Incontinence Treatment Options for Post-Prostatectomy
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Gary E. Leach, MD, Director, Tower Urology Institute for Continence, Los Angeles
Reprinted from PCRI Insights May 2004 vol. 7, no. 2

Loss of bladder control (urinary incontinence) after prostate surgery is a devastating complication, which has a significant negative impact on quality of life. When urinary incontinence persists after radical prostatectomy, appropriate bladder testing called urodynamics can evaluate the function of the bladder and sphincter (valve) muscle to determine the exact cause of the post-prostatectomy incontinence (ppi). Normally, as the bladder fills to capacity, there is very little change in bladder pressure and the sphincter remains closed allowing the man to stay dry. When incontinence occurs following prostatectomy, this normal balance of bladder and sphincter function is disturbed.

Our research1 has defined three main causes of ppi based upon urodynamic findings in men with ppi:
1. High pressure (with ‘spasms’ of the bladder) developing in the bladder as the bladder fills (50% of men with ppi). These bladder spasms may cause urge incontinence, frequent urination, and sometimes loss of urine at night.
2. Damage to the sphincter muscle (35% of men with ppi). This damage results in stress incontinence with loss of urine during coughing, straining, or vigorous physical activity.
3. A combination of bladder malfunction and sphincter damage (10% of men with ppi). Men with this combined problem usually experience “mixed incontinence” symptoms with a combination of both urge and stress incontinence.

With treatment directed by the urodynamic testing, the majority of men are able to experience significant improvement in their urinary control. When the main problem is high bladder pressures, medications to relax the bladder are usually effective. These medicines (generally known as anti-cholinergics) include Ditropan XL, Detrol LA, the Oxytrol patch, and imipramine. Both Ditropan and Detrol are oral medications that are taken once daily. These medications use a ‘time release’ mechanism to maintain adequate blood levels of the drug to relax the bladder and eliminate ‘bladder spasms’ over 24 hours. Side effects of these medications include dry mouth, constipation, and sometimes blurry vision. These drugs should not be used in patients with narrow angle glaucoma or in men who do not empty their bladder well. The Oxytrol patch sends the medication to relax the bladder through the skin. This patch is changed twice per week and may have fewer side effects than the oral medications.

Interstim® “Bladder Pacemaker”
When the usual medical treatments to lower high bladder pressures are not successful, the Interstim “bladder pacemaker” may be an excellent alternative. This treatment involves a two-stage approach with both stages performed under local anesthesia as an outpatient procedure. The first stage involves placing a special stimulation electrode next to the main nerve that controls the bladder. The patient then wears an external stimulation box for 7-10 days as a “test stimulation” to evaluate the response of the bladder to the electrical stimulation to “relax” the bladder. When a good response is obtained, we proceed with the second stage of the procedure, which involves implantation of an internal ‘pacemaker’ that is attached to the stimulation electrode and programmed through the skin. Overall approximately 50% of patients respond to the first stage trial of test stimulation. When we proceed with the second stage implant, about 85% of patients have an excellent response. Thus, use of the Interstim “bladder pacemaker” is an effective treatment option for those patients who have high-pressure bladder dysfunction who do not respond to the usual forms of medical treatment.

Options for treatment of sphincter damage include biofeedback, injection therapy (which is generally not successful), the artificial urinary sphincter, and more recently the male sling procedure. Those men with “mixed” bladder and sphincter malfunction will undergo initial treatment to improve their bladder function (i.e. lower their bladder pressures) followed by treatment to address the weak sphincter.

Artificial Urinary SphincterThe Artificial Urinary Sphincter (AUS)
Perfected over the last 20 years, the artificial urinary sphincter is a device implanted into the body to correct stress incontinence in men with significant sphincter damage. The AUS has three components: a cuff that helps close the urethra, a pump placed inside the scrotum, and a pressure regulating balloon which is placed in the lower abdomen (see Figure 1). When the man wants to urinate, he squeezes the pump in the scrotum, which opens the cuff around the urethra. Automatically, after 3-5 minutes, the fluid returns into the cuff allowing the cuff to close. After the device is tested during surgery, the cuff is “locked” open, and is only activated when swelling around the pump is gone (usually about 4-6 weeks after surgery).

With the current model of the AUS, long-term patient satisfaction has been excellent with less that a 15% mechanical malfunction rate at 7.5 years after implantation of the device.2 Despite these excellent long-term results, however, some men are hesitant to have this prosthetic device placed. For these men, as well as for those with more minor degrees of ppi or for men who do not have the manual dexterity to squeeze the pump in the scrotum, the male sling is a promising alternative.

Male Sling Procedure
Over the last two years, the male sling procedure has become a viable treatment alternative for men with ppi due to sphincter damage causing stress incontinence. The surgical procedure to implant the sling takes about one hour and can be done either on an outpatient basis or with an overnight hospital stay. The purpose of the “sling” is to compress the urethra and help eliminate loss of urine with coughing, sneezing, or vigorous activity.

Bone Screws Secure Male SlingThe sling is placed via an incision between the scrotum and rectum. After exposing the pelvic bone on each side, six titanium bone screws are placed into the pubic bone (three screws on each side). A permanent suture is attached to each bone screw (see Figure 2). These sutures are then passed through the material used to create the sling, which will compress the urethra. The material used for the sling may be cadaveric (from a dead body) tissue, processed non-human tissues, or synthetic materials. The author prefers to use commercially available non-frozen cadaveric fascia lata (connective tissue from thigh).

Male SlingThree sutures on one side are passed through one edge of the sling and tightly tied. The three sutures on the other side of the pubic bone are then passed through the sling and tied to create closure of the urethra at a pressure of 60cm water pressure. This pressure is confirmed by running sterile fluid backward into the urethra at 60cm water pressure and confirming that this fluid perfusion stops when the sling is tightened down (see Figure 3). The incision is then closed. A catheter is usually left in place for 24 hours with most men being able to urinate with good control immediately after the catheter is removed.

Thus far, the results with the male sling have been encouraging. In one series of men undergoing the male sling, 40% of men are completely dry, 40% are significantly improved, and 20% are considered failures. Of those men who did not respond to the male sling, an artificial urinary sphincter could be considered as a second alternative.

Summary
Recent advances in the evaluation and treatment of men with incontinence following prostate surgery have allowed many men to regain their urinary control and improve their quality of life. The male sling is a significant advance in how we treat ppi. In well-selected candidates, the male sling is an effective treatment option for many men.

Illustrations provided courtesy of American Medical Systems, Inc.
If you would like more information or if you have a question, contact Dr. Gary Leach through his website at: www.towerincontinence.com or contact the PCRI Helpline.

References
1. Leach G, Trockman B, Wong A, et al: Post-prostatectomy incontinence: urodynamic findings and treatment outcomes. J. Urology 155:1256, 1996.
2. Haab F, Trockman B, Zimmern P, and Leach G: Quality of life and continence assessment of the artificial urinary sphincter in men with minimum 3.5 years of followup. J. Urology 158:435-439, 1997.

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