Latest Evidence on Post-Prostatectomy Urinary Incontinence

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.

Predictors of Early Continence After Single-port Transvesical Robot-assisted Radical Prostatectomy

OBJECTIVE

To identify the factors associated with a short time of return to continence.

METHODS

We analyzed the first 110 SP TV RARP consecutive cases performed by one surgeon from 2020 to 2022. Continence was defined as zero to one safety pad. Two statistical analyses were done. First, patients were divided: group A (n = 62) included individuals who achieved continence within the initial week postcatheter removal; group B (n = 48) rest of the patients. Descriptive statistics were compared, followed by logistic regression for independent variables. Second, time to continence was analyzed as a continuous variable employing linear regression. The primary outcomes were the independent variables significantly associated with a short time to continence.

RESULTS

All cases were completed successfully, without additional ports or conversions. Median urinary catheter duration and time to continence were 3 and 3.5days, respectively. Patients achieving continence within 1week significantly presented with fewer preoperative urinary tract symptoms, lower prostate-specific antigen levels, and had smaller specimen weights postoperatively. Multivariable logistic regression established low specimen weight as the sole significant factor (P = .04). Furthermore, linear regression demonstrated that alterations in independent variables accounted for 12.7% of the variance in time to continence (P = .62).

CONCLUSION

The regionalization of surgery to the bladder employing a retropubic space-sparing extraperitoneal approach during SP TV RARP contributes to a fast return to continence. According to our model, the factors that significantly predict a shorter time to continence include lower preoperative International Prostate Symptom Score, prostate-specific antigen, and postoperative specimen weight.

Validation of Claims Data for Absorbing Pads as a Measure for Urinary Incontinence after Radical Prostatectomy, a National Cross-Sectional Analysis

The use of healthcare insurance claims data for urinary incontinence (UI) pads has the potential to serve as an objective measure for assessing post-radical prostatectomy UI rates, but its validity for this purpose has not been established. The aim of this study is to correlate claims data with Patient Reported Outcome Measures (PROMs) for UI pad use. Patients who underwent RP in the Netherlands between September 2019 and February 2020 were included. Incontinence was defined as the daily use of ≥1 pad(s). Claims data for UI pads at 12-15 months after RP were extracted from a nationwide healthcare insurance database in the Netherlands. Participating hospitals provided PROMS data. In total, 1624 patients underwent RP. Corresponding data of 845 patients was provided by nine participating hospitals, of which 416 patients were matched with complete PROMs data. Claims data and PROMs showed 31% and 45% post-RP UI (≥1 pads). UI according to claims data compared with PROMs had a sensitivity of 62%, specificity of 96%, PPV of 92%, NPV of 75% and accuracy of 81%. The agreement between both methods was moderate (κ = 0.60). Claims data for pads moderately align with PROMs in assessing post-prostatectomy urinary incontinence and could be considered as a conservative quality indicator.

Prehabilitative versus rehabilitative exercise in prostate cancer patients undergoing prostatectomy

PURPOSE

The study compared the efficacy of commencing supervised exercise in men with prostate cancer before and after prostatectomy on objective and patient-reported outcomes, hospital length of stay, and urinary incontinence.

METHODS

Forty-one men were randomised to a 6-week prehabilitation or rehabilitation exercise programme. Prehabilitation involved resistance and aerobic exercise thrice weekly pre-surgery, while rehabilitation comprised the same commencing 6-weeks post-surgery. Assessments included strength, function (chair rise, stair climb, 400-m, 6-m usual, fast, and backwards walk), body composition, fatigue and quality of life, undertaken at pre-surgery, early post-surgery and late post-surgery phase, with urinary incontinence (24-h pad test) assessed at 2, 6, and 12-weeks post-surgery. Intention-to-treat and sensitivity analyses were undertaken.

RESULTS

Of thirty-eight men (48-73 years), 29 completed all assessments with most undergoing robotic-assisted laparoscopic prostatectomy (92.1%). In the pre-surgery phase, prehabilitation improved muscle strength (leg press: 17.2 kg; chest press: 2.9 kg; p ≤ 0.001), 400-m, chair rise, 6-m fast and backward walk tests (p ≤ 0.001-0.028). Strength and function declines in the early post-surgery phase were maintained late post-surgery. Rehabilitation showed declines of these outcomes after surgery with improvement late post-surgery (leg press: 14.6 kg, p < 0.001; chest press: 6.8 kg, p < 0.001; 400-m walk: -12.0 s, p = 0.005), resulting in no difference between groups at 12 weeks. There were no significant differences between groups for patient-reported outcomes, hospital length of stay or urinary incontinence.

CONCLUSION

Pre-surgical exercise enhanced strength and function, protecting against post-surgery declines. Although exercise post-surgery is beneficial for recouping strength and function, where possible men undergoing prostatectomy are encouraged to exercise pre-surgery.

TRIAL REGISTRATION

ACTRN12617001115325 registered 31 July 2017.

[Use of implants to treat male urinary incontinence]

Treatments for benign and malignant pathologies of the prostate can compromise urine control. Urinary incontinence (UI) affects the quality of life of patients and limits their ability to carry out usual activities. The degree of impact of UI is variable and the associated discomforts make patients seek treatment for it. At the center of the management of urinary incontinence in men are surgical interventions that seek to replace the affected sphincter function through implants. The artificial urinary sphincter since its development in the 1970s has been considered the standard of treatment for UI in men. More recently artificial sphincter and slings have been shown to be effective in a selected group of incontinent men. The goals of surgical treatment of incontinence include the preservation of bladder function, the ability to improve the strength of the urinary sphincter, and to reduce or eliminate urine leakage, and thereby improve the quality of life. The aim of the article is to present various implants for the correction of male urinary incontinence.

Robot-Assisted Radical Prostatectomy by Lateral Approach: Technique, Reproducibility and Outcomes

BACKGROUND

Radical prostatectomy by lateral approach allows performing a prostatectomy through a buttonhole, with direct access to the seminal vesicle and fully sparing the anterior pubovesical complex. Our aim is to show the results of reproducing the technique of robotic radical prostatectomy by lateral approach, in terms of intraoperative, postoperative, oncological and functional parameters.

METHODS

We analyzed 513 patients submitted to robotic radical prostatectomy by lateral approach from January 2015 to March 2021, operated on by two surgeons in our institution. The oncological and functional results of both surgeons were compared.

RESULTS

When comparing both surgeons, the rate of positive surgical margins (PSM) was 32.87% and 37.9% and significant surgical margins (PSM > 2 mm) were 5.88% and 7.58% (p = 0.672) for surgeon 1 and surgeon 2, respectively. Immediate continence was 86% and 85% and sexual potency at one year 73% and 72%, with a similar rate of complications for surgeon 1 and 2.

CONCLUSIONS

Radical prostatectomy by the lateral approach technique with preservation of the anterior pubovesical complex is reproducible and offers good oncological and functional results.

Special Issue: "Latest Advances on Urinary Incontinence"

Urinary incontinence (UI) has a great impact on patients' quality of life [...].

Pelvic floor muscle exercise with or without duloxetine for postprostatectomy urinary incontinence: A retrospective single-center study

This study aimed to evaluate the effectiveness of combined pelvic floor muscle exercise (PFME) and duloxetine treatment in the recovery from postprostatectomy urinary incontinence (PPUI). Participants were patients who underwent radical prostatectomy (RP) between 2018 and 2021 and who were able to attend follow-up appointments every 3 months for at least 12 months. Continence was defined as the use of ≤1 pad per day. PPUI was compared at each follow-up period by dividing the participants into the PFME group (PFME only after RP) and the PFME + DUL group (PFME and 30 mg duloxetine daily after RP). A total of 197 patients were included. No significant differences were observed in the baseline characteristics between the 2 groups. In the PFME group (n = 127), the PPUI was 77.17%, 27.56%, 17.32%, 12.60%, and 9.45% at 2 weeks, 3 months, 6 months, 9 months, and 12 months, respectively. In the PFME + DUL group (n = 70), the PPUI was 62.50%, 17.86%, 12.50%, 8.93%, and 5.36%, respectively, at the same follow-up period. At 2 weeks, the PFME + DUL group demonstrated a better incontinence rate than the PFME group (P = .019). However, no significant differences were found in the incontinence rates between the 2 groups at each follow-up period after 3 months. Compared to PFME monotherapy, the combination therapy of PFME and duloxetine has short-term effectiveness in improving PPUI, but it does not have a significant long-term impact. Therefore, for early recovery from PPUI, duloxetine should be administered for a short period during PFME.

Radical Prostatectomy and Anatomical Controversies: The Urethral Sphincter and the Elusive Continence Mechanisms

Prostate cancer incidence is rising [...].