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AUA: Incontinence after Prostate Therapy (2019): Difference between revisions

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* '''Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the AUA OAB guidelines'''
* '''Patients with urgency urinary incontinence or urgency predominant mixed urinary incontinence should be offered treatment options per the AUA OAB guidelines'''


=== Options ===
=== Non-surgical ===


==== Non-surgical (5): ====
==== Options ====
# '''PFME/PFMT'''
# '''PFME/PFMT'''
# '''Absorbent pads'''
# '''Absorbent pads'''
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*** '''Suprapubic catheter drainage is not a solution for the patient with severe intrinsic sphincter deficiency, as urethral leakage will persist'''
*** '''Suprapubic catheter drainage is not a solution for the patient with severe intrinsic sphincter deficiency, as urethral leakage will persist'''


==== Surgical ====
=== Surgical ===


===== Timing =====
==== Timing ====
* '''If there is no improvement at 6 months despite conservative therapy and the patient has bothersome IPT,''' (i.e. patient does not want to wait until 12 month time point) '''surgery may be considered for early treatment'''
* '''If there is no improvement at 6 months despite conservative therapy and the patient has bothersome IPT,''' (i.e. patient does not want to wait until 12 month time point) '''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
** 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
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** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''
** '''Conversely, treatment should be offered with caution in some patients who continue to display symptom improvement at 12 months'''


===== Pre-surgical Evaluation =====
==== Pre-surgical Evaluation ====
# '''SUI should be confirmed''' by history, physical exam, or ancillary testing
# '''SUI should be confirmed''' 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
#* 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
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#*** 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.
#*** 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 =====
==== 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.'''
* '''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): =====
==== Options (5): ====
# '''Urethral bulking agents'''
# '''Urethral bulking agents'''
# '''Adjustable balloon devices'''
# '''Adjustable balloon devices'''
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* Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model
* Risks, benefits, and expectations of different treatments should be discussed using the shared decision-making model


====== Urethral bulking agents ======
===== Urethral bulking agents =====
* '''Least invasive technique'''
* '''Least invasive technique'''
* '''Least effective surgical technique; cure is rare'''
* '''Least effective surgical technique; cure is rare'''
* '''Consider in patients who are unable to tolerate or refuse more invasive surgical therapy'''
* '''Consider in patients who are unable to tolerate or refuse more invasive surgical therapy'''


====== Adjustable balloon devices ======
===== Adjustable balloon devices =====
* '''Consider for mild SUI'''
* '''Consider for mild SUI'''
* '''Disadvantages: increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
* '''Disadvantages: increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''


====== Male slings ======
===== Male slings =====
* '''Considered for mild to moderate stress urinary incontinence'''
* '''Considered for mild to moderate stress urinary incontinence'''
** '''Poor efficacy in comparison to an AUS in patients with severe incontinence.'''
** '''Poor efficacy in comparison to an AUS in patients with severe incontinence.'''
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*** 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)'''
*** 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 ======
===== AUS =====
* '''Consider for mild to severe stress urinary incontinence'''
 
====== Indications ======
*'''Consider for mild to severe stress urinary incontinence'''
* '''Preferred in patients with prior (3):'''
* '''Preferred in patients with prior (3):'''
** '''Radiation'''
** '''Radiation'''
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** '''Vesicourethral anastomotic stenosis or bladder neck contracture'''
** '''Vesicourethral anastomotic stenosis or bladder neck contracture'''
*** Decreased success rates when undergoing male slings
*** Decreased success rates when undergoing male slings
* '''Contraindications:'''
** '''Inadequate physical or cognitive abilities to operate the device'''
* '''Procedure'''
** '''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision'''
* '''Complications:'''
** '''Intraoperative urethral injury'''
*** '''If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed'''
** '''Persistent leakage'''
** '''Mechanical failure'''
** '''Cuff erosion'''
*** 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'''
** '''Infection'''
*** '''Device infection occurs in <1-5% of cases'''
*** '''Presents with pain at the site of the AUS, fever, scrotal warmth or erythema, or skin changes'''
*** '''Management:'''
**** '''Urgent AUS explantation'''
**** '''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.
** '''Decreased efficacy over time and reoperations are common'''
*** '''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'''
*** '''An AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to:'''
***# '''Urethral atrophy'''
***# '''Improper cuff sizing'''
***# '''Partial fluid loss'''


====== Urinary diversion ======
====== Contraindications ======
* '''Inadequate physical or cognitive abilities to operate the device'''
 
====== Procedure ======
* '''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision'''
 
====== '''Complications''' ======
* '''Intraoperative urethral injury'''
** '''If identified during implantation, procedure should be abandoned and subsequent implantation should be delayed'''
* '''Persistent leakage'''
* '''Mechanical failure'''
* '''Cuff erosion'''
** 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'''
* '''Infection'''
** '''Device infection occurs in <1-5% of cases'''
** '''Presents with pain at the site of the AUS, fever, scrotal warmth or erythema, or skin changes'''
** '''Management:'''
*** '''Urgent AUS explantation'''
*** '''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.
* '''Decreased efficacy over time and reoperations are common'''
** '''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'''
** '''An AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to:'''
**# '''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'''
* '''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.'''
** '''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.
** '''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 =====
 
* Other potential treatments for IPT should be considered investigational
* Other potential treatments for IPT should be considered investigational


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