Post-prostatectomy radiotherapy adversely affects urinary continence irrespective of radiotherapy regime

Purpose

To investigate the influence of different postoperative radiotherapy (RT) regimes on post-prostatectomy continence and QoL.

Methods

Men after prostatectomy (RP) and RT were assigned in adjuvant (ART), early salvage (ESRT) and salvage radiotherapy (SRT) groups depending on time of initiation, indication and pre-RT-PSA (≤/>0.5 ng/ml). Continence and QoL outcomes were evaluated by validated questionnaire. Statistical analysis included students t test, Chi square, Fisher’s test, ROC- and McNemar–Bowker-Analyses.

Results

The mean follow-up was 5.1 years. 33.5, 38.2 and 28.3% received ART, ESRT and SRT, respectively. Mean time to RT was 0.3 (±0.4), 1.8 (±2.5) and 3.3 (±3.6) years respectively. Differences in age at RP (p = 0.54) and RT (p = 0.47) between groups were not significant. Mean-RT-dose was similar (p = 0.70). Differences in continence distribution between groups before (p = 0.56) and after RT (p = 0.38) were not significant. No significant differences were observed for frequency (p = 0.58) or amount (p = 0.88) of urine loss, impact on QoL (p = 0.13) and ICIQ-SF scores (p = 0.69) between groups. Even though no significant difference in post-RT-continence (p = 0.89) was observed in the direct comparison between groups, a significant worsening of long-term continence was observed in all groups (p < 0.001). We found no cutoff and no time-point after RP at which this negative effect of RT on continence became insignificant (AUC = 0.474). A subgroup with apparent local recurrence showed no differences for ICIQ-SF-score (p = 0.155), QoL (0.077), incontinence grade (p = 0.387), frequency (p = 0.182) and amount (p = 0.415) of urine loss. Proportionally more men in this subgroup remembered deterioration of continence after RT (p = 0.029).

Conclusion

Postoperative RT adversely affects long-term continence; this negative effect is irrespective of time of initiation or indication for RT. These results suggest a need for innovative strategies of prostate cancer therapy with lasting oncological, functional and QoL outcomes.

     

A study of the continence mechanism of the external urethral sphincter with identification of the voluntary urinary inhibition reflex

PURPOSE: The role of the external urethral sphincter in the opposition and interruption of the act of voiding was investigated. MATERIALS AND METHODS: The study included 7 men and 5 women with a mean age plus or minus standard deviation of 38.6 +/- 11.2 years. The bladder was filled with saline up to the urge sensation. Detrusor and posterior urethral pressures were recorded before and upon resisting the reflex detrusor contraction, and upon interrupting voiding by voluntary external urethral sphincter contraction. The test was repeated by interrupting the urinary stream with external urethral sphincter electrostimulation. The electromyography response of the internal urethral sphincter to the suppression and interruption of voiding was documented before and after internal urethral sphincter anesthetization. RESULTS: Suppression of the reflex detrusor contraction as well as of urinary stream interruption by external urethral sphincter contraction voluntarily or by electrostimulation resulted in a significant detrusor pressure decrease (p <0.01) and urethral pressure increase (p <0.001). Internal urethral sphincter electromyography activity, which normally disappears during voiding, was still present. After internalurethral sphincter anesthetization subjects suppressed the reflex detrusor contraction by voluntary external urethral sphincter contraction for a mean of 62.6 +/- 9.6 seconds, after which involuntary voiding occurred. The internal urethral sphincter showed no electromyography activity. CONCLUSIONS: The external urethral sphincter induces continence by preventing internal urethral sphincter relaxation at the detrusor contraction, which is suggested to be reflex in nature and is called the voluntary urinary inhibition reflex, and by mechanically compressing the urethra. Contraction of the external urethral sphincter, which is a striated muscle, mechanically occludes the urethra for a few seconds, by which time the detrusor has relaxed as an effect of the voluntary inhibition reflex.     

External sphincter dyssynergia: an abnormal continence reflex

Some of the characteristics of detrusor-external sphincter dyssynergia were examined in 14 patients with traumatic upper motor neuron lesions within 44 weeks of injury. The sacral evoked response latencies of the male patients were shortened at any time after injury. A continence reflex could be demonstrated in most patients at any time after injury. Comparing averaged values for the group at 4-week intervals, resting pressure at the external urethral sphincter and post-void residual volumes reached nadirs at 12 weeks while voiding efficiency peaked at this time. Thus, voiding function appears to be optimal 12 weeks after injury. During reflex detrusor activity, increases in external urethral sphincter electromyographic activity and external urethral sphincter pressure were associated clearly with a positive slope of the intravesical pressure trace, whereas decreases in both parameters were associated with a negative slope. Voiding occurred only during a negative slope. Although propantheline induced detrusor areflexia, episodic peaks in external urethral sphincter pressure and electromyographic activity continued to occur. We propose that external sphincter dyssynergia, which is independent of detrusor contraction, is the continence reflex exaggerated owing to the loss of supraspinal influences. We believe that the multiple patterns of dyssynergia described previously by others are variations, largely owing to technique, of the single pattern we have observed. The observation of synergic-like urethral responses in some patients during a negative slope of the intravesical pressure, even with complete suprasacral spinal lesions, implies existence of a pathway for synergic-like voiding in the spinal cord.     

Long-term continence and patient satisfaction after artificial sphincter implantation for urinary incontinence after prostatectomy.

PURPOSE: We assess long-term continence and patient satisfaction after implantation of the AMS Sphincter 800 (American Medical Systems, Minnetonka, Minnesota) in men who were incontinent after total and subtotal prostatectomy. MATERIALS AND METHODS: Patients who had an artificial urinary sphincter implanted for urinary incontinence after prostatectomy and a minimum of 20 months of followup were identified from a patient database. The medical records of these 209 patients were reviewed, and a questionnaire was mailed. Telephone contact was attempted with patients who did not respond to the questionnaire. Of the 209 patients 11 (5%) had undergone device removal, 34 (16%) were deceased and an additional 51 (24%) could not be contacted for followup. Our study group consisted of the 113 patients with artificial urinary sphincters who could be contacted for followup. Mean followup was 73 months (range 20 to 170). RESULTS: There were 4 (4%) patients who were dry and continent and 68 (60%) were incontinent using 0 to 1 pad daily. An additional 35 (31%) patients required 2 to 3 pads daily and 5 (4%) used more than 3 daily. There were 14 (12%) patients who had undergone surgical revision of the device. Of the 113 patients 31 (28%) were very satisfied, 50 (45%) satisfied, 20 (18%) neutral, 7 (6%) dissatisfied and 4 (4%) very dissatisfied. One patient was not using his device to control continence. CONCLUSIONS: Artificial urinary sphincter implantation offers men who are incontinent after prostatectomy a reasonable chance for obtaining long-term satisfactory urinary control, although complete continence is unusual.     

Isometric detrusor pressure in the male patient: a comparison between voluntary urethral sphincter contraction and forced penile compression techniques

Different functions of detrusor contraction are estimated by measurement of maximum isometric detrusor pressure with voluntary urethral sphincter contraction and forced penile compression flow-stop techniques. Maximum isometric pressure curves with these 2 techniques consist of 2 and 3 phases, respectively. The first phase of each method is a linearly increasing curve whose slope seems to indicate the speed of isometric detrusor contractions. The second phase in the curve obtained by the voluntary flow-stop technique is considered to be an inhibitory phase, while that obtained by the forced technique is considered to be a continuing phase followed by a plateau, the third phase. The maximum isometric pressures obtained with the forced flow-stop technique were statistically higher than those obtained with the voluntary flow-stop technique in patients with enuresis and prostatic obstruction. Although in volunteers the maximum isometric pressure measured with the forced flow-stop technique showed higher values than that measured with the voluntary method there was no statistical difference. There was no statistical difference in the speed of detrusor contractions obtained with either technique in all of the patients except those with urethral stricture, in whom the speed of detrusor contraction measured with the forced flow-stop technique showed a lower value than that obtained with the voluntary method. We believe that the penile urethra distal to the stricture acts as a reservoir when urinary flow is poor. The forced flow-stop technique was necessary to measure maximum isometric pressure in patients with neurogenic bladder dysfunction, many of whom could not stop urinary flow voluntarily.     

Striated sphincter participation in distal passive urinary continence mechanisms: studies in male subjects deprived of proximal sphincter mechanism.

Striated urethral sphincter function was studied in passive incontinent and continenet male subjects who were deprived of the proximal sphincter mechanism. Functional assessment of striated urethral sphincter include electromyography and electrostimulation. Varying degrees of diminished striated sphincter excitability and reflex activity were observed in passive incontinent male subjects who also had varying degrees of somatomotor neuron lesions. The studies indicate that the participating role of periurethral striated musculature in distal passive continence mechanisms cannot be ignored.     

Recovery of the internal anal sphincter and continence after restorative proctocolectomy

The internal anal sphincter (IAS) was assessed prospectively using electromyography and manometry in 66 patients (48 men) undergoing restorative proctocolectomy to determine its role in the gradual return of continence. Twenty-nine patients received a J pouch and 37 a W reservoir. Some 38 pouches (J, ten; W, 28) were hand-sewn (mucosal proctectomy with endoanal anastomosis) and 28 (J, 19; W, nine) stapled (end-to-end pouch-anal anastomosis 1 cm above the dentate line). Twelve patients underwent a one-stage procedure (all J pouches), while the remainder had a covering loop ileostomy. Each patient was reassessed immediately after restorative proctocolectomy and again at 7 days, 1 month, 4 months, 9 months and 18 months after pouch formation. Internal sphincter electromyographic activity was greatly reduced after pouch-anal anastomosis (median preoperative frequency 0·51 Hz versus immediate postoperative frequency 0·21 Hz, P < 0·003) and gradually recovered from 4 months after surgery. At 18 months, measurements of IAS function had not fully recovered to preoperative values (median frequency 0·31 Hz; P < 0·03). Resting anal pressures (median preoperative value 99 cmH₂O) decreased by over 50 per cent after surgery (median immediate postoperative resting pressure 44 cmH₂O) and recovered gradually but incompletely (median pressure at 18 months 63 cmH₂O). Eleven patients reported leakage in the follow-up period. The median (range) resting pressure in these patients (54 (40–71) cmH₂O) was not significantly different at 9 months from that of those who were continent either before or after operation (59 (46–68) cmH₂O). Prolonged recordings in patients with faecal leakage revealed evidence of high-pressure pouch waves that overwhelmed anal sphincter pressures and coincided with leakage. These episodes were most common during sleep, when anal sphincter activity was reduced.     

Experiences with an artificial sphincter to establish anal continence in dogs

An implantable device for establishing urinary continence has been developed and has received FDA approval (AS 800, American Medical Systems, Inc.). The authors have applied this device to the control of anal continence in dogs. Fifteen mongrel dogs underwent either anal sphincter disruption (7) or abdominal-perineal resection (8). Such animals have bowel movements almost hourly. In each case, the device was implanted at the time of surgery. In dogs with working cuffs and disabled or absent sphincters, continence was maintained in seven out of 15 animals for periods of 4-8 hours. After cuff activation, intraluminal cuff pressures of 50-70 cm of water achieved continence for a period of 8 hours. In animals sacrificed from 1 to 12 months after implantation, the device was found to be well tolerated by the body with minimal fibrosis of the mucosa or muscularis of the bowel. Complications observed in the same four out of 15 animals during the study period were infection, device extrusion, and device malfunction. Infection resolved with local wound care and antibiotics (3/4) and the device was successfully replaced in two out of four instances of extrusion. With cuffs of proper size and pressure, this appliance may be effective in the control of human anal incontinence via the establishment of continent perineal colostomies following an abdominal-perineal resection.     

Post-prostatectomy incontinence: the influence of bladder dysfunction

The urodynamic studies of 38 patients referred for evaluation of incontinence after prostatectomy were reviewed. Only 15 patients (39.5 per cent) had pure sphincteric insufficiency as the sole cause of the incontinence. Of the 38 patients 16 (42 per cent) had sphincteric insufficiency combined with a significant component of bladder dysfunction (detrusor instability and/or low bladder wall compliance) as the cause of the incontinence. A total of 7 patients (18.5 per cent) had no evidence of sphincteric insufficiency but they had post-prostatectomy incontinence solely caused by detrusor instability and/or low bladder wall compliance. Of the patients referred for post-prostatectomy incontinence 60.5 per cent had bladder dysfunction as a major factor in the incontinence, which emphasizes the need for comprehensive urodynamic evaluation before treatment is recommended. Of 26 patients whose treatment was based on urodynamic findings and who were available for followup 23 (88 per cent) were adequately continent after treatment, with 35 per cent responding to pharmacological treatment alone and 54 per cent requiring placement of an artificial urinary sphincter with or without associated pharmacological therapy. The potential role of bladder dysfunction as a causative factor in post-prostatectomy incontinence must be considered to optimize the results of treatment and to avoid an unnecessary operation.     

Electromyographic study of the striated urethral sphincter by using the bulbocavernosus reflex: study of the normal voluntary voiding and the involuntary sphincter relaxation

PURPOSE: The aim of this study was to investigate the sacral reflex activity at the striated urethral sphincter relaxation by evoking the potential of the bulbocavernosus reflex (BCR). METHODS: 17 normal male subjects were investigated. BCR was elicited by electrical stimulation of dorsal nerve of the penis, and the evoked potential of the BCR (BCR-EP) was recorded by a concentric needle electrode at the periurethral striated muscle. In normal subjects BCR was performed at rest and during voluntary voiding. In 8 of the normal subjects electrical stimulation was increased gradually during voluntary voiding, and changes of BCR-EP were studied. 3 male patients with neurogenic bladder suffering from urinary incontinence caused by involuntary sphincter relaxation (IVSR) were also investigated. In these patients with neurogenic bladder, BCR was performed at rest and during voluntary voiding as well as during involuntary voiding. RESULTS: In the normal subjects stable BCR-EP was elicited at rest and disappeared during voluntary voiding. But a gradually increased larger stimulation clearly demonstrated BCR-EP during voluntary voiding. In 3 patients with neurogenic bladder, stable ECR-EP was elicited at rest. During involuntary voiding caused by IVSR obvious BCR-EP was also elicited, but its amplitude was slightly less than the amplitude of BCR-EP at rest. During voluntary voiding in 2 of the 3 patients BCR-EP was recognized but the amplitude was much less, and in the third patient BCR-EP could not be recognized. CONCLUSION: BCR-EP was suppressed during voluntary voiding in normal subjects, but insufficiently suppressed in the patients with neurogenic bladder. In these patients BCR-EP during voluntary voiding was suppressed more distinctly than BCR-EP during involuntary voiding due to IVSR. In urodynamic study, the detrusor contraction and the sphincter relaxation were common phenomenon in both voluntary voiding and involuntary voiding, but the difference in the degree of the BCR suppression depended on whether micturition was voluntary or involuntary. It was suggested that the measurement of BCR-EP could distinguish involuntary voiding caused by pathological urethral sphincter relaxation from voluntary voiding.     

Results of artificial sphincter in a case of sphincter incontinence in the multiple surgery patient

Stress incontinence represents 77 to 91% of female urinary incontinence, 10% of witch are sphincterial incontinence. The specific treatment of sphincterial incontinence is of periuretral injections or calls for an artificial sphincter. We present the retrospect of 12 patients having undergone several surgical treatments and having at last the benefit of an artificial sphincter since 1990. In majority, these patients had been operated for bladder neck hypermobility. The indication, preoperatory evaluations, surgical technics and results are discussed. During the mean follow-up of 40.5 months, 91.7% of patients are perfectly continent. The results are equal to those of other publications.     

Sphincter function and continence after 2/3-division of the sphincter ani internus

Pressure and motility in the anal canal in 24 patients with various benign anal disorders were measured before and 4-8 months after partial sphincterotomy. The clinical results were good in most cases. Postoperative manometric measurements showed a drop in pressure and an abolition of irregular slow waves. Partial sphincterotomy is a rational treatment because it corrects a pathological activity of the internal sphincter.     

Diagnosing detrusor sphincter dyssynergia in the neurological patient

Detrusor sphincter dyssynergia (DSD) is variant of neurogenic bladder dysfunction caused by suprasacral neurological abnormalities and may be associated with serious complications if unrecognised. This paper focuses on the clinical features as well as challenges and limitations in the diagnosis of DSD.