce the incidence of anastomotic strictures, thus decreasing the risk of incontinence. Some authors have recommended incorporating the tissue posterior to the urethra into the vesico-urethral anastomosis [21,29].

Indeed, various techniques of vesico-urethral anastomosis have been described in order to reduce the risk of strictures and incontinence. Again, it is difficult to interpret the effectiveness of such modifications, as none of them has yet provided complete continence after RP.

Seminal vesicle-sparing RP

Hollabaugh et al.[13] reported that dissecting the seminal vesicles during RP is important in pelvic denervation. The estimated percentage of patients with prostate cancer progression as a result of a limited resection of the seminal vesicles is only 0.3% [30]. For some surgeons it is therefore possible to undertake a limited resection of the seminal vesicles in patients with favourable biopsy features. In a recent study, John and Hauri [31] prospectively compared the outcome of 34 patients undergoing standard RP with those of 20 patients undergoing a modified RP with preservation of the tip of the seminal vesicles. The continence rate at 6 months was significantly higher in the seminal vesicle-sparing RP than in the standard RP group (95% vs 82%). As only a few patients were enrolled in this study, these conclusions should be interpreted with caution. Further evaluation of seminal vesical-sparing RP is needed to determine its effect on the restoration of continence.

The laparoscopic approach

Some authors reported very encouraging continence rates after a laparoscopic approach for RP. Analysing the outcome of 100 patients undergoing laparoscopic procedures, Rassweiler et al.[32] noted that 81% of patients were completely continent after 6 months. After 9 months, only two patients still had grade II stress incontinence. In another recent report of 240 laparoscopic RPs, Guillonneau et al.[33] noted that 83.5% of patients were perfectly continent (no urine leakage) after 6 months. At 6 months, 19 patients were still wearing pads (four as a precaution, seven one pad daily, and eight >1 pad daily). For these authors, the laparoscopic approach allowed a better visualization and a more precise dissection of the apex. Such good results for continence may be explained by a more elective transection of the dorsal venous complex, preservation of a longer segment of urethra, and a more precise vesico-urethral anastomosis using running sutures.

Treatment of early incontinence

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

Early urinary incontinence affects 30–50% of patients for a variable period (3 weeks to 6 months). Detrusor instability is important in the early postoperative period [5]; it is therefore logical to treat patients with physiotherapy and anticholinergic medication before considering any surgical treatment. Indeed, most of the patients who have early incontinence will have a favourable course with no surgery.

The benefit of pelvic floor re-education on early urinary continence has been widely emphasized; it is reasonable to offer a biofeedback protocol to active patients with moderate incontinence 6–8 weeks after RP [20]. As the effectiveness of physiotherapy mainly depends on motivation, attention should be focused on psychological support offered to the patient and his family.

Treatment of persistent stress incontinence

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

Persistent stress incontinence (after 1 year) affects 2–5% of patients after RP; this form of incontinence is usually severe and has a major effect on quality of life. In most cases it is caused by intrinsic sphincter deficiency and does not respond to physiotherapy (that should be nevertheless be used as a first-line treatment) and to anticholinergic medication. The treatment options are either injection therapy or implantation of an AUS.

Injection therapy

Retrograde injection of various substances (e.g. autologous fat, Teflon, silicone, collagen) in the region of the external sphincter has been reported to yield acceptable short-term success rates. Most of the studies reporting the results of injection therapy have concentrated on collagen. Evaluating the effectiveness of collagen injections in the treatment of stress incontinence after RP, Cummings et al.[34] reported an overall satisfaction rate of 58% with a mean follow-up of 10.4 months.

Some authors administer the injection as an outpatient procedure under local anaesthesia [35]. The main advantage of injection therapy is its low morbidity; in most series of transurethral injections, only a few minor complications have been reported. However, a significant problem of this treatment is its poor success rate in the long-term; in the study of Smith et al.[35], the rate of complete social continence after collagen injections decreased from 60.9% at 1 year to 42.8% at 2 years. Kabalin [36] previously reported no complete continence after transurethral injections of Teflon at a minimum follow-up of 11 months. In that study, 77% of patients experienced no detectable improvement in continence status with such injection therapy.

Moreover, some factors have been identified as predictors of no response to injection therapy. Patients with continuous leakage and those who underwent transurethral incision of a bladder neck stricture are unlikely to respond well to this treatment [35].

Antegrade injections through a suprapubic approach may achieve better results than retrograde injections. Appell et al.[37] studied percutaneous antegrade collagen injection in patients with incontinence after RP. In that series, all the patients had previously undergone retrograde collagen injections with no improvement in urinary continence status. The authors reported a 75% continence rate at 6 months, and a 37.5% continence rate at 12 months of follow-up. For these authors, the suprapubic approach allowed a more precise and generous injection around the bladder neck than from the transurethral approach.

In summary, injection therapy may be proposed to men with persistent incontinence, as this treatment is safe and well tolerated. However, patients should be informed that the effectiveness of such therapy is limited and tends to decrease with time.

The AUS

For men with stress incontinence caused by intrinsic sphincter deficiency, the AUS is a logical therapeutic option; in most RP series <5% of patients receive an AUS. Implanting an AUS has been reported to be the best treatment for incontinence after RP, with satisfactory rates of >80% in some series [38,39]. Fleshner and Herschorn [38] reported that 92% of patients were using two pads or fewer. In the series of Klijn et al.[39], 81% achieved satisfactory continence at a mean follow-up of 35 months.

The AUS can be implanted with the simultaneous correction of an anastomotic stricture, either using incision or placing a urethral stent. While AUS devices are very effective, their implantation may risk many complications, including mechanical failure, infections and erosions. Recently, Clemens et al.[40] reported that 36% of patients undergoing primary AUS implantation after RP required reimplantation at a mean follow-up of 41 months. In this series, the 5-year actuarial rate of revision was 50%. Similarly, in the study of Klijn et al.[39] only half the patients were continent and needed no revision at 5 years. Furthermore, less than half of patients achieve total continence with no pads, and most still have urinary leakage when there is a rapid rise in intra-abdominal pressure [38].

In conclusion, implanting an AUS is the most effective treatment for permanent stress urinary incontinence after RP. An AUS should be proposed to patients with severe intrinsic sphincter dysfunction, or after a failed primary attempt at injection therapy. However, patients should be informed of the risk of incomplete continence, and should be aware that surgical revisions in the years after primary implantation may be necessary.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Incidence
  5. Pathophysiology
  6. Risk factors
  7. Prevention
  8. Treatment of early incontinence
  9. Treatment of persistent stress incontinence
  10. Conclusions
  11. Authors

A significant proportion of patients still complain about urinary incontinence after RP. It is essential to distinguish bladder instability, which mainly occurs in the early postoperative period, from intrinsic sphincter dysfunction, which is mostly responsible for persistent stress incontinence. Indeed, the latter does not respond to physiotherapy and anticholinergic medication. The implantation of an AUS has changed the prognosis of stress incontinence after RP, but there is a high AUS-related morbidity and a significant rate of surgical revision of the device. In the future, new technical improvements might decrease the rate of urinary incontinence after RP.

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Abbreviations
RP

radical prostatectomy

MUCP

mean urethral closure pressure.

V. Ravery, Department of Urology, Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France. e-mail: vincent.ravery@bch.ap-hop-paris.fr