Urinary Incontinence After Radical Retropubic Prostatectomy

Urinary Incontinence; Prostate Cancer

REVIEWING THE LITERATURE Urinary Incontinence • Prostate Cancer Urinary Incontinence After Radical Retropubic Prostatectomy Steven R. Potter, MD Alan W. Partin, MD, PhD The Brady Urological Institute, The Johns Hopkins Hospital Baltimore [Rev Urol 1(2):97-98, 1999] y all accounts, the morbidity of radical prostatectomy performed for clinically localized prostate cancer has fallen dramatically over the past 2 decades as anatomic insights and technical improvements have transformed the practice of this operation. Despite this, postprostatectomy incontinence remains a vexing and incompletely understood problem. Partly because of variation in the definition of incontinence and means and length of patient follow-up, controversy surrounds the issue of incontinence after radical prostatectomy. B Patient-Reported Impotence and Incontinence After Nerve-Sparing Radical Prostatectomy Talcott JA, Rieker P, Propert KJ, et al: J Natl Cancer Inst 89(15):1117-1123, 1997 This study warrants particular notice because it highlights the intellectual chasm that exists between proponents and detractors of radical prostatectomy as a therapy for localized prostate cancer. Talcott and colleagues at the DanaFarber Cancer Institute in Boston report on 94 men with clinically localized prostate cancer prospectively followed by questionnaire, as well as by retrospective chart review, in an attempt to assess impotence and incontinence related to radical prostatectomy (RP). Over a 45-month period, a total of 106 men were enrolled in the study, went on to RP, and were not excluded on the basis of lymph node metastases or adjuvant therapy. Of these, 94 men ultimately completed questionnaires at 3 and 12 months after surgery and had operative notes that allowed retrospective nerve-sparing classification. The operations were performed at multiple facilities by 35 different surgeons. A total of 29 and 41 men underwent bilateral and unilateral nerve-sparing RP, respectively. Of the entire group undergoing nerve-sparing RP, 50% were incontinent (wearing pads) at 1 year follow-up. Of all patients, 39% were wearing pads for leakage of urine at 1 year after operation. Incontinence rates in the cohort undergoing wide excision of both neurovascular bundles (NVBs) were actually lower than in men in whom the NVBs were spared. This finding, which is at odds with most studies, led the authors to speculate that longer operative duration or greater periurethral instrumentation in men undergoing nerve sparing had deleterious effects on continence. No data to support either claim were presented. It seems more probable that few of the men assigned as having undergone nerve-sparing RP actually had nerves spared. The authors posit that the 50% incontinence rate in these men is an indictment of previous studies relying on physician interviews for continence data. It may be more likely that this study confirms the difficulty of performing RP adequately and the susceptibility of postoperative continence and potency to subtleties of technique. Puboprostatic Ligament Sparing Improves Urinary Continence After Radical Retropubic Prostatectomy Poore RE, McCullough DL, Jarow JP: Urology 51(1):67, 1998 Poore and colleagues at the Bowman Gray School of Medicine in Winston-Salem, NC, reported a prospective controlled study of their standard apical dissection technique with a puboprostatic ligament-sparing technique. A total of 43 men were enrolled over 15 months, with 25 undergoing standard RP and 18 undergoing puboprostatic ligament sparing. These groups were comparable in terms of patient age, clinical stage, and preoperative PSA levels. Patients were evaluated postoperatively by telephone using an independent interviewer and standard questionnaire. A control group of 25 age-matched men without history of prostate cancer were interviewed for baseline continence information. The technique of puboprostatic ligament sparing used by the authors involved division of the dorsal vein complex over the midanterior prostate, cranial to the puboprostatic ligaments. The urethra was mobilized within the SPRING 1999 REVIEWS IN UROLOGY 97 Urinary Incontinence continued prostatic apex before division, with the tissue located between the urethra and symphysis pubis left undisturbed. The median time to achievement of continence in the standard and ligament-sparing groups was 12 and 6.5 weeks, respectively (P<0.05). At 1 year, continence rates in the standard and ligament-sparing groups were 94% and 100%, a difference that was not statistically significant. Importantly, the positive margin rate and location of positive margins were compared as well, and did not differ significantly between the 2 study arms. Of note, 20% of the nonsurgical control group reported occasional urge incontinence, but all of these men classified themselves as continent, and none wore pads for their small volume leakage. This study is a model for the evaluation of postoperative incontinence and the initial assessment of a technical modification. The authors offer further support for intrinsic sphincteric function providing a major role in determining postoperative continence status. Although the mechanism by which puboprostatic ligament sparing led to earlier return of continence is unclear, the preservation of periurethral tissue and sphincteric muscle are probably of central importance. The control group suggests that the preoperative incidence of mild, occasional stress incontinence in the age group undergoing RP is not insignificant and may serve as a confounder in studies of treatmentassociated outcomes if careful preoperative assessment is not performed. Urinary Continence After Radical Prostatectomy: The Columbia Experience Goluboff ET, Saidi JA, Mazer S, et al: J Urol 159(4):1276-1280, 1998 Goluboff and colleagues from Columbia University in New York retrospectively evaluated the incidence of post-RP incontinence in 480 men via questionnaire. These men had been operated on over a 12-year period by 1 of 2 surgeons, and all had pathologically organ-confined disease. A minimum of 12 months had elapsed since surgery in all men. Of note, these men answered questions about events transpiring from 1 to approximately 12 years earlier. Men who did not regularly use pads were classified as continent. By this definition, 91.8% of men returning questionnaires were considered continent, although 13.3% of patients had urine leakage at night, and 24% had symptoms of urgency postoperatively. The number of men with leakage at night, many of whom were presumably not wearing pads and thus not classified as incontinent, seems large. In our experience, significant nocturnal leakage postoperatively bodes poorly for chances of return of urinary control. This study refutes the exceedingly high incontinence 98 REVIEWS IN UROLOGY SPRING 1999 rates found after RP in several outcomes-based reports. Although the authors state that age at surgery had no impact on final continence status, they also reported nocturnal incontinence rates of 0% and 20% in men <50 years and >70 years of age, respectively. This provides further inferential evidence that postoperative return of urinary control is a multifactorial process that is at least somewhat impaired in older men. Update on Bladder Neck Preservation During Radical Retropubic Prostatectomy: Impact on Pathologic Outcome, Anastomotic Strictures, and Continence Shelfo SW, Obek C, Soloway MS: Urology 51(1):73-78, 1998 Shelfo and colleagues from the University of Miami, Fla, reported on a retrospective chart review and patient questionnaire study involving 365 consecutive men undergoing RP by a single surgeon over a 5-year period. Patients were carefully evaluated for 3 major groups of postsurgical outcomes: (1) surgical margin status, (2) anastomotic stricture rates, and (3) urinary function. The authors used a bladder neck preserving technique in all men without history of transurethral prostatic resection. A total of 195 patients were evaluated by a validated quality of life questionnaire developed for the American Urological Association. The questionnaire was distributed a single time to men who were 3 to 60 months postsurgery. Continence was defined as requiring no pads. Overall, 84% of these men did not wear pads, while 12% wore 1 to 2 pads/d and 3% wore ≥3 pads/d. The authors reported that risk of postoperative incontinence increased with increasing age, with continence rates of 100% in men aged 40 to 49 years falling to 78% in men aged 70 to 79 years. Interestingly, although 90% of the entire cohort believed their urinary function did not limit social, physical, or occupational activities, 28% of these men felt their urinary function limited sexual activities more than a little. Data on time elapsed from surgery as a function of continence, NVB status at operation, and potency were not gathered or reported. The authors reported a large, contemporary series assessed with a validated questionnaire revealing high levels of satisfaction with postoperative urinary function and an overall continence rate of 84%. This important study provides urologists with further evidence that acceptable morbidity related to urinary function after RP is achievable and that the majority of men are both continent and subjectively satisfied with their urinary function postoperatively.