POSTPROSTATECTOMY INCONTINENCE

Determinar la efectividad de las intervenciones con biofeedback en el tratamiento de la incontinencia urinaria posprostatectomía.

Se realizó una revisión sistemática en las bases de datos de CENTRAL, Pubmed/MEDLINE, EMBASE y CINAHL. El riesgo de sesgo en los estudios incluidos fue evaluado mediante la escala PEDro (Scale for Rating Quality of Randomized Controlled Trials).

Fueron incluidos ensayos controlados aleatorios, con pacientes adultos, con diagnóstico de incontinencia urinaria posprostatectomía que incorporaran el uso de biofeedback dentro del tratamiento conservador.

Ocho estudios cumplieron los criterios de inclusión. Las intervenciones con biofeedback incluyeron el uso de instrucciones verbales y escritas, electromiografía y sonda rectal.

Existe evidencia limitada a favor de la efectividad del biofeedback en el tratamiento de la incontinencia urinaria posprostatectomía.

To determine the effectiveness of biofeedback for the treatment of post-prostatectomy urinary incontinence.

A systematic review was conducted in the CENTRAL, Pubmed/MEDLINE, EMBASE and CINAHL data bases. Risk of bias in the studies included was assessed with the PEDro scale (Rating Quality of Randomized Controlled Trials).

Randomized controlled trials with adult patients diagnosed of post-prostatectomy urinary incontinence involving biofeedback for the conservative management were included.

Eight studies met the inclusion criteria. Biofeedback interventions included verbal and written instructions, electromyography and anal catheter.

There is limited evidence supporting the effectiveness of biofeedback on the treatment of post-prostatectomy urinary incontinence.

Due to the high incidence and prevalence in older men, prostate cancer is best understood as an age-associated disease. Physicians and their older patients commonly face the dilemma of whether or not to initiate treatment for localized disease or early systemic relapse (ie, biochemical recurrence). Although many older men with symptomatic advanced prostate cancer benefit from hormonal treatments and chemotherapies, treatment complications also may influence outcome. Older prostate cancer patients have a high prevalence of other factors that can limit remaining life expectancy (RLE), quality of life (QOL), and tolerance to treatment. A comprehensive geriatric assessment (CGA) can help identify other health status issues that can predict morbidity or mortality in vulnerable or frail older prostate cancer populations. Despite a growing body of evidence, more research is needed to establish optimal treatment strategies for all disease stages in prostate cancer patients diagnosed later in life.

This is the first reported case of recurrent stress urinary incontinence secondary to dislodged bone-anchoring screws. A 71-year-old man who had undergone successful bone-anchored sling placement for post-prostatectomy incontinence, presented with recurrent stress urinary incontinence after a bout of coughing. Pelvic radiography revealed three screws had been dislodged. The mesh was left in place, with replacement of the dislodged screws and the addition of one extra screw. The findings of this case suggest that dislodged screws can be a possible cause of sling failure. Preoperative bone scanning and postoperative pelvic radiography should be a part of the routine workup for patients with bone-anchored slings.

Urinary incontinence and erectile dysfunction remain the long-term complications that affect most patients’ lives after radical prostatectomy. Previous reports evaluating incontinence have focused on volumes of urine loss and daily pad use to assess these issues. We have observed that small volumes of urinary incontinence during sexual activity can be just as disconcerting to patients. We attempt to further describe and assess the phenomenon of urinary incontinence with ejaculation in a series of patients.

We reviewed the experience of one physician who received referrals for the treatment of erectile dysfunction after radical prostatectomy from July 2002 to March 2005 and identified 26 men experiencing urine leak predominantly during ejaculation. Questionnaires assessing urinary incontinence were sent to all these patients.

The mean age was 62 years (range 54 to 73). Sixteen patients underwent bilateral nerve-sparing, five unilateral nerve-sparing, and five nonnerve-sparing radical retropubic prostatectomy. At a median follow-up of 42 months (range 15 to 118), all patients had experienced urine leakage (volume 0.5 teaspoon to 1 cup) during ejaculation. The incontinence questionnaire revealed that most patients had mild incontinence; however, they experienced ejaculatory urine incontinence “most, or all of the time” and considered it a “big problem.”

Although the prevalence of ejaculatory urine incontinence is unclear, in our experience it occurs often enough to be considered a part of the routine postprostatectomy evaluation. A better understanding of the pathophysiology of postprostatectomy incontinence will lead to targeted therapy and an improved quality of life for the patient.

We reviewed our experience with 49 consecutive patients undergoing a male sling procedure.

The 7-item International Prostate Symptom Score and 22-item incontinence quality of life questionnaire (although not validated in Italian) were used to assess the clinical impact of the bulbourethral sling. Surgical outcome was also assessed by videourodynamics at 1 year. Urodynamic success was defined as no leakage during videourodynamic evaluation.

Mean followup was 32 months (range 26 to 48). Preoperatively 3 patients used 2 pads daily (mild incontinence), 34 used 3 to 5 (moderate incontinence) and the remaining 12 used more than 5 (severe incontinence). Clinical success was defined as a decrease in pad use to completely dry (no pad) or to social continence (1 pad daily) at followup. Of the 49 patients 38 (77%), 33 (67%) and 63% (31) were considered socially continent at the 3-month, 1-year and 3-year followup, respectively. Only 15 of the 49 patients (30%) were considered completely dry at the 3-year followup. Significant perineal pain was reported in the early postoperative period but it resolved in all patients. Infection occurred in 3 patients, while no erosion was found.

The male perineal sling is a safe surgical option for post-prostatectomy urinary incontinence, especially when strict patient selection is done. Patient satisfaction is superior to urodynamic results and the procedure allows physiological voiding. Patients should be informed of the possibility of progressive failure with time and significant perineal pain in the early postoperative period.