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Tuesday, February 13, 2007

Post RP Urinary Incontinence Progression

[Updated February 27, 2009]

Toujier, 2007 (also here) points out that the time to continence after prostatectomy is complex as it is affected by many factors:
  • preoperatively by "the patient’s age, urinary function, detrusor status, prostate size, bladder capacity, and compliance"

  • intraoperatively by "the surgical technique and the degree of preservation of the neurovascular bundles"

  • postoperatively by the "definition of urinary continence used, the methodology by which the data are obtained and analyzed, and the time of assessment". The UNH handout on urinary incontinence risk factors mentions that caffeinated drinks and food (including coffee, regular tea, cola and chocolate), smoking, alcohol and body weight are all risk factors for urinary incontinence. Whether or not pelvic floor exercises are performed and whether training is physiotherapist-guided also can impact progression -- see Treatment section of the main page on Urinary Incontinence. Also Scott Tenant in this Urology Times (April 2007) article points out that quality of life considerations are highly dependent on individual patient values and these may be as important as objective measures such as those explored here. Not all incontinent patients seek treatment, suggesting they regard incontinence as less unfavorable than the treatment.

Smither et al (BMC Urology 2007/2/5, 7:2) [PMID: 17280607] quantify the progression of incontinence on 203 patients based on a standard one hour pad weight test measured at various points in time after nerve sparing surgery by a single surgeon. All patients had pre and post operative instruction on pelvic floor exercises.

Pad weight was measured after drinking 500ml of water followed by 1 hour of activity (exercising, bending over, coughing, observing running water, etc.) If the weight was less than 1 gram incontinence was assessed as minimal.

From the green line on the graph above right (click on it for a larger version) we see that 3%, 37%, 66%, 85%, 87% and 91% of the patients had minimal incontinence at 2, 6, 18, 30, 42 and 54 weeks after catheter removal, respectively. The orange and red lines show the percentage of patients having less than 10 grams and 50 grams of pad weight at the same points in time. Those patients in the group that had less than 10 grams would include those patients that had less than 1 gram as well as the patients that had 1-10 grams.

Readers can use these figures as a benchmark to assess their own progress.

A second application would be in evaluating prospective surgeons. If a patient is considering a surgeon through the reference of a single patient then based on this data, rejecting that surgeon if that single patient is incontinent after 54 weeks would only have a 9% chance of rejecting a surgeon whose incontinence rates were equivalent to the reference surgeon.

Hisasue et al [JJCO 2004 34:274-279] [PMID: 15231863] performed a similar study. They divided their sample into those with prostatectomies done in 1995 or earlier and those done later since improved surgical techniques were employed after 1995, namely the use of the dorsal vein complex (DVC) bunching technique which results in lower blood loss which in turn improves outcomes. Hisasue et al used the absence of pad use as their definition of continence so their numerical results are not directly comparable to the ones here yet they were surprisingly consistent anyways with a leveling off the curve at about one year at which point 94.7% of the post 1995 patients were continent.

Lepor and Kaci (2004) [PMID: 14767305] followed 500 men with localized prostate cancer after prostatectomy and using a self-reported questionnaire and found that 33.7%, 63.5%, 76.2% and 80% were not using pads at 3,6, 12 and 24 months respectively. (The figures cited here are taken from the slide on page 6 of [link].)

The above seem to be roughly consistent with Table 10 on page 50 of [Endotext - Chapter 10] which shows average times to recovery of continence in a number of different studies. The average time to recovery of continence ranged from 2 to 18 months depending on which study one views in the table. In those studies 88% to 100% of patients regained continence.

Readers may also be interested in this post on Urinary Incontinence.

Contradicting prevailing wisdom is a Feb 2009 study of 731 men which found that even after 24 months post-prostatectomy that 20% of men showed marked improvement in erectile dysfunction and continence and an even greater percentage showed improvement though not marked. [PMID: 19091349].

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