Urinary incontinence after radical prostatectomy: can men at risk be identified preoperatively?

Latest Evidence on Post-Prostatectomy Urinary Incontinence

A radical prostatectomy is frequently used as the first-line treatment for men with prostate cancer. Persistent urinary incontinence after surgery is one of the most severe adverse events. We report the results of a comprehensive literature search focused on post-prostatectomy urinary incontinence (PPI), performed by a panel of experts on non-neurogenic lower urinary tract symptoms. The data on the prevalence and timing of PPI are very heterogeneous. The etiology of PPI can be multifactorial and mainly dependent on patient characteristics, lower urinary tract function or surgical issues. The medical history with a physical examination, the use of validated questionnaires with a voiding diary and pad tests are determinants in identifying the contributing factors and choosing the right treatment. Lifestyle intervention and urinary containment are the most frequently used strategies for the conservative management of PPI, while antimuscarinics, beta-3 agonists and duloxetine (off-label) are drugs indicated to manage PPI with a concomitant overactive bladder. Surgical therapies for the management of post-prostatectomy SUI include non-adjustable trans-obturator slings in men with mild-to-moderate incontinence and an artificial urinary sphincter in men with moderate-to-severe incontinence.

A Matched-Pair Analysis after Robotic and Retropubic Radical Prostatectomy: A New Definition of Continence and the Impact of Different Surgical Techniques

Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.

Impact of Urinary Incontinence on the Quality of Life After Open Retropubic Radical Prostatectomy

Introduction

Radical retropubic prostatectomy is one of the standard treatments for localized prostate cancer. Evaluating the severity of postoperative urinary incontinence is primordial to guiding the treatment choice, and it still lacks standardization, hence the value of assessing the quality of life.

Methods

We conducted a retrospective study between January 2014 and December 2018 in the Urology Department of La Rabta Hospital, involving 30 patients followed for localized prostate cancer treated with radical prostatectomy for at least one year. Our work aimed to study urinary incontinence after radical retropubic prostatectomy and to evaluate the quality of life of patients who underwent surgery for localized prostate cancer by three validated questionnaires: The International Prostate Symptom Score (IPSS), The International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) and the International Continence Society (ICS) scores.

Results

The preoperative IPSS score ranged from 5-22, averaging 11.13. After the surgery, it ranged between four and 23, with an average of 14.13. This increase was significant, with p = 0.001. The average preoperative ICIQ-SF score was 10.03, and the mean postoperative score was 14.23. The first question dealing with the frequency of episodes of urinary leakage has not demonstrated variation after surgery. In the second question, which deals with the amount of urine loss, we found a significant increase in this parameter with p=0.003. In the third question inherent to perceived discomfort, operated patients reported significant deterioration with p <0.001.

We observed an increase in patients with urinary stress incontinence and enuresis on the ICS score after radical retropubic prostatectomy. Wearing protection or padding was required in 23.3% of patients.

Conclusion

IPSS, ICIQ-SF, and ICS scores are helpful to perform before and after radical retropubic prostatectomy. It helps to study urinary incontinence better, propose to each patient with postoperative complications the appropriate treatment option, and improve the quality of the urinary status.

Changes in quality of life and lower urinary tract symptoms over time in cancer patients after a total prostatectomy: systematic review and meta-analysis

PURPOSE

This study aimed to clarify associations between and changes over time in lower urinary tract symptoms (LUTS) and quality of life (QOL) in cancer patients after a total prostatectomy.

METHODS

The subjects were cancer patients who had undergone total prostatectomy and had participated in non-randomized controlled trials, cohort studies, or case-control studies with outcomes of changes over time in LUTS or QOL. Fourteen studies were included for systematic review and meta-analysis.

RESULTS

Compared to preoperatively, the International Prostate Symptom Score (IPSS)-a LUTS indicator-yielded the following, 3 months after operation (MD [95% confidence interval, CI] = -0.27 [-2.22 to 1.68], p = .7855), 6 months after operation (MD [95% CI] = -2.12 [-3.04 to -1.20], p < .0001), and 12 months after operation (MD [95% CI] = -2.27 [-2.63 to -1.92], p < .0001), demonstrating significant decrease and, therefore, improvement of symptoms after 6 months. International Prostate Symptom Score-Quality of Life (IPSS-QOL), a QOL indicator, was significantly reduced at 12 months after surgery, indicating improved QOL (MD [95% CI] = -0.49 [-0.87 to -0.11], p = .0107), but there was heterogeneity between different studies (I² = 89.19%). A cumulative meta-analysis showed a tendency for greater improvements in IPSS-QOL at 12 months after surgery, the older the mean age and the higher the mean pre-surgery IPSS. Factors of age, prostate volume, and pre-surgery IPSS were related to postoperative LUTS; exacerbation of both urinary incontinence and urinary tract obstruction was related to QOL.

CONCLUSION

While LUTS improves over time after total prostatectomy, it takes 6 to 12 months after surgery. As there is an association between LUTS and QOL, support to promote self-management of LUTS is important.

Patient- and Tumour-related Prognostic Factors for Urinary Incontinence After Radical Prostatectomy for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

While urinary incontinence (UI) commonly occurs after radical prostatectomy (RP), it is unclear what factors increase the risk of UI development.

OBJECTIVE

To perform a systematic review of patient- and tumour-related prognostic factors for post-RP UI. The primary outcome was UI within 3 mo after RP. Secondary outcomes included UI at 3-12 mo and ≥12 mo after RP.

EVIDENCE ACQUISITION

Databases including Medline, EMBASE, and CENTRAL were searched between January 1990 and May 2020. All studies reporting patient- and tumour-related prognostic factors in univariable or multivariable analyses were included. Surgical factors were excluded. Risk of bias (RoB) and confounding assessments were performed using the Quality In Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were performed for all prognostic factor, where possible.

EVIDENCE SYNTHESIS

A total of 119 studies (5 randomised controlled trials, 24 prospective, 88 retrospective, and 2 case-control studies) with 131 379 patients were included. RoB was high for study participation and confounding; moderate to high for statistical analysis, study attrition, and prognostic factor measurement; and low for outcome measurements. Significant prognostic factors for postoperative UI within 3 mo after RP were age (odds ratio [OR] per yearly increase 1.04, 95% confidence interval [CI] 1.03-1.05), membranous urethral length (MUL; OR per 1-mm increase 0.81, 95% CI 0.74-0.88), prostate volume (PV; OR per 1-ml increase 1.005, 95% CI 1.000-1.011), and Charlson comorbidity index (CCI; OR 1.28, 95% CI 1.09-1.50).

CONCLUSIONS

Increasing age, shorter MUL, greater PV, and higher CCI are independent prognostic factors for UI within 3 mo after RP, with all except CCI remaining prognostic at 3-12 mo.

PATIENT SUMMARY

We reviewed the literature to identify patient and disease factors associated with urinary incontinence after surgery for prostate cancer. We found increasing age, larger prostate volume, shorter length of a section of the urethra (membranous urethra), and lower fitness were associated with worse urinary incontinence for the first 3 mo after surgery, with all except lower fitness remaining predictive at 3-12 mo.

Prevalence analysis of urinary incontinence after radical prostatectomy and influential preoperative factors in a single institution

AIMS

To assess prevalence of urinary incontinence (UI) after radical prostatectomy (RP) and to analyze which preoperative characteristics of the patients have influence on UI.

METHODS

Between 2002 and 2012, 746 consecutive patients underwent RP for clinically localized prostate cancer. We defined UI according to International Continence Society (ICS) definition: "the complaint of any involuntary leakage of urine" after 12 months of recovery, international consultation on incontinence questionnaire (ICIQ-SF) and pads/day was collected too. Clinical features and magnetic resonance imaging measurements were assessed. A multivariable logistic regression model predicting incontinence were built-in after adjust by cofounding factors and bootstrapping.

RESULTS

About 172 (23%) of the patients were classified as incontinent according to the ICS definition. The mean value of the ICIQ-SF was 10.87 (±4). 17.8% of patients use at least one pad/day, 11.9% use more than one pad/day. The preoperative factors independently influential in UI are: age [OR: 1.055; CI 95% (1.006-1.107), p = .028], urethral wall thickness [OR: 5.03; CI 95% (1.11-22.8), p = .036], history of transurethral resection of the prostate [OR: 6.13; CI 95% (1.86-20.18), p = .003] and membranous urethral length [OR: 0.173; CI 95% (0.046-0.64), p = .009]. The predictive accuracy of the model is 78.7% and the area under the curve (AUC) value 71.7%.

CONCLUSIONS

Urinary incontinence after radical prostatectomy has different prevalence depending on the definition. Age, prior transurethral resection of the prostate (TURP), membranous urethral length (MUL) and urethral wall thickness (UWT) were risk factors.

Quality of Life after post-prostatectomy intensity modulated radiation therapy to the prostate bed with or without the use of gold fiducial markers for image guidance or higher total radiotherapy doses

Purpose

To evaluate quality of life (QoL) after post-prostatectomy intensity modulated radiation therapy (IMRT) in the “adjuvant” setting starting within 4 months of radical prostatectomy for adverse features; and “salvage” setting for a PSA≥0.2ng/mL.

Materials and Methods

Retrospective review of 130 patients who underwent IMRT to the prostate bed±gold fiducial marker placement for image guidance to 64.8-72.0Gy (median, 70.2Gy) between 2004 and 2013. Higher doses were defined as 70.2-72.0Gy and lower doses were defined as 64.8-68.4Gy. Androgen deprivation therapy (ADT) was given to 4/48 (8%) adjuvant patients and 9/82 (11%) salvage patients. International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM), and Expanded Prostate Cancer Index Composite-26-bowel (EPIC-26-bowel) questionnaires were used to assess urinary, sexual, and bowel QoL, respectively.

Results

Median follow-up was 46 months. There were better urinary (p=0.03) and sexual (p=0.002) QoL scores with adjuvant IMRT relative to salvage IMRT. The use of prostate bed fiducial markers did not significantly affect urinary, sexual, or bowel QoL (p=0.39, p=0.49, and p=0.40, respectively). Higher total radiotherapy doses did not significantly affect urinary, sexual, or bowel QoL (p=0.21, p=0.61, and p=0.36, respectively).

Conclusions

There was no significant change in urinary, sexual, and bowel sexual QoL with post-prostatectomy IMRT regardless of whether prostate bed fiducial markers or higher total radiotherapy doses were used. QoL with IMRT in the present study compares favorably with prior reports for three-dimensional conformal radiation therapy.

Comparison of Robot-Assisted Radical Prostatectomy and Open Radical Prostatectomy Outcomes: A Systematic Review and Meta-Analysis

PURPOSE

To systematically update evidence on the clinical efficacy and safety of robot-assisted radical prostatectomy (RARP) versus retropubic radical prostatectomy (RRP) in patients with prostate cancer.

MATERIALS AND METHODS

Electronic databases, including ovidMEDLINE, ovidEMBASE, the Cochrane Library, KoreaMed, KMbase, and others, were searched, collecting data from January 1980 to August 2013. The quality of selected systematic reviews was assessed using the revised assessment of multiple systematic reviews and the modified Cochrane Risk of Bias tool for non-randomized studies.

RESULTS

A total of 61 studies were included, including 38 from two previous systematic reviews rated as best available evidence and 23 additional studies that were more recent. There were no randomized controlled trials. Regarding safety, the risk of complications was lower for RARP than for RRP. Among functional outcomes, the risk of urinary incontinence was lower and potency rate was significantly higher for RARP than for RRP. Regarding oncologic outcomes, positive margin rates were comparable between groups, and although biochemical recurrence (BCR) rates were lower for RARP than for RRP, recurrence-free survival was similar after long-term follow up.

CONCLUSION

RARP might be favorable to RRP in regards to post-operative complications, peri-operative outcomes, and functional outcomes. Positive margin and BCR rates were comparable between the two procedures. As most of studies were of low quality, the results presented should be interpreted with caution, and further high quality studies controlling for selection, confounding, and selective reporting biases with longer-term follow-up are needed to determine the clinical efficacy and safety of RARP.

Pelvic-Floor-Muscle Training Adherence: Tools, Measurements and Strategies-2011 ICS State-of-the-Science Seminar Research Paper II of IV

AIMS

This paper on pelvic-floor-muscle training (PFMT) adherence, the second of four from the International Continence Society's 2011 State-of-the-Science Conference, aims to (1) identify and collate current adherence outcome measures, (2) report the determinants of adherence, (3) report on PFMT adherence strategies, and (4) make actionable clinical and research recommendations.

METHOD

Data were amassed from a literature review and an expert panel (2011 conference), following consensus statement methodology. Experts in pelvic floor dysfunction collated and synthesized the evidence and expert opinions on PFMT adherence for urinary incontinence (UI) and lower bowel dysfunction in men and women and pelvic organ prolapse in women.

RESULTS

The literature was scarce for most of the studied populations except for limited research on women with UI.

OUTCOME MEASURES

Exercise diaries were the most widely-used adherence outcome measure, PFMT adherence was inconsistently monitored and inadequately reported. Determinants: Research, mostly secondary analyses of RCTs, suggested that intention to adhere, self-efficacy expectations, attitudes towards the exercises, perceived benefits and a high social pressure to engage in PFMT impacted adherence.

STRATEGIES

Few trials studied and compared adherence strategies. A structured PFMT programme, an enthusiastic physiotherapist, audio prompts, use of established theories of behavior change, and user-consultations seem to increase adherence.

CONCLUSION

The literature on adherence outcome measures, determinants and strategies remains scarce for the studied populations with PFM dysfunction, except in women with UI. Although some current adherence findings can be applied to clinical practice, more effective and standardized research is urgently needed across all the sub-populations.

Lower urinary tract symptoms of prostate cancer patients undergoing treatments over eight-month follow-up

AIMS AND OBJECTIVES

To examine the changes in lower urinary tract symptoms after open radical prostatectomy, laparoscopic radical prostatectomy and brachytherapy and to determine which treatment resulted in improved lower urinary tract symptoms at 8 months follow-up.

BACKGROUND

Lower urinary tract symptoms are a primary side effect after prostate cancer treatment.

DESIGN

A time-series survey design with descriptive and comparative elements.

METHODS

A sample of 51 prostate cancer patients was recruited: open radical prostatectomy = 20, laparoscopic radical prostatectomy = 23 and brachytherapy = 8. Data were collected at six time points: before treatment/baseline, 1 week post-treatment, 1 month post-treatment, 2 month post-treatment, 3 month post-treatment and 8 months post-treatment. The lower urinary tract symptoms were assessed using the International Prostate Symptom Score, with a higher score indicating a worse condition. One-way anova was used to predict the progress of urinary symptoms after treatments. Bootstrap re-sampling was conducted to assess the stability of the outcomes.

RESULTS

Although there were no significant differences in the lower urinary tract symptoms among the three groups after treatments, the laparoscopic radical prostatectomy group had the lowest International Prostate Symptom Score score at baseline. Compared with the baseline symptoms for patients undergoing each treatment, there were significant improvements after 2 months in the open radical prostatectomy and brachytherapy groups, and after 3 months in the laparoscopic radical prostatectomy group.

CONCLUSIONS

The prostate cancer patients undergoing the three treatments have similar lower urinary tract symptoms over 8-month follow-up although different lower urinary tract symptoms were presented before treatments.

RELEVANCE TO CLINICAL PRACTICE

Results could be applied to educating and counselling prostate cancer patients regarding symptoms during recovery after surgery. It could also help patients better understand the outcomes related to the differing treatment methods.

Oncological and functional outcomes of 722 robot-assisted radical prostatectomy (RARP) cases: The largest Canadian 5-year experience

INTRODUCTION

While RARP (robotic-assisted radical prostatectomy) has become the predominant surgical approach to treat localized prostate cancer, there is little Canadian data on its oncological and functional outcomes. We describe the largest RARP experience in Canada.

METHODS

Data from 722 patients who underwent RARP performed by 7 surgeons (AEH performed 288, TH 69, JBL 23, SB 17, HW 15, QT 7, and KCZ 303 patients) were collected prospectively from October 2006 to December 2013. Preoperative characteristics, as well as postoperative surgical and pathological outcomes, were collected. Functional and oncological outcomes were also assessed up to 72 months postoperative.

RESULTS

The median follow-up (Q1-Q3) was 18 months (9-36). The D'Amico risk stratification distribution was 31% low, 58% intermediate and 11% high-risk. The median operative time was 178 minutes (142-205), blood loss was 200 mL (150-300) and the postoperative hospital stay was 1 day (1-23). The transfusion rate was only 1.0%. There were 0.7% major (Clavien III-IV) and 10.1% minor (Clavien I-II) postoperative complications, with no mortality. Pathologically, 445 men (70%) were stage pT2, of which 81 (18%) had a positive surgical margin (PSM). In addition, 189 patients (30%) were stage pT3 and 87 (46%) with PSM. Urinary continence (0-pads/day) returned at 3, 6, and 12 months for 68%, 80%, and 90% of patients, respectively. Overall, the potency rates (successful penetration) for all men at 6, 12, and 24 months were 37%, 52%, and 59%, respectively. Biochemical recurrence was observed in 28 patients (4.9%), and 14 patients (2.4%) were referred for early salvage radiotherapy. In total, 49 patients (8.4%) underwent radio-therapy and/or hormonal therapy.

CONCLUSIONS

This study shows similar results compared to other high-volume RARP programs. Being the largest RARP experience in Canada, we report that RARP is safe with acceptable oncologic outcomes in a Canadian setting.

Recommended patient-reported core set of symptoms to measure in prostate cancer treatment trials

The National Cancer Institute (NCI) Symptom Management and Health-Related Quality of Life Steering Committee convened four working groups to recommend core sets of patient-reported outcomes to be routinely incorporated in clinical trials. The Prostate Cancer Working Group included physicians, researchers, and a patient advocate. The group's process included 1) a systematic literature review to determine the prevalence and severity of symptoms, 2) a multistakeholder meeting sponsored by the NCI to review the evidence and build consensus, and 3) a postmeeting expert panel synthesis of findings to finalize recommendations. Five domains were recommended for localized prostate cancer: urinary incontinence, urinary obstruction and irritation, bowel-related symptoms, sexual dysfunction, and hormonal symptoms. Four domains were recommended for advanced prostate cancer: pain, fatigue, mental well-being, and physical well-being. Additional domains for consideration include decisional regret, satisfaction with care, and anxiety related to prostate cancer. These recommendations have been endorsed by the NCI for implementation.

Counseling the post-radical prostatectomy patients about functional recovery: high predictiveness of current status

OBJECTIVE

To develop prediction models to help counsel post-radical prostatectomy patients about functional recovery.

METHODS

The study included 2162 patients undergoing radical prostatectomy at a major cancer center, who reported urinary and erectile function at 1 year or at 2 years and at least 1 prior follow-up at 3, 6, 9, or 12 months. We created logistic regression models predicting function at one or 2 years on the basis of function at 3, 6, 9, and 12 months (2 years only), with the additional predictors of age, stage, grade, prostate-specific antigen levels, nerve-sparing status and baseline functional score.

RESULTS

No variable other than current functional score had a consistent statistically significant relationship with outcome. The area under the curves for predicting function at 2 years based on current function alone at 3, 6, 9, and 12 months were respectively 0.796, 0.831, 0.882, and 0.885 for erectile function and 0.789, 0.862, 0.869, and 0.876 for urinary function. Patients using 1 pad at 6 months had only a 50% probability of being pad free at 2 years; this dropped to 36% for patients using 2 pads. This suggests that there is an opportunity for early identification and possible referral of patients likely to have long-term urinary dysfunction.

CONCLUSION

Assessment of urinary and erectile function in the first postoperative year is strongly predictive of long-term outcome and can guide patient counseling and decisions about rehabilitative treatments.

Post-prostatectomy incontinence: Etiology, evaluation, and management

Urinary incontinence after prostatectomy or radiation is a devastating problem in men and remains the most feared complication following the treatment of localized prostate cancer. With an increasing number of radical prostatectomies performed globally for prostate cancer, the impact of urinary incontinence on quality of life assumes an even greater importance. With the advent of male sling procedures, more men are now seeking treatment for incontinence. Since the introduction of the artificial urinary sphincter almost four decades ago, several surgical procedures have emerged to manage post-prostatectomy incontinence, including the male sling for milder forms of incontinence. Several of the newer procedures have shown promise in the United States; many others have been developed and utilized in other parts of the world, though they have not yet gained FDA approval in the United States. The present review seeks to illuminate the etiology, evaluation, and management of post-prostatectomy incontinence. An effort has been made to provide an algorithm to clinicians for appropriate surgical management. The surgical techniques of commonly performed procedures and their outcomes are described.

Perioperative, oncological and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases

BACKGROUND

Robotic-assisted radical prostatectomy (RARP) is being increasingly done in Canada. Despite this, the Canadian literature lacks publications on the oncologic and functional outcomes of RARP. The objective of this study is to report the longest single surgeon experience in the province of Quebec.

METHODS

We collected prospective data from 250 consecutive patients who underwent RARP by a single fellowship trained surgeon (AEH) from October 2006 to October 2012. Mean follow-up was 28 months (range: 1-72). The D'Amico risk stratification distribution was 34% in low-risk, 48% in intermediate-risk and 18% in high-risk groups.

RESULTS

The mean operation time (±SD) was 194 ± 60.6 minutes, and estimated blood loss 318 ± 179 mL. The transfusion rate was only 0.4%. All procedures were completed robotically. The mean hospital stay was 1.2 days, and 88% of patients were discharged on postoperative day 1. The mean catheterization time was 7 days (range: 6-13). There were 2% major (Clavien III-IV) and 7.2% minor (Clavien I-II) postoperative complications, and no mortalities. On final pathology, 76% of patients were organ-confined and 70% specimen-confined. Pathological Gleason sum ≥7 accounted for 86%. Return of urinary continence (0-pads) at 3, 6, 12, and 24 months was 73.3%, 83.5%, 92.3%, 96.5%, respectively. Potency rate (successful penetration with or without medication) at 6, 12, and 24 months was 49.3%, 85%, and 95.3%, respectively. Operative time and positive surgical margin (PSM) in organ-con-fined disease (pT2) decreased significantly after 50 cases. Seventeen patients (6.8%) had no undetectable prostate-specific antigen (PSA) at first visit (PSA <0.1 ng/mL). Of remaining 233 patients, biochemical recurrence (PSA >0.2 ng/mL) was 4.7% (11 patients), and another 3.4% (8 patients) received early salvage radiotherapy (rising PSA, but <0.2 ng/mL). No patients with undetectable PSA required salvage treatments within 6 months postoperatively.

CONCLUSIONS

Our results compare favourably with high-volume RARP programs, despite mainly intermediate- to high-risk disease. Initial learning curve was estimated to be 50 cases. Fellowship training was instrumental in achieving adequate functional and oncological outcomes, while maintaining low complications rate.

Psychological aspect of qualification to implant an artificial urethral sphincter AMS 800

INTRODUCTION

Implantation of the AMS 800 artificial urethral sphincter is a "gold standard" in the treatment of total urinary incontinence in men. Appropriate qualification of patients to urinary incontinence treatment determines the higher effectiveness of this method. Service of this device requires physical fitness and mental efficiency from a patient.

MATERIAL AND METHODS

The Urological Clinic hospitalized 16 patients, aged from 60 to 80 years, after first qualification for artificial urethral sphincter implantation. Psychological assessment was carried out during anamnesis and medical examination using the MMSE and the GDS.

RESULTS

Psychological deviations were found in 7 out of 16 examined patients, but finally 2 patients were disqualified because of their cognitive function disorders with elements of low level depressive syndrome (1) and benign cognitive and member function disorders (1). Among the patients who were examined by a psychologist: four of them showed mild (3) and temperate (1) features of depressive syndrome and one patient showed benign cognitive disorder without dementia. However, none of these findings were contraindications to incontinence treatment with an artificial urethral sphincter.

CONCLUSIONS

1. Mild and temperate features of depression syndrome are not absolute contraindications for a sphincter AMS 800 implantation. These patients need only pharmacological treatment. 2. Cognitive and other memory disorders are contraindications to this method. 3. The qualification to implantation an artificial urethral sphincter should include a psychological assessment, especially in older patients in whom mental disorders are suspected.

Bladder neck preservation during classic laparoscopic radical prostatectomy - point of technique and preliminary results

Introduction

Stress urinary incontinence after radical prostatectomy for prostate cancer organ-confined patients can significantly affect quality of life. The article presents a technique of bladder neck preservation, because it is believed that this point is one of many crucial points responsible for fast recovery of continence after laparoscopic radical prostatectomy (LRP).

Material and methods

Laparoscopic radical prostatectomy with the intention of bladder neck preservation was performed in 194 patients of clinically organ-confined prostate cancer (cT2 ≤ N0M0). The working space was done by tissues-fingers dissections and insufflation of the cavity under full visual control, without the Gaur-balloon device. We insert two 10 mm trocars, three trocars of 5 mm and both 0° and 30° laparoscopes. The most important points of technique include: identification of landmarks of bladder neck and prostate base; dissection of muscle fibres of the very superficial bladder wall; mobilization of the posterior part of the urethra and simultaneous seminal vesicles release; neuro-vascular bundles preservation. This procedure resulted in a long bladder neck which can be easily anastomosed with the urethra. Tension-free and end-to-end (bladder neck-urethra) anastomosis are the results.

Results

In all cases radical prostatectomy was performed laparoscopically in the extraperitoneal space. There were no complications of bladder neck preservation during laparoscopic radical prostatectomy (LRP) apart from 22 cases with a large medium lobe. The mean time of operation was 150 min (110-210 min). The mean blood loss during LRP was 150 ml (110-350 ml). Blood transfusion was not necessary. There were no postoperative complications. Mean hospitalization time was 5 days. Pathological result of the postoperative specimens was pT2a in 30%, pT2b in 60%, pT3a in 6%, and pT3b in 4% of patients. In 7% of patients a positive surgical margin was affirmed, but the bladder neck was not affected in any case. Full continence after 3, 6, and 12 months was observed in 75%, 85%, and 92% of analysed patients, respectively.

Conclusions

Bladder neck preservation during LRP is an effective, safe procedure that offers good functional results based on fast recovery of continence. Bladder neck preservation offers full tight anastomosis, especially in cases with no large median lobe of prostatic adenoma. Continence of patients who underwent bladder neck preservation was improved during short-term follow-up. Long-term results are still not conclusive. We think that this technique applied to laparoscopy will finally result in real progress of continence preservation after radical prostatectomy, but larger groups of patients have to be compared.

Post-prostatectomy incontinence: implications for home health clinicians

Prostate cancer is the most frequently diagnosed cancer in men in the United States, often requiring a prostatectomy. Incontinence is an almost inevitable consequence of this surgery, either temporary or ongoing. It is important that this quality-of-life issue be considered preoperatively and that patients considering surgery have information about the potential for incontinence. Teaching about noninvasive management of incontinence can begin before surgery and continue in the postoperative period. Home healthcare clinicians and Wound, Ostomy and Continence (WOC) nurses can play a pivotal role in educating patients on the potential sequela of surgery and ways to prevent or treat these conservatively.