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ABU Oral Boards > Incontinence after Prostate Treatment > Flashcards

Incontinence after Prostate Treatment Flashcards

1
Q

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

A

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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2
Q

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

A

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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3
Q

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

A

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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4
Q

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

A

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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5
Q

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

A

GUIDELINE STATEMENT 5

Urinary incontinence

TURP → 70%

urethral fibrosis, endarteritis, decrease functional capacity of sphincter

salvage RP → 20-70%

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6
Q

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

A

GUIDELINE STATEMENT 6

PFME/PFMT

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

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7
Q

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

A

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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8
Q

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

A

GUIDELINE STATEMENT 8

surgical treatment at 1 year

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

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9
Q

Patients should evaluate patients with SUI after prostate treatment how?

A

GUIDELINE STATEMENT 9

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

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10
Q

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

A

GUIDELINE STATEMENT 10

Treat per OAB guideline

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11
Q

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

A

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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12
Q

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

A

GUIDELINE STATEMENT 12

surgical and non-surgical options

(pads/clamps/catheters, PFME/PFMT)

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13
Q

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

A

GUIDELINE STATEMENT 13

different treatment using SDM

improves patient satisfaction

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14
Q

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

A

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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15
Q

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

A

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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16
Q

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

A

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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17
Q

What approach is preferred for AUS implantation?

A

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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18
Q

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

A

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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19
Q

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

A

GUIDELINE STATEMTN 23

NOTHING

same treatment options and indications

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20
Q

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

A

GUIDELINE STATEMTN 24

AUS

preferred over sling

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

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21
Q

What should patient with IPT be counseled about bulking agents?

A

GUIDELINE STATEMENT 25

efficacy low and cure rare

(off label, not FDA approved)

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22
Q

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

A

GUIDELINE STATEMENT 26

investigational

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23
Q

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

A

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)

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24
Q

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

A

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

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25
Q

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

A

GUIDELINE STATEMENT 29

AUS

GUIDELINE STATEMENT 30

revision of AUS

*suboptimal cuff sizing, proximal relocation, tandem cuff placement

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26
Q

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

A

GUIDELINE STATEMET 31

explantation, washout

usually urethral catheter

replacement in 3-6 mo

may need a graft to supplement the urethra (erosion risk)

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27
Q

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

A

GUIDELINE STATEMENT 32

Urinary diversion

*multiple device failures, intractable BNC, severe DO

Mitrofanoff, incontinent, SPT, BNC, IC

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28
Q

Patients with bothersome climacturia?

A

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

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29
Q

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

A

GUIDELINE STATEMENT 34

AUS

higher rate of complications
*may consider transcorporal placement due to changes in urethral blood supply

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30
Q

Patients with SUI and ED may be offered?

A

GUIDELINE STATEMENT 35

concomitant or staged procedures

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31
Q

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

A

GUIDELINE STATEMENT 36

treatment for obstruction
at least 4-6 weeks to document stabilization before SUI tx

AUS considered best in this group

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32
Q

What is differential dx of IPT?

A

SUI
UUI
MUI
overflow
UTI
urethral stricture
BNC

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33
Q

Objective testing for IPT at initial workup?

A

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

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34
Q

After dx SUI after prostate treatment, next steps?

A 
arrange cysto to r/o underlying strictures/BNC or bladder pathology
evaluate sphincter (esp if thinking sling)
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35
Q

Risks for BNC after prostatectomy?

A

DM
tobacco
CAD
obesity
surgeon expertise
hemorrhage
prolonged urine leak
anastomotic disruption

**create watertight seal with good mucosal apposition

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36
Q

Treatment options for BNC?

A

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
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37
Q

When is UDS useful in IPT?

A

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

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38
Q

Describe surgical approach for AUS:

A
  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
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39
Q

Contraindications to AUS?

A

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

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40
Q

most common complications of AUS

A

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

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41
Q

If urethral injury during AUS?

A

abort, foley
repair injury with absorbable suture

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42
Q

Workup and possibilities for persistent incontinence after AUS?

A

inadvertent deactivation

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

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43
Q

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

A

infection of AUS/possible erosion

epididymo-orchitis
perineal cellulitis
Fournier’s

(MC staph/skin and urinary organisms)

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44
Q

How do you handle an AUS erosion?

A

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

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45
Q

Risk of urethral erosion with re-do AUS?

A

8-9%

must place proximal or distal, different location on urethra

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46
Q

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

A

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

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47
Q

What factors have been found to impact recovery of continence after radical prostatectomy (RP)?

A

Younger patient age, smaller prostate size, and longer membranous urethral length have been consistently associated with improved recovery of continence after RP.

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48
Q

Do surgical approaches impact rates of incontinence after RP?

A

No, surgical approaches do not seem to impact rates of incontinence after RP. Open RP and robot-assisted RP have similar rates of urinary incontinence.

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49
Q

What surgical maneuvers result in improved continence recovery after RP?

A

There is no current evidence that any surgical maneuvers, beyond bilateral neurovascular bundle preservation, result in improved continence recovery after RP.

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50
Q

What is the impact of bilateral neurovascular bundle preservation on continence recovery after RP?

A

Men receiving bilateral neurovascular bundle preservation were 26% more likely to be continent at six months compared to men who did not receive it. However, the degree of nerve sparing should be based on the features of the cancer, not preoperative potency.

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51
Q

Does BMI impact incontinence after RP?

A

BMI may impact incontinence in the short-term, but there is little evidence that it is a risk factor for incontinence after RP at one year.

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52
Q

What is sexual arousal incontinence?

A

Sexual arousal incontinence is characterized by the involuntary loss of urine during sexual arousal, foreplay, and/or masturbation.

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53
Q

What is climacturia?

A

Climacturia, also known as orgasm-associated urinary incontinence, is the involuntary loss of urine at the time of orgasm.

54
Q

What is the incidence of sexual arousal incontinence and climacturia following prostate cancer surgery?

A

The incidence of sexual arousal incontinence and climacturia following prostate cancer surgery ranges from 20-93%, with most reporting an overall rate close to 30%.

55
Q

What is the pathophysiology of climacturia?

A

The mechanism is thought to relate to the removal of the internal sphincter during radical prostatectomy (RP), which is exacerbated by prior transurethral resection of the prostate (TURP). Bladder contraction at the time of orgasms with some degree of external sphincter insufficiency is thought to result in leakage during orgasm.

56
Q

What should patients undergoing radical prostatectomy be informed about incontinence?

A

Patients undergoing radical prostatectomy should be informed that incontinence is expected in the short-term and generally improves to near baseline by 12 months after surgery but may persist and require treatment.

57
Q

What is pelvic floor muscle training (PFMT)?

A

PFMT is a training program specific to the pelvic floor muscle group that is practitioner-guided.

58
Q

What is pelvic floor muscle exercises (PFME)?

A

PFME is an exercise program specific to the pelvic floor muscle group that is self-guided as a home exercise program only.

59
Q

When should preoperative PFMT start?

A

Preoperative PFMT should be started three to four weeks prior to surgery.

60
Q

What is the goal of a preoperative PFMT program?

A

The goal of a preoperative PFMT program is to maximize the effectiveness of exercises by providing proper patient education regarding pelvic floor muscle anatomy, physiology, awareness, and motor control.

61
Q

What are the methods used in PFMT to optimize pelvic floor muscle awareness?

A

The methods used in PFMT to optimize pelvic floor muscle awareness include verbal cues, tactile cues, visualization of penile movement, surface electromyography biofeedback, pressure biofeedback, and transabdominal ultrasound imaging.

62
Q

What is the benefit of starting pre-operative PFMT?

A

The benefit of starting pre-operative PFMT is not consistent in the outcome data. Some studies have shown it to be effective in hastening continence recovery after surgery, while others have failed to demonstrate a beneficial effect.

63
Q

What are the rates of urinary incontinence after transurethral resection of the prostate (TURP) following radiation therapy?

A

Following brachytherapy or external beam radiation, TURP has been associated with incontinence rates of up to 70%.

64
Q

What factors are correlated with higher rates of incontinence after TURP following radiation therapy?

A

The factors include the need for subsequent resections, patient age, and pre-TURP urgency.

65
Q

What are the risks of urinary incontinence for patients undergoing TURP or salvage prostatectomy after primary non-surgical treatment for prostate cancer?

A

The risks are high, with incontinence rates ranging from 20-70% for both open and robotic techniques compared to standard radical prostatectomy.

66
Q

What should patients be informed of if they seek long-term continence after TURP or salvage prostatectomy?

A

Patients should be informed that they may require an artificial urinary sphincter (AUS).

67
Q

What should clinicians offer to patients who have undergone radical prostatectomy?

A

Clinicians should offer pelvic floor muscle exercises or pelvic floor muscle training to patients who have undergone radical prostatectomy in the immediate post-operative period.

68
Q

What is the benefit of pelvic floor muscle exercises or training in the immediate post-operative period?

A

In the short-term, pelvic floor muscle exercises or training may be offered to patients who are not able to perform self-directed exercises and who request additional interventions to hasten the recovery of continence after radical prostatectomy. Those who are committed to a progressive program can expect an earlier return to continence, as early as three to six months. However, long-term assessment shows that overall continence rates at one year are similar between those who underwent pelvic floor muscle exercises or training and those who did not.

69
Q

What is the effect of pelvic floor muscle exercises or training on continence at 12 months after radical prostatectomy?

A

Long-term assessment shows that overall continence rates at 12 months after radical prostatectomy are similar between those who underwent pelvic floor muscle exercises or training and those who did not (57% with urinary incontinence in the intervention group versus 62% in the control group). However, if performed in the early post-operative period, pelvic floor muscle exercises or training can improve time to continence and improve quality of life.

70
Q

What is the recommendation for patients with stress urinary incontinence after prostate treatment?

A

In patients with bothersome stress urinary incontinence after prostate treatment, surgery may be considered as early as six months if incontinence is not improving despite conservative therapy.

71
Q

When is the maximum improvement expected in patients with stress urinary incontinence after prostate treatment?

A

Almost all patients have reached their maximum improvement by 12 months.

72
Q

What is the data indicating about the improvement of stress urinary incontinence after robotic-assisted laparoscopic prostatectomy?

A

A review of the data indicates that 90% of patients will achieve continence at six months after robotic-assisted laparoscopic prostatectomy and only an additional 4% of patients will gain continence afterwards.

73
Q

When may patients with severe stress urinary incontinence be offered early treatment?

A

Patients who report a lack of symptom improvement or those experiencing more severe incontinence at six months may be offered early treatment in the form of surgical interventions with such a treatment decision made using a shared decision-making model.

74
Q

What is the recommendation for timing of surgical treatment for stress urinary incontinence after prostate treatment?

A

The recommendation is that surgical treatment should be offered at one year post-prostate treatment.

75
Q

What is the additional improvement of incontinence from 12-24 months after robotic-assisted laparoscopic prostatectomy?

A

Patients followed for 24 months after robotic-assisted laparoscopic prostatectomy revealed that only an additional 1% of patients had continued improvement from 12-24 months.

76
Q

What should the history focus on in evaluating incontinence?

A

The history should focus on characterizing incontinence (stress or activity-related versus urgency-related), the severity of incontinence, the progression or resolution of incontinence over time, and degree of bother.

77
Q

How can the severity of incontinence be determined?

A

The severity of incontinence can be determined by history, such as questioning the patient about pad use, or more objectively, by pad testing. There may also be times when a formal one-hour or 24-hour pad test may be helpful in determining incontinence severity.

78
Q

Why is it important to determine the degree of bother of incontinence and its effect on QoL?

A

It is important to determine the degree of bother of incontinence and its effect on QoL because it will help determine the type of initial treatment or no treatment, and guide counseling through a shared decision-making model.

79
Q

What is the occurrence of urinary frequency, urgency, and urgency urinary incontinence after prostate treatment?

A

The occurrence of urinary frequency, urgency, and urgency urinary incontinence is common after prostate treatment. A review of urinary symptoms after radical prostatectomy reveals that 29% of patients will develop one or more symptoms, with 19% developing urinary urgency and 6% complaining of urgency incontinence.

80
Q

Can a patient with urgency urinary incontinence be excluded from surgical treatment of stress urinary incontinence?

A

No, the presence of urgency urinary incontinence should not exclude a patient from surgical treatment of his bothersome stress urinary incontinence.

81
Q

What should clinicians do before surgical intervention for stress urinary incontinence?

A

Prior to surgical intervention for stress urinary incontinence (SUI), clinicians should confirm that a patient truly has sphincteric insufficiency as a cause for his incontinence through history, physical exam, or ancillary testing.

82
Q

How can stress urinary incontinence be confirmed?

A

Stress urinary incontinence can be confirmed by taking a patient’s history, performing a physical exam with provocative testing such as bending, shifting position, or rising from seated to standing position, or by stress pad testing. In case of doubt, urodynamic studies (UDS) may be performed.

83
Q

What should be considered when evaluating a patient with a persistently elevated post-void residual (PVR)?

A

An elevated PVR in the presence of SUI may impact patient counseling regarding surgical interventions and patient expectations. An elevated PVR may indicate detrusor underactivity or obstruction, and may prompt further diagnostic evaluation such as uroflowmetry, cystoscopy, or multichannel UDS.

84
Q

What is the first-line approach for the management of urinary incontinence after prostate treatment?

A

The first-line approach for the management of urinary incontinence after prostate treatment is a conservative approach, which includes the use of absorbent pads, penile compression devices, and catheters.

85
Q

What are the absorbent products commonly used for incontinence management?

A

Absorbent products commonly used for incontinence management include liners, guards, briefs, and underwear. The patient should be advised on the most effective product based on the degree of incontinence.

86
Q

What are occlusive devices and how do they work in the management of incontinence?

A

Occlusive devices are mechanical compression devices that can be used as a stand-alone therapy or as an adjunct to absorbent products. They work by reducing urine loss, but they can also be associated with decreased penile Doppler flow.

87
Q

What are the different types of catheters used for the management of incontinence?

A

The different types of catheters used for the management of incontinence include condom catheters, urethral catheters, and suprapubic catheters. Condom catheter systems are an effective method of urinary containment for men with severe incontinence, while urethral catheter drainage is a decision of last resort for patients who are unsuitable for alternative management. Suprapubic catheter drainage is not a solution for patients with severe intrinsic sphincter deficiency as urethral leakage will persist.

88
Q

What is the purpose of urodynamic testing in patients with stress urinary incontinence?

A

Urodynamic testing (UDS) allows for a precise evaluation of lower urinary tract function with respect to storage and emptying. It can determine if the incontinence is caused by sphincter dysfunction, bladder dysfunction, or a combination of both, and also assess bladder contractility and the presence of bladder outlet dysfunction.

89
Q

Is UDS required before surgical intervention for incontinence after prostate treatment?

A

No, UDS is not required before surgical intervention unless the clinician is in doubt of the diagnosis or it is felt that patient counseling will be affected. There is no evidence that UDS added value over simple office evaluation in men with stress incontinence.

90
Q

What is the role of pre-operative UDS in patient counseling?

A

Pre-operative UDS may have a role in patient counseling, such as determining which patients may need further treatment of OAB symptoms after implant. However, patient selection for this reason is not well characterized.

91
Q

What is the most concerning UDS finding in patients with incontinence after prostate treatment?

A

The most concerning and potentially dangerous UDS finding is poor bladder compliance, which is rare in incontinence after prostate treatment.

92
Q

What is the importance of removing the catheter and repeating stress testing in men with suspected stress incontinence?

A

It is important to remove the catheter and repeat stress testing in men with suspected stress incontinence as up to 35% of men with post-prostatectomy SUI will not demonstrate SUI with a catheter in place.

93
Q

What should be done for patients with poor bladder compliance and stress incontinence?

A

For patients with poor bladder compliance and stress incontinence, they can be treated with anticholinergics or onabotulinumtoxin A and storage pressure can be rechecked prior to treating stress incontinence. Alternatively, periodic upper tract imaging and/or UDS can be done post-stress incontinence surgery to follow “at risk” patients.

94
Q

What is pelvic floor muscle training (PFMT) used for in patients with incontinence after radical prostatectomy?

A

PFMT is used to support muscle strength and enhance blood flow to the urethral sphincter in patients with incontinence after radical prostatectomy.

95
Q

What are some of the inherent risks of AUS placement?

A

The inherent risks of AUS placement include persistent leakage, mechanical failure, erosion, and infection.

96
Q

What was the result of a study with two-year follow-up on AUS outcomes?

A

In a study with two-year follow-up on AUS outcomes, complete continence was achieved in 20%, 55% had leakage of a few drops daily, and 22% had leakage of less than a teaspoon. The patients were highly satisfied, with 92% reporting they would do the surgery again and 96% willing to recommend the surgery to a friend.

97
Q

What was the result of another study with follow-up of 2-11 years on AUS placement?

A

In another study with follow-up of 2-11 years on AUS placement, a significant pad reduction was seen (4.0 to 0.6 pads per day).

98
Q

What should clinicians consider before implanting artificial urinary sphincter?

A

Prior to implanting artificial urinary sphincter, clinicians should ensure that patients have adequate physical and cognitive abilities to operate the device.

99
Q

What are the requirements for physical ability to operate the AUS device?

A

Patients must demonstrate manual dexterity and cognitive ability to know when, where, and how to use the device. They must also be able to physically pump the device that is in a normal position in the scrotum.

100
Q

What is the minimum physical requirement for operating the AUS device?

A

The minimum physical requirement for operating the AUS device is the ability to squeeze the pump between the index finger and thumb.

101
Q

What is the preferred approach for placing an artificial urinary sphincter in a patient?

A

The preferred approach is a single cuff perineal approach.

102
Q

What are the drawbacks of using a transverse scrotal incision or a tandem cuff placement for AUS placement?

A

The transverse scrotal incision has been found to have inferior outcomes with a higher risk of complications and need for revision surgery compared to the perineal approach. The tandem cuff placement has similar continence outcomes but with an increased risk of complications compared to the single cuff placement.

103
Q

What should be considered before an artificial urinary sphincter is implanted in a patient?

A

Before implantation, meticulous sterile technique should be employed and preoperative antibiotics should be given to cover skin flora. The surgeon should be able to select the appropriate cuff based on intraoperative measurements, fill the components of the AUS with fluid, connect the tubing to make a watertight system, and test the AUS. If an intraoperative urethral injury is identified, the procedure should be abandoned and subsequent implantation should be delayed.

104
Q

What is the recommendation for male slings for patients with severe stress urinary incontinence after prostate treatment?

A

Male slings should not be routinely performed in patients with severe stress incontinence.

105
Q

What is the success rate of adjustable balloon devices for treating mild stress urinary incontinence after prostate treatment?

A

The success rate of adjustable balloon devices is 60-81% with a cure rate defined as 0-1 pads/day after implantation.

106
Q

Is surgical management of stress urinary incontinence after treatment of benign prostatic hyperplasia different from that after radical prostatectomy?

A

No, surgical management of stress urinary incontinence after treatment of benign prostatic hyperplasia is the same as that after radical prostatectomy.

107
Q

What is the rate of persistent stress urinary incontinence in patients undergoing surgical management for benign prostatic hyperplasia?

A

The rate of persistent stress urinary incontinence in patients undergoing surgical management for benign prostatic hyperplasia ranges between 0-8.4%.

108
Q

What is the success rate of AUS implantation for patients undergoing surgical management of benign prostatic hyperplasia?

A

A study found that continence was significantly improved in 90% of patients with a satisfaction rate of 87% after AUS placement after TURP.

109
Q

What is the success rate of male sling after TURP?

A

In a study evaluating the transobturator male sling after TURP, 47% of men were cured and 60% were cured or improved using a cure definition of 0-5 g in the 24-hour pad test.

110
Q

What is the preferred surgical management for men with stress urinary incontinence after radiotherapy?

A

Artificial urinary sphincter (AUS) is the preferred surgical management for men with stress urinary incontinence after radiotherapy.

111
Q

What are the potential complications of AUS placement in radiated patients?

A

Radiated patients undergoing AUS placement may be at increased risk of complications, including compromised functional outcomes and a higher risk of revisions, which are typically secondary to erosion.

112
Q

Are male slings recommended for patients who have undergone adjuvant or salvage radiotherapy?

A

Male slings are not recommended for patients who have undergone adjuvant or salvage radiotherapy due to a lack of compelling evidence regarding their effectiveness in this subgroup.

113
Q

What should patients with incontinence after prostate treatment be counseled about the efficacy of urethral bulking agents?

A

Patients with incontinence after prostate treatment should be counseled that efficacy is low and cure is rare with urethral bulking agents, which are the least effective surgical technique in the treatment of male stress urinary incontinence.

114
Q

What is the best success rate of injectable therapy for male SUI?

A

The best success rates of injectable therapy for male stress urinary incontinence have been described in patients with a high Valsalva leak point pressure, unscarred vesicourethral anastomosis, and no radiotherapy history. However, the efficacy of injectable agents, including collagen, carbon coated zirconium beads, and silicone implants, is generally limited by the number of reports, patient cohort size, and length of follow-up.

115
Q

What is the rate of AUS failure over time?

A

The rate of AUS failure increases over time with failure rates of approximately 24% at 5 years and 50% at 10 years.

116
Q

What is the management of a malfunctioning AUS?

A

If the patient is healthy and requests a replacement, the AUS can be explanted and a new one replaced at the same operative setting.

117
Q

What are the causes of reoperation for an AUS?

A

Device infection and cuff erosion are causes of reoperation and should be discussed in detail with the patient prior to implantation.

118
Q

What is the management of an infected AUS?

A

An AUS should not be replaced in the setting of infection for at least three months to allow the infection to clear and inflammation to subside.

119
Q

What is the management of a cuff erosion for an AUS?

A

Management of cuff erosion is via AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal. The AUS should not be reimplanted until at least three months and preferably at a different location along the urethra.

120
Q

What is the outcome of secondary AUS placements compared to primary AUS placements?

A

Secondary AUS placements generally have similar outcomes to primary AUS placements, however, patient satisfaction is driven by the degree of continence after AUS and not by the number of reoperations.

121
Q

What should be done for patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter?

A

Revision should be considered for patients with persistent or recurrent stress urinary incontinence after artificial urinary sphincter.

122
Q

What is tandem cuff placement and what are the risks associated with it?

A

Tandem cuff placement is the addition of a cuff to the original cuff and has been shown to be effective as a salvage procedure for patients with persistent incontinence. The specific risks of tandem cuff placement include injury to the urethra during dissection and a higher risk of subsequent erosion.

123
Q

What are the options for patients with small urethral caliber after AUS placement?

A

A transcorporal approach may be used to improve urethral coaptation in patients with small urethral caliber after AUS placement, although there is limited evidence to support this approach.

124
Q

What should be done if a patient presents with infection or erosion of an artificial urinary sphincter or sling?

A

If a patient presents with infection or erosion of an artificial urinary sphincter or sling, explantation should be performed and reimplantation should be delayed.

125
Q

What is the recommended waiting period for patients seeking a replacement device after infection or erosion?

A

For patients seeking a replacement device after infection or erosion, a waiting period of three to six months is recommended.

126
Q

What is the recommended approach for AUS patients with prior erosion and thinned spongiosal tissue?

A

For AUS patients with prior erosion and thinned spongiosal tissue, a transcorporal placement of the cuff may be necessary.

127
Q

What is the advantage of using xenograft tissue to supplement the urethra?

A

Using xenograft tissue to supplement the urethra has not been advantageous due to significant complications associated with this approach.

128
Q

What is the recommended solution for patients unable to achieve long-term quality of life after incontinence after prostate treatment?

A

Urinary diversion with or without cystectomy may be considered as an option for patients who are unable to obtain a satisfactory quality of life after incontinence after prostate treatment.

129
Q

What are the alternatives for bladder preservation in patients with intractable BNC or severe detrusor instability?

A

Alternatives for bladder preservation in patients with intractable BNC or severe detrusor instability include conversion to a Mitrofanoff (e.g. Appendix, Monti), incontinent ileovesicostomy, or suprapubic tube with bladder neck closure.

130
Q

What is the recommended treatment for climacturia?

A

The recommended treatment for climacturia depends on the severity of the leakage and the patient’s preference. Conservative management such as emptying the bladder before sex, using condoms, and pelvic floor muscle exercises may improve symptoms in two-thirds of patients. Medications such as imipramine and the use of a penile variable tension loop have also been used successfully. Surgical treatment such as the implantation of an inflatable penile prosthesis has also been reported to be very successful, with 93% of patients noting improvement in climacturia post-operatively.

131
Q

What should be done after treating a vesicourethral anastomotic stenosis?

A

After treating a vesicourethral anastomotic stenosis, an interval cystoscopy should be performed at least four to six weeks later to document improvement and stabilization, after which IPT treatment can be considered.

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