Surgery for urinary incontinence due to presumed sphincter deficiency after prostate surgery

Background

Urinary leakage (incontinence) after surgery to remove the prostate (prostatectomy) for benign or malignant disease is a well-known and often feared outcome. Although a small amount of incontinence may not cause a problem, larger degrees of incontinence can have a major impact on a man's quality of life. Improvement in urinary leakage may occur six to 12 months after the prostatic surgery, but for men with persistent bothersome leakage despite conservative therapy such as pelvic floor exercises, surgery may be offered.

Study characteristics

We searched scientific databases for trials that had considered the effectiveness of the surgical treatments of urinary incontinence after prostate surgery in men. The trials had to compare surgical treatment versus no treatment, non-surgical treatment, or another surgical treatment. The evidence is current to April 2014.

Key results and quality of the evidence

There are five main types of surgery and, despite some of them being in use since the 1990s, we found only one trial that met the inclusion criteria. There was very low quality evidence that the implantation of an artificial urinary sphincter (a manufactured device to prevent urine leaking out) might be more effective than injectable treatment, but with more adverse effects and higher costs. There was no evidence about the other types of surgery.

Authors' conclusions: 

The evidence available at present was of very low quality because we identified only one small randomised clinical trial. Although the result was favourable for the implantation of AUS in the group with severe incontinence, this result should be considered with caution due to the small sample size and uncertain methodological quality of the study found.

Read the full abstract...
Background: 

Incontinence after prostatectomy for benign or malignant disease is a well-known and often a feared outcome. Although small degrees of incidental incontinence may go virtually unnoticed, larger degrees of incontinence can have a major impact on a man's quality of life.

Conceptually, post-prostatectomy incontinence may be caused by sphincter malfunction or bladder dysfunction, or both. Most men with post-prostatectomy incontinence (60% to 100%) have stress urinary incontinence, which is involuntary urinary leakage on effort or exertion, or on sneezing or coughing. This may be due to intrinsic sphincter deficiency and may be treated with surgery for optimal management of incontinence. Detrusor dysfunction is more common after surgery for benign prostatic disease.

Objectives: 

To determine the effects of surgical treatment for urinary incontinence related to presumed sphincter deficiency after prostate surgery for:

- men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) - transurethral resection of prostate (TURP), photo vaporisation of the prostate, laser enucleation of the prostate or open prostatectomy - and

- men with prostate cancer - radical prostatectomy (retropubic, perineal, laparoscopic, or robotic).

Search strategy: 

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, and handsearching of journals and conference proceedings (searched 31 March 2014); MEDLINE (January 1966 to April 2014); EMBASE (January 1988 to April 2014); and LILACS (January 1982 to April 2014). We handsearched the reference lists of relevant articles and conference proceedings. We contacted investigators to locate studies.

Selection criteria: 

Randomised or quasi-randomised trials that include surgical treatments of urinary incontinence after prostate surgery.

Data collection and analysis: 

Two authors independently screened the trials identified, appraised quality of papers, and extracted data.

Main results: 

Only one study with 45 participants met the inclusion criteria. Men were divided in two sub-groups (minimal or total incontinence) and each group was randomised to artificial urethral sphincter (AUS) implantation or Macroplastique injection. Follow-up ranged from six to 120 months. In the trial as a whole, the men treated with AUS were more likely to be dry (18/20, 82%) than those who had the injectable treatment (11/23, 46%) (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.28 to 25.10). However, this effect was only statistically significant for the men with more severe ('total') incontinence (OR 8.89, 95% CI 1.40 to 56.57) and the CIs were wide. There were more severe complications in the group undergoing AUS, and the costs were higher. AUS implantation was complicated in 5/22 (23%) men: the implant had to be removed from one man because of infection and in one man due to the erosion of the cuff, in one man the pump was changed due to mechanical failure, in one man there was migration to the intraperitoneal region, and one man experienced scrotal erosion. In the injectable group, 3/23 (13%) men had a complication: one man treated with Macroplastique injection had to be catheterised because of urinary retention and two men developed urinary tract infections.

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