4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 39 Management of urinary incontinence following treatment of prostate disease prostatectomy (RALP) are estimated to be between 8%-16%. 6,7 It has been shown that patients with UI are at higher risk for mental health issues and experience poorer quality of life. 8 Given the prevalence of prostate disease, risk for IPT, and its associated emotional and financial burdens, it is imperative understand the evaluation and management of these patients. Etiology Prostate cancer treatment SUI following RP is the most common form of IPT, although UUI can also occur. The historical incidence of SUI after RP has been estimated between 2%-87%. 9 However, progressive improvement in post-RP SUI over time has been shown. Lepor et al found the rate of men using 1 pad or fewer at 3, 6, 12, and 24 months after RP to be 71%, 87%, 92%, and 98.5% respectively. 10 Any UI following RP significantly decreases patient quality of life. 11 Four percent of men with post-RP SUI have bothersome enough symptoms to seek surgical intervention. 12 The pathophysiology of UI following RP is thought to be related to rhabdosphincter incompetence, change in urethral length, and change in detrusor compliance and overactivity. 13 Incompetence of the rhabdosphincter (also known as the external urethral sphincter) combined with compromise of the internal urethral sphincter duringRP can lead to intrinsic sphincter deficiency (ISD). ISD can be as high as 88%at 1 year post RP. 14 ISD is the sole cause of incontinence in 37%-59% of these patients. 15 Given the recovery of continence in many patients over time, it is thought that injury to the nerves and supporting tissue (rather than to the rhabdosphincter itself) is the underlying etiology. Preserved membranous urethral length above 12 mm is associated with increased continence. 16 Alternatively, UUI following RP is linked to detrusor overactivity (DO). DO is observed in up to 34% of men following RP. 14 However, this was the sole cause of UI in only a small percentage of patients. Ultimately, it is important to evaluate patients with IPT followingRP for both SUI andUUI in order todetermine the most appropriate treatment. Despite advances in targeting, both the bladder and rectum can still fall within the treatment field during RT for prostate cancer. The negative sequelae from radiation damage to these organs results in chronic tissue inflammation, abnormal cell proliferation, and vascular insults. 17 Importantly for the patient and urologist who will see them, these effects can lead to DO. 18 Hoffman et al found that men who received RT for prostate cancer had a DO rate of 70% compared to 38% in those who did not. 19 This study also showed smaller bladder capacity in post-RT patients compared to those who did not receive RT (253mLversus 307mL, respectively). Patients who present with UI following RT should have bladder function assessed for DO and reduced capacity. BPH treatment While not as significant as RP, prostate reducing surgeries in the setting of BPH can also cause IPT. Studies have demonstrated that patients can experience SUI following transurethral resection of prostate (TURP) or holmium laser enucleation of prostate (HoLEP). However, most cases are transient in nature with rates of IPT dropping to 1% or less at the one year interval. 20,21 Although surgery for BPH can reverse some of the pathological changes of the bladder, some patients experience irreversible changes to their bladder from longstanding BPH that persist following surgery. 22 Long-standing BPH left untreated can lead to persistent DO following surgery. 23 Prophylactic measures against IPT The value of pelvic floor muscle therapy (PFMT) for IPT after RP has been demonstrated. A systematic review by Str ą czy ń ska et al demonstrated not only PFMT’s effectiveness in continence outcomes but also improving patient’s quality of life. 24 This can possibly be attributed to patients actively participating in their own care. The current AUA/SUFU guidelines state that PFMT can be offered prior to RP and should be offered postoperatively. 2 One of the difficulties regarding PFMT is determining the optimal regimen and educatingpatients onproper technique. Fernandez et al performed a meta-analysis of eight randomized trials showing three sets of 10 contractions daily led to improved continence versus no intervention. 25 A trial by Milios et al demonstrated a faster return to continence for patients who were randomized to a more intensive PFMT regimen starting 5 weeks before surgery as compared to those who had a standard treatment regimen in the same period. 26 Improved surgical techniques and advances in technology have also improved continence results following RP. Postoperative continence has been associated with bladder neck preservation, neurovascular sparing, non-thermal ligation of the dorsal venous complex, preserving urethral length and the supporting anatomy of the rhabdosphincter, and anatomic reconstruction. 27 A randomized control trial by Asimakopoulos et al showed faster return to continence for patients undergoing Retzius-sparing RALP compared to the anterior approach. 28