Risk Factors And Prevention

As noted previously, sphincteric incontinence in the male is exceedingly rare, except in the setting of lower urinary tract surgery such as prostatectomy. An important well-defined risk factor for UI following prostatectomy includes pre-existing bladder or sphincter dysfunction.16 The reported incidence of bladder dysfunction as a sole or contributing cause of UI following prostatectomy is highly variable, but has been reported to be as high as 95%.17 Notably, this study and others combined patients with PPI resulting from surgery for both benign and malignant disease. Leach and colleagues looked at 210 patients with PPI, 159 following RP and 51 following transurethral resection of the prostate (TURP) or open prostatectomy, for benign disease.18 Almost 20% of patients had detrusor dysfunction as the sole urodynamic cause for PPI, while an additional 40% had combined sphincteric and detrusor dysfunction. Other authors have reported detrusor dysfunction as the sole or contributing cause of PPI in 38-78% of patients.19-21 The prevalence of detrusor dysfunction in the literature as a contributing factor to PPI may be quite high owing to the mixed population of patients reporting PPI in these series. Those with PPI following prostatectomy for benign disease might be expected to have a higher incidence of detrusor dysfunction owing to their symptomatic presentation with obstructive or irritative symptoms, some of which might be due to pre-existing bladder dysfunction, as opposed to those undergoing RP, many of whom may have been asymptomatic. In a series of 74 patients with PPI following RP, Chao and Mayo reported only 4% with detrusor dysfunction alone, and an additional 39% with combined detrusor and sphincteric dysfunction.22 Groutz and colleagues studied 83 patients with PPI following RP using sophisticated video urodynamics evaluation, pad tests and voiding diaries.23 They concluded that detrusor dysfunction was present in 33.7% of patients, and was the only urodynamic abnormality in 3.6%. However, in only 7.2% (6) of patients was detrusor dysfunction considered to be the primary cause of PPI. Our experience would agree.

Several studies have attempted to identify factors that might be associated with PPI. Advanced age24,25 and the lack of surgical expertise5 seem to correlate with an increased risk of persistent PPI. Eastham and colleagues conducted a univariate and multivariate analysis of 514 patients undergoing RP at one institution.26 In a univariate analysis, prostate size, blood loss and prior history of TURP were considered adverse risk factors. In the multivariate analysis, risk factors for PPI included advanced age, resection of one or both neurovascular bundles, development of a postoperative anastomotic stricture and, finally, surgical technique. Conversely, in a review of over 700 patients at Johns Hopkins, no correlation was noted between PPI and the preservation of one or both neurovascular bundles. These authors concluded that intrinsic anatomical factors were responsible for PPI.27 Others have also reported no difference in continence following resection of one or both neurovascular bundles.28,29 The impact of prior TURP on postoperative continence following RP is controversial. Historically, several authors reported an increased incidence of urinary incontinence in those undergoing RP following TURP.30-32 It is possible that these series included patients with significant pre-existing detrusor dysfunction (see discussion earlier). Other historical series do not report this relationship.26'33 More recent series do not support an increased risk of PPI in patients who have had prior TURP.29'34

Surgical techniques for radical prostatectomy have evolved over the last several decades as a better understanding of the pertinent pelvic neurovascular anatomy has emerged.35 Modifications in surgical technique have allowed better preservation of erectile function' lower intraoperative blood loss and shorter hospital stays. However, whether any of these technical modifications have improved overall continence rates is unclear. In several instances, a number of other modifications to RP have been proposed with the goal of reducing or eliminating postoperative sphincteric incontinence. Careful preservation of the bladder neck fibers during dissection of the prostate has been suggested as providing a faster return to continence postoperatively36,37 and improving continence overall.13 Owing to concerns in preserving cancer-free surgical margins during RP, bladder neck preservation is not always possible. Lowe reported that preservation of the bladder neck did not result in improved overall continence but, as compared to those without bladder neck preservation, the time to achieve maximal continence was shorter.38 Furthermore, it is unproven whether the additional time invested in this sometimes tedious dissection can provide a surgically reconstructed and functionally continent bladder neck as compared to other approaches.39 When compared to those patients without bladder neck preservation at RP, Srougi and colleagues could find no difference in overall continence at 6 months.40 Others have also found no difference in continence with bladder neck sparing procedures.41 It is generally accepted that preservation of adequate functional urethral length during the apical pros-tatic dissection is important. The surgeon must be cognizant of the variety of the anatomic configurations of the prostate (e.g. 'croissant' vs. 'donut')42,43 in order to maximize functional urethral length and attain adequate surgical margins. Maintaining a long urethral stump26 with minimal manipulation during the dissection44 may be additional important factors in preserving sphincteric function. Among the myriad of permutations of RP, minimal dissection distal at the apex of the prostate in the region of striated sphincter,45 preservation of the puboprostatic ligaments,46,47 anastomotic inclusion of the posterior layer of Denonvilliers fascia,48 sparing a portion of the seminal vesicals49 and limiting the number of anastomotic sutures or precise placement of the anastomotic sutures29 have all been proposed as potentially providing improved postoperative continence overall or time to achieve maximum continence. Finally, reconstruction and tubularization of the bladder neck has been proposed by several authors as a method of improving continence. Seamans and Benson reported a 97% continence rate following bladder neck tubularization in 29 patients at follow-up of 6 months.48-50 Continence was achieved in seven patients in less than 24 hours following catheter removal and in 27 patients by 3 months postoperatively. Steiner etal. compared a group of 69 patients undergoing bladder neck reconstruction and tubularization to 45 patients undergoing a standard RP.12 At 6 months, continence was complete in 87% of patients with reconstructed bladder neck vs. 47% of controls.

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