Incontinence after Prostate Treatment Flashcards by Cristina Fox

What should clinicians should inform patients undergoing RP for CaP about continence?

GUIDELINE STATEMENT 1

continence could be affected

factors impact recovery:
younger age
smaller prostate size
longer membranous urethral length (MRI)

Surgical approaches do not seem to impact rates

BUT

B/L nerve sparing does (26% more likely to be continence at 6 mo)

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Following radical prostatectomy, what clinicians should counsel patients regarding sexual arousal and incontinence?

GUIDELINE STATEMENT 2

there is a risk of sexual arousal leakage (arousal, foreplay, masturbation) and climacturia (during orgasm)

can occur with RP +/- RT or RT alone

bladder contraction + external sphincter insufficiency

improves with time since surgery, can take years to resolve

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What should clinicians advise regarding the duration of incontinence after RP?

GUIDELINE STATEMENT 3

incontinence is expected in short term and generally improves to near baseline by 12 mo after surgery but may persist

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Prior to RP, patients may be offered what to help optimize ability and augment continence?

GUIDELINE STATEMENT 4

PFME or PFPT

easier to master before given post-op muscle inhibition, sensory changes, pain

consider therapy +/- biofeedback

3-4 weeks before surgery

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Patients undergoing TURP or RP after RT should be informed of a high rate of?

GUIDELINE STATEMENT 5

Urinary incontinence

TURP → 70%

urethral fibrosis, endarteritis, decrease functional capacity of sphincter

salvage RP → 20-70%

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In patients sp RP, patients should be offered this in the immediate post-op period after catheter removal?

GUIDELINE STATEMENT 6

PFME/PFMT

*shown to improve time to achieving continence compared to control groups in RCTs

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At what interval after prostate treatment can surgery be considered for patients with bothersome SUI?

GUIDELINE STATEMENT 7

as early as 6 mo

90% achieve continence by 6 mo

most patients have reached max improvement by 12 mo

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In patients with bothersome SUI after prostate treatment who failed conservative therapy should be offered what by 12 mo?

GUIDELINE STATEMENT 8

surgical treatment at 1 year

*restore QOL asap, will have max improvement by 12 mo

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Patients should evaluate patients with SUI after prostate treatment how?

GUIDELINE STATEMENT 9

H&P
Appropriate diagnostic modalities
Categorize: type (SUI/UUI, MUI) , severity (pad testing), and degree of bother

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Patients with UUI or MUI, predominant urge, after prostate treatment?

GUIDELINE STATEMENT 10

Treat per OAB guideline

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Prior to tx for SUI post prostate treatment, what should be confirmed?

GUIDELINE STATEMENT 11

confirm leakage with H&P and ancillary testing

SUI on exam or UDS

*every effort should be made to objectively confirm SUI prior to AUS

provocative testing, bending, shifting, rising from seated, pad test, PVR

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Patients with incontinence after prostate treatment should be informed of management options, including:

GUIDELINE STATEMENT 12

surgical and non-surgical options

(pads/clamps/catheters, PFME/PFMT)

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Patients with incontinence after prostate treatment should discuss risks, benefits, and expectations for what?

GUIDELINE STATEMENT 13

different treatment using SDM

improves patient satisfaction

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Prior to surgical intervention for SUI after prostate treatments what procedures may be performed in office?

GUIDELINE STATEMENT 14

SHOULD perform cystourethroscopy to assess urethral and bladder pathology

**stricture, BNC, lesions, sphincter, tumors

GUIDELINE STATEMENT 15

CONSIDER UDS where it may facilitate dx or counseling

*not required but may help, especially if storage issues (DO, compliance, small capacity)

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What first line, non-invasive treatment should be offered in men with incontinence s/p RP?

GUIDELINE STATEMENT 16

PFME/PFPT

*both injury to striated muscle and nerve fibers of rhabdo-spincter to lead to incontinence, support muscle strength and flow and promote healing

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What surgery should be offered to patients with bothersome SUI after prostate treatment? What should be determine pre-op?

GUIDELINE STATEMENT 17

AUS

*risks: persistent leakage, mechanical failure, erosion, infection

GUIDELINE STATEMENT 18

adequate physical and cognitive abilities (manual dexterity)

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What approach is preferred for AUS implantation?

GUIDELINE STATEMENT 19

single cuff perineal approach

antibiotics (aminoglycoside and 1st/2nd Gen Cephalosporin, or Aztreonam and 1st/2nd Gen Cephalosporin, or Vanco/Aminoglycoside or Vanco/Aztreonam; 2nd line Amniopenicillin or Unasyn)

appropriate cuff size (introp msmt)

fill components

connect watertight

test

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What may be offered to patients with mild-moderate IPT?

GUIDELINE STATEMENT 20

male sling

*at least 50% improvement

GUIDELINE STATEMENT 21

male slings not routinely performed for severe SUI

GUIDELINE STATEMENT 22

adjustable balloon devices may be offered

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Regarding SUI after sx for BPH vs. RP, what differs?

GUIDELINE STATEMTN 23

NOTHING

same treatment options and indications

For men with SUI after RT (primary, adjuvant, or salvage) seeking treatment, what is preferred?

GUIDELINE STATEMTN 24

AUS

preferred over sling

RT with small vessel obliteration/endarteritis → ischemic tissue change, fibrosis, necrosis → complications/erosion of sling

What should patient with IPT be counseled about bulking agents?

GUIDELINE STATEMENT 25

efficacy low and cure rare

(off label, not FDA approved)

Other potential treatments besides AUS, sling, balloon, or bulking are considered?

GUIDELINE STATEMENT 26

investigational

Regarding AUS, what should patients be counseled on long term?

GUIDELINE STATEMENT 27

lose effectiveness over time, re-operations common

*devices can fail, any of 3 parts, micro-perforations

can explant and reimplant in same setting

*risks: device infection and erosion (hematuria, dysuria, difficulty emptying)

Persistent or recurrent SUI after AUS or sling, clinicians should?

GUIDELINE STATEMENT 28

perform H&P and other investigations to determine cause

inadvertant deactivation, improper use, re-education
fluid loss → CT/US
urethral atrophy
cystoscopy

Patients with persistent or recurrent SUI after a sling, what is recommended? After AUS?

GUIDELINE STATEMENT 29 AUS GUIDELINE STATEMENT 30 revision of AUS \*suboptimal cuff sizing, proximal relocation, tandem cuff placement

In patients with infection or erosion of AUS, what should be done?

GUIDELINE STATEMET 31 explantation, washout usually urethral catheter replacement in 3-6 mo may need a graft to supplement the urethra (erosion risk)

Patients after IPT treatment treatment failure and poor QOL, can be considered for?

GUIDELINE STATEMENT 32 Urinary diversion \*multiple device failures, intractable BNC, severe DO Mitrofanoff, incontinent, SPT, BNC, IC

Patients with bothersome climacturia?

GUIDELINE STATEMENT 33 treatment \*persistent leakage despite behavioral (empty prior to sex, condoms to catch urine, PFME) imipramine, penile variable tension loop to coapt urethra, IPP with “tutoplast sling”, AUS, sling

Patients with SUI after urethral reconstructive surgery may be offered? What should they be counseled?

GUIDELINE STATEMENT 34 AUS higher rate of complications \*may consider transcorporal placement due to changes in urethral blood supply

Patients with SUI and ED may be offered?

GUIDELINE STATEMENT 35 concomitant or staged procedures

Patients with veiscourethral anastomotic stricture s/p RP, should have what before tx of their SUI?

GUIDELINE STATEMENT 36 treatment for obstruction at least 4-6 weeks to document stabilization before SUI tx AUS considered best in this group

What is differential dx of IPT?

SUI UUI MUI overflow UTI urethral stricture BNC

Objective testing for IPT at initial workup?

voiding diary 24 h pad test (1 h pad test weights → Grade 1 \<10g, Grade 2: 11-50 g, Grade 3: 51-100 g, Grade 4 \> 100g) emphasis on neuroexam (S2-S4) spinal segments, sphincter tone, perineal sensation, bulbocavernosus reflux standing cough test

After dx SUI after prostate treatment, next steps?

``` arrange cysto to r/o underlying strictures/BNC or bladder pathology evaluate sphincter (esp if thinking sling) ```

Risks for BNC after prostatectomy?

DM tobacco CAD obesity surgeon expertise hemorrhage prolonged urine leak anastomotic disruption \*\*create watertight seal with good mucosal apposition

Treatment options for BNC?

Dilation, success 60% Endoscopic incision, cold knife, electrocautery, laser, hot knife, loop (risk higher SUI) ``` after RP (avoid 6:00 near rectum, make incision 3, 9, 12) cath 3-7 days ```

When is UDS useful in IPT?

equivocal when you need to asses capacity, compliance, contractility differentiate SUI from other sxs r/o high storage pressures detrusor hypocontractility → AUS preferable to fixed sling resistance

Describe surgical approach for AUS:

1. Doral lithotomy 2. Midline perineal incision: measure urethral circumference (4.0-4.5 cm for bulbar), cuff at crura just proximal to separating corporal bodies 3. Inguinal incision for reservoir (pressure 61-70 c H20, fill with 23 c of contrast) 4. Connect tubing 5. Cycle sphincter 6. Urethrosocopy to assess sphincter (closed with good coaptation, open to allow voiding) 7. Lock cuff in open

Contraindications to AUS?

impaired cognitive or manual dexterity unresolved stricture or BNC unresolved detrusor overactivity existing infection

most common complications of AUS

hematoma (MC) urinary retention persistent or recurrent incontinence device malfunction urethral atrophy cuff erosion infection

If urethral injury during AUS?

abort, foley repair injury with absorbable suture

Workup and possibilities for persistent incontinence after AUS?

inadvertent deactivation Insufficient urethral compression: mechanical failure, fluid loss, cuff erosion, bladder storage failure, urethral/bladder neck atrophy, kinked tubing

Tender swollen scrotum and leukocytosis and UTI after AUS, dx?

infection of AUS/possible erosion epididymo-orchitis perineal cellulitis Fournier's | (MC staph/skin and urinary organisms)

How do you handle an AUS erosion?

Remove all components 16 Fr foley across erosion for 2-4 weeks for large defects can consider EPA per-catheter RUG before removing foley

Risk of urethral erosion with re-do AUS?

8-9% must place proximal or distal, different location on urethra

How do you work up recurrent SUI 5 years after AUS?

cycle AUS: evaluate for leakage or mechanical dysfunction KUB to look for loss (if filled with contrast) Cysto for poor coaptation (urethral atrophy) for erosion smallest cuff is 3.5, so if you cannot downsize for atrophy → reposition