CHAPTER 19 Committee 15 Surgical Treatment of Urinary Incontinence in Men Chairman S. HERSCHORN (CANADA) Co-Chair J. THUROFF (GERMANY) Members H. BRUSCHINI (BRAZIL), P. G RISE (FRANCE), T. HANUS (CZECH REPUBLIC), H. KAKIZAKI (JAPAN), R. KIRSCHNER-HERMANNS (GERMANY), V. N ITTI (USA), E. SCHICK (CANADA) 1241 CONTENTS IX. CONTINUING PEDIATRIC I. INTRODUCTION AND SUMMARY PROBLEMS INTO ADULTHOOD: THE EXSTROPHY-EPISPADIAS COMPLEX II. EVALUATION PRIOR TO SURGICAL THERAPY X. DETRUSOR OVERACTIVITY AND REDUCED BLADDER CAPACITY III. INCONTINENCE AFTER RADICAL PROSTATECTOMY FOR PROSTATE CANCER XI. URETHROCUTANEOUS AND RECTOURETHRAL FISTULAE IV. INCONTINENCE AFTER XII. THE ARTIFICIAL URINARY PROSTATECTOMY FOR BENIGN SPHINCTER (AUS) DISEASE V. SURGERY FOR INCONTINENCE XIII. NEW TECHNOLOGY IN ELDERLY MEN XIV. SUMMARY AND VI. INCONTINENCE AFTER RECOMMENDATIONS EXTERNAL BEAM RADIOTHERAPY ALONE AND IN COMBINATION WITH SURGERY FOR PROSTATE REFERENCES CANCER VIII. TRAUMATIC INJURIES OF THE URETHRA AND PELVIC FLOOR 1242 Surgical Treatment of Urinary Incontinence in Men S. HERSCHORN, J. THUROFF H. BRUSCHINI, P. GRISE, T. HANUS, H. KAKIZAKI, R. KIRSCHNER-HERMANNS, V. N ITTI, E. SCHICK ry, other pelvic operations and trauma is a particular- I. INTRODUCTION AND SUMMARY ly challenging problem because of tissue damage outside the lower urinary tract. The artificial sphinc- ter implant is the most widely used surgical procedu- Surgery for male incontinence is an important aspect re but complications may be more likely than in of treatment with the changing demographics of other areas and other surgical approaches may be society and the continuing large numbers of men necessary. Unresolved problems from the pediatric undergoing surgery for prostate cancer. age group and patients with refractory incontinence Basic evaluation of the patient is similar to other from overactive bladders may demand a variety of areas of incontinence and includes primarily a clini- complex reconstructive surgical procedures. Other cal approach with history, voiding record, and physi- unique problems encountered are fistulae between cal examination. Since most of the surgeries apply to the urethra and skin and the prostate and rectum. patients with incontinence after other operation or Surgical reconstructions in experienced hands are trauma, radiographic imaging of the lower urinary usually successful. tract, cystoscopy, and urodynamic studies may pro- With extensive worldwide use of the artificial vide important information for the treating clinician. sphincter in the surgical management of male incon- Although prostatectomy for benign disease has beco- tinence, its complications and their management are me less frequent in many countries, the complication well known. Durability of the device is an important aspect that impacts on outcome and cost of treat- of incontinence is a rare but unfortunate occurrence ment. that merits treatment. After a period of conservative therapy has been tried, surgical treatment, with Although the literature is replete with well done implantation of the artificial urinary sphincter, has cohort studies, there is a continuing need for pros- cured 75-80% of sufferers. Injection therapy with pective randomized clinical trials. agents such as collagen has helped 40-50% of men in the short term and fewer in the long term. MATERIALS AND METHODS Radical prostatectomy for prostate cancer, on the The committee was charged with the responsibility other hand, is performed far more frequently now of assessing and reviewing the outcomes of surgical than 10 years ago. Approximately 5-25% of patients therapy that have been published since the Second will experience incontinence and of those a signifi- Consultation [1] for non-neurogenic male inconti- cant minority will require surgical treatment. The nence. Articles from peer-reviewed journals, abs- artificial sphincter has provided a satisfactory cure in tracts from scientific meetings, and literature most cases with a positive impact on quality of life. searches by hand and electronically formed the basis Sling procedures have also been reported to have a of this review. The outcomes were analyzed, discus- good outcome. Injectable agents have had a lower sed among the members of the committee and inclu- success rate and continue to be evaluated. ded in the chapter. Incontinence following radiation therapy, cryosurge- In order to rationally discuss surgical therapy the 1243 incontinence problems were classified according to Wyman et al. [5] the 7-day diary can be considered their etiology, i.e. either primarily sphincter or blad- as the gold standard for voiding diaries. Recently der related, and are listed in Table 1. Treatment of Schick et al.[6] demonstrated that a 4 day frequency- fistulae is covered separately. volume chart is the shortest one which still gives Specific recommendations are made on the basis of reliable results, as compared to the 7 day diary. The published results and determined by the levels of evi- pad test quantifies the severity of incontinence. The dence. Consensus of the committee determined the 24-hour home test is the most accurate pad test for recommendations, which are found at the end of the quantification and diagnosis of urinary incontinence chapter. A new surgical modality and recommenda- because it is the most reproducible.[7] The 1-hour tions for future research are also included. pad test is widely used because it is more easily done and standardized. A pad test may be helpful in quan- Table 1. Classification of surgically correctable problems tifying leak in AUS failures. Postvoid residual urine is a good estimation of voiding efficiency [8, 9]. Sphincter related These basic investigations should be done in every POSTOPERATIVE incontinent male when surgical therapy is planned. Post-prostatectomy for prostate cancer Blood testing (BUN, creatinine, glucose) is recom- Post-prostatectomy for benign disease mended only if compromised renal function is sus- TURP and radiation for prostate cancer pected or if polyuria (in the absence of diuretics) is Post-cystectomy and neobladder for bladder cancer documented by the frequency-volume chart [10]. POST-TRAUMATIC Further evaluation should be adapted to the particu- After prostato-membanous urethral reconstruction lar patient. Cystourethroscopy is useful to verify Pelvic floor trauma integrity of the urethral wall (anterior aspect of the Unresolved pediatric urologic incontinence distal sphincteric mechanism in post-TURP inconti- Exstrophy and epispadias nence [11], erosion by the cuff of the artificial Bladder related sphincter, voluntary contraction of the pelvic floor, Refractory urge incontinence due to detrusor overactivity etc.) and the status of the bladder (trabeculation, Small fibrotic bladder stone, diverticula, etc). Fistulae Imaging techniques include plain film of the abdo- Prostatorectal (urethrorectal) men (KUB or Kidneys, Ureters, Bladder), in cases of Urethrocutaneous incontinence following artificial sphincter implanta- tion when during the original procedure the hydrau- lic system was filled with contrast medium. A KUB immediately following sphincter implantation serves as a reference point for subsequent comparisons [12]. illustrates the case of a young spina II. EVALUATION PRIOR TO Figure 1 bifida patient in whom an artificial sphincter has SURGICAL THERAPY been implanted with the cuff around the bladder neck. After more than 10 years, he became suddenly Before surgical treatment of the incontinent male is incontinent. Second KUB compared to previous one undertaken, the following evaluations should be clearly demonstrated fluid loss from the system. done [2]. Basic evaluation includes history, physical Contrast studies include cystography which may examination (including neuro-urological examina- demonstrate an open bladder neck when bladder tion: perineal sensation, anal tone, voluntary contrac- denervation is suspected [13] (e.g.: following abdo- tion and relaxation of the anal sphincter, bulbocaver- minoperineal resection of the rectum). Cystourethro- nosus reflex [3], urinalysis, and postvoid residual graphy may be used to demonstrate a fistula, strictu- urine. A frequency-volume chart [4], or voiding diary re or urethral diverticulum, eg., following healing of (indicating daytime and nighttime frequency of mic- the urethral wall erosion caused by the cuff of the turition, incontinence episodes, voided volumes, 24- artificial urinary sphincter (Fig. 2). Ultrasound is hour urinary output, etc.) is also helpful. No clear widely used not only to evaluate the upper urinary guidelines can be found in the literature indicating tract, but also to evaluate postvoid residual urine. the minimum number of days necessary to furnish The sensitivity of 66.7% and specificity of 96.5% reliable data for a voiding diary. According to when post-void residual is 100 ml or more is ade- 1244 or cough [18] abdominal leak point pressure, although not by urethral pressure profilometry. A recent study suggested that Valsalva leak point pres- sure is significantly lower than cough leak point pressure [19]. However, its reproducibility has been studied almost exclusively in women. Catheter size seems to have a significant influence, but the corre- lation is extremely high between the test-retest leak point pressure when the same size of catheter is used [20, 21]. In male patients, abdominal leak point pressure should be evaluated via a rectal catheter because ure- thral catheter is much more likely to invalidate Val- salva leak