What are the actual rates of urinary incontinence after radical prostatectomy? · 2016-05-23 · Because the prostate sits just below the bladder and encircles the urethra, the urinary

What are the actual rates of urinary incontinence after radical

prostatectomy?

William O Brant, MD FACS FECSMSMSNA/AUA 2016

Center for Reconstructive Urology and Men’s HealthUniversity of Utah

AKA, Lies and Damned lies (and some statistics)

Disclosures

• Consultant/Proctor/Grant Recipient: Boston Scientific

• Advisory/Safety Board: Urostem, GT Urological

• Board of Directors: Sexual Medicine Society of North America, Western Section AUA

What do prostatectomists say about themselves?

• While incontinence seems to have several definitions, Dr. Catalona uses only one: "If men have to wear any kind of protection at all, they are incontinent."

• Using that definition, five and a half percent of his patients have a very mild incontinence 18 months after surgery and one and a half percent have severe incontinence. Age figures strongly into these outcomes and so does the fact that some men go into the surgery with previous incontinence.

• Conclusion: 5.5% incont, 1.5% severe incont

http://drcatalona.com/quest/quest_spring03_2.htm

• By one year after surgery, 93 percent of the men reported that they were dry -- that during the previous four weeks, they had not needed a pad or adult diaper to control urinary leakage. When the men were asked to say how much their urinary continence bothered them, 98 percent said they had either a small bother, or none at all.

• Conclusion: 7% incontinence, 2% bother

http://urology.jhu.edu/newsletter/prostate_cancer53.php

• Following proper prostatectomy recovery guidelines, patients who experienced normal continence prior to surgery should regain function within 12-13 months.

• Loss of bladder control, or urinary incontinence, is a potential side effect of prostate removal surgery. Because the prostate sits just below the bladder and encircles the urethra, the urinary tract can be damaged during a radical prostatectomy. In the hands of an experienced robotic surgeon like Dr. Samadi, preservation of the urinary sphincter and competent rebuilding of the urinary tract can eliminate the risk of long-term incontinence. Uniquely, Dr. Samadi does not sever the endopelvicfascia and cuts the bladder neck very narrowly during robotic prostatectomy.

• Urinary incontinence is far more common after open prostatectomy, as is risk of infection. - See more at: http://www.roboticoncology.com/prostatectomy/#sthash.ynZyXtaW.dpuf

http://www.roboticoncology.com/prostatectomy/

• Following proper prostatectomy recovery guidelines, patients who experienced normal continence prior to surgery should regain function within 12-13 months.

• Loss of bladder control, or urinary incontinence, is a potential side effect of prostate removal surgery. Because the prostate sits just below the bladder and encircles the urethra, the urinary tract can be damaged during a radical prostatectomy. In the hands of an experienced robotic surgeon like Dr. Samadi, preservation of the urinary sphincter and competent rebuilding of the urinary tract can eliminate the risk of long-term incontinence. Uniquely, Dr. Samadi does not sever the endopelvicfascia and cuts the bladder neck very narrowly during robotic prostatectomy.

• Urinary incontinence is far more common after open prostatectomy, as is risk of infection. - See more at: http://www.roboticoncology.com/prostatectomy/#sthash.ynZyXtaW.dpuf

http://www.roboticoncology.com/prostatectomy/

• “Whereas conventional laparoscopic prostatectomy utilizes an outside–in approach, SMART prostatectomy uses an inside–out methodology, avoiding damage to surrounding nerves and tissues. This is how I achieve 96 percent continence and approximately 80 percent preserved sexual function rates.”

• Conclusion: 4% incont

http://www.mdnews.com/news/2014_10/david-b-samadi-md-advancing-robotic-prostate-surgeries.aspx

Who should tell us if the patient is dry?

• Patient reported vs surgeon reported

– Patient reported more accurate

• PCOS-over 3500 men in cohort, 1,655 in most recent study

• Multicenter (military hospitals), 1100 respondents, minimum of 6 mos postop

Resnick MJ. et. al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013 Jan 1;368(5):436-45.Stanford JL.. et. al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000 Jan 19;283(3):354-60.Kao TC. et. al. Multicenter patient self-reporting questionnaire on impotence, incontinence and stricture after radical prostatectomy. J Urol. 2000 Mar;163(3):858-64.

Stanford JL.. et. al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000 Jan 19;283(3):354-60.

Stanford JL.. et. al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000 Jan 19;283(3):354-60.

Stanford JL.. et. al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000 Jan 19;283(3):354-60.

Stanford JL.. et. al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000 Jan 19;283(3):354-60.

Kao TC. et. al. Multicenter patient self-reporting questionnaire on impotence, incontinence and stricture after radical prostatectomy. J Urol. 2000 Mar;163(3):858-64.

Kao TC. et. al. Multicenter patient self-reporting questionnaire on impotence, incontinence and stricture after radical prostatectomy. J Urol. 2000 Mar;163(3):858-64.

Kao TC. et. al. Multicenter patient self-reporting questionnaire on impotence, incontinence and stricture after radical prostatectomy. J Urol. 2000 Mar;163(3):858-64.

Longitudinal Urinary Function

0

10

20

30

40

50

60

70

3 mos 12 mos 30 mos

% baseline

*

Litwin MS. et. al. Life after radical prostatectomy: a longitudinal study. J Urol. 2001 Aug;166(2):587-92.

Resnick MJ. et. al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013 Jan 1;368(5):436-45.

What ARE the rates of incontinence after RARP?

• Metaanalysis of 54 articles after RARP

– Case series (21), comparisons of different RARP techniques (17), comparisons of RARP to open (8), comparisons of RALP to Lap RP (8)

– Authors: some of highest volume RARP surgeons

Ficarra V. et. al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012 Sep;62(3):405-17.

Ficarra V. et. al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012 Sep;62(3):405-17.

Surgical Dissatisfaction and Regrets

• 400 pts (181 RALP and 219 open)

• Overall, 20% regret

• What is associated with satisfaction or regret?

– RALP

– Urinary QOL

Schroeck FR. et. al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2008 Oct;54(4):785-93.

Schroeck FR. et. al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2008 Oct;54(4):785-93.

Conclusions

• Surgeons tend to overestimate continence

• Patients report higher incontinence

– Rate

– Bother

• Are we undertreating this?