THE ETIOLOGY OF POST-RADICAL PROSTATECTOMY INCONTINENCE AND CORRELATION OF SYMPTOMS WITH URODYNAMIC FINDINGS

Purpose

We evaluated men with post-radical prostatectomy incontinence to determine the incidence of intrinsic sphincter deficiency and bladder dysfunction, and the contribution of each to incontinence. In addition, we determined if subjective symptoms of stress urinary incontinence and urge incontinence correlated with urodynamic findings of intrinsic sphincter deficiency and bladder dysfunction, respectively.

Materials and Methods

A total of 60 consecutive patients (mean age 64.8 years) were prospectively evaluated with multichannel video urodynamics. All patients were evaluated at least 6 months postoperatively and had achieved a stable level of continence. Patients characterized incontinence as stress or urge related, and stress urinary incontinence was graded from 0 to 3. Intrinsic sphincter deficiency was defined as incontinence associated with increased intra-abdominal pressure and was further assessed by Valsalva's leak point pressure. Bladder dysfunction included urodynamic findings of detrusor instability or decreased compliance.

Results

Intrinsic sphincter deficiency was demonstrated in 54 patients (90%). Some component of bladder dysfunction was seen in 27 patients (45%), including detrusor instability in 24 and decreased compliance in 3, but incontinence was actually a result of bladder dysfunction in only 16 (27%). Incontinence was due to intrinsic sphincter deficiency alone in 40 patients (67%), intrinsic sphincter deficiency and bladder dysfunction in 14 (23%), and bladder dysfunction alone in only 2 (3%). Incontinence was not demonstrated on video urodynamics in 4 patients (7%). Of the 57 men who complained of stress urinary incontinence 54 demonstrated intrinsic sphincter deficiency for a positive predictive value of 95%. The 3 patients without stress urinary incontinence did not demonstrate intrinsic sphincter deficiency for a negative predictive value of 100%. Positive and negative predictive values for urge incontinence were 44 and 81%, respectively.

Conclusions

Incontinence after radical prostatectomy is associated with intrinsic sphincter deficiency in the overwhelming majority of patients. Bladder dysfunction rarely is an isolated cause. When present on urodynamic tests bladder dysfunction may not always be a significant contributor to incontinence. The symptom of stress urinary incontinence (or its absence) accurately predicts the finding (or absence) of intrinsic sphincter deficiency on urodynamics. Urge incontinence is not as reliable in predicting incontinence due to bladder dysfunction.     

COLLAGEN INJECTION THERAPY FOR POST-RADICAL RETROPUBIC PROSTATECTOMY INCONTINENCE: ROLE OF VALSALVA LEAK POINT PRESSURE

Purpose

We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection.

Materials and Methods

Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else.

Results

Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compares to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37).

Conclusions

Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.     

SLING OPERATION FOR MALE URINARY INCONTINENCE AFTER ILEAL NEOBLADDER RECONSTRUCTION: A CASE REPORT

In July 1992. sling surgery was performed on a 62-year-old male patient with urinary incontinence following ileal neobladder reconstruction. Incontinence ceased immediately after this procedure which was conducted using five nylon sutures and two dacron tubes to protect the posterior urethra.     

ANATOMICAL AND FUNCTIONAL RESULTS OF PUBOVAGINAL SLING PROCEDURE USING POLYPROPYLENE MESH FOR THE TREATMENT OF STRESS URINARY INCONTINENCE

PURPOSE: The anatomical and functional results of pubovaginal sling procedure using polypropylene mesh were investigated. MATERIALS AND METHODS: A total of 50 women with stress urinary incontinence, including 26 with type 2, 7 with mixed type 2/3 and 17 with type 3 disease, underwent the pubovaginal sling procedure using polypropylene mesh. A self-fashioned 2 cm. polypropylene mesh sling was used in all cases. The slings were fixed without tension at each side of the bladder neck. The sling was further suspended to elevate the bladder neck in patients with type 2 disease and those with a hypermobile bladder base, while it was placed without further tension in those with type 3 disease and those with a nonmobile bladder base. After the operation video urodynamics and transrectal sonography were done to evaluate functional and anatomical results. RESULTS: At a median followup of 24 months 42 women were cured, 6 had improvement and treatment had failed in 2. Although the maximum flow rate increased, no changes were noted in detrusor pressure, post-void residual urine or cystometric capacity at month 3. Transrectal sonography revealed that mean sling width plus or minus standard deviation had decreased to 13.5 +/- 3.3 mm. at 3 months. The endopelvic fascia was thicker in women with type 2 than in those with types 2/3 or 3 disease (mean 5.3 +/- 1.5 versus 3.5 +/- 1.3 mm., p = 0.001). The position of bladder neck on video urodynamics was elevated a mean of 2.01 +/- 2.01 and 3.07 +/- 2.07 cm. compared to baseline elevation during resting and straining, respectively (p = 0). No hypermobility was noted while the patients coughed and no kinking of the urethra was observed while they performed the Valsalva maneuver. Detrusor instability resolved in 6 of 8 women (75%) and new onset detrusor instability was noted in 7 (14%). In 2 women with persistent stress urinary incontinence a repeat sling procedure was necessary to treat type 3 disease and cure incontinence. The overall success rate was 96%. One patient with sling erosion into the vaginal wall was treated with simple revision. CONCLUSIONS: Fixation of a polypropylene mesh sling at the bladder neck and adequate suspension may effectively achieve a hammock effect without creating bladder outlet obstruction in patients with types 2 and 2/3 stress urinary incontinence. The anatomical and functional results of this study show that a well suspended bladder neck did not create bladder outlet obstruction after a pubovaginal sling procedure using polypropylene mesh.     

PUBOVAGINAL FASCIAL SLING FOR ALL TYPES OF STRESS URINARY INCONTINENCE: LONG-TERM ANALYSIS

Purpose

There is a lack of consensus regarding indications and long-term efficacy of the many surgical techniques for treating stress incontinence. Historically pubovaginal sling has been reserved for cases of intrinsic sphincter deficiency or prior surgical failure. Transvaginal needle and retropubic suspensions have been used mainly for sphincteric incontinence unassociated with intrinsic sphincter deficiency. We report the long-term results of pubovaginal sling for all types of stress incontinence.

Materials and Methods

A total of 251 consecutive women with all types of stress incontinence who underwent pubovaginal fascial sling by a single surgeon were retrospectively and prospectively reviewed. Patients were evaluated preoperatively with history, physical examination, standardized symptom questionnaire, voiding diary, pad test, uroflow, post-void residual urine, video urodynamics and cystoscopy. Postoperatively women with at least 1-year followup were assessed by an independent third party (J. R.) who had no prior knowledge of them, and who recorded the parameters of the questionnaire, examination with a full bladder, voiding diary, pad test, uroflow and post-void residual urine.

Results

Overall stress incontinence was cured or improved in 92% of the patients with at least 1-year followup (median 3.1 years, range 1 to 15). The majority of patients with postoperative incontinence had de novo (3%) or persistent (23%) urge incontinence. Permanent urinary retention developed in 4 patients (2%).

Conclusions

Fascial pubovaginal sling is an effective treatment for all types of stress incontinence with acceptable long-term efficacy.     

STIMULATED GRACILIS NEOSPHINCTER: A NEW PROCEDURE FOR ANAL INCONTINENCE

Background: The gracilis muscle has been used previously to construct an anal neosphincter, but this was not successful since a short-lived muscle contraction was insufficient to restore continence. Recently, a procedure was described in which conversion to a fatigue-resistant muscle was achieved by chronic low frequency electrical stimulation, and the resultant ability to sustain a constant contraction was associated with improved continence. Our initial results with this procedure, using a standardized operation and treatment protocol in 12 consecutive patients. is reported. Methods: Seven women (mean age 50 years, range 22–71 years) had faecal incontinence, and five patients (F:M. 3:2; aged 53–72 years) underwent reconstruction after abdominoperineal excision of the rectum for cancer. A detailed questionnaire including continence score was completed pre-operatively. Eight patients have been assessed after ileostomy closure at a mean time of 10 months. Results: Slow-twitch muscle conversion was achieved in each case and all patients have a functional neosphincter. Mean continence score was 6.8 (range 4–12), and seven patients were continent. There was significant improvement in continence in the non-cancer group (p= 0.03). Mean pre-operative resting anal pressure, functional neosphincter pressure (NPfunc), and maximal neosphincter pressure (NPmax) were 36, 102 and 207 cmH₂O, respectively. There was a significant improvement in pressure comparing NPfunc (P= 0.03) and NPmax (P= 0.03) with pre-operative pressure. Complications included deep vein thrombosis. pulmonary embolism, saphenous nerve injury, leg wound haematoma, and late pacemaker infection. Conclusion: The stimulated gracilis neosphincter achieves satisfactory continence in a majority of patients.     

RESULTS OF PUBOVAGINAL SLING FOR STRESS INCONTINENCE: A PROSPECTIVE COMPARISON OF 4 INSTRUMENTS FOR OUTCOME ANALYSIS

PURPOSE: Presently to our knowledge there are no standardized techniques to assess outcomes after surgery for stress incontinence. We performed a prospective blinded study to assess the correlation among physician and patient assessments, and a validated 24-hour pad test and voiding diary. MATERIALS AND METHODS: A total of 84 women were evaluated before and after pubovaginal sling for stress incontinence with a voiding diary, pad test and symptom questionnaire (patient assessment) administered by a blinded third party. The operating surgeon evaluated the patient using history, physical examination, pad test and voiding diary but was blinded to results of the outcome questionnaire. Preoperative focused neurourological examination and video urodynamics confirmed stress incontinence. Patients were assessed at least 1 year postoperatively. We compared patient assessment (cured, improved, failure) to the outcome of the pad test, voiding diary and physician assessment. The physician and questioner were blinded to each other. We considered patients with a pad test of 0 to 2 ml. as cured, 50% or more volume reduction as improved and less than 50% volume reduction as failure. Postoperative assessment did not differentiate between stress and urge incontinence. The kappa coefficient was used for statistical comparison. RESULTS: Average patient age was 58 years and average followup for the entire group was 4 years. Agreement among the 4 instruments to assess outcome was excellent (k >0.9) with respect to cured/improved versus failure but only good for cured versus improved versus failure (k >0.5). CONCLUSIONS: Outcomes following incontinence surgery may vary depending on how the analysis was performed, patient selection, definition of success and so forth. Our results indicate that a pad test and voiding diary are reliable and should be part of the normal followup after pubovaginal sling for sphincteric incontinence. When these tests are used in conjunction with defined parameters of success, there is excellent agreement with patient feelings in regard to success or failure of surgery. Nevertheless, these instruments and methods are imperfect at best.     

INEFFICIENT URETHRAL MILKING SECONDARY TO URETHRAL DYSFUNCTION AS AN ADDITIONAL RISK FACTOR FOR INCONTINENCE AFTER RADICAL PROSTATECTOMY

PURPOSE: Continence after radical prostatectomy is thought to depend completely on the striated urethral sphincter. However, some patients complain only of occasional post-void dribbling. Therefore, we determined whether urethral dysfunction may be another cause of incontinence. MATERIALS AND METHODS: The sensory threshold of electric stimulation was measured by double ring electrodes in the membranous urethra and 2.5 cm. distal in 29 men before and in 29 after radical retropubic prostatectomy. In addition, voiding cystourethrography was performed in 66 patients before and in 49 after surgery to determine complete post-void urethral emptying or milking. RESULTS: The mean sensory threshold of the membranous urethra was 15 +/- 3 mA. preoperatively versus 38 +/- 17 postoperatively (p <0.0001). The sensory threshold 2.5 cm. further distal was 12 +/- 5 mA. before and 10 +/- 4 after radical prostatectomy, which was not statistically significant. Postoperatively in completely continent patients and in those with dribbling the mean threshold was 32 +/- 12 and 43 +/- 18 mA. in the membranous urethra (p = 0.09), and 11 +/- 4 and 9 +/- 4 mA. in the bulbar urethra, respectively, which was not statistically significant. Of the 66 patients 36 (55%) showed post-void urethral milking before surgery but only 8 of 49 (16%) showed it postoperatively (chi-square test p <0.0001), including 7 who were completely continent and 1 who complained of occasional post-void dribbling. CONCLUSIONS: After radical prostatectomy sensitivity of the membranous but not of the bulbar urethra is affected, correlating with postoperative continence. In addition, post-void dribbling seems to be associated with the loss of urethral milking. We conclude that preserving urethral function is another important continence factor after radical prostatectomy.     

THE YOUNG-DEES-LEADBETTER BLADDER NECK REPAIR FOR NEUROGENIC INCONTINENCE

PURPOSE: We review our experience with the Young-Dees-Leadbetter bladder neck repair among patients with neurogenic incontinence. MATERIALS AND METHODS: Between 1978 and 1997, 25 girls and 13 boys with a mean age of 10.5 years (range 5 to 25) underwent a standard Young-Dees-Leadbetter bladder neck repair for neurogenic incontinence. Of the 38 patients 26 had undergone prior urological surgery, including bladder neck surgery in 6 and bladder augmentation in 4. A primary Young-Dees-Leadbetter bladder neck repair was performed in 24 patients, a secondary Young-Dees-Leadbetter procedure in 6 and a primary Young-Dees-Leadbetter procedure with periurethral silicone sheath placement in 8. RESULTS: Of the 38 patients 30 (79%) are dry, 7 (18%) are partially dry and 1 remains incontinent. Total or partial dryness was achieved after the initial repair in 26 cases (68%), while 8 required an additional procedure and 3 required more than 2 procedures to achieve continence. All patients who underwent silicone sheath placement were initially dry but incontinence developed subsequently in 5 due to sheath erosion. Of the 38 patients 35 (92%) ultimately required bladder augmentation. CONCLUSIONS: The management of neurogenic incontinence remains difficult. Success with the Young-Dees-Leadbetter procedure in our experience nearly always requires augmentation cystoplasty. The majority of patients will achieve continence after the initial procedure, and persistent incontinence can frequently be cured with further bladder neck surgery.     

THE TEFLON SLING OPERATION FOR REPAIR OF COMPLETE RECTAL PROLAPSE

Sixty-four cases of complete rectal prolapse have been treated by the Teflon sling operation since 1969. One case has recurred. No sepsis has occurred. Approximately 80% of patients followed are totally continent. This relatively simple operation seems to be the procedure of choice in this disease.     

DESMOPRESSIN FOR NOCTURNAL INCONTINENCE IN THE SPINA BIFIDA POPULATION

Purpose

We report our experience with the use of desmopressin in the spina bifida population that is dry during the day but wet at night.

Materials and Methods

From 1994 to 1996, 18 patients with myelodysplasia were treated with desmopressin for persistent nocturnal enuresis. Initial dose was 40 mcg. before bedtime, decreased by intervals of 10 mcg. every 3 weeks. Patients were kept on the minimum dose required to keep them dry. We reviewed morning catheterized volumes, side effects and dosages needed to stay dry, and compared augmented patients with nonaugmented patients.

Results

Of 18 patients 14 (78%) reported marked improvement in nocturnal enuresis. Of 6 augmented patients 5 (83%) are dry compared to 9 of 12 nonaugmented patients (75%). There were no adverse side effects from the use of desmopressin. Average dose to stay dry was 20 mcg. for augmented and 30 mcg. for nonaugmented patients. Of the 4 patients who had persistent nocturnal incontinence despite desmopressin 3 (75%) became dry with a single catheterization in the middle of the night.

Conclusions

Desmopressin is successful in treating nocturnal enuresis in the spina bifida patient with diurnal continence.