Sandi Poteko, urologist, Dept. of Urology, GH Celje, Slovenia
Radical prostatectomy (RP)is the most common reason for male stress urinary incontinence. Post-prostatectomy incontinence (PPI) has a major impact on patient’s quality of life. Despite improvements in surgical technique, reported rates of PPi vary between 6% and 69%. There are still missing a standardization of definition and grading of severity of PPI. Biological risk factors that accompany increased risk of PPI are age, pre-existing LUTS, functional bladder changes, TURP before RP, prostate size, membranous urethral length, body mass index and radiation therapy after RP.
Surgical factors contributing to PPI with negative impact are neurovascular bundle damage, devascularization, extensive dissection, laxity of the posterior support, fibrosis and stricture. Factors with positive impact are posterior reconstruction of the Denonvilliers’ musculofascial plate (Rocco stitch), anterior reconstruction, bladder neck sparing and Retzius sparing RP.
Therapies of PPI are conservative and operative. Conservative therapy includes physiotherapy (pelvic floor muscle training, PFMT) and pharmacotherapy. PFMT should be offered to all men undergoing RP to speed up postoperative continence recovery. PFMT does not cure urinary incontinence in men after RP.
There are conflicting evidences on whether the addition of bladder training, electrical stimulation or biofeedback increases the effectiveness of PFMT alone. Lifestyle interventions are also advised. Duloxetin (off-label treatment) can temporary improve PPI. Antimuscarinics should be applied to patients experiencing additional urgency.If conservative treatment of PPI failed surgical treatment is recommended. Artificial urinary sphincter (AUS) is the most commonly used device. Success rate depends on definition and collecting the data and varied between 4,3% and 85,7%. AUS is treatment of choice to men with moderate to severe PPI.
Male slings have been introduced to treat PPI in last years. Fixed slings are positioned under the urethra. The concepts of continence restoration are by urethral compression or by repositioning the bulb of urethra. Success rate is between 8,6% and 73,7% (mean 49,5%). Adjustable male slings offer to adjust the tension of the sling post-operatively. Initial reports show cure rates of 60,5% and improvement rates of 23,7%. The most suitable candidates for fixed slings are patients with mild to moderate PPI. The candidates for adjustable slings are also previously irradiated patients.
Bulking agents are used for temporary relief of mild PPI.