Post-Prostatectomy Incontinence: Urodynamic Findings and Treatment Outcomes

Suppression of detrusor overactivity in rats with bladder outlet obstruction by a type 4 phosphodiesterase inhibitor

OBJECTIVE

To investigate the effects of a selective type 4 cyclic nucleotide phosphodiesterase (PDE4) inhibitor, IC486051, on bladder activity in normal rats and those with and bladder outlet obstruction (BOO), as inhibition of PDE4 leads to elevation of intracellular cAMP levels and relaxation of smooth muscle.

MATERIALS AND METHODS

BOO was induced in female Sprague-Dawley rats by tying a silk ligature around the urethra. At 4 or 6 weeks after inducing BOO, conscious rats were assessed by cystometry with the urethral ligature intact. In unobstructed rats, blood pressure was also measured.

RESULTS

In unobstructed rats, IC486051 (0.1 mg/kg intravenously) produced no significant changes in cystometric variables, while at a dose of 0.5 mg/kg maximum voiding pressure was reduced by 34%. At both doses, there was a small, transient increase in blood pressure. In both 4- and 6-week BOO rats IC486051 dose-dependently decreased the number and amplitude of non-voiding bladder contractions by up to 80%, relative to pre-treatment values. At doses of 0.1 and 0.5 mg/kg IC486051 had no significant effect on voiding variables. In the 4-week BOO rats, a dose of 1.0 mg/kg decreased bladder capacity, voided volume and residual volume by 21%, 32% and 18%, respectively. In 6-week BOO rats, a dose of 1.0 mg/kg decreased maximal voiding pressure by 17% and pressure threshold for voiding by 28%. In both groups of rats with BOO, voiding efficiency was unchanged.

CONCLUSIONS

A selective PDE4 inhibitor can effectively suppress detrusor overactivity in rats with BOO, at doses that have no effect on voiding bladder contractions. Thus, selective PDE4 inhibitors should be considered for the treatment of overactive bladder in patients with BOO.

An adjustable male sling for treating urinary incontinence after prostatectomy: a phase III multicentre trial

OBJECTIVE

To evaluate the efficacy and safety of a new adjustable bulbourethral sling (Argus, Promedon SA, Cordoba, Argentina) in the treatment of male stress urinary incontinence (SUI) after prostate surgery.

PATIENTS AND METHODS

In all, 48 patients with SUI because of prostatic surgery for prostate cancer (39) or benign prostatic hyperplasia (nine) had a new sling implanted in a multicentre trial at six institutions between April 2003 and September 2004. All patients were fully evaluated, including a questionnaire (International Consultation on Incontinence Questionnaire-Short Form, ICIQ-SF, range 0-21), endoscopy, and urodynamic evaluation. The Argus system comprises a 4.2 x 2.6 x 0.9 cm thick silicone foam pad for soft bulbar urethral compression. The pad is attached to the silicone cone columns that, after being passed with needles from the perineum to the abdominal wall, are adjusted with silicone washers to regulate and keep the desired tension against the urethra. The pad and washers are radio-opaque, which allows their position to be assessed during follow-up. The surgical technique was one described previously, with some modifications.

RESULTS

At a mean (range) follow-up of 7.5 (1-17.5) months, 35 (73%) of the 48 patients were dry, five (10%) were improved, and eight (17%) were incontinent, including four (8%) who needed sling adjustment. The mean (range) ICIQ-SF improved from 19.2 (12-21) to 4 (0-21). There were three (6%) urethral perforations during surgery that were resolved by re-passing the needle. The sling was removed in three men (6%) due to erosion and in two (4%) due to infection. Seven (15%) cases of acute urinary retention resolved spontaneously, except for one that needed the sling loosening. No cases of chronic retention were reported. There was perineal discomfort and mild dysuria soon after surgery that resolved spontaneously after a few weeks.

CONCLUSION

This new adjustable male sling safely and effectively controls sphincter incontinence in men after prostate surgery, with an acceptably low complication rate. The early results are encouraging; the Argus is a valid alternative to the artificial urinary sphincter, the standard therapy for this condition.

The role of imaging in urinary incontinence

A detailed history, physical examination, symptom and quality-of-life assessment, and urine analysis are unanimously considered essential components of the initial evaluation of urinary incontinence. Beyond these assessments, there are no universally accepted recommendations and, to date, imaging is not recommended in the initial management of urinary incontinence. In selected patients, urodynamics and/or a radiographic evaluation may be indicated. According to International Continence Society guidelines, imaging of the upper and lower urinary tract is indicated only if renal damage or pelvic pathology are suspected; video-urodynamics and voiding cysto-urethrography are considered optional diagnostic tests and continue to be refined; magnetic resonance imaging is considered an important research tool in evaluating lower urinary tract disorders, but at present its clinical role remains investigational.

Recovery of health related quality of life after radical prostatectomy in Japanese men: A longitudinal study

BACKGROUND

We performed a longitudinal survey of health related quality of life (HRQOL) after radical retropubic prostatectomy (RP) in Japanese men with localized prostate cancer.

METHODS

The present study started with self-reported HRQOL assessments provided by 72 patients who received only RP. The RAND 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index were administered before and 3, 6 and 12 months after RP.

RESULTS

Patients who underwent RP showed problems in some domains of general HRQOL, but these problems diminished over time. Urinary function declined substantially at 3 months and continued to recover at 6 and 12 months, but scored lower than the baseline. Urinary bother at 3 months had a significant decrease, but at six months it turned out to be the same as the baseline. The data of sexual function and bother showed a substantially lower score after RP. The sexual bother score of the younger men was significantly worse than that of the older men. Those who underwent nerve sparing procedures experienced significantly better recovery of urinary and sexual functions than the non-nerve sparing group.

CONCLUSION

Despite reports of problems with sexuality and urinary continence, general HRQOL was mostly unaffected by RP after 6 months. Although there was a substantial decrease in urinary function, recovery from urinary bother was rapid. Deterioration of the sexual domain was remarkable throughout the postoperative period. Therefore, careful attention should be given to preoperative counseling, especially for younger patients.

Delayed recovery of urinary continence after laparoscopic radical prostatectomy

AIM

To study the rate at which patients regained urinary continence during our institution's early experience with laparoscopic radical prostatectomy.

METHODS

The urinary continence of 34 patients was recorded at various intervals following laparoscopic radical prostatectomy. These data were compared with those from 49 patients who had undergone radical retropubic prostatectomy.

RESULTS

For laparoscopic prostatectomy patients, 2.9% had regained urinary continence at 1 month, 29.4% at 3 months, 46.9% at 6 months, 56.0% at 9 months and 60.0% at 12 months. For retropubic prostatectomy patients, the corresponding rates were 22.4% at 1 month, 63.3% at 3 months, 84.1% at 6 months, 92.9% at 9 months and 92.9% at 12 months. Backward stepwise logistic regression analysis indicated that laparoscopic surgery itself significantly predicted urinary incontinence at every interval from 1 to 9 months following surgery (P < 0.05).

CONCLUSION

Patients' postoperative recovery of urinary continence was not satisfactory in our early experience with laparoscopic radical prostatectomy. Further efforts to elucidate the reason for this poor functional outcome are mandatory before the procedure is accepted as part of standard practice.

The artificial urinary sphincter in men incontinent after radical prostatectomy: 5 year actuarial adequate function rates

OBJECTIVE

To determine the success (as both continence and revision rates) of the artificial urinary sphincter (AUS) in men incontinent after radical prostatectomy, and thus improve the preoperative counselling provided for these patients.

PATIENTS AND METHODS

The AUS was implanted in 27 men incontinent after radical prostatectomy (mean age 69 years, range 59-75) at a mean (range) interval of 20 (4-60) months after surgery. The Kaplan-Meier method of survival analysis was used to determine the 'primary adequate function' (PAF) rate and the 'additional procedure-assisted adequate function' (APA-AF) rate. Adequate function was defined as satisfactory continence (use of at most one pad per 24 h) in combination with good AUS function. PAF was defined when no revisions of the AUS were required and APA-AF when one or more revisions of one or more parts of the AUS were required; a complete exchange or explantation of the AUS defined failure, i.e. the end of APA-AF.

RESULTS

At a mean follow-up of 35 months, 81% of the patients had achieved satisfactory continence. However, the 5 year PAF and APA-AF rates, based on the Kaplan-Meier curves, were 49% and 71%, respectively.

CONCLUSIONS

Implantation of an AUS can provide excellent continence rates in patients incontinent after radical prostatectomy, but only at the expense of a considerable re-operation rate. The outcome is best represented by Kaplan-Meier curves of the PAF and the APA-AF.

Therapeutic efficacy of clenbuterol for urinary incontinence after radical prostatectomy

BACKGROUND

Urinary incontinence is one of the most common complications occurring after radical prostatectomy. We evaluated the efficacy of clenbuterol, a selective beta 2-adrenoceptor agonist, in the treatment of incontinence occurring after radical prostatectomy, using urodynamic assessment.

METHODS

Fourteen men (mean age, 68 years) with post-radical-prostatectomy incontinence were treated with 20 mg of clenbuterol twice a day for 1 month. The urodynamic assessment was performed on all patients before and after the administration of clenbuterol. A pad scoring system was used to gauge the severity of incontinence before and after treatment.

RESULTS

At 1 month after administration of clenbuterol, 9 of the 14 patients (64%) had dramatic improvement in pad scores. Treatment failed in 5 patients (36%) with severe incontinence. The results of urodynamic studies showed that the mean functional urethral length of the patients with post-radical-prostatectomy incontinence increased significantly after treatment.

CONCLUSION

These results suggest that clenbuterol can be used as an effective agent for treating mild-to-moderate stress incontinence after radical prostatectomy.