Editing AUA: Incontinence after Prostate Therapy (2019) (section)

=== Surgical ===

==== Timing ====
* '''<span style="color:#ff0000">If there is no improvement at 6 months despite conservative therapy and the patient has bothersome IPT,</span>''' (i.e. patient does not want to wait until 12 month time point) '''<span style="color:#ff0000">surgery may be considered for early treatment'''
** While almost all patients have reached their maximum improvement by 12 months, most patients with severe SUI will show no significant improvement after 6 months and may be candidates for early intervention
* '''<span style="color:#ff0000">Otherwise, treatment should be offered to patients with persistent bothersome SUI at 12 months.</span>'''
** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''

==== Pre-surgical Evaluation ====
# '''<span style="color:#ff0000">SUI should be confirmed</span>''' by history, physical exam, or ancillary testing
#* If there is any doubt as to whether the patient has SUI; all reasonable measures to '''demonstrate SUI on physical exam''', with or without provocative testing such as bending, shifting position, or rising from seated to standing position, should be taken
# '''<span style="color:#ff0000">Cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery</span>'''
#* '''Patients with symptomatic vesicourethral anastomotic stenosis or bladder neck contracture should be treated prior to surgery for IPT'''
# '''<span style="color:#ff0000">Urodynamics (UDS) may be performed.</span>'''
#* '''UDS are not required before surgical intervention for IPT unless the clinician is in doubt of the diagnosis or it is felt that patient counseling will be affected.'''
#** '''During UDS, it is important that the catheter be removed and stress testing repeated in patients with suspected SUI who do not demonstrate stress incontinence with a catheter in place'''
#*** Up to 35% of males with post-prostatectomy SUI will not demonstrate SUI with a catheter in place. This may be due to some scarring at the site of the anastomosis. In such cases, even a small catheter can occlude the urethra and prevent stress leakage.

==== Contraindications ====
* '''It is not known if poor bladder compliance and an uncorrected storage pressure are absolute contraindications to SUI surgery in IPT patients (***Campbell's lists this as contraindication***). However, these patients should be carefully followed to avoid upper tract decompensation.'''

==== Options (5): ====
# '''<span style="color:#ff0000">Urethral bulking agents</span>'''
# '''<span style="color:#ff0000">Adjustable balloon devices</span>'''
# '''<span style="color:#ff0000">Slings</span>'''
# '''<span style="color:#ff0000">AUS</span>'''
# '''<span style="color:#ff0000">Urinary Diversion</span>'''
* Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model

===== Urethral bulking agents =====
* '''Advantage'''
**'''Least invasive technique'''
* '''Disadvantage'''
**'''Least effective surgical technique'''
*** Cure is rare
* '''<span style="color:#ff0000">Indication</span>'''
**'''<span style="color:#ff0000">Consider in patients who are unable to tolerate or refuse more invasive surgical therapy</span>'''

===== Adjustable balloon devices =====
* '''Disadvantages'''
**'''Increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
*'''<span style="color:#ff0000">Indication</span>'''
**'''<span style="color:#ff0000">Consider for mild SUI</span>'''

===== Male slings =====
* <span style="color:#ff0000">'''Indication'''</span>
**'''<span style="color:#ff0000">Consider for mild to moderate SUI</span>'''
*** '''<span style="color:#ff0000">Poor efficacy in comparison to an AUS in patients with severe incontinence.</span>'''
* '''Risks''' (generally low complication rate):
** Urinary retention
*** Typically resolves within 1 week
** Pelvic and perineal pain and paresthesia
*** Typically resolves within 12 weeks
** '''Erosion or infection'''
*** '''Both are exceedingly rare.'''
*** If a male sling is thought to be infected or documented to be eroded on cystoscopy, the '''management is similar to management of an infected or eroded AUS (see below)'''

===== AUS =====

====== Indications ======
*'''<span style="color:#ff0000">Consider for mild to severe SUI</span>'''
* '''<span style="color:#ff0000">Preferred in patients with prior (3):</span>'''
** '''<span style="color:#ff0000">Radiation</span>'''
*** Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy
*** '''Complication rates are higher'''
** '''<span style="color:#ff0000">Urethral reconstruction</span>'''
*** Urethral strictures of the anterior urethra and urethral stenosis of the posterior urethra can arise after RP, RT, or treatment for IPT. Urethral reconstructive surgery is often used to treat narrowing in the urethra.
*** '''Male slings will not be effective given post-surgical changes related to most types of urethral reconstruction in the posterior and anterior urethra'''
*** '''Complications rates are higher'''
**** Depending on the technique employed (urethra transecting or not) the blood supply to the urethra may be diminished and potentially decrease the life span of an AUS.
** '''<span style="color:#ff0000">Vesicourethral anastomotic stenosis or bladder neck contracture</span>'''
*** Decreased success rates when undergoing male slings

====== Contraindications ======
*'''<span style="color:#ff0000">Inadequate physical or cognitive abilities to operate the device</span>'''

====== Procedure ======
* '''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision'''

====== Complications ======
* '''<span style="color:#ff0000">Intraoperative urethral injury</span>'''
** '''<span style="color:#ff0000">If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed</span>'''
* '''<span style="color:#ff0000">Persistent leakage</span>'''
* '''<span style="color:#ff0000">Cuff erosion</span>'''
** Can be due to unrecognized urethral injury at the time of initial surgery or more likely due to subsequent instrumentation of the urethra including catheterization.
** '''Management:'''
*** '''AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal'''
*** '''AUS should not be re-implanted until at least 3 months'''
* '''<span style="color:#ff0000">Infection</span>'''
** '''<span style="color:#ff0000">Device infection occurs in <1-5% of cases'''
** '''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''<span style="color:#ff0000">History and Physical Exam'''
****'''<span style="color:#ff0000">Presents with (4):'''
****#'''<span style="color:#ff0000">Pain at the site of the AUS'''
****#'''<span style="color:#ff0000">Fever'''
****#'''<span style="color:#ff0000">Scrotal warmth or erythema'''
****#'''<span style="color:#ff0000">Skin changes'''
** '''<span style="color:#ff0000">Management:'''
*** '''<span style="color:#ff0000">Urgent AUS explantation'''
*** '''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.
* '''<span style="color:#ff0000">Mechanical failure</span>'''
*'''<span style="color:#ff0000">Decreased efficacy over time and reoperations are common</span>'''
** '''The current version consists of''' a hydraulic system composed of '''3 separate parts:'''
**# '''A urethral cuff''' of varying sizes
**# '''A pressure regulating balloon reservoir''' with three available pressure profiles
**# '''A control pump'''
*** The device will fail if any of the 3 parts, the tubing, or connections suffer a micro-perforation with loss of fluid
** The rate of device failure increases with time, with '''failure rates of'''
*** '''≈24% at 5 years'''
*** '''≈ 50% at 10 years'''
** '''AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to (3):'''
**# '''Urethral atrophy'''
**# '''Improper cuff sizing'''
**# '''Partial fluid loss'''

===== Urinary diversion =====
* '''Can be considered in appropriately motivated and counseled patients who are unable to obtain adequate long-term quality of life'''
** '''If bladder preservation is feasible, conversion to a Mitrofanoff (e.g. Appendix, Monti), incontinent ileovesicostomy, or suprapubic tube with bladder neck closure may confer an improved QoL.'''
** '''In the event of the “hostile” bladder, cystectomy in combination with either an ileal conduit or continent catheterizable pouch''' would best manage incontinence while protecting the upper tracts.

===== Other =====

* Other potential treatments for IPT should be considered investigational