Committee 13 Surgical Treatment of Urinary Incontinence in Men Chairman S. HERSCHORN (Canada) Members H. BRUSCHINI (Brazil), C.COMITER (USA), P.G RISE (France), T. HANUS (Czech Republic), R. KIRSCHNER-HERMANNS (Germany) 1121 CONTENTS I. INTRODUCTION VIII. TRAUMATIC INJURIES OF THE URETHRA AND PELVIC FLOOR II. EVALUATION PRIOR TO SURGICAL THERAPY IX. CONTINUING PEDIATRIC III. INCONTINENCE AFTER RADICAL PROBLEMS INTO ADULTHOOD: THE PROSTATECTOMY FOR PROSTATE EXSTROPHY-EPISPADIAS COMPLEX CANCER X. DETRUSOR OVERACTIVITY AND IV. INCONTINENCE AFTER REDUCED BLADDER CAPACITY PROSTATECTOMY FOR BENIGN DISEASE XI. URETHROCUTANEOUS AND V. SURGERY FOR INCONTINENCE IN RECTOURETHRAL FISTULAE ELDERLY MEN VI. INCONTINENCE AFTER XII. THE ARTIFICIAL URINARY EXTERNAL BEAM RADIOTHERAPY SPHINCTER (AUS) ALONE AND IN COMBINATION WITH SURGERY FOR PROSTATE CANCER XIII. SUMMARY AND RECOMMENDATIONS VII. INCONTINENCE AFTER OTHER TREATMENT FOR PROSTATE CANCER REFERENCES 1122 Surgical Treatment of Urinary Incontinence in Men S. HERSCHORN, H. BRUSCHINI, C. COMITER, P. GRISE, T. HANUS, R. KIRSCHNER-HERMANNS high-intensity focused ultrasound, other pelvic I. INTRODUCTION operations and trauma is a particularly challenging problem because of tissue damage outside the lower Surgery for male incontinence is an important aspect urinary tract. The artificial sphincter implant is the of treatment with the changing demographics of society most widely used surgical procedure but complications and the continuing large numbers of men undergoing may be more likely than in other areas and other surgery and other treatments for prostate cancer. surgical approaches may be necessary. Unresolved problems from pediatric age and patients with Basic evaluation of the patient is similar to other areas refractory incontinence from overactive bladders may of incontinence and includes primarily a clinical demand a variety of complex reconstructive surgical approach with history, frequency-volume chart or procedures. Other unique problems encountered are bladder diary, and physical examination. Since most fistulae between the urethra and skin and the prostate of the surgeries apply to patients with incontinence after other operations or trauma, other investigations such and rectum. Surgical reconstructions in experienced as radiographic imaging of the lower urinary tract, hands are usually successful. cystoscopy, and urodynamic studies may provide With extensive worldwide use of the artificial sphincter important information for the treating clinician. in the surgical management of male incontinence, its Although prostatectomy for benign disease has complications and their management are well known. become less frequent in many countries, the Durability of the device is an important aspect that complication of incontinence is a rare but unfortunate impacts on outcome and cost of treatment. occurrence that merits treatment. After a period of Although the literature is replete with well done cohort conservative therapy has been tried, surgical studies, there is a continuing need for prospective treatment, with implantation of the artificial urinary randomized clinical trials. sphincter, has cured or improved 75-80% of sufferers. Injection therapy with agents such as collagen has 1. MATERIALS AND METHODS helped 40-50% of men in the short term but fewer in the long term. New sling techniques have shown The committee was charged with the responsibility of promising results in studies. assessing and reviewing the outcomes of surgical therapy that have been published since the Third Radical prostatectomy for prostate cancer is performed Consultation [1] for non-neurogenic male incontinence. far more frequently now than 10-15 years ago. Articles from peer-reviewed journals, abstracts from Approximately 5-25% of patients will experience scientific meetings, and literature searches by hand incontinence and of those a significant minority will and electronically formed the basis of this review. The require surgical treatment. The artificial sphincter has outcomes were analyzed, discussed among the provided a satisfactory result in most cases with a members of the committee and included in the chapter. positive impact on quality of life. Sling procedures are The incontinence problems were classified according increasingly being reported to have a good outcome. Injectable agents have not shown durable long-term to their etiology, i.e. either primarily sphincter or bladder results but newer technologies such as volume- related, and are listed in Table 1. Treatment of fistulae adjustable balloons have shown reasonably favourable is covered separately. early results in a number of reports. Specific recommendations are made on the basis of published results and determined by the levels of With new data emerging stratification of treatment evidence. Consensus of the committee determined the based on the degree of stress incontinence may recommendations, which are found at the end of the become feasible. chapter. Recommendations for future research are Incontinence following radiation therapy, cryosurgery, also included. 1123 Table 1. Classification of surgically correctable are recommended in incontinent males prior to surgical problems therapy. • SPHINCTER RELATED Blood testing (BUN, creatinine, glucose) is Postoperative recommended only if compromised renal function is Post-prostatectomy for prostate cancer suspected or if polyuria (in the absence of diuretics) Post-prostatectomy for benign disease is documented by the frequency-volume chart [10]. TURP and radiation for prostate cancer Further evaluation should be adapted to the particular Post-cystectomy and neobladder for bladder patient. cancer Post-traumatic Cystourethroscopy is useful to verify integrity of the After prostato-membanous urethral urethral wall (anterior aspect of the distal sphincteric reconstruction mechanism in post-TURP incontinence [11], erosion Pelvic floor trauma by the cuff of the artificial sphincter, voluntary Unresolved pediatric urologic incontinence contraction of the pelvic floor, etc.) and the status of Exstrophy and epispadias the bladder (trabeculation, stone, diverticula, etc). •BLADDER RELATED Imaging techniques include plain film of the abdomen Refractory urgency incontinence due to detrusor (KUB or Kidneys, Ureters, Bladder), in cases of overactivity incontinence following artificial sphincter implantation Small fibrotic bladder when during the original procedure the hydraulic system was filled with contrast medium. A KUB • FISTULAE Prostatorectal (urethrorectal) immediately following sphincter implantation serves Urethrocutaneous as a reference point for subsequent comparisons [12]. Figure 1 illustrates the case of a young spina bifida patient in whom an artificial sphincter has been implanted with the cuff around the bladder neck. After more than 10 years, he became suddenly incontinent. II. EVALUATION PRIOR TO Second KUB compared to previous one clearly SURGICAL THERAPY demonstrated fluid loss from the system. Contrast studies include cystography which may demonstrate Recommendations for evaluation prior surgery have an open bladder neck when bladder denervation is not changed substantially from the last edition in suspected [13] (e.g.: following abdominoperineal 2005[1]. Before surgical treatment of the incontinent resection of the rectum). Cystourethrography may be male is undertaken, the following evaluations should used to demonstrate a fistula, stricture or urethral be done [2]. Basic evaluation includes history, physical diverticulum eg., following healing of the urethral wall examination (including neuro-urological examination: erosion caused by the cuff of the artificial urinary perineal sensation, anal tone, voluntary contraction and sphincter (Figure 2). Ultrasound is widely used not only relaxation of the anal sphincter, bulbocavernosus to evaluate the upper urinary tract, but also to evaluate reflex [3], urinalysis, and postvoid residual urine. A postvoid residual urine. The sensitivity of 66.7% and frequency-volume chart [4], or bladder diary (indicating specificity of 96.5% when post-void residual is 100 ml daytime and nighttime frequency of micturition, or more is adequate for routine clinical use [14]. It incontinence episodes, voided volumes, 24-hour has been shown to be cost-effective when compared urinary output, etc.) is also helpful. No clear guidelines to catheterization [15]. Other modalities, for example can be found in the literature indicating the minimum transurethral ultrasound [16] and magnetic resonance number of days necessary to furnish reliable data for imaging of the external sphincter are still under a voiding diary. According to Wyman et al. [5] the 7- development. day diary can be considered as the gold standard for 1. URODYNAMIC TESTING voiding diaries. Schick et al.[6] demonstrated that a 4 day frequency-volume chart is the shortest one In the opinion of the Committee a thorough which still gives reliable results, as compared to the urodynamic evaluation to characterize the 7 day diary. The pad test quantifies the severity of underlying pathophysiology is useful prior to incontinence. The 24-hour home test is the most invasive therapy. However, there are factors that accurate pad test for quantification and diagnosis of must be considered. In patients with incontinence urinary incontinence because it is the most secondary to radical prostatectomy who developed reproducible [7]. The 1-hour pad test is widely used bladder neck stenosis, the urethral catheter can