Chicago, Illinois (UroToday.com) Stress urinary incontinence (SUI) is a potential complication of treatment for localized prostate cancer in men. Yet myths about the incidence and treatment of this complication persist—and can stand in the way of providing the most effective treatments, according to Victor Nitti, MD, Professor of Urology and Obstetrics and Gynecology and the Vice Chairman of the Department of Urology at New York University Langone Medical Center. Dr. Nitti spoke about male SUI after prostate cancer treatment at a Continuing Medical Education (CME) session, “Optimizing Bladder Disease Management,” at the 2016 annual meeting of the Large Urology Group Practice Association (LUGPA) in Chicago.
Contrary to myth, radical prostatectomy—including radical and open prostatectomy- and radiation for prostate cancer have the potential to cause SUI. Even if a patient is continent right after treatment, prostatectomy or radiation for prostate cancer may increase that patient’s risk for incontinence months or years later, Dr. Nitti said.
“When a patient is treated with surgery or radiation for prostate cancer, there is a chance that they will wind up with incontinence. But this complication should not be viewed as a failure by a surgeon. It’s something that happens, and the good news is that it can be treated,” Dr. Nitti said.
“As urologists, we also need to keep in mind that some men will not develop incontinence until months after their treatment. And when men treated for prostate cancer in their 40s or 50s reach their 70s or 80s, they are also at increased risk for developing incontinence, since they may no longer have a strong intrinsic sphincteric unit,” Dr. Nitti added.
Medicare outcomes data from 1988-1990 indicates that 37% of men who underwent treatment for prostate cancer with radical prostatectomy had “no problem with wetness,” but 31% wore pads or used clamps to deal with SUI afterward, Dr. Nitti noted. In one study of incontinence after radical prostatectomy, 17% of men who underwent laparoscopic radical prostatectomy were incontinent a year later—defined as having a 24-hour pad weight of > 8 grams. By contrast, 13% of men who underwent open radical prostatectomy were incontinent a year later.1
A 2013 New England Journal of Medicine study analyzed long-term functional outcomes after treatment for prostate cancer, and found that at 2 years, 9.6% of men who underwent radical prostatectomy and 3.2% of those who received radiation had no control or frequent urinary leakage.2 By 5 years and 15 years after prostatectomy, however, the rate of men with SUI increased significantly to 13.4% and 18.3% of men respectively. After radiation, 4.4% of men had no control or frequent urinary leakage 5 years after treatment and 9.4% had the same level of symptoms 15 years later. Yet a significant percentage of men were bothered less severe SUI—with symptoms of some dripping or leaking urine—after prostatectomy and radiotherapy. At 2 years, 10.6% of men who underwent prostatectomy and 2.4% of men who were treated with radiotherapy showed dripping or leaking urine. By 15 years, the incidence of less severe SUI had increased significantly to 17.1% of those who underwent prostatectomy and 18.4% of men who received radiation.2
In males, treatment for SUI should be driven by the degree of bother associated with the incontinence and its effect on quality of life—rather than the degree of incontinence, Dr. Nitti said. Thus, it’s importance to ask about the presence of incontinence, the severity of symptoms and degree of bother associated with SUI after prostate cancer treatment. To make sure that the concerns of these patients are addressed, it’s important to have clinicians who are dedicated to the treatment of SUI in your urology practice, or to make early referrals to incontinence experts.
Another myth about male incontinence after prostate cancer treatment is that slings are a great treatment option, and they are best in “properly selected” patients, Dr. Nitti said. In fact, all slings have similar success rates in properly selected patients– about 70 to 75% after 12 to 48 months of follow-up. Cure rates—defined as having to use 1 or fewer pads per day soaked with <8 grams—is about 50%. Data also indicates that outcomes with slings are equivalent for different subtypes of patients, no matter which type of sling is used, Dr. Nitti said. Studies also show that adjustable slings are no better than fixed slings. However, radiated patients tend to have poorer outcomes with slings than patients who did not receive radiation.3
Slings result in a low rate complications—including infection, erosion and obstruction. Yet since the success rate is for slings is in the range of 70-75%, it’s important to set realistic expectations for patients who will undergo sling procedures. To avoid complications and to achieve the best outcomes, Dr. Nitti uses slings in patients who have not received radiation, and have mild to moderate SUI (<300 g/day) with no gravitational incontinence. In addition, the best candidates for slings can void normally when active and have no urethral scarring, according to Dr. Nitti.
By contrast, the use of artificial urinary sphincters (AUS) is considered the gold standard for treatment of male SUI. Ninety percent of men who undergo procedures for SUI using AUS are satisfied with their outcomes. In fact, 50% of men who undergo AUS no longer have enough incontinence to need pads, and only 4 to 5% of men require reoperations due to urethral atrophy, device malfunction, erosion or infection, according to Dr. Nitti.
“Since the success rate of slings is 75%, the choice of treatment often comes down to whether a patient prefers superior efficacy or convenience,” Dr. Nitti said.
In counseling men with SUI after prostate cancer treatment, the clinician should tell patients that AUS is the gold standard for treatment, and the long-term efficacy and safety of AUS is proven. By contrast, slings are most appropriate for mild to moderate SUI, and their long-term safety and efficacy is still an open question. The failure rate of male slings for severe incontinence is also high—75%. However, a patient may prefer to receive a sling as treatment, and if so, the clinician should counsel him that if the sling fails, AUS can still be tried, Dr. Nitti noted.
Presented by: Victor Nitti, MD
Lepor H, Kaci L, Xue X. Continence following radical retropubic prostatectomy using self-reporting instruments. J Urol. 2004; 171 (3): 1212-5.
Resnick MJ, Koyama T, Fan KH, et al. Long-term functional outcomes after treatment for localized prostate cancer. NEJM. 2013; 368; 5: 436-45.
Weld BK and Herschorn S. The male sling for post-prostatectomy urinary incontinence: A review of contemporary sling designs and outcomes. BJU Int. 2012; 109: 3328-44.