Urinary incontinence and use of incontinence surgery after radical prostatectomy: a national study using patient-reported outcomes

NHS cancer services and systems-ten pressure points a UK cancer control plan needs to address

In this Policy Review we discuss ten key pressure points in the NHS in the delivery of cancer care services that need to be urgently addressed by a comprehensive national cancer control plan. These pressure points cover areas such as increasing workforce capacity and its productivity, delivering effective cancer survivorship services, addressing variation in quality, fixing the reimbursement system for cancer care, and balancing of the cancer research agenda. These areas have been selected based on their relative importance to ensuring sustainable cancer services, persistence as key issues in the NHS, and their impact on delivering better and more equitable and affordable patient outcomes. Many of these pressure points are not acknowledged explicitly in any current discourse. The evidence we provide points to their impact on the ability to deliver world class cancer care, but also to their amenability to affordable solutions if given the relevant prioritisation and investment. The current narrative needs to move away from a technocentric approach to improving care, to one focused on understanding the complexity of cancer services and the wider health system to drive improvements in survival, quality of life, and experience for patients.

[Structural health care reality in the surgical treatment of male stress incontinence in Germany]

BACKGROUND

Stress urinary incontinence in men is predominantly iatrogenic after radical prostatectomy or transurethral interventions. Current studies show that there is a deficit in the availability of surgical therapy not only in Germany. The aim of this study is to investigate in more detail the structural health care situation of surgical treatment of male stress incontinence in Germany.

MATERIALS AND METHODS

The evaluation of the surgical therapy of male stress incontinence in Germany is based on the OPS (Operationen- und Prozedurenschlüssel-German procedural classification) codes from hospital quality reports from 2011-2019.

RESULTS

From 2012-2019, the number of male incontinence surgeries declined from 2191 to 1445. The number of departments performing incontinence surgeries decreased from 275 to 244. In the multivariate analysis, a high number (≥ 50) of radical prostatectomies/year (RPE/year) is an independent predictor of a high-volume centre (≥ 10 procedures/year; odds ratio [OR] 6.4 [2.3-17.6]; p < 0.001). The most significant decrease was in sling surgery (from 1091 to 410; p < 0.001). Here, the number of cases decreased especially in departments that implanted a high number of slings (≥ 10 slings/year; -69%; -62.4 ± 15.5 surgeries/year; p = 0.007). In addition, the number of departments implanting slings decreased over the investigated time period (from 34 to 10; p < 0.001). This particularly affected departments that also had a low number of RPE/year (from 9 to 0; -100%).

CONCLUSION

The situation of surgical treatment of male stress urinary incontinence in Germany shows a clear decline in sling implantation, especially in small departments. On the one hand, this reflects the increasingly differentiated indications for sling implantation. On the other hand, it raises the suspicion that a gap in care has developed, as the decline was not compensated for by other surgical therapies.

The association between pre-diagnostic levels of psychological distress and adverse effects after radical prostatectomy

Objectives

To prospectively analyse the associations between pre-diagnostic levels of anxiety and depression and patient-reported urinary and sexual adverse effects after radical prostatectomy in a population-based setting.

Patients and Methods

In three Norwegian county hospitals, men referred with a suspicion of prostate cancer were asked to fill out a patient-reported outcome measurement (PROM) questionnaire prior to prostate biopsy. Those who later underwent radical prostatectomy were stratified into three distress groups according to their Hopkins Symptom Checklist 5-score. Additional PROM questionnaires, including the EPIC-26 to measure adverse effects, were collected at 6 and 12 months postoperatively. Multivariable mixed models were estimated and post hoc pairwise comparisons performed to explore differences in adverse effects between distress groups.

Results

A total of 416 men were included at baseline and of those, 365 (88%) returned questionnaires at 6 months and 360 (87%) at 12 months. After adjusting for confounders, men with high distress at baseline had worse urinary incontinence domain score (58.9 vs. 66.8, p = 0.028), more urinary bother (64.7 vs. 73.6, p = 0.04) and a higher risk of using incontinence pads (70.6% vs. 54.2%, p = 0.034) at 6 months than those with low distress. There was no difference in the sexual domain scores between distress groups postoperatively, but the high-distress group expressed more sexual bother (24.9 vs. 37.5, p = 0.015) and the intermediate-distress group had a greater probability of using sexual medications or devices (63.8% vs. 50.0%, p = 0.015) than the low-distress group at 6 months. At 12 months scores generally improved slightly and differences between distress groups were less evident.

Conclusion

Men with higher levels of anxiety and depression before prostate biopsy report more urinary and sexual adverse effects after radical prostatectomy. This should be considered both in treatment decision-making and during follow-up after radical prostatectomy.

Post-prostatectomy incontinence: a guideline of guidelines

AIM

To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI).

MATERIALS AND METHODS

The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018).

RESULTS

In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well.

CONCLUSION

This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

Outcomes with the Adjustable Transobturator Male System (ATOMS) for the Treatment of Male Stress Urinary Incontinence After Prostate Surgery and the Impact of Previous Radiotherapy

Background and objective

The adjustable transobturator male system (ATOMS) is an established treatment for patients with urinary incontinence after prostate surgery. Our objective was to evaluate the efficacy and the complication burdens associated with ATOMS with a focus on exploring the potential impact on previous radiotherapy (RT).

Methods

We performed a retrospective analysis for consecutive patients who underwent ATMOS implantation procedure at a tertiary center over an 11-yr study period. Outcomes of interest were dryness at 3-mo follow up, postoperative complications (≤30 d), and late treatment failures (>30 d).

Key findings and limitations

A total of 118 patients underwent ATOMS surgery performed by five different surgeons. Median follow-up was 67 mo (interquartile range 41-95). The mean 24-h pad count after surgery was 1.1 (range 0-8) and the mean reduction in pad weight was 179 g (range 0-1080). There was no significant difference in the reduction in pad use between groups with and without RT (-1.7 vs -2.4; p = 0.13). Multivariable analysis revealed that RT, degree of incontinence, and age were not risk factors for reoperation.

Conclusions and clinical implications

ATOMS implantation is feasible in patients who have undergone prostate RT and patients with severe stress urinary incontinence after prostate surgery. We found that RT was not a risk factor for reoperation and there was no significant difference in pad weight reduction by RT status. This study offers new insight into potential incontinence surgery for male patients with stress urinary incontinence and previous RT.

Patient summary

We assessed outcomes for patients who had an ATOMS (adjustable transobturator male system) device implanted to control stress urinary incontinence after prostate surgery. After implantation, 52.5% of the patients reported zero leakage and 39.9% reported only mild incontinence. Our results show that this device can improve continence after prostate surgery and is also suitable in patients who underwent radiotherapy.

What can patient-reported experience measures tell us about the variation in patients' experience of prostate cancer care? A cross-sectional study using survey data from the National Prostate Cancer Audit in England

OBJECTIVES

A national survey aimed to measure how men with prostate cancer perceived their involvement in and decisions around their care immediately after diagnosis. This study aimed to describe any differences found by socio-demographic groups.

DESIGN

Cross-sectional study of men who were diagnosed with and treated for prostate cancer.

SETTING

The National Prostate Cancer Audit patient-reported experience measures (PREMs) survey in England.

PARTICIPANTS

Men diagnosed in 2014-2016, with non-metastatic prostate cancer, were surveyed. Responses from 32 796 men were individually linked to records from a national clinical audit and to administrative hospital data. Age, ethnicity, deprivation and disease risk classification were used to explore variation in responses to selected questions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Responses to five questions from the PREMs survey: the proportion responding to the highest positive category was compared across the socio-demographic characteristics above.

RESULTS

When adjusted for other factors, older men were less likely than men under the age of 60 to feel side effects had been explained in a way they could understand (men 80+: relative risk (RR)=0.92, 95% CI 0.84 to 1.00), that their views were considered (RR=0.79, 95% CI 0.73 to 0.87) or that they were involved in decisions (RR=0.92, 95% CI 0.85 to 1.00). The latter was also apparent for men who were not white (black men: RR=0.89, 95% CI 0.82 to 0.98; Asian men: RR=0.85, 95% CI 0.75 to 0.96) and, to a lesser extent, for more deprived men.

CONCLUSIONS

The observed discrepancies highlight the need for more focus on initiatives to improve the experience of ethnic minority patients and those older than 60 years. The findings also argue for further validation of discriminatory instruments to help cancer care providers fully understand the variation in the experience of their patients.

[Urinary incontinence after radical prostatectomy: risk factors and utilisation of care]

Stress urinary incontinence is a relevant risk of radical prostatectomy (RP), which significantly affects patients' quality of life. The risk of developing stress urinary incontinence depends on pre-, intra- and postoperative factors. In particular, intraoperative factors regarding different surgical techniques are often focused on in order to improve continence rates. If stress urinary incontinence develops after RPE, patients affected should be treated adequately. In this respect, there are indications of healthcare insufficiencies in Germany. On the one hand, these include deficits in the use of incontinence materials. On the other hand, surgical treatment of stress urinary incontinence after RPE is insufficient.

Comparison of In-person FPMRS-directed Pelvic Floor Therapy Program Versus Unsupervised Pelvic Floor Exercises Following Prostatectomy

OBJECTIVE

To compare comprehensive continence outcomes in patients receiving pelvic floor muscle training (PFMT) vs standard unsupervised home pelvic floor exercise therapy (UPFE).

METHODS

As part of the UVA prostatectomy functional outcomes program, participating patients complete a 12-month PFMT program under FPMRS specialist supervision. We performed a retrospective review of prospectively collected longitudinal outcomes in patients receiving PFMT vs UPFE through 12-month follow-up. Primary study outcome was ICIQ-MLUTS SUI domain score (SDS). Secondary outcomes included daily pad use (PPD), SUI Cure (SDS=0), and quality of life score (IIQ-7). Multilevel mixed effects linear regression was used to model SDS over time.

RESULTS

Analysis included 40 men. No difference in patient characteristics was seen in comparison of PFMT vs UPFE cohorts (P = NS, all comparisons). Mean predicted SDS was significantly better in the PFMT vs UPFE cohorts at 6-month (0.81 ± 0.21 vs 1.75 ± 0.34, respectively) (P = .014) and 12-month (0.72 ± 0.17 vs 1.67 ± 0.30, respectively) (P = .004) time points. At 12-month follow-up, 11 (55%) vs 4 (20%) patients reported absence of SUI in PFMT vs UPFE cohorts, respectively. Predicted probabilities of SUI cure in PFMT vs UPFE cohorts at 12months were 0.52 ± 0.14 vs 0.23 ± 0.13, respectively (P = .14). At 12-month follow-up, the mean predicted PPD and IIQ score was 0.19 ± 0.10 vs 0.79 ± 0.33 and 2.86 ± 0.86 vs 2.55 ± 1.07 in PFMT vs UPFE cohorts, respectively (P = NS).

CONCLUSION

In-person, FMPRS-directed PFMT is associated with improved SUI domain scores following robotic-assisted laparoscopic prostatectomy, a finding durable through 12-month follow-up.

Insufficient utilization of care in male incontinence surgery: health care reality in Germany from 2006 to 2020 and a systematic review of the international literature

PURPOSE

Data suggest that the utilization of care in male incontinence surgery (MIS) is insufficient. The aim of this study was to analyse the utilization of care in MIS from 2006 to 2020 in Germany, relate this use to the number of radical prostatectomies (RP) and provide a systematic review of the international literature.

METHODS

We analysed OPS codes using nationwide German billing data and hospitals' quality reports from 2006 to 2020. A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).

RESULTS

MIS increased by + 68% from 2006 to 2011 (1843-3125; p = 0.009) but decreased by - 42% from 2011 to 2019 (3104-1799; p < 0.001). In 2020, only 1435 MISs were performed. In contrast, RP increased from 2014 to 2019 by 33% (20,760-27,509; p < 0.001). From 2012 to 2019, the number of artificial urinary sphincters (AUSs) changed minimally (- 12%; 1291-1136; p = 0.02). Sling/sling systems showed a decrease from 2011 to 2019 (- 68% 1632-523; p < 0.001). In 2019, 63% of patients received an AUS, 29% sling/sling systems, 6% paraurethral injections, and 2% other interventions. In 2019, few high-volume clinics [n = 27 (13%)] performed 55% of all AUS implantations, and few high-volume clinics [n = 10 (8%)] implanted 49% of retropubic slings.

CONCLUSION

MIS have exhibited a relevant decrease since 2011 despite the increase in RP numbers in Germany, indicating the insufficient utilization of care in MIS. The systematic review shows also an international deficit in the utilization of care in MIS.

Patient-Reported Outcomes 12 Years after Localized Prostate Cancer Treatment

BACKGROUND: Long-term patient-reported outcomes are needed to inform treatment decisions for localized prostate cancer. METHODS: Patient-reported outcomes of 1643 randomly assigned participants in the ProtecT (Prostate Testing for Cancer and Treatment) trial were evaluated to assess the functional and quality-of-life impacts of prostatectomy, radiotherapy with neoadjuvant androgen deprivation, and active monitoring. This article focuses on the outcomes of the randomly assigned participants from 7 to 12 years using mixed effects linear and logistic models. RESULTS: Response rates exceeded 80% for most measures. Among the randomized groups over 7 to 12 years, generic quality-of-life scores were similar. Among those in the prostatectomy group, urinary leakage requiring pads occurred in 18 to 24% of patients over 7 to 12 years, compared with 9 to 11% in the active monitoring group and 3 to 8% in the radiotherapy group. In the prostatectomy group, 18% reported erections sufficient for intercourse at 7 years, compared with 30% in the active monitoring and 27% in the radiotherapy groups; all converged to low levels of potency by year 12. Nocturia (voiding at least twice per night) occurred in 34% in the prostatectomy group compared with 48% in the radiotherapy group and 47% in the active monitoring group at 12 years. Fecal leakage affected 12% in the radiotherapy group compared with 6% in the other groups by year 12. The active monitoring group experienced gradual age-related declines in sexual and urinary function, avoiding radical treatment effects unless they changed management. CONCLUSIONS: ProtecT provides robust evidence about continued impacts of treatments in the long term. These data allow patients newly diagnosed with localized prostate cancer and their clinicians to assess the trade-offs between treatment harms and benefits and enable better informed and prudent treatment decisions. (Funded by the UK National Institute for Health and Care Research Health Technology Assessment Programme projects 96/20/06 and 96/20/99; ISRCTN number, ISRCTN20141297; ClinicalTrials.gov number, NCT02044172.)

The Efficacy of Urinary Continence in Patients Undergoing Robot-Assisted Radical Prostatectomy with Bladder-Prostatic Muscle Reconstruction and Bladder Neck Eversion Anastomosis

Background and Objectives: To evaluate the efficacy of bladder-prostatic muscle reconstruction and bladder neck eversion anastomosis in the recovery of urinary continence after robot-assisted radical prostatectomy (RARP). Materials and Methods: From January 2020 to May 2022, 69 patients who underwent RARP in our hospital were recruited. Thirty-seven patients underwent RARP with the Veil of Aphrodite technique (control group). On the basis of the control group, 32 patients underwent bladder-prostatic muscle reconstruction and bladder neck eversion anastomosis during RARP (observation group). The recovery of urinary continence was followed up at 24 h and 1, 4, 12, and 24 weeks after catheter removal. Results: There were no significant differences in operative time (127.76 ± 21.23 min vs. 118.85 ± 24.71 min), blood loss (118.27 ± 16.75 mL vs. 110.77 ± 19.63 mL), rate of leakage (3.13% vs. 2.70%), rate of positive surgical margin (6.25% vs. 10.81%), or postoperative Gleason score [7 (6−8) vs. 7 (7−8)] between the observation group and the control group (p > 0.05). After catheter removal, the rates of urinary continence at 24 h, 1 week, 4 weeks, 12 weeks, and 24 weeks were 46.88%, 68.75%, 84.38%, 90.63%, and 93.75% in the observation group, respectively. Meanwhile, the rates of urinary continence in the control group were 21.62%, 37.84%, 62.16%, 86.49%, and 91.89%, respectively. There was a significant difference between the two groups (p = 0.034), especially at 24 h, 1 week, and 4 weeks after catheter removal (p < 0.05). Conclusions: Bladder-prostatic muscle reconstruction and bladder neck eversion anastomosis were beneficial to the recovery of urinary continence after RARP, especially early urinary continence.

Surgeon volume and patient-reported urinary incontinence after radical prostatectomy. Population-based register study in Sweden

OBJECTIVE

To investigate the association between surgeon volume and urinary incontinence after radical prostatectomy.

METHODS

A total of 8326 men in The National Prostate Cancer Register of Sweden (NPCR) underwent robot-assisted radical prostatectomy (RARP) between 2017 and 2019 of whom 56% (4668/8 326) had responded to a questionnaire one year after RARP. The questionnaire included the question: 'How much urine leakage do you experience?' with the response alternatives 'Not at all', 'A little', defined as continence and 'Moderately', 'Much/Very much' as incontinence. Association between incontinence and mean number of RARPs/year/surgeon was analysed with multivariable logistic regression including age, Charlson Comorbidity Index (CCI), PSA, prostate volume, number of biopsy cores with cancer, cT stage, Gleason score, lymph node dissection, nerve sparing intent and response rate to the questionnaire.

RESULTS

14% (659/4 668) of the men were incontinent one year after RARP. There was no statistically significant association between surgeon volume and incontinence. Older age (>75 years vs. < 65 years, OR 2.29 [95% CI 1.48-3.53]), higher CCI (CCI 2+ vs. CCI 0, OR 1.37 [95% CI 1.04-1.80]) and no nerve sparing intent (no vs. yes OR 1.53 [95% CI 1.26-1.85]) increased risk of incontinence. There were large differences in the proportion of incontinent men between surgeons with similar annual volumes, which remained after adjustment.

CONCLUSIONS

The lack of association between surgeon volume and incontinence and the wide range in outcome between surgeons with similar volumes underline the importance of individual feedback to surgeons on functional results.