Treatment of stress incontinence after BPO surgery Persistent SUI after BPO surgery is one of the biggest challenges in urological clinical practice Van: Jarka Bloemberg j.bloemberg@uroweb.org Onderwerp: RE: EAU23 Congress Newsletter - Gacci Datum: 30 januari 2023 om 15:27 Aan: Dunja Blom dunja@buroblom.nl
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Groet, Jarka
outcomes [7]. The International Index of
Mechanical distension of the bladder from BOO may cause epithelial and smooth muscle cells in the bladder wall to undergo modifications of gene expression and protein synthesis via several transduction mechanisms. The result is smooth muscle hypertrophy and collagenous deposition, which eventually creates a thickened bladder wall with poor contractility, small capacity and low compliance. Following sudden relief of BOO, however, these hyperactive neuronal pathways may persist and be the source of irritative storage symptoms and DO. BOO can exist either with or without symptoms characteristic of the overactive bladder (OAB) complex, including urgency, frequency and nocturia [4]. "Permanent SUI is a severe complication after surgery for LUTS/BPO that can be caused by several pathophysiological mechanisms." Correct pre-operative diagnosis and characterisation of LUTS is crucial before offering surgical intervention to relieve BOO. Machino et al. noted that post-operative persistent DO was more frequently reported in patients without clear obstruction at the pre-operative Abrams-Griffiths nomogram (60%) than in those who were obstructed (27%). Multiple studies suggest that recurrent or persistent obstruction accounts for only a minority of LUTS cases after TURP, as suggested by Nitti et al. Cases of direct surgery failure (persistent obstruction), prostatic regrowth (recurrent obstruction) or other strictures (bladder neck contracture, urethral stricture, meatal stenosis) can nonetheless occur and require repeat intervention. Transient SUI might be due to anatomical changes once enucleation has been done, and dependent of the healing of the prostatic fossa, once the surgery is done. Persistent SUI may be more related to definitive sphincter injury (purely iatrogenic), but also to a very low sphincter function already existing before the intervention, or because of a severe bladder dysfunction or a neurogenic background that further worsens the situation. Before any treatment, an accurate evaluation of detrusor activity is mandatory; if a bladder dysfunction is present, it can lead to the persistence or worsening of storage symptoms and/or voiding symptoms after BPO relief [5] Diagnostic evaluation The first evaluation is of the medical history to evaluate the type, timing and severity of UI, define the surgical procedure technique used and to record associated voiding dysfunction and/or other urinary symptoms. The
Prof. Mauro Gacci Associate Professor Unit of Urological Robotic Surgery and Renal Transplantation, at University of Florence (IT)
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Erectile Function (IIEF) can be used to investigate the coexistence of erectile dysfunction. Laboratory testing can also provide clues to alternative aetiologies of LUTS, such as infection (urinalysis with microscopy, culture) or malignancy (urinary cytology, prostate-specific antigen). The fundamental examination to be carried out in patients with LUTS after surgery is the urodynamic examination (UDS), as it serves to elucidate the nature of LUTS and guide appropriate subsequent therapy. Pressure-flow studies are required to evaluate detrusor function and exclude obstruction [8]. Endoscopic evaluation (urethro-cystoscopy) is also suggested to assess the absence of concomitant bladder disease and rule out any urethral stenosis or bladder neck sclerosis [1].
From: Dunja Blom
(Dry Rate)
PERI-URETHRAL INJECTION OF BULKING AGENTS
Increase passive urethral resistance -
SLING
Reloca#on and compression of the bulbar urethra with the chance to adjust or not the level of compression on the urethra (adjustable and fixed respec#vely)
Fixed
AdVance XP™
47%
Male LUTS/BPO, a common condition in patients above 50 years, is initially treated through lifestyle modifications and/or medications. For more severe symptoms, surgery for BPO is usually performed by resection, vaporization or enucleation of the prostate. The main postoperative complications include bleeding, sexual dysfunction, persistent or de novo LUTS, recurrent BPO, urethral stenosis, bladder neck stricture and stress urinary incontinence (SUI). The frequency of these adverse events depends on patient characteristics (age, comorbidities, prostate size, evolution of the disease, etc.), surgical technique and peri-operative parameters, learning curve and postoperative interval [1]. The concept of stress urinary incontinence (SUI) after BPO surgery covers various situations. First is ‘short term’ SUI, which covers the issue of SUI in the months following surgery for BPO relief. These symptoms are also named ‘transient’ SUI because of their spontaneous improvement with time. The rate of short-term SUI varies according to the technique used. Historical cohorts with transurethral resection of the prostate (TURP) have shown rates of 0–40% of short-term incontinence [2]. Modern endoscopic enucleation of the prostate (EEP) techniques have shown to lead to a 3-43% rate of SUI in the postoperative period [3]. Most cases of transient incontinence lead to conservative management, including physiotherapy. Medium and long-term SUI are defined as persistent SUI. An overall rate of 0–8.4% has been reported for persistent SUI [1]. Persistent SUI after BPO surgery is one of the most challenging situations for urologist’s daily clinical activity, due to the severe impact on patients’ quality of life, which can jeopardise the improvement of preoperative male LUTS [1]. Pathophysiology The pathophysiology of transient and persistent SUI after BPO surgery is not precisely understood, but some hypotheses have been raised. Hypoxic insult, changes in neuroplasticity and/or progressive detrusor hypertrophy from chronic outlet obstruction over time are the main investigated etiological factors for postoperative SUI [4].
The Virtue™
50%
IStop TOMS™
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Adjustable
ATOMS™
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Remeex™
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Argus™ and ArgusT™
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PERI URETHRAL BALLOONS
Adjustable peri-urethral compression
Pro-ACT™
45%
ARTIFICICAL URINARY SPHINCTER
Circumferen#al compression of the urethra by a cuff filled with liquid.
58%
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<dunja@buroblom.nl> Sent: Monday, January 30, 2023 3:23 PM
Table 1. Surgical treatment of male SUI after BPH surgery. To: Jarka Bloemberg <j.bloemberg@uroweb.org> Subject: Re: EAU23 Congress Newsle_er - Gacci
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Treatments Conservative treatment for SUI post-BPO surgery includes: lifestyle advice, containment, bladder training and pelvic floor muscle training (PFMT). Modifications of lifestyle factors include: diet, physical activity, and reduction of fluid intake based on 24-h urine output measurement [9]. This option could be proposed for patients with minimal incontinence during the first months after surgery. Containment devices, such as absorbent pads, external collection devices or penile clamps, should be considered as palliative options for patients with massive incontinence. Bladder training allows patients to increase the amount of urine they can hold and to control the urgency, with concomitant improvement of the stress component of urinary incontinence [10]. PFMT, such as Kegel exercises, have been shown to significantly improve SUI after EEP without any significant adverse events [11]. in particular, PFMT significantly reduces the time needed to reach continence recovery, though at 12 months the continence rate for SIU after TURP could be similar in patients with vs. without treatment [12]. "Before any treatment, an accurate evaluation of detrusor activity is mandatory." In the case of failure of conservative management, no specific medication has been proven to be effective in treating pure SUI after BPO surgery [1], though muscarinic receptors antagonists and beta-3 agonists can be used for persistent or de novo urge incontinence/ OAB [3]. Duloxetine has been extensively tested for SUI after prostate surgery, but mainly after RP. In particular, as reported in a systematic review of 8 studies, duloxetine resulted in a mean dry rate of 58%, mean improvement in pad number of 61% and mean improvement in 1-h pad weight of 68% in a short (<12 months) follow up [3]. Surgical options are considered after a minimum of 12 months of follow-up after surgery, given the high recovery rate in the short-term. Periurethral injections of bulking agents have been proposed for the management of male SUI after BPH surgery, but available evidence remain scarce. In particular, a systematic review based on data from 5 trials did not reach a significant level of evidence to define any recommendation [13]. Fixed or adjustable male slings have been introduced as alternatives to artificial urinary sphincter (AUS) in patients with mild to moderate UI, while those with more severe UI (>250 grams of urine loss per day) seemed to be more satisfied after AUS than after a sling [1].
Urinary retention, chronic pain, wound infection, urethral erosion and risk of explantation are the main complications. The retro-urethral transobturator fixed male sling (AdVance XP) has demonstrated encouraging results, with a dry rate close to 50% at a follow up of more than 5 years [14]. Encouraging results also appear to be related to implantation of a Virtue male sling (satisfaction rate 50%) [1]. Angulo et al. reported a clinically meaningful efficacy of the ATOMS device - an adjustable male sling - for the management of SUI after TURP (satisfaction rate 80% at 3 years) [1]. This result is confirmed by a retrospective trial, but with a lower safety profile (10% explantation rate, 5% of urinary retention, 7% of hematoma) [15]. The Pro-ACT system is a non-circumferential compression device based on two balloon devices introduced under fluoroscopic control transperineally. In a retrospective cohort study, 45% of patients were dry and 31% improved UI 20 months after implantation [16]. Migration, infections, erosion, multiple subsequent adjustments and need of reinterventions are the most frequently reported complications. AUS has been the principal treatment of male SUI, whatever the underlying etiology. However, very few articles make the actual distinction between patients with a history of RP and a history of BPO surgery. Overall, the literature seems to be in accordance with the fact that AUS results in RP patients are comparable to those with SUI after BPO surgery (dry rate 58%) [17]. In particular, in a systematic review of 87 UI after BPO surgery, AUS showed good results in terms of dry rate, improvement of quality of life and patient satisfaction [18]. Conclusions Permanent SUI is a severe complication after surgery for LUTS/BPO that can be caused by several pathophysiological mechanisms involving bladder, bladder neck, prostate, urinary sphincter and urethra. An adequate evaluation to measure the severity of incontinence, understand the aetiology and plan a tailored treatment is mandatory. Conservative and invasive intervention options to improve both symptoms and QoL are mainly derived from the literature on post-PR, with a very low level of evidence.
physical examination includes an abdominal examination (to detect an enlarged bladder), a genital exam, a perineal and digital rectal exam. This phase assists in better defining incontinence (pure SUI or mixed) and identifying other medical conditions that need rapid referral to an appropriate specialist [6] A voiding diary and pad test should be used to quantify symptom severity, including urinary frequency, number of incontinence episodes, voided volume, and diurnal or nocturnal micturition. Validated symptom score questionnaires, like International Prostate Symptom Score (IPSS) or AUA symptom index (AUA-SI), can help to measure UI severity and evaluate clinical
Patients with SUI after BPO surgery
First clinical examination steps
• Patient history: prostate surgery history, comorbidities, overall health status and medication • Physical examination: abdominal and genital exam, digital rectal exam and neurologic evaluation
Additional clinical work-up
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Voiding diary and Pad Test
• Symptoms score questionnaires (IPSS or AUA-SI) and sexual score questionnaires (IIEF)
Further investigations
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Urinalysis with microscopy and urine culture, Urinary cytology
Urodynamic examination (UDS)
Urethrocystoscopy
Plan treatment
Conservative Treatment Lifestyle advice Containment Bladder training Pelvic floor muscle training (PFMT)
Medical Treatment
Surgical Treatment
The list of references are available upon request.
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Muscarinic receptors antagonists Beta-3 agonists (For coexistent urge incontinence / OAB)
Bulking agent
Male sling
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Peri Urethral Balloons Artificical Urinary Sphincter
Sunday 12 March 12:05 - 12:15 State-of-the-art lecture Evaluation and treatment of stress incontinence after BPO surgery Yellow Area, eURO Auditorium 2
Figure 1. LUTS’ treatment after BPH surgery.
European Urology Today
February/March 2023
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