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MALE INCONTINENCE > differential indication

Differential indication for surgical treatment of male post-prostatectomy incontinence

presentation at the ICS-Male Incontinence Workshop 2015 (Montreal)

W. Huebner

Department of Urology Weinviertelklinikum Korneuburg, Karl Landsteiner research institute for tumors and dysfunction of the urinary tract

Today a variety of surgical treatment options for male incontinence are available. Although they differ in therapeutic potential, complexity, price, limits and long-term experience, some methods can be used as alternative for each other, in case of treatment failure [1-8]. Hence, today many patients can be offered several treatment options. The choice of the most appropriate procedure should still be done with extraordinary diligence, which requires understanding of the pathophysiology of post-prostatectomy incontinence as well as an open mind concerning the entirety of the patient in regard to cognitive, manual and physical attributes.

Post-prostatectomy incontinence

The notion of Dorschner et. Al. [9] distinguishing between the interior bladder neck sphincter and an external urethral sphincter (raptussphincter urethrae) can be seen as foundation for diagnostics and treatment of post-prostatectomy incontinence. The external sphincter, which is mostly responsible for continence is also divided into a smooth (musculus sphincter urethrae glaber) and a striated (musculus sphincter urethrae transversostriatus) muscle component. Following this approach the smooth muscle component is responsible for baseline continence, and does not suffer from fatigue. Yet during surgery the innervating structures can be damaged, leading to impaired baseline continence [10].
The striated muscle component, together with the (also striated) pelvic floor muscles, has a much stronger contraction and can provide sufficient closing of the urethra during short periods of elevated abdominal pressure, ensuring stress continence. The innervation of the striated muscle component through the pudendal nerve is usually not compromised by the radical prostatectomy, thus allowing even severely incontinent patients to interrupt their urinary stream, also visible as a short closing of the urethra in cystoscopy after the patient is prompted to clench [11,12]. The clinical presentation of most post-prostatectomy incontinent patients also supports this claim, where the urinary stream can be interrupted and coughing does not prompt any loss, while suffering from a substantial baseline incontinence, especially during the second half of the day, caused by fatigue of the striated sphincter. With understanding of these mechanisms, targeted and reasonable diagnostics can be done, leading to a successful and individually adjusted therapy.

Outline of the current options for surgical treatment of post-prostatectomy incontinence

Hydraulic sphincter:

AMS-800 (Scott-sphincter), bulbar – infradiaphragmal target location, long-term experience, very reliable outcome, usable in patients with detrusor contractility (open-close mechanism), limited through manual and/or cognitive impairments, expensive.

Retrourethral sling:

Advance, retrourethral – diaphragmal target location, sphincter repositioning, preoperative elevation test necessary, postoperative retention 10-20%, limited in patients with radiation, neobladder and severe incontinence.

Adjustable slings:

Argus, Remmex, Atoms, Phorbas, suburethral – diaphragmal target location, possible intra/postoperative adjustment of the urethral pressure, verification of stream-interruption advised, limited in patients with neobladder.

Adjustable balloons:

Pro-ACT, bladder neck – supradiaphragmal target location, over 10 years of experience, minimally invasive, low dry rates, prolonged start-up phase till adjustment, contraindicated in patients with radiation, limited in patients with previous surgery around the bladder neck.

Bulking agents:

Numerous products, target location mostly right at the anastomosis, very restricted effect in male incontinence.

Differential indication

Although the choice of surgery should not be solely based on the extent of incontinence, suburethral devices (adjustable slings, AMS-800) with comparable success rates seem to achieve higher dry rates than retrourethral slings. Pro-ACT shows similar success in patients with different grades of incontinence, yet overall those are a little lower than those of suburethral procedures [1-3, 13-21]. Bladder voiding dysfunction (detrusor insufficiency/neobladder) presents a contraindication for slings (of any kind). Here, only treatment with an AMS-800 or the easily adjustable pro-ACT implants should be used. If this is not possible due to radiation or manual restriction the necessity of self-catheterization should be expected.
Cerebral and manual limits should be considered contraindications of the AMS-800, yet even this surgery is considered to only expose the patient to a low level of stress.
If the proximal urethra was damaged (through incision or radiation) or otherwise compromised, the conditions for implantation of Pro-ACT or retrourethral slings are unfavorable. In these cases more distal (suburethral) devices are recommended (scott-sphincter, suburethral slings).
The psychological situation must also be considered, as (e.g.) the idea of using a pump can be a personal obstacle for many patients. If a patients circumstances have already brought him to the edge of his coping capacity (e.g. insufficient/untreatable erectile dysfunction), we still prefer the AMS-800, since it has the lowest rate of treatment failure.
The time between surgeries does not factor in to the indication. Even years after prostatectomy, a surgery can lead to complete success.  However the possibility of a high micturition frequency due to decrease in bladder capacity should be discussed.

Basically all methods mentioned above may potentially provide very good outcomes. Therefore differential indication is mostly done through contraindications and limits of the possible treatments (differential indication through exclusion!). Secondly the decision is influenced by such factors surgical expertise and personal preference of the patient. Table 1 shows which method should be indicated positive, neutral or only with great caution in patients with certain medical findings.

Given all these factors the indication for a certain procedure must certainly be made upon the patient`s needs and not on the surgeons preference or repertoire.

 Table 1

References:

1)        Hübner WA, Schlarp OM. Treatment of incontinence after prostatectomy using a new minimally invasive device: adjustable continence therapy. BJU Int  2005, 96: 587-94.

2)        Hübner WA, Schlarp OM. Adjustable continence therapy (ProACT): evolution of the surgical technique and comparison of the original 50 patients with the most recent 50 patients at a single centre. Eur Urol 2007, 52(3):680-6.

3)        Romano SV, Metrebian SE, Vaz F, et al. An adjustable male sling for treating urinary incontinence after pros- tatectomy: a phase III multicentre trial. BJU Int 2006, 97: 533–9.

4)        Romano SV, Hubner W, Trigo Rocha F, Muller V, Nakamura F.
The adjustable male sling can be successfully implanted by transobturator approach for treating post – prostatectomy urinary incontinence. Surgical technique and early results of a multicenter trial. ICS 2009.

5)   Sousa A, Rodriguez JI, Uribarri C, Marques A.
Externally readjustable sling for treatment of male stress urinary incontinence: points of technique and preliminary results. J Endourol 2004, 18:113–8.

6)        Sousa-Escandon A, Cabrera J, Mantovani F, et al.
Adjustable suburethral sling (Male Remeex System®) in the treatment of male stress urinary incontinence: a multicentric European study. Eur Urol 2007, 52:1473-80.

7)        Rehder P,, Gozzi C., Transobturator sling suspension for male urinary incontinence including post-radical prostatectomy. EurUrol2007;
52:860–7.

8)        Bauer R.M., Margit E. Mayer, Christian Gratzke, Irina Soljanik, Alexander Buchner, Patrick J. Bastian, Christian G. Stief, Christian Gozzi. Prospective Evaluation of the Functional Sling Suspension For Male Postprostatectomy Stress Urinary Incontinence: Results after 1 Year. Eur Urol 56(2009) 928–933

9)        W. Dorschner, J.U. Stolzenburg, J. Neuhaus. Anatomic principles of urinary incontinence [in German]. Urologe A 40 (2001) (223 - 233)

10)     Walsh PC: Anatomic radical prostatectomy: evolution of the surgical technique, J.Urol Dec 160/6 Pt 2): 2418-24, 1998.

11)     Hübner W, Trigo Rocha S, Plas E, Tanagho E, Urethral function after cystectomy: a canine in vivo experiment, Urol.Res. 21, 45-48, 1993

12)     Porena M, Mearini E, Mearini L, Vianello A, Giannantoni A. Voiding dysfunction after radical retropubic prostatectomy: more than external urethral sphincter deficiency. Eur Urol 2007;52:38-45.
Incontinence; in (ed) AG (ed). EAU Guidelines. Arnheim, European Association of Urology, 2010, 11-28.

13)     Gousse AE, Madjar S, Lambert MM, Fishman IJ.; Artificial urinary sphincter for post radical porstatectomy urinary incontinence: long term subjective results, J.Urol. Nov; 166(5): 1755-8, 2001
 
14)     Montague DK, Angermeier KW, Paolone DR.; Long-term continence and patient satisfaction after artifical sphincter implantation for urinary incontinence after prostatectomy, J Urol Aug 166(2): 547-9, 2001.

15)     Walsh IK, Williams SG, Mahendra V, Nambirajan T, Stone AR, Artificial urinary sphincter implantation in the irradiated patient: safety, efficacy and satisfaction, MJU Int Mar 89(4): 364-8, 2002.

16)     Litwiller SE, Kim KB, Fone PD, de Vere White RW, Stone AR, Evaluation and Management of Male Urinary Incontinence
 J Urol 1996, 156, 1975-1980.

17)     Bauer RM, Soljanik I, Füllhase C, Karl A, Becker A, Stief CG, Gozzi C., Mid-term results for the retroluminar transobturator sling suspension for stress urinary incontinence after prostatectomy. BJU Int. 2011 Jul;108(1):94-8. doi: 10.1111/j.1464-410X.2010.09729.x. Epub 2010 Sep 30.

18)     Bauer RM, Soljanik I, Füllhase C, Buchner A, May F, Stief CG, Gozzi C., Results of the AdVance transobturator male sling after radical prostatectomy and adjuvant radiotherapy. Urology. 2011 Feb;77(2):474-9. Epub 2010 Dec 16.

19)     Cornu JN, Sèbe P, Ciofu C, Peyrat L, Cussenot O, Haab F., Mid-term evaluation of the transobturator male sling for post-prostatectomy incontinence: focus on prognostic factors. BJU Int. 2011 Jul;108(2):236-40. doi: 10.1111/j.1464-410X.2010.09765.x. Epub 2010 Oct 18.

20)     Hübner WA, Gallistl H, Rutkowski M, Huber ER. Adjustable bulbourethral male sling: experience after 101 cases of moderate-to-severe male stress urinary incontinence. BJU Int 2011;107:777-82

21)     Mayer M, Bauer RM, Walther S, Becker AJ, Stief CG, Bastian PJ, Gozzi C, Belastungsinkontinenz nach radikaler Zystektomie
Anlage einer Neoblase und Einlage der funktionellen retrourethralen Schlinge
Der Urologe A, Volume 48, Number 6, 645-648

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