Urinary incontinence remains an impactful complication following prostate cancer treatment.¹ The incidence of urinary incontinence following radical prostatectomy varies widely, from 1%–40% depending on the length of followup and definition of incontinence.² Despite recent trends with respect to declining rates of prostate specific antigen screening, increased active surveillance and refinements in curative therapies, post-prostatectomy incontinence (PPI) remains and will likely always be a clinically relevant entity.³

The persistence of PPI is related (at least in part) to a trend toward treating higher grade and stage prostate cancers with prostatectomy, which are well-established risk factors for incontinence and an associated increase in the rate of local salvage therapies in particular radiotherapy and high-intensity focused ultrasound (HIFU).⁴ This practice pattern of increasing prostatectomy use in high-risk cancer and salvage local therapies has resulted in increased complexity and complication risk of patients presenting with and undergoing treatment for PPI.⁵

Determining the best course of treatment for these increasingly more complicated cases can be challenging especially given the overall poor quality of evidence. With a lack of effective nonsurgical therapy, patients are left with little choice other than surgical intervention. Woefully, the majority of studies in this domain are retrospective, single-centered and absent of any completed prospective randomized studies evaluating surgical outcomes. There is also a lack of consensus on what constitutes success, which makes comparison between studies and centers difficult. Lastly, all current surgical devices are effective but flawed in some form or another, especially when concurrent radiation is present.⁶

Insertion of an artificial urinary sphincter (AUS) remains the gold standard for treatment of PPI, but there are several ongoing drawbacks to this procedure, including a continence rate of 75%–80% (inferring a 20%–25% incontinence rate), a revision rate of 15%–60% at 7–10 years, requirement for an intra-abdominal pressure regulating balloon, a mechanical control pump requiring manual dexterity and a lack of adjustability (without a re-operation).⁷ Despite patient satisfaction rates consistently approaching 90%, these drawbacks combined with an overwhelming patient preference to avoid a mechanical pump has led to the development of male slings, which unfortunately are less successful when applied to the increasingly complex cases of PPI.^8,9

When caring for a patient with concurrent lower urinary tract pathology and associated increased risk of AUS complications, several key questions and concerns may arise when traveling on the road to continence. The best way to optimize the lower urinary tract prior to surgical intervention warrants discussion and attention. For example, when is it safe to offer treatment for incontinence to patients with intermittent hematuria due to radiation cystitis, previous urethral stenosis, previous urothelial cancer or prior intravesical Hem-o-Lok Clip® erosion? The ideal timing of disease quiescence prior to surgery for an optimal outcome needs to be balanced with patient quality of life. Information regarding risk factors for AUS or sling complications is critical prior to intervention.

Sometimes, despite a surgeon’s best preventative efforts, once a device is placed complications related to radiation cystitis, dystrophic calcification or urinary tract fistula can arise de novo. Management of episodic gross hematuria with clots or obstructing calcifications may risk the functionality of the AUS cuff and integrity of the overlying urethral mucosa. History of a bladder neck contracture requiring stabilization prior to AUS placement, a rigid/pale bladder neck and the identification of calcifications are risk factors for decompensation of the outlet. Patient complaints of perineal pain relieved by sphincter deactivation should be investigated with a high suspicion for compromised bladder neck integrity. Recognition of these signals can allow for intervention before the development of major complications and significant morbidity for the patient. It is critically important to be aware of the clinical spectrum of these troublesome scenarios, viable treatment options and the evidence behind them.

Additionally, when a patient treated for PPI unfortunately develops a complication such as urethral erosion and they desire further treatment, understanding the viability of further intervention, modifications in technique and evidence to reduce the risk of further cuff erosion are important. When is it best to perform a trans-corporal cuff placement as opposed to reducing the pressures in the pressure-regulating balloon? Is it ever indicated to insert the AUS device as a staged procedure? How many times should the device be replaced following repetitive erosion? Patient discussion determining the limits of surgical intervention and deciding when “enough is enough” is a delicate issue and often best approached systematically.

Please join us on Monday, September 13, 2021 from 8:35–8:55 a.m. as we delve into the depths of complex scenarios in the management of post-prostatectomy incontinence.