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Management of Post-Prostatectomy Incontinence (PPI) Primary Care Conference 2/25/04

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Primary Care Conference 2/25/04 MARY JO WILLIS, MS, APRN-BC CLINICAL ASSOCIATE PROFESSOR NURSE PRACTITIONER, USIM OBJECTIVES Discuss the incidence of incontinence in ... – PowerPoint PPT presentation

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Title: Management of Post-Prostatectomy Incontinence (PPI) Primary Care Conference 2/25/04


1
Management of Post-Prostatectomy Incontinence
(PPI)Primary Care Conference2/25/04
  • MARY JO WILLIS, MS, APRN-BC
  • CLINICAL ASSOCIATE PROFESSOR
  • NURSE PRACTITIONER, USIM

2
OBJECTIVES
  • Discuss the incidence of incontinence in males
    post radical prostatectomy for Prostate cancer
  • Address the common causes of the incontinence
    post prostatectomy
  • Describe which conservative treatments offer
    benefit
  • Describe the surgical options for treatment

3
CONFLICTS OF INTEREST
  • I have not received compensation for this
    presentation
  • I have a personal interest in understanding what
    options for treatment exist and what works.
  • I wish to thank Dr Wade Bushman for his
    assistance with this presentation

4
CASE STUDY
  • Patient is a 69 y/o w/m who underwent retropubic
    radical prostatectomy for prostate cancer 4/02.
  • Prostate cancer was a moderately aggressive
    Gleason 7 found on biopsy after patient had
    increased problem with nocturia, frequency and
    inability to completely empty bladder. No
    incontinence
  • PSA history 4.4 in 10/2000, 4.5 in 10/2001, and
    5.0 at the time of diagnosis 4/02

5
RISKS OF RADICAL PROSTATECTOMY COMPLICATIONS
  • Multi-center study of over 1069 men provided self
    reported incidence of incontinence, impotence,
    and bladder neck contracture /stricture revealed
    the following results
  • Incontinence65
  • Impotence88.4
  • Bladder neck contracture/stricture20.5
  • Even though complications of post radical
    prostatectomy are common and affects overall
    quality of life, most patients would elect the
    same treatment again.
  • Journal of Urology 163,858-864, March 2000

6
GENERAL MALE POPULATION URINARY INCONTINENCE
  • Community population rate on incontinence in
    persons over 60 is 15-30 10-15 in women 50
    in institutionalized elderly
  • Prevalence rate on incontinence in men gt60 in
    Michigan study in 1998 was 19 with
  • 34.9 had urge incontinence
  • 7.9 had stress incontinence
  • 28.9 had mixed
  • 28.3 had other
  • Ostomy/Wound Management 44(6), 54-59, (1998)

7
GENERAL MALE POPULATION URINARY INCONTINENCE
  • Study conducted by questionnaire in one county in
    Minnesota assessing UI in men gt50 in previous 12
    months found a prevalence rate of 23 with
  • 24.9 with stress and urge incontinence
  • 40.8 had only urge incontinence
  • 30.88 had neither stress or urge incontinence
  • 77.8 rated it as mild and 22.2 moderate to
    severe

8
RISKS FOR PPI
  • Age
  • Size and configuration of the prostate
  • Size and location of tumor
  • Presence and degree of bladder outlet obstruction
    and detrusor muscle dysfunction preoperatively
  • Surgical technique and skill of surgeon
    resection of neurovascular bundles, bladder neck
    preservation/reconstruction
  • Other studies found no association based upon the
    above variables nor cancer stage, tumor grade

9
CAUSES OF PPI
  • Injury to bladder
  • Bladder instability
  • Trigonal denervation (reduced sensitivity in the
    trigone with altered voiding sensation)
  • Bladder wall damage from longstanding outlet
    obstruction or decreased bladder wall
    compliance
  • Bladder outlet obstruction (BOO) causing
    overflow incontinence is rare

10
CAUSES OF PPI
  • Injury to the sphincter with
  • Difficulty emptying the urethra leading to
    post void dribble
  • Intrinsic sphincter deficiency/weakness is most
    common cause
  • Sphinter injury, pudendal nerve injury
  • Ischemia and immobilization by scar,
    atrophy
  • Shortening of the urethra below critical
    functional length of 2.8 cm

11
ANATOMY
  • There are 2 separate continence zones
  • Proximal urethral sphincter (PUS) includes
  • The bladder neck, prostate and prostatic urethra
    to veru montanum
  • Distal urethral sphincter DUS extending from the
    veru montanum to the bulbar urethra
  • Includes slow twitch intrinsic rhabdosphincter
    fibers that sustain urethral lumen tone
  • Fast twitch fibers of the periurethral extrinsic
    skeletal muscle layer that supplement the
    activity of slow twitch fibers
  • Intrinsic smooth muscle layer that is a
    continuation of the superficial layer of the
    detrusor muscle lining the posterior prostatic
    urethra

12
POINTS OF DAMAGE POST OP
  • Either the PUS or DUS must be intact to maintain
    continence
  • After prostatectomy the PUS is destroyed and
    continence relies totally upon an intact DUS
  • During a radical prostatectomy, the proximal
    portion of the DUS is also removed
  • Continence therefore is dependent on an intact
    distal sphincter as well as normal bladder
    function (capacity and compliance without
    detrusor instability)
  • Any bladder dysfunction resulting in an
    intravesical pressure that exceeds that of the
    distal urethral spincter resistence leads to PPI
  • Urodynamically based studies point out that
    sphincter weakness with secondary detrusor
    weakness based upon reduced maximum urethral
    closure pressure, low leak point pressure and
    shortened urethral length lead to incontinence

13
ANATOMY
14
PROBLEMS DEFINING INCONTINENCE RATES
  • Krane(2000) and Parekh(2003) found incidence post
    op to range from2.5-87 depending on definition,
    method and time of data collection
  • Centers of excellence research indicate overall
    rates from 6-2070-90 were dry at 1 year
  • Reported incontinence rates were influenced by
    the
  • Lack of consensus of definition
  • Optimal time to assess continence
  • Methodology
  • Inclusion of pts incontinent prior to surgery
  • Variations of operative technique

15
PPI
  • Multicenter study 1990-97
  • Immediately after surgery 81.5
  • 6 months post op status65.6)
  • 53.9 lt15ml
  • 23.2 notice leakage once or less daily
  • 44 used protection with 27 using pads
  • Most commonly used Rx was pelvic exercise (34)

16
PPI
  • Study by Gomha and Boone(2003) found
  • 100 of patients with stress incontinence
  • 48 with urgency and urge incontinence
  • 42 had delayed first sensation
  • Study by Chao and Mayo (1995) found
  • 57 reported sphincter weakness
  • 39 had detrusor dysfunction
  • 50 had combined causes

17
PPI
  • Findings of Eastham et. al. from Baylor College
    of Medicine and The Methodist Hospital
  • Continence returned at a median of 1.5 months in
    pts treated since 1990 and 95 eventually
    regained control
  • Patients age (less than 70) and technical
    features of the surgery significantly improved
    recovery of continence (e.g wide resection of 1
    bundle substantially decreased recovery), and
    increase in functional length of the urethra
    improved continence
  • Incontinence was largely refractory to
    conservative measures

18
CONSERVATIVE TREATMENT
  • Urodynamic Testing
  • Role of Pelvic Floor Exercises
  • Commonly recommended
  • May be effective when employed in an intensive,
    supervised program
  • Improved continence at 3 mo (88 vs 56).
    Difference diminished at 1 year (14).
  • Van Kampen et al., Lancet 2000
    355(9198)98-102
  • Benefit of office based instruction is
    questionable
  • Sueppel et.al (2001) found that starting PFM
    exercises prior to surgery improved outcomes

19
CONSERVATIVE TREATMENT
  • INSTRUCTIONS DIETARY IRRITANTS TO THE URINARY
    TRACT
  • If your bladder symptoms are related to dietary
    factors, strict adherence to a diet which
    eliminates certain food products should bring
    significant relief in 10 days.
  • The proof is resuming your old dietary habits
    followed by the return of your symptom complex.
    Once you are feeling better, you can begin to add
    these things back into your diet, one item at the
    time. This way, if something really does cause
    you symptoms, you will be able to identify what
    it is. When you do begin to add foods back into
    your diet, it is crucial that you maintain a
    significant water intake. Water should be the
    majority of what you drink everyday
    (approximately 1-2 quarts a day).  Mayo Clinic
    Urology Clinic 11/02

20
CONSERVATIVE TREATMENT
  • FOODS TO BE AVOIDED
  • All alcoholic beverages Chocolate
  • Apples, apple juice Grapes
  • NutraSweet Guava
  • Cantaloupe
    Vitamin E if powered
  • Carbonated beverages Peaches,
    pineapple, plums
  • Chiles/spicy foods Citrus foods incl
    lemons
  • Coffee, tea, (incl decaf) Tomatoes
  • Strawberries, cranberries Onions
  • Vinegar Vitamin B
    complex(B6 okay)

21
CONSERVATIVE TREATMENT
  • DAILY DIET SUBSTITUTIONS
  • 1. Coffee-acid removed Kava, cold brewed coffee
  • 2. Weak or Herbal teas-if free of large amounts
    of citrus. dunk a tea bag in water 4 times
    quickly to color the water. Sun-brewed tea
  • 3. Carob for chocolate Ovaltine instead of
    chocolate drinks
  • 4. Fruit juices apricot, nectar, pear nectar,
    papaya, watermelon
  • 5. Late harvest dessert wines
  • 6. Fructose, as in Superose instead of NutraSweet
    or saccharin
  • 7. Orange or lime peel without white part of rind
  • 8. Pine nuts in place of other types of nuts
  • 9. Consider wheat allergy breads made of potato,
    soya, rice flour
  • 10. Vitamins Vit. C in calcium ascorbate
    co-buffered with calcium carbon

22
CONSERVATIVE TREATMENT
  • Electomyography (EMG) can be used as an adjunct
    when teaching the PFM exercises to provide visual
    and audible assessment of the pelvic floor.
  • Low EMG profile is an identifiable risk factor
    for incontinence. Can be done preoperatively to
    establish risk

23
CONSERVATIVE TREATMENT
  • Bladder retraining
  • Helpful if detrusor dysfunction is present,
    especially with adjunctive anticholinergics
  • Useful for urinary urge and frequency
  • Patient needs to keep a bladder diary with
    information on voiding pattern, frequency and
    voided volumes

24
MEDICAL AND SURGICAL TREATMENT OPTIONS
  • Medical In addition to conservative measures
  • Anticholinergics for detrusor instability
  • Surgical
  • Bulbourethral Sling
  • Artificial Urinary Sphincter

25
BULBOURETHRAL SLlNG
  • Northwestern technique bulbourethral sling
  • Recent interest in male sling procedures for
    post-radical prostatectomy incontinence
  • preserve volitional voiding
  • quick, simple to perform

26
PRE-OPERATIVE URODYNAMIC EVALUATION
  • Confirm Sphincter deficiency
  • R/O detrusor instability as cause of leakage
  • R/O diminished bladder compliance

27
BACKGROUND
  • Northwestern technique (bulbourethral sling)
  • Gore-tex bolsters placed beneath bulbar urethra,
    suspended from rectus fascia
  • Intraoperative urodynamics
  • Goal analogous procedure to pubovaginal sling

28
BACKGROUND
  • Previous analysis with 12-month follow-up
  • 91 cured or improved
  • 85 0-2 pads per day
  • 6 removal rate for infection, erosion
  • The purpose of this study was to review the
    long-term outcomes of the first 95 patients
    (10/94 to 6/00) who underwent the bulbourethral
    sling procedure at Northwestern.

29
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30
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31
STUDY MATERIALS AND METHODS
  • 95 patients from 10/94 to 6/00
  • 8 patients deceased at time of questionnaire
  • 71/87 patients completed survey (82 contact
    rate)
  • Mean follow-up interval 4.0 years (0.27-6.55)
  • Mean age at time of surgery 69 years (55-81)
  • Preoperative adjuvant radiation therapy 9 (13)

32
PREOPERATIVE INCONTINENCE
()
Complete 20
gt 5 pads 40
gt 2 pads 98
Median duration of incontinence 68 month
(range 14-198)
33
RESULTS AT 4 YEARS
Overall Sling Intact
Total patients 71 64
Cured (n25) 35 39
Cured/ Improved (n52) 73 81
0 pads (n23) 32 36
lt2 pads per day (n44) 62 69
34
POSTOPERATIVE CONTINENCE STATUS Non-radiated
Patients
U
gt2
C
0
I
1-2
35
POSTOPERATIVE CONTINENCE STATUS Radiated Patients
C
0
I
gt2
1-2
U
36
PATIENT SATISFACTION Non-radiated Patients
N
Y
37
PATIENT SATISFACTION Radiated Patients
Y
N
38
POST-OPERATIVE PAIN
39
INCONTINENCE QUALITY OF LIFE Questionnaire
40
SLING COMPLICATIONS
  • no. ()
  • Retightening 15 (21)
  • Sling removal 7 (10)
  • - infection 6 (8)
  • -urethral erosion 1 (1)

41
COMPARISON TO SHORT TERM Follow-up
  • Follow-up Duration
  • 12 months 4 years
  • Cured/Improved 91 81
  • 2 or less pads 85 69
  • No perineal numbness/pain 47.5 82
  • Moderate/severe pain 26 12
  • Bolster removal 6 10

42
COMPLICATIONS SUMMARY
  • Infection/erosion rate10
  • AUS 6.8
  • Barrett 2000
  • Revision rate 21
  • XRT 66 no XRT 15
  • AUS 20-40
  • Light 1989 Barrett 1989 Montague 1992 Webster
    1992 Singh 1996 Herschorn 1996 Castro Diaz 1997

43
CONCLUSIONS
  • Bulbourethral Sling is effective for post-radical
    prostatectomy incontinence
  • Radiation significantly reduced efficacy
  • Post-operative discomfort resolved in most
    patients

44
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45
ARTIFICIAL URINARY SPHINCTER
  • Gold standard for surgical treatment of PPI
  • First developed in 1947 by Foley refined in the
    1970s. AMS 800 developed in 1983
  • AUS implantation usually delayed for 12 months
    after RP
  • Men usually seeking this option have significant
    incontinence

46
ARTIFICIAL URINARY SPHINCTER DATA
  • Gousse et al1 mean follow-up 7.7 years
  • 0 pads 27 very satisfied 58
  • gt3 pads 25 satisfied 19
  • 16 revision rate unsatisfied 23
  • Montague et al2 mean follow-up 73 months
  • 0-1 pads 64 very satisfied 28
  • 2 pads 35 satisfied 45
  • 12 revision rate dissatisfied/
  • very dissatisfied 10

47
ARTIFICIAL URINARY SPHINCTER DATA
  • Elliot and Barrett3 245 of 271 pts (90) had
    functioning AUS at 5 years
  • Complications Mean follow-up 68.8 months
    (narrow-backed cuff data)
  • 17 (31 of 184) required a first re-operation
  • 7 required 2nd re-operation
  • 1 required 3rd operation
  • 7 Infection/erosion rate
  • 7.6 Mechanical failure
  • Quality of Life Several recent studies have
    found patient satisfaction with the AUS in PPI is
    85-95 even in the face of revisions and
    complications
  • 1. Gousse, A.E., Madjar S., Lambert, M-M,
    Fishman Artificial urinary sphincter for
    post-radical prostatectomy urinary incontinence
    long-term subjective results. J. Urol 166 1755,
    2001.
  • 2. Montague, D.K, Angermeier, K.W., and Paolone,
    D.R Long-term continence and patient
    satisfaction after artificial sphincter
    implantation for urinary incontinence after
    prostatectomy. J Urol 166 547, 2001.
  • 3. Elliot, D.S., and Barrett, D.M. Mayo Clinic
    long-term analysis of the functional durability
    of the AMS 800 artificial urinary sphincter a
    review of 323 cases J. Urol 159 1206, 1998.
  • 4. Tse,Vand Stone,A.R. Incontinence after
    prostatectomy the AUS. BJU 92(9),2003.

48
CONCLUSIONS
  • Pelvic floor exercises are not helpful for
    patients with established SUI
  • Medical therapy is of limited value
  • Urodynamic testing is useful to R/O detrusor
    instability or diminished compliance
  • Artificial Sphincter and BUS show similar
    efficacy.
  • Artificial sphincter is preferred in patients
    with history of radiation and in post-TUPR
    incontinence.

49
CASE STUDY OUTCOME
  • Initial reaction to incontinence
  • Patient uses lt2 pads per day
  • Stress incontinence continues to limited
    patients hobbies such as golf, tennis and
    landscaping
  • Has limited social events to avoid embarrassment
  • PFM exercises were never really beneficial in
    fact it worsened the problem after 6 months
  • Will not consider further surgery unless the PPI
    gets worse.
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