Advertisement

Pathophysiologic Mechanisms in Postprostatectomy Urinary Incontinence

  • Joseph LaBossiere
  • Sender Herschorn
Chapter

Abstract

Urinary incontinence is a common and debilitating complication after radical prostatectomy (RP). Though the majority of men will experience significant improvement in continence, up to 5% of men will ultimately have surgery to correct persistent incontinence. A fundamental understanding of the pathophysiologic mechanisms involved in postprostatectomy incontinence may aid the urologist in preoperative counseling and prognostication and guide intraoperative decision-making and choice of surgical technique as well as in selecting appropriate treatment option(s) for persistent postprostatectomy incontinence. Our understanding of the factors influencing postprostatectomy incontinence continues to evolve. Many studies have demonstrated the impact of surgical/anatomical factors on postprostatectomy incontinence including the status of the external urethral sphincter, bladder neck preservation or repair, preservation of the neurovascular bundles, postoperative membranous urethral length, and reconstruction of periurethral support structures. Patient factors such as age and body mass index as well as biologic factors including preoperative membranous urethral length, prostate size, pre-existing lower urinary tract symptoms, and the presence of bladder dysfunction have also been implicated. Investigation into surgical techniques that may impact on continence rates (bladder neck sparing, periurethral reconstruction, and the use of robotic-assisted technology) is currently ongoing.

References

  1. 1.
    Litwin MS, et al. Urinary function and bother after radical prostatectomy or radiation for prostate cancer: a longitudinal, multivariate quality of life analysis from the Cancer of the Prostate Strategic Urologic Research Endeavor. J Urol. 2000;164(6):1973–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Ficarra V, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol. 2009;55(5):1037–63.CrossRefPubMedGoogle Scholar
  3. 3.
    Penson DF, et al. 5-Year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol. 2008;179(5 Suppl):S40–4.CrossRefPubMedGoogle Scholar
  4. 4.
    Stanford JL, et al. Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: the Prostate Cancer Outcomes Study. JAMA. 2000;283(3):354–60.CrossRefPubMedGoogle Scholar
  5. 5.
    Nam RK, et al. Population based study of long-term rates of surgery for urinary incontinence after radical prostatectomy for prostate cancer. J Urol. 2012;188(2):502–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Karakiewicz PI, et al. Erectile and urinary dysfunction after radical prostatectomy for prostate cancer in Quebec: a population-based study of 2415 men. Eur Urol. 2004;46(2):188–94.CrossRefPubMedGoogle Scholar
  7. 7.
    Matsushita K, et al. Preoperative predictive model of recovery of urinary continence after radical prostatectomy. BJU Int. 2015;116(4):577–83.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Kadono Y, et al. Use of preoperative factors including urodynamic evaluations and nerve-sparing status for predicting urinary continence recovery after robot-assisted radical prostatectomy: nerve-sparing technique contributes to the reduction of postprostatectomy incontinence. Neurourol Urodyn. 2016;35(8):1034–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Catalona WJ, Basler JW. Return of erections and urinary continence following nerve sparing radical retropubic prostatectomy. J Urol. 1993;150(3):905–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Wiltz AL, et al. Robotic radical prostatectomy in overweight and obese patients: oncological and validated-functional outcomes. Urology. 2009;73(2):316–22.CrossRefPubMedGoogle Scholar
  11. 11.
    Wolin KY, et al. Risk of urinary incontinence following prostatectomy: the role of physical activity and obesity. J Urol. 2010;183(2):629–33.CrossRefPubMedGoogle Scholar
  12. 12.
    Huckabay C, et al. A urodynamics protocol to optimally assess men with post-prostatectomy incontinence. Neurourol Urodyn. 2005;24(7):622–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Groutz A, et al. The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study. J Urol. 2000;163(6):1767–70.CrossRefPubMedGoogle Scholar
  14. 14.
    Ficazzola MA, Nitti VW. The etiology of post-radical prostatectomy incontinence and correlation of symptoms with urodynamic findings. J Urol. 1998;160(4):1317–20.CrossRefPubMedGoogle Scholar
  15. 15.
    Giannantoni A, et al. Bladder and urethral sphincter function after radical retropubic prostatectomy: a prospective long-term study. Eur Urol. 2008;54(3):657–64.CrossRefPubMedGoogle Scholar
  16. 16.
    Giannantoni A, et al. Assessment of bladder and urethral sphincter function before and after radical retropubic prostatectomy. J Urol. 2004;171(4):1563–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Song C, et al. Urodynamic interpretation of changing bladder function and voiding pattern after radical prostatectomy: a long-term follow-up. BJU Int. 2010;106(5):681–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Wei JT, et al. Prospective assessment of patient reported urinary continence after radical prostatectomy. J Urol. 2000;164(3 Pt 1):744–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Rodriguez E, Skarecky DW, Ahlering TE. Post-robotic prostatectomy urinary continence: characterization of perfect continence versus occasional dribbling in pad-free men. Urology. 2006;67(4):785–8.CrossRefPubMedGoogle Scholar
  20. 20.
    van Randenborgh H, et al. Improved urinary continence after radical retropubic prostatectomy with preparation of a long, partially intraprostatic portion of the membraneous urethra: an analysis of 1013 consecutive cases. Prostate Cancer Prostatic Dis. 2004;7(3):253–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Paparel P, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol. 2009;55(3):629–37.CrossRefPubMedGoogle Scholar
  22. 22.
    Nguyen L, Jhaveri J, Tewari A. Surgical technique to overcome anatomical shortcoming: balancing post-prostatectomy continence outcomes of urethral sphincter lengths on preoperative magnetic resonance imaging. J Urol. 2008;179(5):1907–11.CrossRefPubMedGoogle Scholar
  23. 23.
    Borin JF, et al. Impact of urethral stump length on continence and positive surgical margins in robot-assisted laparoscopic prostatectomy. Urology. 2007;70(1):173–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Konety BR, et al. Recovery of urinary continence following radical prostatectomy: the impact of prostate volume--analysis of data from the CaPSURE Database. J Urol. 2007;177(4):1423–5. discussion 1425-6CrossRefPubMedGoogle Scholar
  25. 25.
    Boczko J, et al. Impact of prostate size in robot-assisted radical prostatectomy. J Endourol. 2007;21(2):184–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Pettus JA, et al. Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy. J Urol. 2009;182(3):949–55.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Palisaar JR, et al. Open radical retropubic prostatectomy gives favourable surgical and functional outcomes after transurethral resection of the prostate. BJU Int. 2009;104(5):611–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Su YK, et al. Does previous transurethral prostate surgery affect oncologic and continence outcomes after RARP? J Robot Surg. 2015;9(4):291–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Koraitim MM. The male urethral sphincter complex revisited: an anatomical concept and its physiological correlate. J Urol. 2008;179(5):1683–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Strasser H, Bartsch G. Anatomy and innervation of the rhabdosphincter of the male urethra. Semin Urol Oncol. 2000;18(1):2–8.PubMedGoogle Scholar
  31. 31.
    Lee SE, et al. Impact of variations in prostatic apex shape on early recovery of urinary continence after radical retropubic prostatectomy. Urology. 2006;68(1):137–41.CrossRefPubMedGoogle Scholar
  32. 32.
    Stolzenburg JU, et al. Effect of bladder neck preservation during endoscopic extraperitoneal radical prostatectomy on urinary continence. Urol Int. 2010;85(2):135–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Ma, X., et al.. Bladder neck preservation improves time to continence after radical prostatectomy: a systematic review and meta-analysis. Oncotarget. 2016;7(41):67463–5.Google Scholar
  34. 34.
    Skeldon SC, et al. Striated muscle in the prostatic apex: does the amount in radical prostatectomy specimens predict postprostatectomy urinary incontinence? Urology. 2014;83(4):888–92.CrossRefPubMedGoogle Scholar
  35. 35.
    Tuygun C, et al. Significance of fibrosis around and/or at external urinary sphincter on pelvic magnetic resonance imaging in patients with postprostatectomy incontinence. Urology. 2006;68(6):1308–12.CrossRefPubMedGoogle Scholar
  36. 36.
    Asimakopoulos AD, et al. Randomized comparison between laparoscopic and robot-assisted nerve-sparing radical prostatectomy. J Sex Med. 2011;8(5):1503–12.CrossRefPubMedGoogle Scholar
  37. 37.
    Novara G, et al. Systematic review and meta-analysis of perioperative outcomes and complications after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):431–52.CrossRefPubMedGoogle Scholar
  38. 38.
    Novara G, et al. Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):382–404.CrossRefPubMedGoogle Scholar
  39. 39.
    Ficarra V, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):405–17.CrossRefPubMedGoogle Scholar
  40. 40.
    Ficarra V, et al. Systematic review and meta-analysis of studies reporting potency rates after robot-assisted radical prostatectomy. Eur Urol. 2012;62(3):418–30.CrossRefPubMedGoogle Scholar
  41. 41.
    Yaxley JW, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet. 2016;388(10049):1057–66.CrossRefPubMedGoogle Scholar
  42. 42.
    Yucel S, Baskin LS. An anatomical description of the male and female urethral sphincter complex. J Urol. 2004;171(5):1890–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Gosling JA, et al. A comparative study of the human external sphincter and periurethral levator ani muscles. Br J Urol. 1981;53(1):35–41.CrossRefPubMedGoogle Scholar
  44. 44.
    Steiner MS. The puboprostatic ligament and the male urethral suspensory mechanism: an anatomic study. Urology. 1994;44(4):530–4.CrossRefPubMedGoogle Scholar
  45. 45.
    Zhang C, et al. Perirectal fascia and spaces: annular distribution pattern around the mesorectum. Dis Colon Rectum. 2010;53(9):1315–22.CrossRefPubMedGoogle Scholar
  46. 46.
    Stolzenburg JU, et al. Nerve sparing endoscopic extraperitoneal radical prostatectomy--effect of puboprostatic ligament preservation on early continence and positive margins. Eur Urol. 2006;49(1):103–11. discussion 111-2CrossRefPubMedGoogle Scholar
  47. 47.
    Rocco F, et al. Early continence recovery after open radical prostatectomy with restoration of the posterior aspect of the rhabdosphincter. Eur Urol. 2007;52(2):376–83.CrossRefPubMedGoogle Scholar
  48. 48.
    Nguyen MM, et al. Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy. BJU Int. 2008;101(9):1135–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Rocco B, et al. Posterior musculofascial reconstruction after radical prostatectomy: a systematic review of the literature. Eur Urol. 2012;62(5):779–90.CrossRefPubMedGoogle Scholar
  50. 50.
    Grasso AA, et al. Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis. BJU Int. 2016;118(1):20–34.CrossRefPubMedGoogle Scholar
  51. 51.
    Hurtes X, et al. Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial. BJU Int. 2012;110(6):875–83.CrossRefPubMedGoogle Scholar
  52. 52.
    Tan GY, Jhaveri JK, Tewari AK. Anatomic restoration technique: a biomechanics-based approach for early continence recovery after minimally invasive radical prostatectomy. Urology. 2009;74(3):492–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Akita K, Sakamoto H, Sato T. Origins and courses of the nervous branches to the male urethral sphincter. Surg Radiol Anat. 2003;25(5–6):387–92.CrossRefPubMedGoogle Scholar
  54. 54.
    Karam I, et al. The precise location and nature of the nerves to the male human urethra: histological and immunohistochemical studies with three-dimensional reconstruction. Eur Urol. 2005;48(5):858–64.CrossRefPubMedGoogle Scholar
  55. 55.
    Karam I, et al. The structure and innervation of the male urethra: histological and immunohistochemical studies with three-dimensional reconstruction. J Anat. 2005;206(4):395–403.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982;128(3):492–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Tanagho EA, Schmidt RA, de Araujo CG. Urinary striated sphincter: what is its nerve supply? Urology. 1982;20(4):415–7.CrossRefPubMedGoogle Scholar
  58. 58.
    Burkhard FC, et al. Nerve sparing open radical retropubic prostatectomy–does it have an impact on urinary continence? J Urol. 2006;176(1):189–95.CrossRefPubMedGoogle Scholar
  59. 59.
    Kaye DR, et al. Urinary outcomes are significantly affected by nerve sparing quality during radical prostatectomy. Urology. 2013;82(6):1348–53.CrossRefPubMedGoogle Scholar
  60. 60.
    Steineck G, et al. Degree of preservation of the neurovascular bundles during radical prostatectomy and urinary continence 1 year after surgery. Eur Urol. 2015;67(3):559–68.CrossRefPubMedGoogle Scholar
  61. 61.
    Marien TP, Lepor H. Does a nerve-sparing technique or potency affect continence after open radical retropubic prostatectomy? BJU Int. 2008;102(11):1581–4.CrossRefPubMedGoogle Scholar
  62. 62.
    Sacco E, et al. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU Int. 2006;97(6):1234–41.CrossRefPubMedGoogle Scholar
  63. 63.
    Magheli A, et al. Comparison of surgical technique (open vs. laparoscopic) on pathological and long term functional outcomes following radical prostatectomy. BMC Urol. 2014;14:18.CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Pan XW, et al. Robot-assisted radical prostatectomy vs. open retropubic radical prostatectomy for prostate cancer: a systematic review and meta-analysis. Indian J Surg. 2015;77(Suppl 3):1326–33.CrossRefPubMedGoogle Scholar
  65. 65.
    Grise P, Thurman S. Urinary incontinence following treatment of localized prostate cancer. Cancer Control. 2001;8(6):532–9.PubMedGoogle Scholar
  66. 66.
    Petrovich Z, et al. Comparison of outcomes of radical prostatectomy with and without adjuvant pelvic irradiation in patients with pathologic stage C (T3N0) adenocarcinoma of the prostate. Am J Clin Oncol. 1999;22(4):323–31.CrossRefPubMedGoogle Scholar
  67. 67.
    Petrovich Z, et al. Postoperative radiotherapy in 423 patients with pT3N0 prostate cancer. Int J Radiat Oncol Biol Phys. 2002;53(3):600–9.CrossRefPubMedGoogle Scholar
  68. 68.
    Suardi N, et al. Impact of adjuvant radiation therapy on urinary continence recovery after radical prostatectomy. Eur Urol. 2014;65(3):546–51.CrossRefPubMedGoogle Scholar
  69. 69.
    Fontaine E, et al. Urinary continence after salvage radiation therapy following radical prostatectomy, assessed by a self-administered questionnaire: a prospective study. BJU Int. 2004;94(4):521–3.CrossRefPubMedGoogle Scholar
  70. 70.
    Petroski RA, et al. External beam radiation therapy after radical prostatectomy: efficacy and impact on urinary continence. Prostate Cancer Prostatic Dis. 2004;7(2):170–7.CrossRefPubMedGoogle Scholar
  71. 71.
    Sowerby RJ, et al. Long-term complications in men who have early or late radiotherapy after radical prostatectomy. Can Urol Assoc J. 2014;8(7–8):253–8.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Ornstein DK, et al. Evaluation and management of the man who has failed primary curative therapy for prostate cancer. Urol Clin North Am. 1998;25(4):591–601.CrossRefPubMedGoogle Scholar
  73. 73.
    Rogers E, et al. Salvage radical prostatectomy: outcome measured by serum prostate specific antigen levels. J Urol. 1995;153(1):104–10.CrossRefPubMedGoogle Scholar
  74. 74.
    Nguyen PL, et al. Patient selection, cancer control, and complications after salvage local therapy for postradiation prostate-specific antigen failure: a systematic review of the literature. Cancer. 2007;110(7):1417–28.CrossRefPubMedGoogle Scholar
  75. 75.
    Matei DV, et al. Salvage radical prostatectomy after external beam radiation therapy: a systematic review of current approaches. Urol Int. 2015;94(4):373–82.CrossRefPubMedGoogle Scholar
  76. 76.
    Chade DC, et al. Cancer control and functional outcomes of salvage radical prostatectomy for radiation-recurrent prostate cancer: a systematic review of the literature. Eur Urol. 2012;61(5):961–71.CrossRefPubMedGoogle Scholar
  77. 77.
    Cozzarini C, et al. Clinical factors predicting late severe urinary toxicity after postoperative radiotherapy for prostate carcinoma: a single-institute analysis of 742 patients. Int J Radiat Oncol Biol Phys. 2012;82(1):191–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.University of TorontoTorontoCanada

Personalised recommendations