Fourth International Consultation On Incontinence (ICI) - Surgery For Urinary Incontinence In Men Committee Highlights

Main Category: Urology / Nephrology
Article Date: 26 Jul 2008 - 0:00 PDT

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PARIS, FRANCE (UroToday.com) - Dr. Herschorn opened the final day of the 4th ICI with Committee 13's recommendations on surgical treatments for UI in men. He began by outlining the areas that the committee chose to examine, notably surgery for post-prostatectomy incontinence (PPI) (including benign disease, radiation therapy, cryosurgery, with cystectomy), post-traumatic incontinence, unresolved pediatric incontinence, refractory urge incontinence, male urinary fistulae, and a separate section on special considerations with the artificial urinary sphincter (AUS). The recommended initial pre-surgical evaluation should include a history and physical exam, urinalysis and post-void residual measurement (Grade A to C). Pad tests and voiding diaries may also be helpful. Cystoscopy may be useful to rule out urethral stricture and bladder pathology. While urodynamics (UDS) with or without fluoroscopy is commonly performed for male UI, the committee reviewed two retrospective studies that failed to show the ability of UDS to predict outcomes after AUS. This does not imply, of course, that UDS is not useful in selecting patients for AUS or other anti-incontinence surgery. In fact, the committee gave a Grade B recommendation that UDS is useful to characterize the underlying bladder/sphincter pathophysiology prior to surgery.

Rates of incontinence after surgery for benign disease were shown to be similar across the various treatment modalities, but trended slightly higher with open benign prostatectomy. Rates of incontinence after surgery for prostate cancer were noted to be highly variable and dependent on data collection techniques and definitions of incontinence. Perioperative risk factors for incontinence include patient age, preoperative continence, presence of bladder neck contracture, tumor stage and nerve-sparing. A difference has not been demonstrated between open, laparoscopic and robotic techniques.

Dr. Herschorn reviewed the main treatments for post-prostatectomy incontinence, notably injectable bulking agents, male slings and the AUS. In terms of bulking agents, the committee looked at collagen, Macroplastique and Tegress, although Tegress has been withdrawn from the market. No difference was found between antegrade and retrograde techniques for injection, and no difference has been demonstrated among the different agents. Complete cure rates are low (<20%) and "improved" rates are variable (usually <60%). A history of radiation, bladder neck scar, and large-volume incontinence negatively correlate with success.

Dr. Herschorn discussed a 2005 RCT in 45 men with PPI who received either urethral bulking with Macroplastique or an AUS. Success rates in men with minor degrees of incontinence were similar, but the AUS was superior in men with severe incontinence. The committee concluded there is an approximately 40% short-term improvement rate and a 50% failure rate with injectables. Dr. Herschorn reviewed success rates (defined as 0-1 pads per day) across multiple studies of the AUS; rates ranged from 59-90% with variable follow-up periods (Level 2-3 evidence). Next, male slings were reviewed, and Dr. Herschorn highlighted several historical urethral compression procedures that have been abandoned over the years. The current technologies were reviewed (bone-anchored, composite grafts, retropubic suspensions, adjustable slings), although notably the transobturator male sling (Advance, American Medical Systems) was not included as it is a relatively new introduction. 17 separate studies were reviewed with different procedures and sling materials. Overall, the committee found a minimum success rate of 58% (Level 3 evidence) with acceptable complication rates. Predictors of success were low to moderate leakage and no history of radiation (especially with bulbourethral slings).

Dr. Herschorn briefly addressed the ProACT balloon procedure. Success rates are acceptable (60-70% 0-1 pads per day), but complication rates are relatively high. In summary, the committee recommended a 6-12 month period of conservative management for PPI. The AUS was recommended as the preferred procedure for men with moderate to severe incontinence, while the sling is a good alternative for men with mild to moderate leakage. Injectables are a less effective option and do not preclude subsequent sling or AUS (Grade B recommendation). One slide addressed options for treating PPI incontinence associated with bladder neck contracture. Treatments include visual internal urethrotomy or urethral stent placement combined with AUS, or other complex reconstructive procedures. The committee also addressed issues with external beam radiation therapy (EBRT). The committee reaffirmed several well-known factors, including an increase risk of UI with transurethral resection of the prostate before or after EBRT (5-11%), a high risk of UI with salvage prostatectomy after EBRT, and increased risk of UI from adjuvant EBRT after radical prostatectomy. Issues with the AUS after radiation were addressed.

Treatment success seems to be similar to those without radiation, although revision rates and complication rates are higher (~20-50%). There is a higher incidence of erosion, infection and urethral atrophy. The committee recommended placing the cuff outside of the radiation field when possible and considering extended periods of cuff deactivation (Grade C).

Incontinence rates after cryotherapy (~3-15%), brachytherapy (~0-6%) and HIFU (~6-28%) were briefly discussed. Previous radiation was noted to be a risk factor for UI with cryotherapy, and TURP was associated with higher rates of incontinence with brachytherapy. With HIFU, incontinence rates seem to improve with experience. Dr. Herschorn discussed incontinence after neobladder diversion. Continence rates are high during the day and somewhat lower at night (~80-90%). AUS is the most commonly reported treatment. Nerve-sparing cystectomy does not seem to affect continence rates (Grade C).

With respect to adult patients with exstrophy-epispadias with unresolved incontinence, the committee recommended referral to centers of excellence for evaluation and treatment, and the importance of an organized transition from the pediatric urologist was stressed. A number of different procedures are available, including bladder neck reconstruction, bladder neck closure and urinary diversion, but not enough data is available for specific recommendations.

Dr. Herschorn moved on to discuss the treatment of refractory urgency incontinence and detrusor overactivity. Limited data is available on intravesical treatment with capsaicin and resiniferatoxin. There was one 2007 RCT on 58 women treated with resiniferatoxin, and there was no significant treatment effect compared with sham. 13 studies regarding botulinum toxin injection therapy were noted to show good results with approximately 60-90% improvement in symptoms; however, most of the data is for female patients. A similar paucity of data was noted for neuromodulation on male patients. The limited data available shows decent success in men. Autoaugmentation and bowel augmentation are infrequently used for this indication in neurologically intact patients, but success rates are good (~80%) with acceptable complication rates. Augmentation cystoplasty is also successful in patients with small capacity bladders although success rates are noted to be lower after radiation therapy (Grade C).

The committee reviewed reports involving 263 patients with rectourethral fistualae and described numerous surgical approaches. The committee made several Grade C recommendations. Surgical closure may be attempted if the fistula does not close with or without temporary urinary and/or fecal diversion. Closure can be done in collaboration with a colorectal surgeon.

The final portion of the presentation focused on issues with the AUS. Urethral atrophy rates were determined to be 3-9%, and erosion/infection rates were 0-25%, although Dr. Herschorn noted that the new AUS coated with antibiotic (Inhibizone) have lower infection rates. Risk factors for erosion were deemed to be radiation, previous pelvic surgery, urethral catheterization and endoscopy. A Kaplan-Meier "survival" curve was presented, revealing a device half-life of approximately 7 years. A 2007 study by Lai et al. showed that 75% of patients with an AUS were free of device-related complications at 5 years post-implantation. Evaluation of recurrent incontinence after AUS involves physical examination and pump cycling, cystoscopy, urodynamics, and selected radiographic studies, if the system was filled with contrast.

Dr. Herschorn concluded by suggesting areas for future study. More work is needed on the pathophysiology of PPI and device mechanics. More RCTs are needed comparing different procedures, and longer-term follow-up data would be useful. Validated outcome measures and standardized reporting are also needed to better evaluate outcomes. He also recommended honest reporting of complications and patient education regarding the experimental nature of new procedures.

Sender Herschorn, MD, Committee Chair

Moderated by Linda Cardozo, MD, and Alan Wein, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.com

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