Surgical options for improving post-prostate surgery incontinence

BE AWARE THAT ONCE YOU INSTALL THE ARTIFICIAL SPHINCTER, YOU’VE ELIMINATED ALL POSSIBILITIES FOR A RETURN TO NORMAL CONTROL: “Urologists I dealt with were reluctant to do the sphincter, because there would be no possibility of return to normal control. “Burning a bridge” was the term.” [a mailing list]

This link provides a list of options and their pros and cons.

In the last years, the urological community has been developing new procedures to treat postprostatic surgery urinary incontinence. Despite their long history of use, collagen injections are associated with low cure rates. Moreover, collagen is gradually reabsorbed by the organism, leading to additional applications of the product, along with no significant increase in long-term cure.

** proact device at the bladder neck

The proact device is a newer treatment which involves a minor surgical procedure to place two balloons next to the bladder neck. This is done as a day only or overnight stay procedure. It gives one the opportunity to top up the balloons until urinary control is markedly improved or perfect. It often takes up to six months to get to that stage. There is a 10% risk of infection and a 10% chance of incorrectly positioning these balloons, or erosions. Four-year results appear to have very promising outcomes at this stage. At St Vincent’s we have been performing these for almost two years and results are very encouraging. [Source]

1) Artificial sphincter: Artificial Urinary Sphincter – The AMS 800™ Urinary Control System is  the “Gold Standard Treatment” for incontinence. This implantable device  mimics the function of a healthy urinary sphincter, closing off the urethra  in order to stop the flow of urine. The procedure involves implanting an  inflatable cuff around the urethra, which is inflated by a fluid-filled balloon  that is placed behind the pelvic bone. A pump inside the scrotum allows  the man to deflate the cuff when he needs to urinate. It will automatically  re-inflate, firmly closing off the urethra, preventing leakage. [Source]

The AMS 800 is a body-shaped strap that is placed around the bladder neck or bulbar urethra. This body is connected to a balloon pressure regulator via a control pump, located in the scrotum of the patient. The whole system is filled with saline, hydraulic operation. The pressure in the system and therefore the strength of the occlusive balloon body is determined by the throttle, being maintained in the system except when the pump is activated voluntarily by patients who do not account for intermittent catheterization. This activation provides the rapid emptying of saline in the body, which fluid is directed to the balloon pressure regulator, momentarily removing the occlusive force of the body and allowing urination by the patient. The body is kept empty for long enough (2-3 min) so that urination is complete before returning to gain momentum due to the return of occlusive saline.

Follow-up ranged from 27 to 132 months (mean 53.4 +- 21.4 months). There was a significant reduction in pad count from 4.0 +- 0.9 to 0.62 +- 1.07 diapers per day (P<0.001) leading to continence in 90%. Twenty patients (50%) were completely dry, and 16 (40%) required 1 pad per day. There was a significant reduction on the impact of incontinence decreasing from 5.0 +- 0.7 to 1.4 +- 0.93 (P _0.001) in a visual analogue scale (VAS). Surgical revision rate was 20%.

The main complications related to the AMS 800 are: Revision rate of the device in 5 years (26%), malfunctioning device (8%), pain/discomfort (6,9%), slow healing of wounds (5,7%), bladder spasms (2,3%), activation difficult (2,3%), displacement of the device (3,5%), erosion tissue (2,3%), disabling difficult (1,1%), infection (2,3%), recurring incontinence (3,5%), fistula formation (1,1%), hematoma (1,1%), swelling (2,3%), hydrocele (1,1%), erosion tissue/infection (1,1%), patient dissatisfaction (1,1%), incontinence position (1,1%), wound infection (1,1%), urinary retention (1,1%) (Shellock F, et al. 1988; Litwiller SE, et al. 1996) [Source: Urinary Incontinence (Edited by Ammar Alhasso and Ashani Fernando)]

2) Constrictor Inflatable Periurethral: The AMS 800 is the best treatment for the patients with severe sphincter incontinence, but preliminary data from the Constrictor Inflatable Periurethral are encouraging.  Despite their recognized efficacy, the greater structural complexity of the AMS 800 has a direct impact on their high cost. Meanwhile, the Constrictor has provided preliminary efficacy results similar to the AMS 800, on a smaller device cost about 16 times.

The Constrictor Inflatable Periurethral SILIMED (Rio de Janeiro – Brazil) device consists essentially of 2 parts – body and valve constriction. The main functional difference between the two devices is that the force of the occlusive body Constrictor Inflatable Periurethral remains constant throughout the duration of use of the device. If necessary, the patient’s physician can make periodic adjustments of pressure in order to increase or decrease the force of the occlusive body, through the injection or removal of saline through the valve device in an outpatient setting. Meanwhile, the literature indicates a technical difficulty related to the change in pressure in the system of the AMS 800, possible only after revision surgery for the exchange of the balloon pressure regulator (Mundy, 1991).

The medical and scientific literature presents both AMS 800 and the Constrictor Inflatable Periurethral (preliminary data) as trusted devices and with good durability. Any problems would be reversed, in most cases, for simple or surgical outpatient review, which would ensure good continence rates, according to the criteria of effectiveness adopted by different authors.

The relative simplicity of the Constrictor apparently does not interfere with its effectiveness. Studies of the groups of Dr. Salvador Vilar and Dr. João Schiavini Constrictor present with continence rates of around 85% during treatment, as mentioned ahead. Moreover, the Constrictor was also able to provide some patients voiding spontaneously, especially in adults with urinary incontinence after prostate surgery sphincter. Even in cases where intermittent catheterization was used, the rate of patient satisfaction were generally high. [Source: Urinary Incontinence (Edited by Ammar Alhasso and Ashani Fernando)]

3) Collagen injections: Injecting bulk-producing agents, such as collagen into the  bladder neck, can help keep the urethra and bladder opening closed and  may help prevent small leaks. Even if successful, repeated injections over  time may be required to maintain continence. [Source]

Treatments such as collagen injections and the periurethral sling men do not appear as effective alternatives for long-term treatment of severe forms of this type of incontinence. Despite the long history of use, collagen injections are associated with success rates that generally do not exceed 40% cure rate. Due to the metabolism of collagen in the body, there is a gradual decrease in cure rates associated with the technique. This transient effectiveness usually takes the need for applying multiple injections on each patient, increasing the treatment without increasing the rates of long-term success. [Source: Urinary Incontinence (Edited by Ammar Alhasso and Ashani Fernando)]

4) Male sling:  The AdVance™ Male Sling System from American Medical  Systems (AMS) is positioned in the body with a minimally invasive,  surgical procedure for correcting stress urinary incontinence.  A small “sling” made of synthetic mesh is placed inside the body  through three small incisions. The sling supports the urethra, restoring  normal bladder control. Most patients are continent immediately following the procedure. [Source]

The male sling appeared as a possible treatment for patients with sphincter incontinence after prostate surgery. However, the results were effective only in patients with mild to moderate incontinence. Sahaja & Terris, 2006, also pointed out that the male sling would not be as effective as a device with more physiological action, such as the artificial sphincter. For the structural similarity between the body of the AMS 800 and the Constrictor, this reasoning could be extended to the Constrictor.

In 2007, Schiavini & Resende Jr and colleagues, University Hospital Pedro Ernesto, Rio de Janeiro, study, eighteen patients had urinary incontinence after radical retropubic prostatectomy, and five were previously submitted to procedures for the treatment of bladder neck strictures. In all patients, the body of the device was placed around the bulbar urethra, with activation of the device after 8 weeks. Patients were followed from 6 to 36 months. For the authors, successful treatment was predefined as the need to use a diaper until the day -social continence, together with patient satisfaction.

The patient is subjected to anesthesia. Ureteroscopy with internal urethrotomy was performed when it was not possible to place a bladder catheter preoperatively. To implement the Constrictor Inflatable Periurethral around the bulbar urethra, the surgical access of up to 10cm in the perineal raphe, with the developer in the lithotomy position. The muscle fibers bulb-cavernous must be separated in the longitudinal direction, and the bulbar urethra dissected easily visible and later by creating the space for placing the constriction around her body.

The Constrictor Inflatable Periurethral should have your air completely removed before being introduced into 2 ml of pyrogen-free saline. Meticulous haemostasis is essential to reduce risk of haematoma formation.

The urethral catheter can be withdrawn on the 1st postoperative day. Activation of Inflatable Periurethral Constrictor should be held approximately 8 weeks (at least 6 and at most 12 weeks) after implantation, when a urodynamic study should be performed in conjunction with the measurement of pressure inside the device. [Source: Urinary Incontinence (Edited by Ammar Alhasso and Ashani Fernando)]