The pre-surgery biopsy is available here. Post surgery biopsy below.
MAIN POINT TO NOTE: I have a small positive surgical margin [“To the naked eye, it can look as if all of the cancer has been removed, but when a pathologist examines tissue samples, cancer cells may be lurking right along the edge of the cut tissue. This means that some cancer cells may have been left behind, in what doctors and pathologists term a positive surgical margin.” –Source]
HOWEVER, it is in the para-apical area, which seems to suggest it is less like to cause a problem. [“Positive margins are more common at the apex, where there’s much less surrounding tissue, but they can occur in other areas, such as the bladder neck. A positive margin at the bladder neck probably has the highest likelihood of leading to biochemical recurrence…. The researchers found that patients with a positive margin at the bladder neck were three timesmore likely to have biochemical recurrence than patients with negative margins. Positive margins at the apex or laterally were equivalent in terms of recurrence, with patients twice as likely to experience biochemical recurrence as those with negative margins.” [Source] But also see this blog post.
FURTHER, it is the lowest category, i.e. Gleasen pattern 3. Obviously, if that area had Gleasen 4 pattern, the risk would be higher.
INITIAL VIEW: Regular PSA testing is essential in my case.
CLINICAL NOTES: HISTOPATHOLOGY
G1 3+4=7 PCA. Radical prostate.
1) “Prostate gland” – A prostate gland with attached seminal vesicles and vasa deferentia, 35mm apex to base, 45mm right to left lateral and 43mm anterior to posterior. Prostate weight without attached seminal vesicles and vasa deferentia is 39.7g. The attached right seminal vesicle is 25mm and the right attached vas deferens is up to 10mm. A possible detached left vas deferens is 25mm in length and a short stump of seminal vesicle is 5mm in maximum dimension. Specimen serially sliced from base to apex into 9 slices, with slice 1 being the base and slice 9 the apex. Within all slices are multilobulated circumscribed creamy nodules, predominantly in the anterior right and left lateral quadrants which appear to be closely abutting the anterior margin. Inking: anterior yellow, posterior black, left lateral green and false resection margin post seminal vesicle and vasa deferentia resection orange. RS, part processed. 36 blocks.
1A-1G – LS base slice 1:
1A-4, 1B-2, 1C-2, 1D-1, 1E-1, 1F-2, 1G-3LS
1H-1K – composite slice 2:
1H-1 left posterior slice, 1I-1 left anterior slice, 1J-1 right anterior slice, 1K-1 right posterior slice.
1L-1Q – composite slice 4:
1L-1 left posterior slice, 1M-1 left middle slice, 1N-1 left anterior slice, 10-1 right anterior slice, 1P-1 right middle slice, 1Q-1 right posterior slice.
1R-1W – composite slice 5:
1R-1 left posterior slice, 1S-1 left middle slice, 1T-1 left anterior slice, 1U-1 right anterior slice, 1V-1 right middle slice, 1W-1 right posterior slice.
1X-1AA – composite slice 6:
1X-1 left posterior slice, 1Y-1 left anterior slice, 1Z-1 right anterior slice, lAA-1 right posterior slice.
1AB-1AE – composite slice 7:
1AB-1 left posterior slice, lAC-1 left anterior slice, 1AD-1 right anterior slice, 1AE-1 right posterior slice.
1AF-1AG – composite slice 8:
1AF-1 left lateral half, 1AG-1 right lateral half, 1AH-1AJ-LS slice 9 apex.
lAH-3, lAI-2, lAJ-4LS.
1AK-1 – shave of right seminal vesicle and vas deferens
1AL-1 – shave of left seminal vesicle and vas deferens.
2) “Anterior prostate fat” – Multiple pieces of fatty tissue in aggregate 30 x 25 x 5mm. All in. 2 blocks. kp
1-2) The sections from this extensively sampled radical prostatectomy confirm acinar adenocarcinoma, predominantly characterised by separate well-formed infiltrative glands, with a minute component (<5%) represented by poorly-formed glands with ill-defined lumina, evoking modified Gleason score 3+4=7. Tumour is centred in the right anterior quadrant, and extends into both sides of the organ from apex to base in a patchy infiltrative pattern (estimated span 30mm). Tumour reveals no extraprostatic extension and there is no invasion of sampled seminal vesicles. The bladder neck shows unremarkable smooth muscle, and lymphovascular invasion is not identified. The tumour involves one anterior surgical margin over 1 mm span (Gleason pattern 3 disease, block 1AD), and 2 separately sampled lymph nodes within the preprostatic fat are free of tumour (specimen 2, 0/2). Background prostatic parenchyma exhibits nodular hyperplasia.
SYNOPTIC REPORT FOR PROSTATE CANCER
1-2) RADICAL PROSTATECTOMY (39.7g) AND PRE-PROSTATIC FAT
– ACINAR ADENOCARCINOMA,
– GLEASON SCORE 3+4=7 (ISUP GRADE GROUP 2),
– TUMOUR LOCATION: CENTRED IN RIGHT ANTERIOR QUADRANT,
– MAXIMUM SIZE OF DOMINANT NODULE: 30mm,
– OTHER TUMOUR NODULES >10MM: ABSENT,
– EXTRA-PROSTATIC EXTENSION: ABSENT,
– MARGIN STATUS: INVOLVED,
-> LOCATION: ANTERIOR, PARA-APICAL,
-> EXTENT OF INVOLVED MARGIN: 1mm,
-> TYPE OF INVOLVED MARGIN: SURGICAL,
-> GLEASON PATTERN AT MARGIN: PATTERN 3,
– SEMINAL VESICLES: NOT INVOLVED,
– BLADDER NECK: NOT INVOLVED,
– LYMPH NODE STATUS: IDENTIFIED IN ANTERIOR PROSTATIC FAT, NOT INVOLVED (0/2),
Most men wear diapers and just wait for several months until their bladder control returns, but current medical research tells us that an exercise program targeting the pelvic floor muscle below the bladder can help these men regain their control earlier,” said Daniel Kirages. [Source]
“17.91% (range 5% to 30%) of patients have post operative perineal pain. A quick survey of those on the call it appears between 10 and 20% of men undergoing robotic prostatectomy have post operative perineal pain. Open procedures result in 25 to 30% post operative pain especially the perineal approach.” [Source]
TEAR IN ANASTOMOSIS
This is a very serious complication when the stitches that join the bladder and urethra are torn due to strain. Straining can occur from constipation.
“Walsh had warned of the danger of straining the muscles while passing a stool—it was the thing that any patient recovering from a radical prostatectomy had to be most careful about.”
Straining can also occur from bicycling or weight lifting. [Hence, only start these exercises after 12 WEEKS]
The urethral meatus, which is the opening at the tip of the peni
The fossa navicularis, which is the urethra located proximal to the urethral meatus and within the glans, head of the penis [Sub-meatal stricture is in this area]
The penile urethra, which is the urethra that goes from the urethral meatus to the distal edge of the muscle, the bulbocavernosus muscle
The bulbar urethra, which goes from the beginning of the proximal urethra back to the end of the membranous urethra
The membranous urethra is a short area of the urethra that extends from the proximal bulbar urethra to the distal verumontanum (the verumontanum is a small mound in the urethra where the ejaculatory ducts open into and sperm enters the urethra).
The prostatic urethra is the urethra that goes from the end of the bladder neck (outlet of the bladder) to the verumontanum.
The bladder neck, the outlet of the bladder
THIS IS VERY UNCOMMON AFTER PROSTATECTOMY
“Urethral stricture disease (other than bladder neck contracture) is uncommon after radical prostatectomy.” [Source] (Sanjeev: However, it did occur in my case due to forced insertion of catheter).
WHEN IT HAPPENS, MOST COMMON AREA AFFECTED IS FOSSA NAVICULARIS
“When urethral strictures occur as a complication of prostate surgery, the most common location is the fossa navicularis, the portion of the urethra near the tip of the penis. This is likely related to the urethral catheter that is required during and after prostate surgery. Although the catheter passes through the entire urethra, the fossa navicularis is particularly susceptible to narrowing.” [Source] (Sanjeev: this is indeed where it occurred in my case)
HALF THE STRICTURES IN MEN ARE CAUSED BY CARELESS DOCTORS
“about one-half of causes of urethral stricture are from medical procedures and manipulation of the urethra or nearby structures (surgeries, catheter insertion, etc.).” [Source]
Many strictures are caused by poor use of catheters: “Judicious use of catheters and instrumentation may decrease the risk of urethral strictures”. [Source]
THE UNDERLYING REASON WHY IT RECURS
“For whatever reason a scar develops as a consequence of changes in the structure and function of the urethral epithelium and the sub-epithelial spongy tissue causing a fibrotic narrowing of the urethra” [Source]
RECURRENCE IS SOMETIMES VERYQUICK
“When the stricture recurs, it usually does so within weeks or months and almost always within two years.” [Source]
“Symptoms of urethral strictures are mostly urinary – painful urination, reduced urine output, slow urine stream, spraying of the stream, incomplete emptying of the bladder, and inability to void. Urinary tract infections are also common, and blood will occasionally appear in the urine. Diagnostic tests include urinalysis, urine cultures, uroflowmetry studies measuring the flow from the bladder, and post-void residual studies, in which an ultrasound measures the amount that is left after a normal voiding.” [Source]
Also known as Direct vision internal urethrotomy (DVIU)
“The literature is relatively uniform in stating that the patient who may enjoy success from an internal urethrotomy or dilation with curative intent will have a short segment stricture (1 to 1 1?2 cm.), will have relatively superficial spongiofibrosis, and the stricture will be located in the bulbous urethra. The success rate for internal urethrotomy and dilation for strictures other than in the bulbous urethra is dismally poor.” [Source]
OPTICAL URETHROTOMY IS NOT EFFECTIVE IN FOSSA NAVICULARIS
“Although the catheter passes through the entire urethra, the fossa navicularis is particularly susceptible to narrowing. This is not a common complication. However, when there is a stricture, the narrowing is usually severe and NOT cured with dilation.” [Source]
“For individuals with a soft stricture that is short, <1 cm long, located in a segment of the urethra called the bulbar urethra, DVIU has a stricture-free rate of 50%-70%. The success of DVIU in other locations and more dense strictures is often less.” [Source]
“Strictures which respond better to DVIU are those <1 cm in length, located in the bulbar urethra, and have a larger urethral lumen at the time of treatment.” [Source]
“DVIU may be repeated if the stricture recurs, however, after the third treatment or recurrence of the stricture less than three months after the procedure, repeat DVIU offers no long-term success.” [Source]
“Strictures which recur <3 months following treatment with DVIU have a stricture-free rate of 30% at 2 years and 0% at 4 years. Patients undergoing >3 DVIUs have a 100% failure rate.”[Source]
INTERMITTENT CATHERISATSION NOT EFFECTIVE/ CAN WORSEN THINGS
“There is a conflicting data regarding intermittent catheterization (IC), and if it reduces time to recurrence, however, IC necessitates continued urethral instrumentation and increases the likelihood of progression of the initial stricture.[22,23] Patients who perform IC have a greater chance of complication (urinary tract infection, infection, bleeding, etc.,).” [Source]
AUGMENTED URETHROPLASTY: THE ONLY SUSTAINABLE SOLUTION IN FOSSA NAVICULARIS:
“If the stricture is long and/or located in the penis, the stricture may be open or removed and the area is more commonly patched or less commonly replaced with a tube, made from surrounding tissues, such as nearby skin or from tissue removed from other areas in the body such as from the inside of the cheek (buccal mucosa). To allow the tissue to heal and minimize urine leakage during healing, a catheter is left in place. The duration of the catheter may vary with the extent and location of the stricture and whether the procedure is being performed in a single stage or in two stages.” [Source]
In such cases, “our preferred treatment is a urethral reconstruction using a small amount of penile skin (as a flap) as a patch to widen the narrow urethra. To date, we have had uniform success with this treatment, first published by Dr. Gelman’s mentor, Dr. Gerald Jordan.” [Source]
“The preferred treatment for penile urethral strictures and pan-urethral strictures is a buccal graft urethroplasty. This is a versatile option that can be placed anywhere along the urethra and can even extend the entire length of the urethra.” [Source]
REPEATED CUTTING OR DILATION IS A BAD IDEA
“Dilations and incisions should only be performed on short strictures
Repeat dilations and incisions don’t cure the problem and they may decrease the success of future urethroplasty.
The current standard of care is imaging, one incision or dilation, followed by the urethroplasty procedure.” [Source]
“Patients should only have one DVIU, as repeat DVIUs do not cure the disease and can render more effective urethroplasties less effective.” [Source]
DO NOT UNDERGO ANY MORE DVIU: STRAIGHT URETHROPLASTY
“multiple studies have evaluated cost-effectiveness of treatment of urethral strictures and found that either immediate urethroplasty or a single attempt at DVIU, followed by urethroplasty for failures, was more cost-effective than long-term dilation, or DVIU with urethroplasty used only for salvage procedures.” [Source]
UNFORTUNATELY, THERE IS NO UNANIMITY BETWEEN UROLOGISTS ON THIS ISSUE
“Treatment for urethral stricture and stenosis remains inconsistent between reconstructive and nonreconstructive urologists due to varying treatment algorithms and approaches to disease management.” [Source]
“Internal scarring from the operation is a further potential complication. If your urine flow deteriorates after surgery, it may mean that you will have to undergo dilatation (stretching) of the join between the bladder and urethra; this is usually curative, but sometimes has to be repeated. Some patients will require a period of self-catheterization to ensure that the join between the bladder neck and the urethra remains wide open as it heals. The risk of this is now thankfully much lower after laparoscopic or robot-assisted surgery.” [Source]
“Some men develop a narrowing of the urethra where it is surgically attached to the bladder, and thus a narrowing of the urinary stream. Severe cases of this bladder neck obstruction require surgical dilation, which can be done as an outpatient procedure.”
Some of the symptoms associated with contracture of the bladder neck include:
Needing to push to begin urination
Delayed onset of urination (following the urge to urinate)
Men usually begin to experience symptoms of bladder neck contracture within 3 to 6 months after prostate surgery. At first, a man may notice a gradual reduction in the flow of urine. This symptom may be overlooked at first, and can progress to the point where he becomes unable to urinate. In other cases, a man might experience urine leakage when the bladder becomes too full. This condition is known as overflow incontinence.
The symptoms of Bladder Neck Contracture usually start to appear within 5-6 months after a prostate surgery. There will be a gradual decline in the urinary output. This may sound normal first but over time the individual may not be able to urinate.
BNC typically presents with lower urinary tract symptoms in particular reduced stream shortly following radical prostatectomy or ultimately retention of urine. Retrospective series have reported that the majority of BNCs present within 6 months following prostatectomy [18, 19]. In a series with prospective followup, Giannarini et al. reported development of BNC at a median time of 3.8 months after radical prostatectomy
The effect of bladder neck contracture on urinary incontinence may be several fold. Firstly, bladder outflow obstruction due to a contracture may aggravate overactive bladder symptoms and thus worsen any component of urge incontinence contributing to the patients overall symptoms. Secondly, it has been suggested that, in determining the rigidity of the anastomotic region, presence of a bladder neck contracture may impair the ability of even a preserved external sphincter contraction to close the bladder outlet efficiently . THIS MIGHT BE CAUSING INCONTINENCE IN MY CASE
“Bladder neck contracture (BNC) or vesicourethral stenosis is a known complication of RP occurring in 0% to 17.5% of cases.”
“Bladder neck obstruction after prostate surgery or radiation is suggested by a slow urinary stream. However, patients can develop other symptoms such as male urinary incontinence. Although incontinence in men after prostate cancer treatment is often due to a lack of sphincter function and control, when there is bladder neck obstruction, the leakage can be from what is called overflow incontinence. The blockage associated with bladder neck contractures can lead to bladder and possibly kidney damage.” [Source]
Scar tissue can form between the bladder and urethra. The symptoms usually include a slow urinary stream, increased urinary frequency, painful urination, or urinary retention. Treatment includes dilation (stretching the tissue under anesthesia with an instrument that is passed up the urethra). In severe cases, it may require cutting the scar tissue away (under anesthesia) and injection of a cortisone-like drug.[Source]
Just over 8 out of every 100 men (8%) need treatment to help them pass urine more easily again. A doctor stretches the narrow area during a short operation. They might slide a thin rod into the urethra to widen it. Or they may use a thin flexible tube with a light and camera on the end. They can see the narrowed area and put a tiny knife down the tube to cut away tissue and open up the urethra. You have these operations under local or general anaesthetic. You might need to have this operation repeated if the urethra gets narrower again.[Source]
Further: – diagnosis tools
There are several tests available to confirm the diagnosis of Bladder Neck Contracture. To begin with the physician will take a history of the patient inquiring as to whether there is a history of prior prostate problems and/or surgery. If the history of the patient points towards Bladder Neck Contracture then the physician may perform a cystoscopy in which a thin tube is inserted through the urethra into the bladder to look at the internal structures. The bladder is filled with sterile water so as to expand the bladder for a better view. This test will clearly show scar tissue formation within the bladder neck and confirm the diagnosis of Bladder Neck Contracture. Additionally, a cystourethrogrammay be performed which utilizes x-ray.
In this study, a catheter is inserted through the urethra into the bladder. A contrast material is introduced into the bladder and x-ray studies are taken. This study will also show the presence of scar tissue formation near the bladder neck confirming the diagnosis of Bladder Neck Contracture. [Source]
FIX IT AS SOON AS POSSIBLE
“I had a bladder neck contracture after my RP three years ago. I noticed a gradually diminished flow for about six months, then a rapid decrease in volume and rate. Eventually, I needed a dilatation and had to self-catheterize once daily over six weeks. Not a lot of fun, but my urologist had wanted to do the dilation months earlier, at the first sign of decreased flow. As soon as you can reach your urologist, you may want to ask for this to be done, as waiting in the ER for someone to come dilate you while your bladder is maximally filled cannot be enjoyable. Better to do it on your schedule.” [Source]
“A slowly diminishing stream and eventually constant trips to the bath room because I couldn’t empty the bladder totally. I didn’t wait around (fear of ER visit and cath). Two trips to the Uro involved dilation and catheter for a few days and the third time actual surgery to correct the stricture. Pay attention to the problem because as David can affirm, you don’t want to get totally plugged up. ” [Source]
“I patiently (maybe not so much) waited about 2 months before I complained to my uro. After about 90 days of no progress he scheduled surgery to remove a stricture in the bladder neck. That solved the problem” [Source]
“the fact that he is dry at night suggests that he will eventually be dry during the day as well. Men who are left with permanent problems tend to have no control night or day.” [Source]
RECOVERY IN NINE WEEKS
THE FOLLOWING IS FROM Pre- and Postoperative Pelvic Floor Physical Therapy Enhances the Return to Continence Following Robot-Assisted Laparoscopic Prostatectomy: A Case Report by Natalie Herback, Journal of Women’s Health Physical TherapyJ Issue: Volume 34(1), January/April 2010, p 18–23
Case Description: A 52-year-old man was referred to PFPT 4½ weeks prior to RAP by the urologist. The patient reported good health overall and denied any UI symptoms. The patient returned to PFPT 13 days following surgery and 4 days following catheter removal. He reported constant leakage with all activity, use of 2 to 3 pads per day, use of 1 to 2 pads per night, and full saturation. At the preoperative visit, a full pelvic floor examination was performed, including electromyogram biofeedback. The patient displayed pelvic strength score of 5/5 with 8-second endurance contractions and an average of 66.5 mV on biofeedback. These quantitative measures were used to compare pre- and postoperative strengths.
Outcomes: In this study, objective measures demonstrated the patient’s success with PFPT. After 2 PFPT appointments, the patient’s pelvic floor strength score returned to the presurgical strength score of 5/5. By the fourth visit, the patient’s strength had surpassed his presurgical strength by more than 40%. Additionally, the Internal Index of Erectile Function and Urinary Distress Inventory were used as assessment scales.
Discussion: UI is a common complication of RAP and is most effectively treated with conservative PFPT. PFPT has been found to be most effective if initiated preoperatively and then again immediately following catheter removal. This case report clearly supports this hypothesis, as the patient’s postoperative physical therapy was initiated shortly after catheter removal and he was discharged 9 weeks later, fully continent.
“When my catheter was removed I ( like many others ) had no control whatsoever .… For the first few months I made very little progress and was using between 6 to 8 pads a day ( very expensive! )….
Slowly but surely things started to improve gradually after about 3 to 4 months post op. I am now 7 months post op and still need to use 2 pads daily on average, but am hopeful that I will improve more over the next 6 months or so….” [Source]
RECOVERY IN FOUR MONTHS
“Dryness comes first at night usually pretty quickly as it has with you. The rest takes longer. With me it took 4 months to be completely dry and pad free. Even now though a good laugh, cough, sneeze or fart especially after too much alcohol will lead to a small squirt and some dampness but nothing that would show outside.” [Source]
RECOVERY IN 4 1/2 MONTHS
“30 March: After 2 weeks I have absolutely no flow control. It’s as though the catheter was still in place, since urine dribbles continuously if I am standing or walking. There is no leakage while I am sitting or lying down, but the urine starts flowing as I’m in the process of standing to get out of the chair or bed.
“19 May: I now have some flow control. I can walk around the house, slowly, without leaking. When I get the urge to pee, I can (usually) make it to bathroom without leaking. If I take it easy, I can go a whole day without leaking!
“17 June: I can now walk up and down stair without squirting.
“29 July: I can now run without draining my bladder. Sprinting is out of the question, but I can run for 2 miles at 5 mph then get off the treadmill and go to the bathroom to empty my bladder. Most days I no longer worry about leakage.” [Source]
RECOVERY IN 12 WEEKS (four months)
Terry achieved continence 9-10 weeks after the catheter was removed. He stopped using pads at night during week eight, and 10 days later stopped using a pad in the day. Overall, he was continent fewer than 12 weeks after the operation. [Source]
RECOVERY IN NINE MONTHS – ALL OF A SUDDEN
“An elderly man told me not to lose hope. He had been incontinent for over a year, then one day, out of the blue, it had stopped, and he’d been dry ever since.” [Michael Korda in his book, MAN TO MAN
RECOVERY IN TEN MONTHS
“For the first 3 months he had no bladder control, did his excersizes faithfully. Then he started having less and less leakage. He had to wear a condom catheter when he went back to work as he could feel the need to go, but could not hold it. We are now 10 months post-op and he has total control. Wears nothing.” [Source]
RECOVERY IN 15 MONTHS
My daVinci surgery took place in December 2008. My incontinence lasted for 15 months. I was 100 percent incontinent for about the first 12 months using about 15 super absorbent pads per day. From the beginning I had no leakage as long as I was sitting or lying down. As soon as I got up the flood gates would open. I would keep a jar next to the bed because as soon as I got up to relieve myself I completely lost control.
After 12 months my ability to control urine flow began to return. By 15 months I was fully continent. Here I am more than 6 years after surgery and fully continent. I’m a runner. I wear a light pad for security for runs exceeding 5 miles. Often there is nothing in the pad after a run.
When my journey began and I found myself incontinent I was devastated. Many posts on this site urged me to be patient and my situation would improve. It did improve. It improved beyond my wildest expectations to almost 100 percent.
Others have said you will regain your continence after surgery 98 percent of the time. When I was at my worst I didn’t believe it. Your chances of regaining continence are very good. It might take time but the odds are clearly on your side! [Source]
DECENT RECOVERY IN NINE MONTHS
02/16/2011 – catheter removed, total incontinence, impotence
11/30/2011 – surgery for penile prosthesis, incontinence down to 1 pad a day [Source]
TOLERABLE RECOVERY IN THREE YEARS
My RP was in February of 1998. I am 6′ tall and weigh about 150. My incontinence is still there, but has diminished to the point where many days of the week, my Depends pads are totally dry. I do not need the pads during the night. I still try to keep practicing the Kegel exercises in the hopes that the incontinence will totally be cured. My worst times are when I need to squat down as in weeding the planters and other
jobs close to the ground. Even during the worst times, I estimate the volume as less than a tablespoon. The exercise of stopping and then starting the flow while urinating seems to have been the most help in training the muscles needed to prevent leakage. Each person is certainly different, and the surgury may have done differing amounts of damage, but with the exercises and trying to stop the flow at various times, there has been considerable improvement over these three years. After the RP, I was using several Depends pads per day. I’m still noticing improvements as time goes by, so I would encourage Tom to keep up with the
exercises and concentrating on urinary control.” [MAILING LIST]
“In April 08 Discovered US TOO and went to local session in Fairfax Virginia where I met BJ CZarapata, a nurse practitioner specializing in female and male incontinence with major focus on post RP incontinence. After some exploration and initial testing we started e-stim (electrical stimulation) and low dose of Vesicare to help relax bladder. Over next 12 weeks conducted daily e-stim therapy at home with varying levels of success. Current status is: 25% to 50% incontinent depending on day, how much I move around.” [Source]
“We developed sacral surface therapeutic electrical stimulation (SSTES) as a therapy for urinary incontinence using neuromodulation . In this therapy, skin surface electrodes are applied on the sacral surface to provide stimulation, making the treatment very easy to perform. It has been shown that SSTES has not only an inhibitory effect on detrusor overactivity but also an efferent stimulant effect to the pudendal nerve. It is thus expected that SSTES initiated in an early postoperative period would be effective for early recovery of postoperative urinary continence.”
To investigate whether sacral surface therapeutic electrical stimulation (SSTES) initiated during the early postoperative period would be effective towards early recovery of postprostatectomy urinary continence.
A total of 35 consecutive patients who underwent radical prostatectomy by a single surgeon were enrolled in this study. Twenty early patients began pelvic floor muscle exercise (PME). Fifteen subsequent patients received SSTES postoperatively with no instruction for PME provided. Immediate urinary function just after catheter removal was evaluated with frequency-volume chart and 24-hour pad test.
There were no differences between the SSTES and PME groups in maximum voided volume capacity (MVV) and urine loss ratio (ULR) on the first day after removal of urethral catheter. However, on day 3 MVV was significantly larger and ULR was also significantly lower in the SSTES group.
SSTES treatment is feasible and appears to be effective for early recovery of urinary continence after radical prostatectomy.
From day one, I have had continual incontinence and that is how it has remained. I feel no urgency, no flow, no evacuation. I don’t feel anything but the warm wet in my crotch.
Over night, things changed rapidly: Things started to change. Three times, while sitting at my computer, I got up slowly, made my way to the bathroom and was able to pee. The real change came in the night. I couldn’t sleep until about 2:00 AM. Each hour thereafter until 6:30 AM, I was awakened with an urge to pee. I made my way to the bathroom and did, in fact, pee, even felt relief. This miracle was repeated at 8:00 AM and 9:30 AM when I finally decided that additional sleep was not in the cards.
As I enter my 14th week after surgery, I believe I’m gaining some control over incontinence. Points of encouragement: (1) I used fewer diapers on my two week trip than expected; (2) I was able to hold my urine while gassing up, getting off the bike, paying and working my way to the men’s room where I would deposit some pee. I’m far from diaper free. I’m still a 24/7 wearer but they are less wet over a longer amount of time; (3) I am quite good at holding my urine while sleeping although I have to get up about every 1-1.5 hours to pee; (4) I can usually get about 50% of my urine in the bowl if I am only sitting around and talking or working on the computer. As expected, moving around and doing stuff, even as simple as standing up, still causes significant wetting.
After 21 weeks: I’m back at my usual tasks – incontinence is a persistent inconvenience. I am still experiencing continual incontinence. When I sleep there is still some degree of control and I don’t always dribble all over the bathroom after I shower. That is progress but the progress has not continued. I appear to have reached a recovery plateau.
At six months: I am still plagued by near continual incontinence. There is little to no sensation of urgency, flow, or evacuation and as I grow accustomed to life in wet diapers, I tend to overlook the sense of wetness often with embarrassing results. I am best when prone, when I do experience a small sense of urgency that awakens me. My sphincter is strong enough to keep me from wetting the floor or the toilet seat but the urine already past the sphincter does leak out into the diaper when I arise. I can usually make it through the night with a single diaper soiled only by the slight leakage mentioned from a few trips to the bathroom. I continue half-heartedly and sporadically with the Kegel exercises.
NINE MONTHS: “Having reviewed the blood and lab work ordered by my doctor previously, the team that she had assembled agreed that the most likely conclusion was neurological damage incurred during the prostatectomy.” [The doctor “advised that my anal sphincter had been neurologically damaged by the surgery and that it accounted for some of my symptoms.”. Further “The second sphincter, the one below the prostate, was badly damaged and not likely to ever function properly again.”]
SLING SURGERY: “Dr. Ng and I are on the same page about all the alternatives and the Plan B and C options should the procedure of choice (the latest in incontinence technology, the AdVance Sling, which replaced the Invance sling and has a number of improvements). Dr. Ng, always conscious of the patients feeling and concerns, suggest I think it over and let her know. I say, no. Do it. Dr. Ng immediately set the ball rolling and I expect the surgery will be sometime this month or early March. … After 8 plus months of persistent incontinence, that is continual incontinence (I feel nothing), I have opted for an implant of the AMS AdVance sling. ”
AFTER SLING SURGERY: “Eleven days later, I still leak when coughing, sneezing, or during any degree of exertion. When the doctor tells you to take it easy for 6-8 weeks – DO NOTHING!!! The bottom line is that despite the slight leakage, I am 99% dry, the cost of pads is significantly lower, and I continue to do my Kegels to aid the process.”
SLING SURGERY IS VERY DELICATE: “the sling is “anchored” only in the muscle, and stretching it by spreading the legs applies pressure to the sling and tends to pull it free from the muscle, this is not a desirable activity. (I should have had my son lift both my legs into the car for me.) The mechanism is like Velcro hooks on a strap which are intended to grow into the muscle to secure the sling. However, great care must be taken not to engage in any activity that might pull the sling taught and this create a little slack when the tension is released. ”
SURGERY DID NOT WORK: “There is a standard for measuring the strength of the sphincter. Either the sling or a normal sphincter requires a rating of 40. Mine is at 12. Very weak.”
NEXT STEP: ARTIFICIAL SPHINCTER: “Six weeks ago I endured the uncomfortable and mind scrambling surgical implant of a device designed to operate as an artificial urinary sphincter (AMS 800 Urinary Control System)”
The surgeon in my case DID cause quite a terrible injury (sub-meatal urethral stricture) during the radical prostate surgery which was conducted on 7 August 2017.
I needed an emergency urethrotomy first (on 11 September 2017). That did NOT work and the stricture came back very quickly. He wanted me to use dilation but I did not agree, given the literature does not support it.
Fortunately, my surgeon was good enough to refer me to another surgeon who specialises in urethral strictures and he managed to conduct a 1st stage penile urethroplasty and cystoscopy on 11 October 2017. That managed to fix the sub-meatal stricture and I was able to return to work more or less regularly after mid-November.
The stuff below is my research conducted starting 20 August 2017.
RESEARCH August 20 2017 PRIOR TO SOLUTION
Removal of catheter after prostate surgery was very painful in my case. I’m also having continuing severe pain inside the tip of my penis – making it almost difficult to urinate and even walk. It is now nearly two weeks after surgery.
COULD BE FROM THE CATHETER:
“burning in the urethra could be as a result of the catheter or having urinary tract infection.
the best thing is first to check the urine and make sure that there is no infection… ” [Source]
My research has suggested that catheters CAN injure. These are called IATROGENIC INJURIES (i.e. caused BY INSTRUMENTS). “Endourological procedures are the most common cause of iatrogenic ureteral injuries. When identified at injury and treated properly such injuries seldom lead to loss of renal function. [Source]”
Iatrogenic Trauma: Iatrogenic urethral injuries caused by instrumentation are by far the most common cause of urethral trauma. Urethral ischemic injuries related to cardiac bypass procedures are not infrequent and can result in long and fibrotic strictures. ” [M. Hohenfellner · R.A. Santucci (Eds.) Emergencies in Urology]
However, it also seems to be the case that catheter trauma would lead to bleeding and clotting. There is none in my case.
“In the absence of blood at the meatus or hematoma [a solid swelling of clotted blood within the tissues], a urological injury is very unlikely” [ibid]. Note that “The amount of urethral bleeding correlates poorly with the severity of injury, as a mucosal contusion or small partial tear may be accompanied by copious bleeding, while total transection of the urethra may result in little bleeding (Antoci and Schiff 1982).” [ibid]
COULD BE REFERRED PAIN FROM THE SURGERY
“I’m seven months post-op from a robotic RP. After walking or standing for a period of time–30-60 minutes is typical–I slowly develop a burning pain in the tip of my penis. … I just about always have burning during urination, too. That burning typically lingers for a few minutes after urination. ” [Source]
“I believe that’s [pain in the penis] common, but varies from person to person. My pain in the tip of my penis lasted 2 months.My doctor said to take advil and stay off my feet when possible. You’re right, sometimes the pain was excruciating. The good news is it goes away.” [Source]
“I had penile pain up to 8 mos post surgery.” [Source]
“I still have a slight sting/burn on occasion , my surgery was sept 19th 07” [one year earlier] [Source]
“I did have stinging at the tip but it slowly diminished over time.” [Source]
“It is getting better very slowly. This is week 4. It’s like watching grass grow” [Source]
“doc felt that it may be a scab or existing bruise in urethra..dont think it UTI or a strciture as the urine is clear and flow strong. doc suggested to wait and see for improvement…aggressive approach may to put a scope in the penis and see the problem and also do CT scan..but that will only irritate the urethra more..” [Source]
“Lots of guys complain of that pain. My theory is that in a lot of cases it is caused by irritation from the stitches that were used to stitch the urethra to the bladder neck. Those stitches will be attacked by his body as he heals and absorbed but that process can take months and months and in the meanwhile they can be irritating. His problem could also be some sort of entrapment of the pudendal nerve in the area of his surgery. The good news is that the pain usually goes away eventually.” [Source]
“It’s possible that ibuprofenmight help. Your discomfort is caused by irritation and/or inflammation in your internal stitches and ordinary pain killers might actually help, especially those that are anti-inflammatories as well. If that doesn’t work, you might ask your doctor if he minds if you try some pyridium to see if it helps with your discomfort. It’s a urinary analgesic that is available over the counter in the US and Canada.” [Source]
One GP (doesn’t sound like one) has recommended Amoxycillin [Source]
OTHER DATA RE: IATROGENIC TRAUMA
(watch below at 25:05)
Mechanism of injury include: blunt trauma such as MVA or falls, penetrating injuries, straddle injuries and Iatrogenic injury like traumatic catheter placement. Posterior urethral injuries commonly associated with pelvic fractures. Anterior urethral injuries come from blunt trauma to the perineum (straddle injuries)