Stuhlbeschwerden nach radikaler perinealer Prostatektomie

PURPOSE. The true incidence of bowel symptoms prior to radical prostatectomy, as evaluated by a differentiated questionnaire, is unknown. We therefore performed a prospective study on patients who were scheduled for radical perineal prostatectomy. MATERIAL AND METHODS. A total of 67 patients with cT1-cT3, N0, M0 prostate cancer underwent an extrafascial, radical, perineal prostatectomy. The patients received a questionnaire prior to surgery as well as 6 months and 12 months after surgery. This took into account demographic data, stool symptoms (Kelly questionnaire) and questions concerning bladder function (ICS male continence questionnaire). The questionnaires were evaluated by three of the authors not involved in patient care. RESULTS. The mean age of the patients was 64 years. The PSA range was 0.9-55.6 ng/ml (mean 12.7 ng/ml). There were 47 pT2, 19 pT3 and a single pT4 tumour. A total of 59 patients had a Gleason score of 6 or less. Positive surgical margins were present in four patients. The 12 months follow-up questionnaire could be evaluated for 82% of the patients (n=55). In addition, 46 patients answered the questionnaire at 6 months post-surgery.Three or more problems in relation to bowel movements were reported preoperatively by 21% of the patients. Straining with bowel emptying was the symptom which was indicated most often. Stool smearing was reported by 13% of patients at least once or twice monthly. In addition, 6% of patients reported that they had difficulties in differentiating soft stool from gas. After 1 year, seven (13%) of the patients reported stool smearing which was not present prior to surgery. Six of these patients observed this problems only once or twice a month. Only one patient had stool smearing once a week. Two patients reported urgency, two had a decreased warning time and one reported decreased sensibility. Two patients used protective pads. The most frequent symptom reported postoperatively was straining with bowel emptying (24% preoperatively and 16% postoperatively). CONCLUSION. It is evident that men scheduled for radical prostatectomy already have significant stool problems preoperatively. Newly developed, postoperative stool smearing on a daily basis occurred extremely seldom. They same is true for the discrimination between soft stool and gas. From our point of view, it is important to use the extrasphincteric approach to the prostate described by Young. Furthermore, the pubo-anal sling should be preserved.     

OUTPATIENT RADICAL PROSTATECTOMY: IMPACT OF STANDARD PERINEAL APPROACH ON PATIENT OUTCOME

PURPOSE: As managed care becomes more prevalent, urologists must critically evaluate the economic aspect of and patient satisfaction with urological practice patterns. We have previously reported the advantages of radical perineal prostatectomy, which decreases hospitalization and morbidity, and provides a more rapid return to normal activity, translating into cost savings. We have since evaluated the satisfaction of patients who underwent outpatient radical prostatectomy with and without laparoscopic pelvic lymph node dissection. MATERIALS AND METHODS: We evaluated the charts of 250 consecutive patients who underwent outpatient radical perineal prostatectomy with less than 24 hours of hospitalization from 1992 to 1997. Complications, pain management, blood transfusion, and bowel and urinary dysfunction were assessed. Validated quality of life questionnaires were mailed to 200 patients several months postoperatively and a 62% response rate was achieved. RESULTS: Mean followup in the series was 30 months. In the perioperative period there were rectal perforation in less than 2% of patients, anastomotic stricture in 3%, perineal fistula in 0.4% and blood transfusion in 11%. Some problems with bowel movements immediately after the procedure, such as diarrhea, constipation or soiled underwear, developed in 17% of patients, of whom up to 20% had had some bowel dysfunction before surgery. In the majority bowel problems resolved in an average of 7.3 weeks. Persistent new onset bowel trouble developed in 9 of the 124 patients (7%). The questionnaire demonstrated persistent significant urinary incontinence in 8 cases (7%). Nerve sparing was attempted in 54 patients, including 22 (41%) who achieve erection sufficient for vaginal penetration and are satisfied with sexual function. Of the patients 17% reported problems after hospital discharge that were mostly related to Foley catheter management. Overall 94.8% of patients were satisfied with treatment. Physical and social/family well-being appeared to be excellent according to the questionnaire. Only 12% of patients would have preferred longer hospitalization. The preferred method of pain control was nonsteroidal anti-inflammatory drugs. CONCLUSIONS: Radical perineal prostatectomy is a low morbidity alternative for localized prostate cancer. Outpatient radical perineal prostatectomy may be performed with good patient satisfaction and safety. There appear to be few bowel problems after long-term followup.     

Preservation of fecal continence and bowel function after radical perineal and retropubic prostatectomy: a questionnaire-based outcomes study

PURPOSE: To assess fecal incontinence rates and bowel function for radical perineal (RPP) or radical retropubic (RRP) prostatectomy patients and to compare them with a matched control group. METHODS: The bowel function domain of the Expanded Prostate Cancer Index Composite (EPIC) was mailed to 150 consecutive patients who had undergone RPP (79) or RRP (71) by the same surgeon (HJK) and an age-matched control group (75). RESULTS: Fecal incontinence and bowel dysfunction were statistically equivalent for the study groups. CONCLUSIONS: There is no difference in fecal incontinence rates or bowel function when comparing RPP patients to RRP or control patients.     

Prospective and longitudinal patient self-assessment of health-related quality of life following radical perineal prostatectomy

PURPOSE: We provide a comprehensive, longitudinal assessment of health related quality of life (HRQOL) following radical perineal prostatectomy (RPP). MATERIALS AND METHODS: We report the results of a prospective cohort study of 109 patients with at least 3 months of followup who underwent RPP between January 2001 and July 2003. A validated patient self-assessment questionnaire, the Expanded Prostate Cancer Index Composite, was administered preoperatively, and 1, 3, 6, 9, 12 and 18 months postoperatively. Mean domain specific HRQOL scores were calculated as well as the proportion of patients achieving an individual baseline by each interval. The Cox proportional hazards model was used to identify predictors of a successful return to baseline of disease specific HRQOL scores. RESULTS: HRQOL scores were lowest 1 month postoperatively and they increased with time. By 6 months a majority of patients had recovered baseline summary scores in urinary (65.1%), bowel (93.6%) and hormonal (91.7%) domains at a median of 5.8 (95% CI 3.6 to 6.2), 1.3 (95% CI 1.1 to 1.5) and 1.3 (95% CI 1.2 to 1.8) months, respectively. One in 4 patients recovered the sexual summary score by 18 months. Significant independent predictors for the recovery of domain summary scores were younger age in urinary (p = 0.001), individual surgeon in bowel (p = 0.022), and older age (p = 0.017) and absent medical comorbidities (p = 0.012) in hormonal domains. CONCLUSIONS: A majority of patients undergoing RRP experience an early recovery of individual urinary, bowel and hormonal HRQOL. Future studies should establish the benefit of bilateral nerve sparing RPP on the recovery of sexual domain HRQOL.     

The role of early adopter bias for new technologies in robot assisted laparoscopic prostatectomy

PURPOSE: We determined the potential influence of an early adopter bias in patients undergoing robot assisted laparoscopic prostatectomy. MATERIALS AND METHODS: We compared baseline demographic, clinical and health related quality of life characteristics of patients undergoing 3 different surgical procedures for clinically localized prostate cancer following the introduction of robot assisted laparoscopic prostatectomy at our institution. Patients included in this analysis were participating in a prospective health related quality of life study using the SF-12(R) and Expanded Prostate Cancer Index Composite validated questionnaires. RESULTS: Of 402 patients 159 (39%) underwent robot assisted laparoscopic, 144 (36%) underwent radical perineal and 99 (25%) underwent radical retropubic prostatectomy. There were no statistically significant associations between procedure type and patient age (p = 0.267), race (p = 0.725), number of medical comorbidities (p = 0.490), income (p = 0.056) and level of education (p = 0.495). Mean prostate specific antigen was 5.9 +/- 3.3, 7.3 +/- 5.5 and 5.7 +/- 5.0 ng/ml for robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy, respectively (p = 0.030). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with a final Gleason score of 4-6 was 55%, 45% and 39%, respectively (p = 0.037). The proportion of robot assisted laparoscopic, radical perineal and radical retropubic prostatectomy patients with stage T2 disease was 91%, 68% and 80%, respectively (p = 0.001). Statistically significant associations of higher income and education with higher baseline health related quality of life scores were seen in the sexual and physical domains (each p <0.01). CONCLUSIONS: We failed to find evidence of an early adopter bias for patients undergoing robot assisted laparoscopic prostatectomy. Nevertheless, observational studies comparing robot assisted laparoscopic prostatectomy to radical perineal and radical retropubic prostatectomy should account carefully for patient baseline characteristics to allow meaningful comparisons of surgical outcomes.     

Urinary continence following radical prostatectomy assessed by a self-administered questionnaire

OBJECTIVES: A total aim of this study was to assess the incidence of urinary incontinence in patients following radical prostatectomy and determine the factors that may influence this incidence. METHODS: A total of 135 men underwent radical retropubic prostatectomy at our center between 1987 and 1997. 120 patients were sent a questionnaire regarding preoperative and postoperative voiding habits. Data collected included preoperative and postoperative continence status, interval to postoperative continence status, associated urinary symptoms, willingness to undergo radical prostatectomy again if need be and additional postoperative procedures. Patient age, date of surgery, number of neurovascular bundles resected at prostatectomy and duration of follow-up were also noted. RESULTS: Of the 120 patients, 116 (96.7%), a mean of 65.2 (range 48-76) years old, responded to the questionnaire. Mean follow-up was 4.3 years (range 1-10.8). Continence was defined as no regular use of pads. Our overall urinary incontinence rate was 14.4%. Of the respondents, 88. 8% (103/116) had achieved final continence status by 6 months postoperatively, and 95% (110/116) would undergo surgery again if need be. Of the patients considered incontinent postoperatively, 66. 6% had associated urgency. Age, year of surgery, number of neurovascular bundles resected at prostatectomy, preoperative urinary leakage of postvoiding dribbling, postoperative pelvic floor exercises, and anastomotic stricture had no significant impact on postoperative continence status. CONCLUSIONS: Using an anonymous self-administered questionnaire, we found a 14.4% incontinence rate after radical prostatectomy. These results allow patients to have realistic expectations when counseled prior to this operation.     

Bone‐anchored sling using the Mini Quick Anchor Plus and polypropylene mesh to treat post‐radical prostatectomy incontinence: Early experience

Herein we describe our experience with a bone‐anchored sling using a suture anchor and polypropylene mesh for the treatment of post‐radical prostatectomy urinary incontinence. Eight patients with urinary incontinence as a result of intrinsic sphincter deficiency after radical prostatectomy were included in the analysis. The procedure involved piercing the pubic bone with a bone drill, inserting the suture anchor and fixing a soft or rigid polypropylene mesh to press firmly on the bulbar urethra. Urinary incontinence was significantly improved according to changes in the daily number of pads used at 1, 3 and 6 months postoperatively in comparison with preoperatively. However, no meaningful improvement at 6 months postoperatively was seen with the soft mesh. Complications included perineal pain in four cases, but pain control was achieved using non‐steroidal anti‐inflammatory drugs. The bone‐anchored sling with a suture anchor and polypropylene mesh appears to be safe and effective for the treatment of post‐radical prostatectomy urinary incontinence. Soft mesh appears inappropriate as material for the bone‐anchored sling because of the progressive likelihood of worsened urinary incontinence.     

Absorbable versus nonabsorbable graft: outcome of bone anchored male sling for post-radical prostatectomy incontinence

PURPOSE: We determined the outcome of the bone anchored male sling procedure for stress urinary incontinence in men regarding the graft material used. MATERIALS AND METHODS: A total of 39 men with post-radical prostatectomy incontinence received a perineal bone anchored male sling. Patients with previous salvage external beam radiotherapy and high serum prostate specific antigen, incontinence due to neurogenic or posttraumatic etiology, or previous benign prostatectomy were excluded. Urodynamic evaluation was performed preoperatively. The number of pads daily used by patients was recorded preoperatively and during postoperative visits. To compress the urethra 2 types of materials were used. Absorbable biomaterials were used in the first 12 patients and nonabsorbable material was used in the following 27. RESULTS: Mean patient age +/- SD was 67.3 years (range 50 to 79). The mean duration between radical prostatectomy and male sling surgery was 57.9 +/- 40.4 months (range 5 to 135). The procedure was successful in 26 patients (96.2%) in the nonabsorbable group and in 1 (8.3%) in the absorbable group at a mean followup of 18.9 and 28.8 months, respectively. CONCLUSIONS: The absorbable sling materials that were used for the bone anchored male sling demonstrated disintegration of the material. Autolysis of these absorbable materials removed active compression forces on the urethra after a short period. Nonabsorbable graft is associated with the best outcome following the perineal bone anchored male sling procedure.     

Morbidity of radical perineal prostatectomy following transurethral resection of the prostate

Radical prostatectomy in patients who have had prior transurethral resection of the prostate has been reported to result in significant morbidity. From 1974 to 1982, 30 patients who had had previous transurethral resection of the prostate underwent radical perineal prostatectomy for localized prostatic cancer. Operative time and blood loss were similar to a group of patients who had not had prior transurethral resection of the prostate. Over-all, 3 patients (10 per cent) had total incontinence and 3 (10 per cent) had stress incontinence requiring a pad or device. No patient undergoing radical prostatectomy less than 4 weeks or more than 4 months after transurethral resection of the prostate had postoperative incontinence. When radical perineal prostatectomy was performed between 4 weeks and 4 months after transurethral resection of the prostate the incidence of incontinence was 50 per cent. Five patients experienced prolonged perineal urinary drainage, all but 1 of whom healed spontaneously. Of the 6 patients with incontinence 3 had prolonged drainage. No patient had a rectal injury and there was no operative mortality. Two patients died without cancer and 1 has evidence of disease recurrence. We conclude that radical prostatectomy may be performed safely with acceptable morbidity following transurethral resection of the prostate and that if 4 weeks has elapsed since resection it might be advantageous to wait 4 months before performing radical surgery to lessen the risk of incontinence.     

Open versus laparoscopic radical prostatectomy: a prospective comparison of postoperative urinary incontinence rates

PURPOSE: We compared the 12-month postoperative urinary incontinence rates of open radical retropubic and laparoscopic radical prostatectomy. MATERIALS AND METHODS: This prospective study included all men with clinically localized prostate cancer scheduled for radical prostatectomy (open retropubic or laparoscopic) at the University of Alberta between October 1999 and July 2002. Preoperative evaluation included a 24-hour pad test, fluid volume voiding diary and International Prostate Symptom Score questionnaire. Postoperative evaluation included a 24-hour pad test at 3 and 12 months, as well as a voiding diary and International Prostate Symptom Score questionnaire at 3, 6, 9 and 12 months. RESULTS: A total of 239 patients met the eligibility criteria and consented to participate (172 open radical retropubic prostatectomy, 67 laparoscopic radical prostatectomy). Of the patients 87% (148) treated with open radical retropubic prostatectomy and 88% (57) of those treated with laparoscopic radical prostatectomy completed 12-month followup (p = 0.50). According to 24-hour pad testing 13% of those treated with open radical retropubic prostatectomy and 17% of those treated with laparoscopic radical prostatectomy remained incontinent at 1 year (p = 0.26). There was no difference in 24-hour pad weight, urinary symptom score and urinary quality of life at 1 year between the open and laparoscopic groups overall, or when stratified according to 12-month continence status. The majority of subjects in both groups described mild symptoms and a general satisfaction with urinary quality of life. CONCLUSIONS: Based on objective and subjective measures, there were no differences in urinary functional outcomes 1 year after open radical retropubic prostatectomy or laparoscopic radical prostatectomy. Urinary incontinence was found to affect a similar proportion of patients who underwent open (13%) and laparoscopic (17%) radical prostatectomy 12 months postoperatively.     

Bowel dysfunction after transposition of intestinal segments into the urinary tract: 8-year prospective cohort study

PURPOSE: Bowel function may be disturbed after intestinal segments are transposed into the urinary tract to reconstruct or replace the bladder. In 1997 our group was the first to report major bowel dysfunction in a cohort of such patients. Up to 42% of those who were asymptomatic preoperatively described new bowel symptoms postoperatively including explosive diarrhea, nocturnal diarrhea, fecal urgency, fecal incontinence and flatus leakage. We now describe bowel symptoms in this same cohort 8 years later (2005). MATERIALS AND METHODS: A total of 116 patients were evaluable. Of the remaining 37 from the original study 30 had died, 5 no longer wished to be involved and 2 could not be located. Patients were asked to complete postal questionnaires identical to those used in the first followup, assessing the severity of bowel symptoms and quality of life using 2 validated instruments. Responses were compared with those from the original study. The Nottingham Health Profile quality of life scores were also compared to age and sex matched norms. RESULTS: There were 96 patients (83%) who completed 8-year followup questionnaires, including 43 after ileal conduit diversion (group 1), 17 after clam enterocystoplasty for overactive bladder (group 2), 18 after bladder reconstruction for neurogenic bladder dysfunction (group 3) and 18 with bladder replacement for nonneurogenic causes (group 4). High prevalence rates of bowel symptoms persisted with no statistically significant differences between the 2 times. Of those with symptoms in 2005, approximately 50% had reported similar symptoms in 1997. Patients treated with clam enterocystoplasty (group 2) still reported the highest prevalence (59%) of troublesome diarrhea with 1 in 2 on regular antidiarrheal medication. They also had high rates of fecal incontinence (47%), fecal urgency (41%) and nocturnal bowel movement (18%), and a large number reported a moderate or severe adverse effect on work (36%), social life (50%) and sexual activity (43%). High rates were also reported by patients with neurogenic bladder dysfunction, including 50% with troublesome diarrhea. This symptom was reported by 19% after ileal conduit and by 17% after bladder replacement for nonneurogenic causes. The impact of bowel symptoms on everyday activities and quality of life persisted, remaining most severe after clam enterocystoplasty, with 24% regretting undergoing the procedure because of subsequent bowel symptoms. CONCLUSIONS: After more than 8 years, operations involving transposition of intestinal segments continue to be associated with high rates of bowel symptoms which impact everyday activities. These are particularly troublesome following enterocystoplasty for overactive bladder and bladder reconstruction for neurogenic bladder dysfunction. These risks should influence patient selection and potential patients should be warned before undergoing surgery.     

Urinary incontinence after radical prostatectomy: can men at risk be identified preoperatively?

BACKGROUND: Incontinence after radical prostatectomy for early stage prostate cancer can significantly affect quality of life. Identification of risk factors preoperatively would enable clinicians to counsel men and their partners about the risk of incontinence following surgery. We conducted a population-based study to identify subjective and objective preoperative factors, other than PSA and Gleason score, that may predict urinary incontinence following radical prostatectomy. METHODS: Men booked for radical prostatectomy at 2 sites in Alberta were enrolled prospectively. Assessment was completed 2 weeks prior to surgery and included the International Prostate Symptom Score (IPSS) with a single quality-of-life (QOL) question, 24-hour pad test, and bladder diary. These parameters were repeated at 3 and 12 months postoperatively. A model predicting incontinence was developed using stepwise multivariable logistic regression analysis. Incontinence was defined as more than 8 g of urine loss on 24-hour pad test. RESULTS: A total of 245 patients from 2 centers were enrolled; 228 (93%) completed data collection up to 12 months postsurgery. At the baseline preoperative assessment, 4% (10/228) of subjects had > or = 8 g of urine loss on 24-hour pad test, although these and all other subjects described complete continence. At 3 months postop, 43% had > or = 8 g on 24-hour pad testing (our definition of incontinence) (median 31 g, range 8.3-1654 g, SD 219.12); at 12 months, 15% had more than 8 g of urine loss on pad test (median 21.0 g, range 8.1-3380 g, SD 578.0). For all subjects, mean IPSS and the single QOL scores at baseline (7.4 and 1.5) did not change significantly at 3 months (7.2 and 2.5), but both were lower than or equal to baseline at 12 months (5.4 and 1.5). The IPSS was predictive of incontinence at 3 months, but not at 12 months. Bladder diary did not correlate with IPSS. Risk factors affecting continence at 12 months were preoperative urine loss > or = 8 g, previous transurethral resection of prostate (TURP), and age greater than 65 years. CONCLUSION: Our results support previous research on risk factors for incontinence after radical prostatectomy and add to the current data by having presurgery (baseline) measures. Interestingly, a small percentage of men (4%) who reported complete continence were incontinent preoperatively, based on our definition of > or = 8 g weight gain on 24-hour pad test. Identified preoperative risk factors affecting continence were increasing age, baseline incontinence, and previous TURP. Mean IPSS was lower at 12 months than at baseline, suggesting that even mildly symptomatic men will improve after surgery. Men reported that regular contact with the continence research nurse provided a much-appreciated source of informed support as they recovered.     

Impact of nerve sparing technique on patient self-assessed outcomes after radical perineal prostatectomy

PURPOSE: We investigated the impact of nerve sparing technique on erectile function, urinary continence and health related quality of life after radical perineal prostatectomy using a validated self-assessment questionnaire. MATERIALS AND METHODS: The Expanded Prostate Cancer Index Composite questionnaire was administered preoperatively and at defined intervals after surgery to 265 patients who underwent radical perineal prostatectomy at 2 institutions between January 2001 and December 2004. Of these patients 153 (57.7%) and 112 (42.3%) underwent nonnerve sparing and nerve sparing approaches, respectively. Kaplan-Meier analysis was used to determine time to recovery of erectile function (erections firm enough for intercourse) and urinary continence (0 pads per day). RESULTS: Median patient age was 60.6 years. Median followup was 15 months. In multivariate analysis preoperative erectile function (p = 0.005) and preservation of the neurovascular bundle (p = 0.018) were independent predictors of earlier recovery of erectile function, with hazard ratios of 2.3 (95% CI 1.2-4.6) and 4.0 (95% CI 1.5-10.3), respectively. Median time to recovery of urinary continence was 4.8 months in the nerve sparing group and 6.1 months in the nonnerve sparing group (p = 0.001). In multivariate analysis nerve sparing technique (p = 0.001, HR 1.4, 95% CI 1.1-1.9) and age (p = 0.012, HR 1.7, 95% CI 1.3-2.2) were independent predictors of recovery of continence. CONCLUSIONS: This analysis suggests that nerve sparing radical perineal prostatectomy is associated with improved recovery of urinary continence and favorable health related quality of life scores and, therefore, should be considered a viable alternative to other nerve sparing approaches.     

An artificial anal sphincter. Phase 2: Implantable sphincter with a perineal colostomy

To find an alternative to the stigmata of abdominal colostomy, an artificial anal sphincter (utilizing the currently available artificial urinary sphincter) was implanted around an end perineal colostomy following standard abdominal perineal resection. Of 13 swine, 7 completed full evaluation with working sphincters, 3 animals died prematurely of unrelated causes, and 3 animals were sacrificed due to sphincter slough before inflation was begun. Seven animals had long-term evaluation of the sphincter for 2 to 6 months' duration. In 5 animals (72%) there was complete fecal continence; one animal (14%) had occasional partial incontinence and one had total incontinence, both due to sphincter malfunction from breakage of the connecting tab. Two of the seven animals had delayed slough of the sphincter after 2 months and 4.5 months of success, and 2 animals had erosion of the intraperitoneal balloon reservoir into the small bowel. In addition, 5 of 9 (55%) control pumps were complicated by skin erosion or infection; all were relocated successfully. The fact that an intact artificial anal sphincter can provide excellent continence demonstrates that this concept of perineal placement for bowel control is valid. Refinements in the device to prevent tab breakage, investigation of correct sphincter pressures to prevent sloughing, and better sites for implantation of the pump and balloon reservoir are requisite solutions for a fully implantable system to restore near-normal bowel function after radical abdominal perineal resection.     

Impact of radical perineal prostatectomy on urinary continence and quality of life: A longitudinal study of Japanese patients

AIM: We used self-completed questionnaires to obtain a longitudinal assessment of urinary continence and urinary, bowel, and sexual domain-related quality of life (QOL) in Japanese patients undergoing radical perineal prostatectomy (RPP). METHODS: A total of 41 Japanese patients with a median age of 69 years who underwent RPP between February 2002 and February 2004 were included in the study. We measured QOL by the University of California, Los Angeles, Prostate Cancer Index (UCLA-PCI) and assessed urinary continence on the basis of three different definitions of continence. The International Prostate Symptom Score (I-PSS) was also included to evaluate lower urinary tract symptoms (LUTS). RESULTS: When urinary continence was de fi ned as none, one, or two protective pads per day, 100%, 73%, 94%, 97%, or 100% of the patients were continent before, and 1, 3, 6, and 12 months after, RPP, respectively. When it was de fi ned as total control or occasional dribbling, the corresponding values were 97%, 70%, 84%, 94%, and 97%. Urinary function returned to the preoperative baseline level by 6 months postoperatively and scores for urinary bother had significantly surpassed the baseline by 12 months (P = 0.043). The I-PSS was significantly improved (P = 0.014), with a mean 4.7-unit decrease. Sexual function worsened significantly after surgery, and its recovery was less favorable. No significant change was observed in scores for bowel function or bowel bother. CONCLUSIONS: The majority of patients who undergo RPP rapidly regain urinary continence and QOL within 3-6 months. RPP has a favorable impact on LUTS.     

阴道封闭术对老年盆腔器官脱垂患者肠道困扰症状的疗效观察

目的:观察阴道封闭术对老年重度盆腔器官脱垂(POP)患者肠道梗阻及失禁等肠道困扰症状的疗效.方法:在2005年10月-2010年2月期间,采用盆底功能障碍症状问卷结直肠肛门困扰量表(CARDI-8)及生活质量问卷结直肠肛门影响问卷(CARIQ-7),对60例因POP-Q Ⅲ～Ⅳ期重度POP而实施阴道封闭手术的患者,分别...     

Preliminary results of the effect of extracorporeal magnetic stimulation on urinary incontinence after radical prostatectomy: a pilot study

INTRODUCTION: Radical prostatectomy is a common procedure for the treatment of clinically localized prostate cancer. However, urinary incontinence is a significant potential source of morbidity following surgery. Extracorporeal magnetic stimulation (ExMS) is a new technology used for pelvic muscle strengthening in the treatment of stress urinary incontinence. We investigated the clinical effects of ExMS on urinary incontinence after retropubic radical prostatectomy. PATIENTS AND METHODS: Ten patients who had suffered from urinary incontinence for more than 12 months following radical prostatectomy were enrolled in this study. The Neocontrol system was used. Treatment sessions were for 20 min, twice a week for 2 months. The frequency of the pulse field was 10 Hz for 10 min, followed by a second treatment at 50 Hz for 10 min. Objective and subjective measures included voiding diaries, 1-hour pad weight testing, and a quality of life survey at 1, 2, 3, and 6 months after starting the treatment. Urodynamic studies were performed before and after treatment. RESULTS: Three patients became dry (30%), 3 patients improved (30%), and 4 patients showed stationary symptoms (40%). In the 1-hour pad weight testing, the mean pad weight decreased from 25 to 10.3 g, and the quality of life scores had improved from 70.5 to 84.9 2 months after treatment. The frequency of leak episodes per day was reduced from 5.0 times before to 1.9 times after treatment. In the urodynamic study, mean maximum cystometric capacity and Valsalva leak point pressure increased from 197 +/- 53.2 to 309 +/- 85.3 ml and from 67.3 +/- 22.6 to 97.1 +/- 22.7 cm H2O after treatment, respectively (p < 0.05). 3 of 6 patients who showed improvement returned to the baseline values within 12 months after treatment and requested maintenance ExMS therapy. No side effects were observed. CONCLUSIONS: ExMS therapy offered a new option for urinary incontinence treatment after radical prostatectomy. Further studies are required to determine how long the benefits of treatment last and whether maintenance therapy is necessary.     

URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY: THE COLUMBIA EXPERIENCE

Purpose

We determine the incidence of urinary incontinence after radical prostatectomy and the factors that may influence this incidence.

Materials and Methods

A total of 615 men who underwent radical retropubic prostatectomy performed by 1 of us (C. A. O. or M. C. B.) at our center between 1988 and 1996 were mailed a questionnaire regarding preoperative and postoperative voiding habits. Data collected included preoperative and postoperative continence status, interval to postoperative continence status, associated urinary symptoms, willingness to undergo radical prostatectomy again if given the chance and additional postoperative procedures. Patient age, date of surgery and duration of followup were also noted.

Results

Of the 615 patients 480 (78.2%), a mean of 62.6 years old, responded to the questionnaire. Mean followup was 3.3 years (range 1 to 8.8). Continence was defined as no regular use of pads. Of the respondents 91.8% were considered continent, 92% had achieved final continence status by 6 months postoperatively, 10.6% required 1 or more additional procedures related to urinary control and 90% would undergo surgery again if given the chance. Of the patients considered incontinent postoperatively 44% had associated urgency. Age, year of surgery and preoperative urinary leakage or post-void dribbling had no significant impact on postoperative continence status.

Conclusions

Using an anonymous self-administered questionnaire we found an 8.2% incontinence rate after radical prostatectomy. This rate was similar to that in large, single institutional studies in which physician interview was used to elicit responses but significantly less than that in a national sample of Medicare patients also given a self-administered questionnaire. With minimal potential for adverse consequences in the hands of experienced surgeons, radical prostatectomy remains well tolerated with excellent patient satisfaction.     

Biofeedback therapy after perineal rectosigmoidectomy or J pouch procedure

The aim of this study was to determine the outcome and to identify possible predictors of success for biofeedback therapy after perineal rectosigmoidectomy (PRS) or coloanal or ileoanal J pouch. A retrospective chart review of all patients with electromyography-based biofeedback therapy due to fecal incontinence after PRS or a J pouch procedure was undertaken. Follow-up was obtained by telephone survey. Fourteen patients (4 men and 10 women) were included in this study. In the 9 patients after PRS, the frequency of daily bowel movements was 3.6+/-2.8 preoperatively, 4.1+/-3.2 prebiofeedback, and 2.2+/-1.3 postbiofeedback (P<.05). The frequency of daily incontinent episodes was reduced from 2.4+/-2.2 preoperatively and 2.0+/-1.9 prebiofeedback to 0.26+/-0.3 postbiofeedback (P<.05). The incontinence scores decreased from 17+/-3.1 preoperatively to 16+/-2.1 prebiofeedback and to 8.2+/-5 postbiofeedback (P<.001). At a follow-up of 15.8+/-7.1 months, 5 patients after the J pouch had decreased daily bowel frequency from 6.6+/-4.2 prebiofeedback to 3.3+/-2 postbiofeedback and 3.1+/-2 at follow-up (P<.05). The frequency of daily incontinent episodes was reduced from 1.9+/-1.3 prebiofeedback to 0.9+/-0.7 postbiofeedback to 0.7+/-0.8 at follow-up (P<.05). The incontinence scores decreased from 13.4+/-2.7 prebiofeedback to 8.8+/-5.1 postbiofeedback to 6.8+/-5.5 at follow-up (P<0.05). In both groups, the postbiofeedback incontinence score correlated with the prebiofeedback incontinence score. Furthermore, there was no correlation between outcome and age, interval between surgery and biofeedback therapy, frequency of biofeedback sessions, or manometry results in either group. Biofeedback therapy is an effective option for patients with fecal incontinence after perineal rectosigmoidectomy or colonic or ileal J pouch.     

Management of full thickness rectal prolapse

Rectal prolapse occurs when the rectum invaginates and descends into the anal canal or beyond the anal sphincter muscles. Patients often report fecal incontinence, obstructed defecation, pain, and urgency and of patients who present with rectal prolapse, up to 30% will also have anterior or middle compartment prolapse. This review describes the preoperative management of patients with rectal prolapse and principles for determining the operative approach.All patients should be optimized ahead of surgery with attention to bowel habits, pelvic floor strength and coordination, and baseline nutrition and fitness. If multi-compartment prolapse is identified, those patients should be referred for multidisciplinary management. Determining the best operation for an individual patient is best done through a shared decision-making model weighing the risks and benefits of abdominal versus perineal operations. Many patients can tolerate minimally invasive abdominal operations, but for those who cannot, perineal operations are a safe and effective option.