Urinary Control or Continence
Loss of continence is one of the most stress-producing potential side effects of radical prostatectomy because urinary functions are so frequent throughout the day and dysfunction brings into embarrassing highlight what was for most of a man’s life an unconscious function requiring little attention.
Anatomy of Continence
Continence is achieved by coordinated activity of pelvic nerves and muscles that must act in cooperation with muscles outside the pelvis that have to do with motion rather than urinary control.
After removing the prostate, the surgeon reconnects the bladder to the urethra, and the Foley catheter put in place at the start of surgery is left in place for approximately one week (rarely longer due to possibility of infection). Once the catheter is removed, most men leak urine for a period of time. The leakage occurs mainly due to stress incontinence - failure of the urethral sphincter to close properly (Ficazzola 1998). The sphincter can be thought of like a valve or aperture of a camera; it lies just beyond the prostate. The sphincter malfunctions because of swelling, inflammation, and neuromuscular dysfunction. A significant portion of men may also have some degree of detrusor instability (overactive bladder) causing urge incontinence. The severity of incontinence and timeline of recovery of urinary function is complex and depends on multiple factors including age, preoperative voiding function, prostate size, nerve sparing and operative technique. We believe that inflammation plays a crucial role in this process.
Whatever the cause of incontinence, there is no question that leakage of urine is the single most bothersome issue to men after surgery. Recovery of urinary continence can take weeks to months. For many men this may take 6-18 months. Permanent incontinence after robotic prostatectomy, however, is rare when performed by an experienced surgeon.
What To Expect After Surgery
After surgery you will have a catheter in the penis draining the bladder. The catheter is well tolerated by most men but can be annoying for some because it can cause a sensation that you need to urinate or irritate the tip of the penis. Medication such as lidocaine jelly applied to the tip of the penis is available to help make you more comfortable.
The catheter is kept in place by a balloon inside the bladder and a strap on your leg. There is no sensation from the balloon inside the bladder – you will not even know it is there. The catheter attaches to a small bag worn on the leg during the daytime and a larger bedside bag for night-time use. Emptying the catheter bag for the first night or two requires attention, since urine flow will be large due to your drinking extra water to flush the bladder. The urine draining through the catheter will vary in color from yellow to pinkish-red. Don’t worry if the urine is a little red as long as it is draining through the catheter well. Make sure you drink a lot of fluids to maintain clear urine. If you notice the catheter is not draining because it is clogged, it may require simple irrigation by your doctor or nurse or by yourself, using a back-flush of saline solution into the catheter tube to dislodge the accumulation of sediment. This occurs most often in the first day or two following surgery, and then is not a problem thereafter. If there is a problem with the catheter and it needs to be changed or removed prematurely only your urologist should do this.
Once the catheter is removed you will most likely leak variable amounts of urine. Almost everyone requires urinary pads or some other form of collection device (briefs, drip collector, condom catheter etc) for a period of time. Patients should be advised they will likely be using pads for weeks to months. Most men will experience leakage with activity (laughing, coughing, exercising). Leakage may range from just a few drops intermittently to a large volume of continuous leakage. Others will have the sudden unexpected urge to urinate and feel the need to rush to the restroom.
After the catheter is removed we recommend exercising your pelvic floor muscles (Kegel KEY-gul exercises). Kegel exercises are performed by contracting and relaxing the pubococcygeal muscle and other muscles of the pelvic diaphragm. To contract these muscles, try to stop the flow of urine midstream just like you would if someone walked into the bathroom when you are urinating.
It is best to perform these exercises when sitting. Perform these immediately after surgery and continue until you regain continence.
Suggested Kegel regimen
• Contract your pelvic floor muscles
• Hold the contraction for two or three seconds, then relax
• Repeat 10 times
• Do this three times per day
There is data to support this recommended regimen - A meta-analysis of randomized controlled trials concluded that pelvic floor muscle training with biofeedback early in the postoperative period immediately following removal of the catheter may promote an earlier return to continence (Hunter 2007).
Patient Expectations and Results
While many urologists still consider the open radical prostatectomy to be the “gold standard” for the surgical management of localized prostate cancer, over the past 5 years a paradigm shift has occurred that clearly positions RALP as the new gold standard.
In 2001, approximately 250 RARPs were performed. Only six years later, in 2007, 50,000 cases were performed and by 2008, this number exceeded 77,000. The preponderance of available data indicates that functional outcomes after RALP are at least equivalent to RRP, if not superior. There is no question that improved optical magnification and visualization of the prostate, urethra, and sphincter muscles is enhanced with 3-D optics. In addition, robotic assistance is particularly valuable for the reconstructive portion of the procedure, allowing for technically superior anatomic restoration of the bladder and urethra due to increased dexterity of the wristed-instruments. Emerging data have begun to demonstrate that these technical benefits are translating into superior functional outcomes.
Before reviewing robotic continence outcomes it is informative to briefly discuss patient expectations and how those expectations correlate with reality. There has been a recent flurry of information available on the internet about robotic surgery. Intense advertising by private and academic medical centers has led to the creation of websites which abound with exaggerated promises and unverified claims about what the robot can offer. This is coupled with surgeons quoting numbers extracted from the literature and not from their actual outcomes, based on data they’ve culled and analyzed. As such, many patients may be armed with unrealistic or unattainable data. The robot cannot overcome or compensate for certain anatomic or physiologic hurdles, nor can it make up for poor operative technique. Thus, the outcomes for a 50 year old man may be very different than that of a 70 year old man. It goes without saying that some 70 year olds are younger than others due to an unmeasurable “vitality” variable. Obviously, results will also vary from surgeon to surgeon depending on their technique and experience. For more on this topic refer to chapter 9, selecting a robotic surgeon.
For patients, chief among these outcomes is urinary continence. Continence should be defined as achieving pad-free status. Yet, urinary continence is defined, measured, and reported in a variety of different ways. As a result, when examining the medical literature it can be difficult to compare results between surgeons. When examining continence rates, the reader must carefully consider the specific definition that is being used as there is a clear difference between a patient who uses no pads and a patient who requires a security pad. In addition the vast minority of surgeons track or publish their data. The outcomes published in the scientific literature therefore represent in many cases the experience of the top few percent of surgeons and not that of the general urologist (i.e. they are a best case scenario). Further complicating matters, the prevalence of incontinence varies considerably among reports not only due to lack of a consensus on the definition of continence, but also because of differences in data collection and reporting methods (i.e. patient self-reported, doctor-reported), patient demographics, and surgical technique. As mentioned in the introduction to this chapter, anatomic and physiologic variables such as patient age, preoperative voiding function, prostate size, nerve sparing, and co-morbidities such as obesity, smoking, and diabetes also play a role.
Other factors such as hormonal therapy, radiation therapy and chemotherapy also affect results. Finally, continence is a moving target. That is to say, continence rates continue to improve beyond 12 months and thus the length of follow-up time is essential to consider when digesting continence data.
Comparing Robotics vs. Open Continence Outcomes
There are few head-to-head comparisons of open versus robotic surgery performed by the same surgeon at the similar points in their learning curve or case experience. It would be easy to skew the comparison in favor of the robotic camp by cherry-picking a handful of favorable robotics series and several low quality open radical prostatectomy studies. It is more informative to take an honest look at all of the available literature and analyze the outcomes data from the highest quality available studies from the top robotic and open surgeons.
When analyzing these data from high volume surgeons (i.e. > 500 cases) where the technique from case to case is nearly identical, we have technical data so-to-speak, that is, data which is more influenced by surgical modality and operative technique than by patient factors. We must also review, however, bread-and-butter studies, which are more representative of the experience the average patient will have in a general community surgeon practice. The reality is that many patients are not having their operation done at the high volume academic centers from the top tier surgeons who are writing the papers from which we are extracting this data.
Continence Results after Open Retropubic Radical Prostatectomy (RRP)
The hands-down godfather of open radical prostatectomy is Dr. Patrick Walsh, Professor of Urology at The Johns Hopkins Medical Center. On April 26th, 1982 he performed the first purposeful nerve-sparing open radical prostatectomy. Since then he has continued to improve upon the technical aspects of the operation (most of which have been assimilated into the robotic operation). In one of his studies he prospectively followed a group of 70 men, with a median age of 57, undergoing open RRP. Patient-reported continence rates, defined as “no pads” at 3, 6, 12, and 18 months post-operatively were 54%, 80%, 93%, and 93% among the 59 men who had complete follow-up (Walsh et al 2000) . This study is a good example of what can potentially be achieved with arguably the best open surgeon and a relatively young cohort of patients.
In a study by another highly regarded open surgeon, Dr. William Catalona, the outcomes of 1,870 consecutive open RRPs (mean patient age of 63) were analyzed (Catalona 1999). Men were considered continent if they “did not require protection to keep outer garments dry.” Overall, of 1,325 men who had >18 month follow-up, 92% recovered urinary continence. This recovery varied slightly by age such that continence rates for men in their 40s, 50s, 60s, and 70s were 92%, 97%, 92%, and 87%, respectively. A recent notable study by Eastham and Scardino analyzed outcomes of 1,577 men after open RP (Eastham 2008). Continence was assessed by patient reported questionnaire or physician interview and defined as answering “no” to the question, “Do you wear any protective material because you leak urine?” Among these patients (mean age 58 years), 79% were continent at 12 months. Litwin et al. investigated the longitudinal recovery of quality of life (back to preoperative baseline) after open RRP in 247 men followed for up to 4 years after surgery (Litwin 2001). At 3, 12, and 30 months after surgery, 21%, 56%, and 63% of men recovered to baseline function and overall about 80% recovered to baseline urinary bother at about 8 months.
Outcomes gleaned from the Prostate Cancer Outcomes Study (PCOS) were extracted from a population-based cancer registries and not necessarily high volume academic medical centers, perhaps rendering the results more representative and generalizeable to patients treated in community based practices (Stanford 2004). Of 1291 patients who underwent open RRP, at 12 months following surgery, 60.5% reported using no pads, 20.6% reported using 1-2 pads, and 6.6% ≥ 3 pads/day; 31% reported total urinary control, 43% reported occasional leakage, 10.9% reported frequent leakage, and 2.8% of men reported no urinary control. Mean patient age was 62.9 years.
Continence Results after Robotic-Assisted Radical Prostatectomy (RARP)
A single-center prospective comparative study between open prostatectomy and RALP by Tewari et al found that robotic surgery allowed a statistically significant earlier continence recovery compared with the traditional retropubic approach (Tewari 2003). In this study, 50% of the patients recovered continence (defined as no pads or a security liner) at 44 days with the robotic approach vs. 160 days with the open approach.
Patel reported on the results of his first 500 consecutive patients (mean age 63.2 years) over a mean follow-up period of 9.7 months (Patel V 2006). Complete continence (no pads) was achieved in 89%, 95%, and 97% of patients at 3, 6, and 12 months, respectively.
Menon reported at 1 year follow-up on more than 1100 patients, an overall continence rate (defined as ≤ 1 pad) of 93% (Menon 2007). The median time to complete urinary control in this series (< 1 pad per day or a security liner) was 3 weeks (range, 0–120 weeks).
Hakimi recently reported on the urinary outcomes for the first 75 patients in their RALP experience and matched them to 75 patients at the tail end of their substantial laparoscopic RP series. The 12-month continence rate was 93.3% after RALP (Hakimi 2009).
In another excellent study, at 12 months post-RALP, 354 of 395 patients (89.6%) were completely dry, as defined by the use of no pads (Murphy 2009).
In our own patients at UC Irvine Department of Urology, using the strictest definition of continence (patient-reported use of no urinary pads), out of 600 patients the median time to pad-free status was 59 days with an overall pad-free rate at 3 and 12 months of 68.6% and 86%, respectively. Utilizing our hypothermia technique, among the first 100 patients, the median time to zero pads was 39 days with 88% pad-free at 3 months (Finley et al, 2009).