Elsevier

European Urology

Volume 50, Issue 5, November 2006, Pages 903-913
European Urology

Review – Prostate Cancer
Minimising Postoperative Incontinence Following Radical Prostatectomy: Considerations and Evidence

https://doi.org/10.1016/j.eururo.2006.08.009Get rights and content

Abstract

Objectives

To review evidence regarding perioperative predictors of incontinence after radical prostatectomy (RP), related anatomic and patient factors, and surgical techniques used to minimise incontinence.

Methods

A search of the Pubmed, Cancerlit, Cochrane, and ISI Web of Science databases was performed for the key words prostatectomy, incontinence, and continence. Relevant articles were reviewed, summarised, and analysed.

Results

Enhanced understanding of pelvic anatomy applied to surgical approaches has improved continence rates following RP; however, incontinence remains a potential adverse outcome. Evidence suggests that increasing patient body weight and prostate volume are not associated with continence outcomes, but increasing patient age may be predictive. Behavioural therapy may aid in early return to continence although the timing of therapy and benefit of biofeedback assistance are unclear. Various surgical techniques are used to improve continence, but no evidence overwhelmingly supports any specific technique. At best, evidence supports early return to continence with some techniques. No technique significantly increased margin positivity solely at the experimental anatomic site.

Conclusions

Despite enhanced knowledge of anatomy and improved surgical approach, incontinence persists as a potential adverse outcome of RP. Urologists may not find an evidence-based rationalisation for any particular surgical technique due to the nature of surgical series, variability in the definition of incontinence, and individual surgical skills, preferences, and techniques. Giving careful consideration to the trial design can potentially improve the resulting level of evidence.

Introduction

An estimated 234,460 new cases and 27,350 deaths due to prostate cancer are expected in 2006 [1]. It is the most common noncutaneous, newly diagnosed cancer in men and accounts for one third of newly diagnosed cancers and 9% of male cancer deaths [1].

Radical prostatectomy (RP) is the most common treatment for localised prostate cancer in the United States. RP has excellent oncologic results [1], [2]. Incontinence and erectile dysfunction are the most common associated postoperative morbidities.

A broad range of incidence for incontinence after RP results from variability in defining continence, the surgeon’s experience and surgical technique, patient selection, and time of assessment relative to surgery [3]. Some investigators use the strict definition of no pad use, whereas others allow for a particular frequency of pad use. Time lapse between surgery and assessment, as well as method of assessment, affect reported rates as well. Incontinence is subjectively measured by patient reported pad use, perceived wetness, degree of bother, and frequency of leakage. Objective measures include urodynamic studies, pad tests, and validated questionnaires.

Karakiewicz et al. used self-administered surveys to investigate long-term function (range: 17 mo to 8.5 yr) in a large cohort (n = 2415) of Canadian men treated with RP (level III evidence) [4]. Almost 50% of the men reported some degree of urinary dysfunction (UD). Severe UD, defined as >1 tablespoon of leakage, was reported in 6.6% overall and was 4% in men <60 yr of age and 10% in men ≥75 yr of age. Anastomotic stricture formation (16.3%) was associated with a 2-fold increase in severe UD (p < 0.001). This observational study aids in defining the incidence of long-term incontinence.

The etiology of post-RP incontinence is unclear. Intrinsic sphincter deficiency and de novo detrusor instability are believed to be the most important factors [5]. Goluboff et al. used urodynamic studies to investigate post-RP incontinence in 25 men. Detrusor instability was the sole finding in 40% of cases [6]. In a larger series of 83 men, urodynamic studies suggested sphincter injury in 88% and detrusor instability in 33% [7]. One third had sphincter injury as their sole finding.

Multiple studies suggest that postoperative incontinence has a negative impact on quality of life (QOL) [8], [9]. Comparison with age-matched controls suggest that RP is associated with worse urinary continence [8]. In a population-based, prospective, longitudinal study 5 yr in length, Penson et al. report that incontinence peaks at 6 mo following diagnosis (25%) and decreases to 10.4% at 24 mo [9].

Section snippets

Materials and methods

A search of the Pubmed, Cancerlit, Cochrane, and ISI Web of Knowledge databases was performed for the key words prostatectomy, incontinence, and continence published in English between 1989 and 2006. Relevant articles were reviewed, summarised, and analysed. Quality of evidence, as defined by the American Society of Clinical Oncology (ASCO) was assessed (Table 1) [10]. Articles were also identified in the references of pertinent papers.

Perioperative, anatomic, and technical factors have been

Perioperative patient factors

Perioperative patient factors include body weight, prostate volume, and patient age. In addition, investigations of pelvic floor exercise (PFE) suggest an impact on continence.

Conclusion

With the exception of a few randomised controlled trials, level III evidence provides the majority of evidence-based rationale for minimising incontinence after RP. The literature suggests that increasing patient body weight and prostate volume are not associated with worsening continence outcomes; however, increasing patient age may increase risk. Behavioural therapy may aid in early return to continence. Ongoing anatomic studies will further define the pelvic anatomy and refine the surgical

Acknowledgements

Dr. Cambio was supported by the Aventis Clinical Research Fellowship in Urologic Oncology.

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