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The Ongoing Challenge of Urinary Incontinence after Radical Prostatectomy THE only sure way to avoid the urinary incontinence associated with radical prostatectomy is to not perform the operation. Surgeons must often develop a reluctant expertise in managing this complication with most of the care postoperatively being psychological: cajoling patients to adhere to some version of pelvic floor exercise and encouraging timed voiding and pad weaning coupled with liberal reassurances of likely resolution. For patients, unlike the episodic nature of erectile dysfunction, the suffering associated with urinary incontinence can be constant and functionally devastating. It is not uncommon for men so afflicted to abstain socially, develop profound depression or even become suicidal. Given the joylessness of post-prostatectomy urinary incontinence, it is not surprising that urologists tend to minimize its frequency, adopt definitions such as social continence, as if the lack of public embarrassment is the same as having total control, or equate a safety pad and no pads when they are logical opposites: presence is the absence of absence. This is a bigger problem than we have been willing to admit. In a systematic review of the issue the 12-month urinary incontinence rates ranged from 4% to 31% in surgeon reported outcomes whereas the rates reported by patients themselves were consistently at the upper end of that range.1,2 When using a strict definition of urinary continence, 50.8% of men report persistent involuntary urinary loss at 12 months postoperatively.3 This tenfold difference in the reported rates of incontinence emphasizes a central challenge in addressing the problem: there is a lack of commonly accepted definitions of the condition and no standards about the timing and method of assessments. Perhaps the most vexing problem is the inability to predict who will be affected. In a recent study of 439 patients with preoperative endorectal prostate magnetic resonance imaging who underwent robotassisted radical prostatectomy a longer membranous urethral length and a shorter inner levator distance (the narrowest distance from the inner border of the levator muscle to the urethra below the prostatic apex) were independent predictors of continence recovery.3 Unfortunately the absolute difference in mean
0022-5347/17/1986-0001/0 THE JOURNAL OF UROLOGY® Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
membranous urethral length between continent and incontinent patients was only 1.4 mm while the difference in inner levator distance was only 1.2 mm. Armed with this information, should radical prostatectomy be discouraged for anyone with unfavorable features, knowing that most men will eventually regain a pad-free life despite their anatomy? Attempts to improve continence rates after radical prostatectomy can be classified into the 2 general categories of tissue preservation and reconstructive techniques. In this issue of The Journal Tyson et al (page 0000) report an example of tissue preservation, specifically the bladder neck.4 The size of a preserved bladder neck was not associated with improved continence 6 and 12 weeks following surgery after controlling for several covariates. They conclude correctly that if maximal preservation of the bladder neck does not result in an improved functional outcome but could compromise cancer control, it should not be performed. In the study by Tyson et al it should be noted that the covariates in the analysis were reasonable but not independently tested in rigorous, prospective fashion, a practice not unique to this study.4 Consider, for example, the potential role of nerve sparing on subsequent continence, which is supported by several clinical series but not uniformly observed. Cadaveric studies suggest that autonomic fibers from the neurovascular bundles directly innervate the membranous urethra and yet others have equated their role in continence to that of the Higgs boson or God particle: possible but requiring the urological equivalent of the Large Hadron Collider to prove their contribution.5,6 There is broad agreement that continence recovery is multifactorial but much less consensus about the factors involved. Is there really a causal link between bladder neck preservation and improved early continence after surgery? Some surgeons (like me) routinely resect a generous margin of bladder in continuity with the prostate gland, reconstruct the new bladder neck to a 16Fr diameter and find return of continence within the published rates. Continence after radical prostatectomy depends on a functional external sphincter, not
http://dx.doi.org/10.1016/j.juro.2017.09.053 Vol. 198, 1-3, December 2017 Printed in U.S.A.
www.jurology.com Dochead: Editorials
EDI 5.5.0 DTD JURO14991_proof 13 September 2017 4:38 pm EO:
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on a carefully tapered or reconstructed internal sphincter which has still been functionally obliterated. Efforts to re-create the passive internal sphincteric mechanism, whether through a bladder tube, plication or imbrication, may simply be increasing outlet resistance through degrees of bladder neck obstruction. Reconstruction of the periprostatic tissues after the removal of the prostate has been the other area replete with techniques to improve continence. A recent systematic review of the literature found 354 reports of pelvic floor reconstruction, of which 32 could be analyzed.7 Reconstruction techniques included posterior reconstruction (the Rocco stitch), anterior suspension and anterior reconstruction. Only 7 of the 32 studies were randomized with the majority using historic controls as the comparison arm. The authors found that posterior reconstruction was associated with an improved rate of continence at several time points postoperatively while anterior suspension was associated with improvement only in the 4 to 6-week range. Anterior reconstruction was always performed with posterior reconstruction so that its independent contribution to continence could not be assessed. Interestingly combining these presumably beneficial techniques did not routinely improve continence. In every study at least a few patients remained permanently incontinent, emphasizing that nothing preserved or reconstructed will guarantee continence. Why has it been so hard to solve this problem? The roulette nature of urinary incontinence after radical prostatectomy is not simply a matter of bad luck, bad anatomy or bad technique; it is probably the result of all 3 elements. A long, plumb urethra and a muscular external sphincter may be enough to assure continence even when a prostate is ripped from its investments with little concern about the collateral damage. On the other hand, the most delicate preservation and reconstruction of the (yet undefined) critical structures will not assure continence. Furthermore, surgeon perception of intraoperative performance during radical prostatectomy has been shown to be a poor predictor of subsequent continence.8 The pernicious effects of the many known and unknown confounders associated with radical prostatectomy make well done, controlled clinical trials difficult to perform and with results even harder to interpret. Accepting that regaining continence after radical prostatectomy remains a mystery opens the door to hypothesis generation. Setting aside whether either of these is testable, here are 2 hypotheses that I describe to my patients. 1) Postoperative continence is directly related to how continence was originally achieved. Those who have been using a combination of the external and internal sphincters since childhood for passive continence will have a more muscularly developed pelvic floor to which they are Dochead: Editorials
(unknowingly) neurologically wired. Removing the upper part of the continence mechanism has no demonstrable effect on their control. These immediately continent patients (and sometimes their surgeons) will incorrectly assume that this is the manifestation of exquisite surgical technique when in fact only a formal external sphincterotomy performed during the operation would have changed their fate. 2) Most men regain urinary control because they learn how. Consider the anal sphincter. It has about the same muscular investments and innervation as its anteriorly placed neighbor, the external urinary sphincter. It can distinguish solid from gas, tightens with rectal pressure when not socially acceptable, and relaxes when no one is around. It functions subconsciously, largely independent of its physical stature: thick, thin, long or short, it works. How? Just like our house trained animals, we learned. Finding continence using the external urinary sphincter is no different. Variability in time to continence occurs because some men are naturals and some are not. Reassuring the laggard that this learned skill is the rule goes a long way to helping them through this challenge. Radical prostatectomy is a difficult operation to master for oncologic and functional outcomes. The positive surgical margin rate in my series was not routinely under 2% for pT2 tumors and 15% for pT3 tumors until I had performed more than 2,000 procedures and there were certainly more incontinent patients earlier in my experience than there are now. Others find that it may take more than 400 cases for continence outcomes to plateau.9 For those performing radical prostatectomies who are still on the learning curve, here is some advice. Patients should be told about potential results in your hands, which requires tracking your outcomes. Avoid minimizing the risk of urinary incontinence. Speak plainly: instead of saying “a 16% risk,” say “1 out of 6 patients will be affected.” Do not avoid your incontinent patients. Although you may have had a role in their incontinence, it is no one’s fault. Recommend continence restoring procedures to them; there is underuse of these potentially beneficial procedures.10 Finally, the biggest improvement in continence for men with prostate cancer will come from the growing practice of not operating on low risk disease. For men who rationalize a life in diapers as the price of being cured, the wise surgeon remains silent about the generally nonlife threatening nature of most prostate cancers and, more importantly, puts fewer of their patients at risk. Joel B. Nelson Department of Urology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
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REFERENCES 1. Ficarra V, Novara G, Rosen RC et al: Systematic review and metat-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012; 62: 405. 2. Barry MJ, Gallagher PM, Skinner JS et al: Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of Medicare-age men. J Clin Oncol 2012; 30: 513. 3. Grivas N, van der Roest R, Schouten D et al: Quantitative assessment of fascia preservation improves the prediction of membranous urethral length and inner levator distance on continence outcome after robotic-assisted radical prostatectomy. Neurourol Urodyn 2017; doi: 10.1002/nau.23318.
Dochead: Editorials
4. Tyson MD, Ark J, Gregg JR et al: The null effect of bladder neck size on incontinence outcomes after radical prostatectomy. J Urol 2017; 198: 0000. 5. Strasser H and Bartsch G: Anatomic basis for the innervation of the male pelvis. Urologe A 2004; 43: 128. 6. Murphy DG and Costello AJ: How can the autonomic nervous system contribute to urinary continence following radical prostatectomy? A “boson-like” conundrum. Eur Urol 2013; 63: 445. 7. Cui J, Guo H, Li Y et al: Pelvic floor reconstruction after radical prostatectomy: a systematic review and meta-analysis of different surgical techniques. Scientific Reports 2017; 7: 2737.
8. Stern J, Sharma S, Mendoza P et al: Surgeon perception is not a good predictor of perioperative outcomes in robot-assisted radical prostatectomy. J Robot Surg 2011; 5: 283. 9. Fossati N, Di Trapani E, Gandaglia G et al: Assessing the impact of surgeon experience on urinary continence recovery after robot-assisted radical prostatectomy: results of four highvolume surgeons. J Endourol 2017; doi: 10.1089/end.2017.0085. 10. Kim PH, Pinheiro LC, Atoria CL et al: Trends in the use of incontinence procedures after radical prostatectomy: a population based analysis. J Urol 2013; 189: 602.
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The Ongoing Challenge of Urinary Incontinence after Radical Prostatectomy THE only sure way to avoid the urinary incontinence associated with radical prostatectomy is to not perform the operation. Surgeons must often develop a reluctant expertise in managing this complication with most of the care postoperatively being psychological: cajoling patients to adhere to some version of pelvic floor exercise and encouraging timed voiding and pad weaning coupled with liberal reassurances of likely resolution. For patients, unlike the episodic nature of erectile dysfunction, the suffering associated with urinary incontinence can be constant and functionally devastating. It is not uncommon for men so afflicted to abstain socially, develop profound depression or even become suicidal. Given the joylessness of post-prostatectomy urinary incontinence, it is not surprising that urologists tend to minimize its frequency, adopt definitions such as social continence, as if the lack of public embarrassment is the same as having total control, or equate a safety pad and no pads when they are logical opposites: presence is the absence of absence. This is a bigger problem than we have been willing to admit. In a systematic review of the issue the 12-month urinary incontinence rates ranged from 4% to 31% in surgeon reported outcomes whereas the rates reported by patients themselves were consistently at the upper end of that range.1,2 When using a strict definition of urinary continence, 50.8% of men report persistent involuntary urinary loss at 12 months postoperatively.3 This tenfold difference in the reported rates of incontinence emphasizes a central challenge in addressing the problem: there is a lack of commonly accepted definitions of the condition and no standards about the timing and method of assessments. Perhaps the most vexing problem is the inability to predict who will be affected. In a recent study of 439 patients with preoperative endorectal prostate magnetic resonance imaging who underwent robotassisted radical prostatectomy a longer membranous urethral length and a shorter inner levator distance (the narrowest distance from the inner border of the levator muscle to the urethra below the prostatic apex) were independent predictors of continence recovery.3 Unfortunately the absolute difference in mean
0022-5347/17/1986-0001/0 THE JOURNAL OF UROLOGY® Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
membranous urethral length between continent and incontinent patients was only 1.4 mm while the difference in inner levator distance was only 1.2 mm. Armed with this information, should radical prostatectomy be discouraged for anyone with unfavorable features, knowing that most men will eventually regain a pad-free life despite their anatomy? Attempts to improve continence rates after radical prostatectomy can be classified into the 2 general categories of tissue preservation and reconstructive techniques. In this issue of The Journal Tyson et al (page 0000) report an example of tissue preservation, specifically the bladder neck.4 The size of a preserved bladder neck was not associated with improved continence 6 and 12 weeks following surgery after controlling for several covariates. They conclude correctly that if maximal preservation of the bladder neck does not result in an improved functional outcome but could compromise cancer control, it should not be performed. In the study by Tyson et al it should be noted that the covariates in the analysis were reasonable but not independently tested in rigorous, prospective fashion, a practice not unique to this study.4 Consider, for example, the potential role of nerve sparing on subsequent continence, which is supported by several clinical series but not uniformly observed. Cadaveric studies suggest that autonomic fibers from the neurovascular bundles directly innervate the membranous urethra and yet others have equated their role in continence to that of the Higgs boson or God particle: possible but requiring the urological equivalent of the Large Hadron Collider to prove their contribution.5,6 There is broad agreement that continence recovery is multifactorial but much less consensus about the factors involved. Is there really a causal link between bladder neck preservation and improved early continence after surgery? Some surgeons (like me) routinely resect a generous margin of bladder in continuity with the prostate gland, reconstruct the new bladder neck to a 16Fr diameter and find return of continence within the published rates. Continence after radical prostatectomy depends on a functional external sphincter, not
http://dx.doi.org/10.1016/j.juro.2017.09.053 Vol. 198, 1-3, December 2017 Printed in U.S.A.
www.jurology.com Dochead: Editorials
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ONGOING CHALLENGE OF URINARY INCONTINENCE
on a carefully tapered or reconstructed internal sphincter which has still been functionally obliterated. Efforts to re-create the passive internal sphincteric mechanism, whether through a bladder tube, plication or imbrication, may simply be increasing outlet resistance through degrees of bladder neck obstruction. Reconstruction of the periprostatic tissues after the removal of the prostate has been the other area replete with techniques to improve continence. A recent systematic review of the literature found 354 reports of pelvic floor reconstruction, of which 32 could be analyzed.7 Reconstruction techniques included posterior reconstruction (the Rocco stitch), anterior suspension and anterior reconstruction. Only 7 of the 32 studies were randomized with the majority using historic controls as the comparison arm. The authors found that posterior reconstruction was associated with an improved rate of continence at several time points postoperatively while anterior suspension was associated with improvement only in the 4 to 6-week range. Anterior reconstruction was always performed with posterior reconstruction so that its independent contribution to continence could not be assessed. Interestingly combining these presumably beneficial techniques did not routinely improve continence. In every study at least a few patients remained permanently incontinent, emphasizing that nothing preserved or reconstructed will guarantee continence. Why has it been so hard to solve this problem? The roulette nature of urinary incontinence after radical prostatectomy is not simply a matter of bad luck, bad anatomy or bad technique; it is probably the result of all 3 elements. A long, plumb urethra and a muscular external sphincter may be enough to assure continence even when a prostate is ripped from its investments with little concern about the collateral damage. On the other hand, the most delicate preservation and reconstruction of the (yet undefined) critical structures will not assure continence. Furthermore, surgeon perception of intraoperative performance during radical prostatectomy has been shown to be a poor predictor of subsequent continence.8 The pernicious effects of the many known and unknown confounders associated with radical prostatectomy make well done, controlled clinical trials difficult to perform and with results even harder to interpret. Accepting that regaining continence after radical prostatectomy remains a mystery opens the door to hypothesis generation. Setting aside whether either of these is testable, here are 2 hypotheses that I describe to my patients. 1) Postoperative continence is directly related to how continence was originally achieved. Those who have been using a combination of the external and internal sphincters since childhood for passive continence will have a more muscularly developed pelvic floor to which they are Dochead: Editorials
(unknowingly) neurologically wired. Removing the upper part of the continence mechanism has no demonstrable effect on their control. These immediately continent patients (and sometimes their surgeons) will incorrectly assume that this is the manifestation of exquisite surgical technique when in fact only a formal external sphincterotomy performed during the operation would have changed their fate. 2) Most men regain urinary control because they learn how. Consider the anal sphincter. It has about the same muscular investments and innervation as its anteriorly placed neighbor, the external urinary sphincter. It can distinguish solid from gas, tightens with rectal pressure when not socially acceptable, and relaxes when no one is around. It functions subconsciously, largely independent of its physical stature: thick, thin, long or short, it works. How? Just like our house trained animals, we learned. Finding continence using the external urinary sphincter is no different. Variability in time to continence occurs because some men are naturals and some are not. Reassuring the laggard that this learned skill is the rule goes a long way to helping them through this challenge. Radical prostatectomy is a difficult operation to master for oncologic and functional outcomes. The positive surgical margin rate in my series was not routinely under 2% for pT2 tumors and 15% for pT3 tumors until I had performed more than 2,000 procedures and there were certainly more incontinent patients earlier in my experience than there are now. Others find that it may take more than 400 cases for continence outcomes to plateau.9 For those performing radical prostatectomies who are still on the learning curve, here is some advice. Patients should be told about potential results in your hands, which requires tracking your outcomes. Avoid minimizing the risk of urinary incontinence. Speak plainly: instead of saying “a 16% risk,” say “1 out of 6 patients will be affected.” Do not avoid your incontinent patients. Although you may have had a role in their incontinence, it is no one’s fault. Recommend continence restoring procedures to them; there is underuse of these potentially beneficial procedures.10 Finally, the biggest improvement in continence for men with prostate cancer will come from the growing practice of not operating on low risk disease. For men who rationalize a life in diapers as the price of being cured, the wise surgeon remains silent about the generally nonlife threatening nature of most prostate cancers and, more importantly, puts fewer of their patients at risk. Joel B. Nelson Department of Urology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
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REFERENCES 1. Ficarra V, Novara G, Rosen RC et al: Systematic review and metat-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012; 62: 405. 2. Barry MJ, Gallagher PM, Skinner JS et al: Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of Medicare-age men. J Clin Oncol 2012; 30: 513. 3. Grivas N, van der Roest R, Schouten D et al: Quantitative assessment of fascia preservation improves the prediction of membranous urethral length and inner levator distance on continence outcome after robotic-assisted radical prostatectomy. Neurourol Urodyn 2017; doi: 10.1002/nau.23318.
Dochead: Editorials
4. Tyson MD, Ark J, Gregg JR et al: The null effect of bladder neck size on incontinence outcomes after radical prostatectomy. J Urol 2017; 198: 0000. 5. Strasser H and Bartsch G: Anatomic basis for the innervation of the male pelvis. Urologe A 2004; 43: 128. 6. Murphy DG and Costello AJ: How can the autonomic nervous system contribute to urinary continence following radical prostatectomy? A “boson-like” conundrum. Eur Urol 2013; 63: 445. 7. Cui J, Guo H, Li Y et al: Pelvic floor reconstruction after radical prostatectomy: a systematic review and meta-analysis of different surgical techniques. Scientific Reports 2017; 7: 2737.
8. Stern J, Sharma S, Mendoza P et al: Surgeon perception is not a good predictor of perioperative outcomes in robot-assisted radical prostatectomy. J Robot Surg 2011; 5: 283. 9. Fossati N, Di Trapani E, Gandaglia G et al: Assessing the impact of surgeon experience on urinary continence recovery after robot-assisted radical prostatectomy: results of four highvolume surgeons. J Endourol 2017; doi: 10.1089/end.2017.0085. 10. Kim PH, Pinheiro LC, Atoria CL et al: Trends in the use of incontinence procedures after radical prostatectomy: a population based analysis. J Urol 2013; 189: 602.
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