Sunday, June 26, 2011

Managing Urinary Incontinence After Prostatectomy Part II: When Conservative Measures Fail

In my last post, I stressed the point that most men will regain continence within 12-18 months after prostatectomy.  I emphasized that although men undergoing prostatectomy should be proactive about pelvic floor muscle exercises to regain their continence more quickly, they should also remain patient because the vast majority of men do reach almost complete if not total dryness after prostatectomy.  For some men, however, this relief from urinary incontinence never comes.  Ten to fifteen percent of men remain significantly wet even years after surgery.   For some of these men, this incontinence requires changing diapers several times per day which ruins their quality of life, destroys their self esteem, and limits their ability to take part in beloved pastimes and activities.  For these men, more aggressive options are available to limit the leakage of urine.  In this post I review the invasive, surgical treatments of urinary incontinence.  I, again, stress that these options should be reserved for intractable incontinence that persists 12-18 months post prostatectomy and beyond.

Urethral Bulking Agents

The least invasive surgical option for refractory incontinence after prostatectomy is the injection of urethral bulking agents.  Such a procedure is performed using a camera to visualize the inside of the urethra and, specifically, the area of the urinary sphincter.  Once this muscle is visualized, a bulking agent (gluteraldehyde crosslinked collagen) is injected endoscopically (through the camera) into the lining of the sphincter.  The idea behind this treatment is to “bulk up” the sphincter, increasing the resistance to urine travelling from the bladder.  Early studies on the use of urethral bulking agents after prostatectomy were encouraging.  One study reported that 58% of men with incontinence who underwent the procedure had either good or at least improved results at a follow up of 10.3 months.  More recent studies were not so positive, however, with reports of complete dryness of 8-17% and social dryness (no more than 1 pad per day) of 38% after multiple injections.  A recent study of over 300 men treated with injectable bulking agents reported that men undergoing the procedure still required an average of up to 3 pads per day.  The same study reported that the therapy was only effective for an average of 6 months, after which another injection was required.  Due to these suboptimal results, bulking agents are generally NOT recommended for men with incontinence after prostatectomy.

Male Slings

A more invasive surgical option for men with incontinence after prostatectomy is the male sling.  While numerous types of slings are commercially available, they all share a common mechanism of action: compression of the urethra.  As with the bulking agents, the idea is to compress the urethra so as to increase the resistance to urine leaking from the bladder.  Unlike the direct injection of agents into the sphincter, however, slings are secured underneath the urethra.  Created as an artificial polyester mesh, the sling is like a hammock which sits under the urethra to serve as a backstop and provide gentle pressure to restrict urinary leakage.

Various versions of male slings date back to the late 1990s.  The first male slings were fashioned after slings used for female incontinence during the same time period.  The hammock portion of the sling was connected to sutures (strings) that were pulled out above the muscles of the anterior wall of the abdomen (the muscles referred to as a “six pack” in those of us who work out).  The sutures would then be tied above these muscles(but below the skin) to secure the sling in place.  The whole procedure could be carried out through a small incision underneath the scrotum and another, even smaller, incision just over the bladder.  A study evaluating men undergoing this early version of male slings reported complete dryness in 56% and satisfaction in 90% of men undergoing the procedure.

This early version of the male sling was refined in 2001 with the development of the bone-anchored sling.  This new variant avoided passing sutures through the abdomen (and the associated risk of damaging the bladder and intestines) in order to secure the sling.   Instead, this new sling was secured in place under the urethra via sutures that were actually anchored into the pelvic bones adjacent to the urethra.  Success rates reported with the bone anchored sling have been variable, ranging from 37-87%, depending on the definition of complete continence. 

      


 Diagram of a Bone Anchored Sling


More recently, yet another version of the male sling has been developed.  This version is called the Transobturator (or AdVance) Sling.  The sling, also placed under the urethra for compression, is secured by passing it through a canal within the pelvic bones.  As such, the synthetic material is passed through an incision underneath the scrotum and out of another incision in the inner thigh (just underneath the groin crease).  The sling is then cut at the skin surface of the incision in the thigh so it is not visible after surgery.  The results of this technique mirror those of the bone anchored sling.  The transobturator sling and bone anchored sling
are currently the two most commonly used slings for incontinence after prostatectomy.



                                       Diagram of a Transobturator Sling

Like any other surgery, implantation of the male sling can result in complications.  Urinary retention can sometimes be experienced (3%) if the sling is made to tight, requiring a subsequent surgery to loosen or remove it.  Because the sling is a foreign object within the body it can become infected (6%) or can actually erode into the urethra (2%).  Either of these complications requires a repeat operation with complete removal of the sling.

Artificial Urinary Sphincter

Although more invasive then urethral bulking agents or male slings, the artificial
urinary sphincter (AUS) remains the gold standard for men with persistent incontinence after prostatectomy.  The AUS is composed of three interconnected parts.  The main part of the device is comprised of an inflatable cuff which is wrapped around the urethra (in the same location as where the male sling is usually placed).  The cuff is connected to a reservoir (containing fluid) that is implanted in the abdomen and a pump that is implanted in the scrotum.  At baseline, the cuff encircling the urethra is inflated with fluid.  As such, the cuff compresses the urethra, preventing leakage of urine from the bladder.  However, when the patient pushes on the pump within the scrotum (which can be manipulated through the skin), fluid from the cuff is transferred to the reservoir.  When all of the fluid is transferred from the cuff to the reservoir, the cuff is deflated and no longer compresses the urethra.  This allows urine to flow from the bladder and out of the penis. The fluid in the reservoir drains back into the cuff after a fixed period of time, inflating it and allowing it to compress the urethra again.  The whole process is carried out via hydraulics. 







Diagram of Artificial Urinary Sphincter


The advantage of the AUS is that it replicates normal continence.  Men with the AUS remain dry until they want to void at which time they activate the device, allowing the urine to drain for a set period of time.  Success rates with the AUS have been notable.  Initial studies reported complete dryness ranging from 79-100% with one study finding a decrease in pad usage from 2.7 to 1 per day.  More recent studies have demonstrated social continence (up to 1 pad per day) of 58-88%.  There are some drawbacks, however.  First, any man that wants an AUS needs some level of manual dexterity that will allow him to operate the pump in the scrotum.  In addition, as with all machines, the device can and does break down (6% rate over 5 years), requiring the parts to be removed or replaced through further surgery.  Other complications associated with an AUS include infection (5.5%) and erosion into the urethra (6%).  As with the male sling, either of these two complications requires removal of the device.  Another potential complication is  recurrent incontinence.  This complication usually occurs due to urethral atrophy, which prevents the cuff from successfully compressing the urethra.  In this situation, a repeat procedure is performed in which a second (tandem) cuff is added to provide additional compression of the urethra.

Take Home Message

While most men will eventually regain continence after prostatectomy, some will continue to have moderate to severe, debilitating leakage.  Fortunately, men with this complication still have hope in the form of surgical techniques.  While minimally invasive and creating the least risk, urethral bulking agents are not very effective and generally not recommended for the treatment of incontinence after prostatectomy.  Male slings, although somewhat more invasive have been demonstrated to have significant efficacy and are being used more and more commonly for mild to moderate incontinence.  The gold standard, however, remains the artificial urinary sphincter.  Although not a panacea and definitely plagued by its own risks and complications, the AUS has provided reliable dryness for men with moderate to severe incontinence after prostatectomy.  Regardless of the technique chosen, the decision to proceed with surgical management should be considered carefully after thoroughly weighing the risks and benefits with a qualified urologist.  This decision should not even be considered until at least a year after surgery.




This blog is not a medical practice and cannot provide specific medical advice. This information should never be used to replace or discount the medical advice you receive from your physician

11 comments:

  1. Interesting post, doc. How does a guy who needs surgical intervention decide whether to try the sling first, or just go for the AUS? Also, for someone who wants to try the sling, how does a guy choose between AdVance or Virtue sling? Are there some situations or patients for which one is better than the other, or is it just a toss up?

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  2. chamorgadol: in general, slings are usually reserved for men with mild to moderate incontinence only. For this category of men, the decision is often based on patient dexterity (ability to manipulate the pump in scrotum) and patient preference. For men with severe incontinence, the AUS is generally first line. As for AdVance vs Virtue, the Virtue sling is like an AdVance plus and old fashioned sling. It has four arms, two going through the obturator foramen (like the AdVance) and two going up to the anterior abdomen(like the old fashioned sling). Proponents of the Virtue claim that it is more effective than AdVance because of the extra compression from the extra two arms. However, the Virtue has only been around for about 2 years and does not have a great deal of data by which to judge it. I guess time will tell which one is better.

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  3. Thanks doctor, for your amazing information. How much risks involved in minimally invasive surgery.
    I heard, it is more efficient than Open, Is it true? can you explain?.. feel free to visit my site also.
    Pelvic Floor Dysfunction Houston

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  4. bartley: thanks for the feedback...as for minimally invasive versus open surgery, check out my post called The Truth About Da Vinci Surgery...it covers that question in detail.

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  5. I just found your informative blog, doc. I'm at the 11 week point after Di Vinci prostate removal surgery. Watchful waiting was suggested, but I wanted my localized cancer gone. All has gone well,so far. I've even had erections. But I'm confused about my incontinence. I leak during the day, but am completely dry at night from the day the catheter was removed. Even bulking up on liquids in the evening has not affected my nite continence. I just have to get up to pee. I do Kegels every day, and have no problem doing them up to 20 minutes at a time. But I still leak 2-3 pads during the day, when gravity takes over. I plan to be patient, but I'd like to understand how this can happen; continent at nite, but incontinent during the day.

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  6. thad1940: Thanks for the positive feedback! Believe it or not, you actually answered your own question. As I mentioned in the post, most men leak after prostatectomy due to a sphincter muscle that is not strong enough post surgery. This muscle is tested during the day when you are up and about. During the day, the force of gravity on the urine as well as the pressure of the abdominal contents sitting on the bladder overcome the strength of the sphincter and cause men to leak. At night, you are recumbent and the pressure of gravity pushes the urine against the back of the bladder rather than against the sphincter. Unless your bladder is full beyond capacity(which it would rarely be at night) your sphincter is not doing much work at all at night and can easily keep you dry. As I mentioned in the post, it can take upwards of a year to regain full or nearly full continence. When it comes to continence after prostatectomy, patience and Kegels are the way to go. Hope that helps.

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  7. Great post, very informative. I also liked a lot, that you are interacting with your visitors and trying to answer their questions. These kinds of blogs I like to bookmark and come back to visit.
    I heard from a friend that Botox injections can be used for incontinence issues. It came as a shock to me. Is that even true, and if yes, is the Botox used as the bulking agent or has a different purpose?
    I also found a few legal sites relating about some issues with bladder sling devices used for female SUI. Coming from a legal site, the problem is probably overblown(or not, I don't know, I'm not the one to judge) but I was wondering if there are any similar problems associated with male slings as well?

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  8. John: Thanks for the kind words. Botox is actually for overactive bladders. It relaxes the bladder in men and women with a condition called urge incontinence where they cant hold their urine when they get the urge to urinate. It is not a bulking agent. Sling erosions have mostly been reported in women but erosions can certainly occur in men as well and are definitely a risk of this type of surgery.

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  9. I just want to share this personal story about how my husband survived the problem of NO ERECTION after prostate surgery.
    My husband undertook prostate surgery 3 years ago and before then i always looked forward to great sex with him and after the surgery he was unable to achieve any erections, we were bothered and we tried so many drugs, injections and pumps and rings but none could give him an erection to even penetrate. I searched for a cure and got to know about Dr. Hillary who is renowned for curing problems of this nature and he did encouraged me not to give up and he recommended his herbal medication which my hubby took for 3 weeks and today his sexual performance is optimum. You too can contact him for similar problems on hillaconn@gmail.com. A man who cannot satisfy his wife's sexual need is not a real man!

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