Editing Incontinence after Prostate Therapy (2024) (section)

=== Surgical ===

==== Timing ====
* '''<span style="color:#ff0000">In patients with bothersome stress urinary incontinence after prostate treatment despite conservative therapy, clinicians</span>''' 
** '''<span style="color:#ff0000">May offer surgery as early as 6 months if incontinence</span>'''
*** Patients who report a lack of symptom improvement or those experiencing more severe incontinence at 6months may be offered early treatment in the form of surgical interventions with such a treatment decision made using a shared decision-making model.
**'''<span style="color:#ff0000">Should offer surgical treatment at 12 months post-prostate treatment.</span>'''
***'''<span style="color:#ff0000">Majority of patients will reach their maximum improvement by 12 months with minimal to no improvement afterwards.</span>'''
**** Withholding surgical treatment after 12 months is unlikely to result in improved patient symptoms and will delay restoration of continence.
**** Conversely, treatment should be offered with caution in patients who are displaying symptom improvement.

==== Pre-surgical Evaluation ====
# '''<span style="color:#ff0000">SUI should be confirmed</span>''' by history, physical exam, or ancillary testing
#* '''Demonstrate SUI on physical exam''', with or without provocative testing such as bending, shifting position, or rising from seated to standing position
#* Stress pad testing can also be performed. 
#* If there is any doubt as to whether the patient has SUI, UDS may be performed.
# '''<span style="color:#ff0000">Cystourethroscopy should be performed to assess for urethral and bladder pathology that may affect outcomes of surgery</span>'''
#* '''The presence of urethral pathology (e.g., stricture, vesicourethral anastomotic stenosis (VUAS), BNC, urethral lesions) may affect the outcome of surgery'''
#** Cystourethroscopy has also been recommended prior to placement of transobturator slings to assess urethral function (patients should have visual voluntary contraction of the external sphincter), and luminal closure of the urethra should be demonstrated with bulbar compression and elevation (repositioning test). However, success of the procedure has not been shown to be dependent on these findings in any controlled study.
#**'''Patients with symptomatic VUAS or BNC should be treated prior to surgery for IPT'''
#***Although a VUAS or BNC will not necessarily cause SUI, treatment of them may worsen SUI. This is important because a patient may be considered for a sling procedure if he had “mild” incontinence, but he would likely need an AUS if it worsens after treatment.
#***'''Following treatment of VUAS, an interval cystoscopy should be performed at least 4-6 weeks later to document improvement and stabilization, after which IPT treatment can be considered.'''
#*In cases where pre-operative cystourethroscopy is not performed, it may be done at the start of the AUS or sling implantation before any incision is made. 
#**In such cases, patients should be made aware of the potential consequences and the possibility of aborting an AUS or sling insertion if significant urethral or bladder pathology is discovered.
# '''<span style="color:#ff0000">Urodynamics (UDS) may be performed in cases where it may facilitate diagnosis or counseling.</span>'''
#* Can aid in determining if IPT is cause by sphincter dysfunction, bladder dysfunction, or a combination of both, and also assess bladder contractility and the presence of bladder outlet dysfunction.
#* '''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.'''
#** No controlled studies that assess the value of UDS versus no UDS in men with SUI prior to surgery.
#** Presence of UDS abnormalities of storage (e.g., detrusor overactivity, impaired compliance, small cystometric capacity) do not affect outcomes of AUS or sling surgery in men with SUI.
#** Similarly, detrusor over-activity found on UDS has not been shown to negatively impact sling outcomes in men with SUI after prostate treatment.
#** Abdominal leak-point pressure has not been shown to affect outcomes of AUS
#** if the clinician is unsure of how prevalent sphincteric versus bladder affecting incontinence, or if there is unexplained poor bladder emptying, then UDS may be helpful in providing that additional information. Examples of this may be 
#*** Patient reports significant mixed incontinence and stress incontinence is not demonstrated
#*** Impaired compliance is suspected and incontinence could be related to high storage pressures without urgency
#*** Overflow incontinence is suspected (PVR) may be helpful to rule out significant retention of urine)
#* '''<span style="color:#ff0000">★In patients with suspected SUI who do not demonstrate SUI during UDS with a catheter in place, it is important that the catheter be removed and stress testing repeated''' 
#** 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. However, these patients should be carefully followed to avoid upper tract decompensation.'''
** UDS likely has the highest yield for poor compliance in patients with severe radiation cystitis or those who have advanced neurogenic lower urinary tract dysfunction.
** Patients with significantly elevated storage pressures can be treated primarily (if no stress incontinence) with anticholinergics or onabotulinumtoxin A to lower such pressures. UDS then can be repeated to document adequate reservoir function
==== 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>'''
===== Urethral bulking agents =====
* '''Most commonly used procedure to treat male SUI'''
* Considered off-label
** Currently no FDA-approved available agents for the treatment of male incontinence

====== Advantages ======
*'''Least invasive technique'''

====== Disadvantages ======
*'''Least effective surgical technique'''
** In male patients, the best success rates have been described in patients with a high Valsalva leak point pressure, unscarred vesicourethral anastomosis, and no RT history.

====== <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 =====
* In 2017, adjustable balloon devices became available in the United States for the treatment of male intrinsic sphincter deficiency after prostatectomy or TURP.

====== Advantages ======

* Compared to AUS (3):
*# Shorter procedure length
*# Less invasive placement
*# Elimination of the need for patient manipulation

====== Disadvantages ======
*'''Higher intraoperative and early complication rates compared to other anti-incontinence procedures'''
**Most common intraoperative complication is urethral or bladder perforation
**Mean all-cause (i.e., erosion, infection, balloon migration or balloon failure) explantation rate is 27%, more common that AUS
**Efficacy, complication rates, and complication types have been associated with surgeon volume.
***Obtaining specialty training from an experienced implanter would be beneficial before device implantation.

====== <span style="color:#ff0000">Indications</span> ======
*'''<span style="color:#ff0000">Consider for non-radiated patients with mild to moderate SUI</span>'''
**RT negatively affects success and is associated with a higher complication rate.
===== Male slings =====

====== <span style="color:#ff0000">Indications</span> ======
*'''<span style="color:#ff0000">Consider for mild to moderate SUI</span>'''
**Might consider a sling in patients who have not undergone radiation, who have minimal incontinence at night, bothersome isolated climacturia, or who would be unable to use the AUS given poor hand function or cognitive abilities.
* Prior male sling does not typically interfere with subsequent sling revision or placement of an AUS in the setting of an unsatisfactory continence outcome.

====== <span style="color:#ff0000">Contraindications</span> ======
*'''<span style="color:#ff0000">Severe SUI</span>'''
**'''<span style="color:#ff0000">Poor efficacy in comparison to an AUS</span>''' 

====== Complications ======
* Generally low complication rate
* '''Urinary retention'''
** '''Typically resolves within 1 week'''
* '''Pelvic and perineal pain and paresthesia'''
** '''Typically resolves within 12 weeks'''
* '''Erosion and infection are''' '''rare'''
** '''If occurs, sling should should removed as soon as possible with a catheter left in place in the setting of erosion.'''
===== 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>'''
*#* Patients with IPT following primary, adjuvant or salvage RT should be offered the same conservative management as a patient with postprostatectomy SUI. Patients who fail conservative measures should be offered surgical management, preferably placement of AUS. 
*#* Radiated patients undergoing AUS placement should be counseled on potentially compromised functional outcomes and an increased risk of complications.
*#* '''Slings may be a potential option in some radiated patients but adjustable balloons are significantly less effective [different than 2019 guidelines which only supported AUS after radiation]'''
*# '''<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>'''
**Should be some assurance that patients can physically pump a device that is in a normal position in the scrotum.
***There are no uniform ways to demonstrate such dexterity, but a simple demonstration of strength in the fingers and the ability to squeeze the pump between the index finger and thumb should be minimal requirements.

====== Procedure ======
* '''Approach: single cuff perineal approach is preferred'''
** Superior outcomes compared to transverse scrotal incision, likely due to a more distal cuff placement, and reduced risk of complications and need for revision
** Similar outcomes compared to tandem cuff placement but reduced risk of complications

====== 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">Erosion</span>''' 
* '''<span style="color:#ff0000">Infection</span>'''
* '''<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'''
**A malfunctioning AUS does not necessarily need to be replaced, but if the patient is healthy and requests a replacement, the AUS can be explanted and a new one replaced at the same operative setting. 
***The durability and efficacy of a secondary re-implant in this setting is the same as that of a primary AUS, except in the setting of erosion
*Risk factors for complications
** Radiation
** Urethral compromise 
*** Can be due to surgical intervention, including urethroplasty, multiple treatments for BNC or stricture, urethral stent placement, and prior AUS erosion1

===== Urinary diversion =====
* '''Can be considered in patients who are unable to obtain long-term quality of life due to incontinence after prostate treatment.'''
** In patients who are unable to obtain a satisfactory QoL long-term with an AUS due to multiple device failures, intractable BNC, or severe detrusor instability, urinary diversion with or without cystectomy may be an option
** '''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
** Promising results reported in small case series for interventions such as extracorporeal magnetic intervention and penile vibratory stimulation.