Surgery for urinary incontinence after radical prostatectomy
When involuntary loss of urine after removal of the prostate, there are numerous surgical treatment options. New to this was to learn on the German Association of Urology congress in 2008.
After radical prostatectomy may lead to a persistent urinary incontinence. It is usually a stress urinary incontinence, which means a loss of urine without urinary urgency with increased pressure in the abdomen (eg coughing, sneezing or laughing; details, see urinary incontinence). Cause is a weakness of the sphincter, for example because the muscle or its stabilizing ligaments were harmed in the operation or because the bladder neck is no longer supported by the prostate.
Treatment is initially in the context of rehabilitation through templates, medications and pelvic floor muscles, the latter with the help of biofeedback (with feedback of success) or the electric or magnetic field stimulation. If the incontinence so not to get a grip, can be considered depending on the patient and findings is one of a number of different surgical procedures.Many of them are fairly new and are constantly being developed and tested in trials. They can be on the nature of the method and the size of the necessary procedure divided into the following three groups:
"Bulking": placing of fill material
The narrowing of the urethra with filler (English "bulking agents" of bulk = large amount, bulky = bulky) can be done by injections of their mucous membrane with various substances (eg, silicone, collagen). This is the simplest procedure, but its success is lower than with other methods.
Another possibility is to place a short engagement of the dam from a small balloon each left and right of the urethra below the bladder. Of them, from thin tubes lead into the scrotum. If necessary, can also increase later with a syringe filling the balloons. Available on this system before some investigation.
After a French work (see Adler, fresh), it is unsuitable if a post-irradiation of the prostate area is done, and it often has to be removed because of complications relative, but can be used sometimes later. Overall, 71% of patients needed after 6 months maximally only one template.According to a new study (Verweyen 1 +2), this applied to 68% of patients at the end of filling.After an average of just under a year, at least a significant improvement was about 70% was recorded, and a similar number were satisfied with the result.
Loop systems: narrowing and displacement of the urethra
Such systems include the urethra from below or behind with a belt whose ends are led to the ischium to the pubis or the front-side forward-up. So that the urethra more or less concentrated and displaced to its former position. The systems differ also in the material and in whether a later adjustment (adjustment of voltage) is possible or not. In new, small studies, two systems showed to be safe and effective: A adjustierbare, pulling the pubic bone loop (Orth, 14 patients) and a transobturatorisches (run by the seat leg openings) band (Durner, 49 patients).
After a further new investigations, for vast majority of men with mild to moderate stress urinary incontinence after radical prostatectomy, this also applies for the currently most discussed system in which it is not a adjustierbare transobturator sling. It was found that the daily consumption template after surgery significantly plummeted (mean values, continent = maximum a security template needed): Right after that from 5.1 to 1.8 (Melchior, more than 40 patients, of which 38% continent and 48% improved) or from 4.4 to 1.1 (Gozzi, 67 patients, 52% of continent and 38% maximum 2 assists), after three months from 4.3 to 0.5 (Betz 1-3, 15 patients), after 4 months from 5.3 to 1.5 (Amend, 13 patients, 54% continent) and after an undisclosed period of time in 81% of patients previously nachkontrollierten by at least 50% (Heberling, 25 patients).
However, some authors also reported complications, especially urinary retention after removal of the bladder catheter and wound healing problems, from the occasionally necessary repetition of the procedure and additional treatments to improve the results. In addition, it is noted that the use is not recommended in severe stress incontinence and long-term results are missing (Hübner), which should apply to most loop systems.
Artificial sphincter implantation of an artificial sphincter
This is to be regarded as the gold standard for the treatment of stress urinary incontinence after radical prostatectomy. For more than 20 years, there is a system whose efficacy and safety is proven by many studies. It consists of a cuff around the urethra, a small balloon under the skin and a pump in the scrotum, with whose help the patient to urinate can pump fluid from the cuff into the balloon. The continence rate is 60-93% (percentage of those who are "dry"), where complications can occur and over time often re-intervention for correction or replacement will be necessary. The disadvantages are the greater engagement, the high cost and the required skill of the patient.
In order to reduce a possible pressure damage to the urethra (also a problem with many loop systems), a new system was developed. It is later refillable and comes out with a lower closure pressure because this is increased via an auxiliary balloon with increase in pressure in the abdomen (eg coughing). According to initial investigations, the implantation is done quickly and with few complications, and continence rate is very high (Khatib-Shahidi, 7 of 8 patients).Technically, the system seems not yet perfect, and there are no long-term results (Groh, Hübner).
Conclusion
For the treatment of stress urinary incontinence after radical prostatectomy, there are plenty of methods that are constantly being developed nowadays. And it will be added always new. This fact, and the plurality of the process indicate that none of the methods can prove ideal long-term results. Which one is the most appropriate in a particular case depends very individually based on previous therapy (eg radiation), the findings (eg severity of incontinence) and according to the wishes and choices of the person concerned.
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