Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1010 - файл
.pdf
Chapter 24 Postoperative Management After Surgery for Incontinence and Prolapse
24.3.1 Medium Term:
쐽 Incontinence surgery: did symptoms improve?
Women should be advised to come for a follow-up appointment if incontinence symptoms persist after 6 weeks. At this time, residual urine has to be checked to exclude
overflow incontinence and urinary tract infection. Ultrasound precisely checks for
urethral mobility and tape placement. Urodynamics testing should be performed to
differentiate between persistent stress urinary incontinence and de novo urge incontinence. Women with urge incontinence should receive anticholinergic therapy if there
is no significant residual urine. If residual urine is more than 50 cc the amount has to
be closely monitored when the patient is treated with anticholinergic drugs. Residual
urine of more that 100 cc in women with symptoms of urgency and urge incontinence
mandate treatment by cholinergic or alpha-blocking drugs. If medical treatment is not
successful clean intermittent cauterization is required.
If clinical and urodynamic testing confirmed persistent stress urinary incontinence
2 months postoperatively the reasons for failure should be analyzed. If the bladder
neck is still hypermobile after colposuspension sutures might have torn out.If the patient still leaks after TVT placement the tape may be too loose. If stress urinary incontinence is mild the patient might be happy to undertake pelvic floor training. However,most women with surgical failure have had trials of unsuccessful physical therapy
before.If the new drugs for stress urinary incontinence (duloxetine) are useful, in mild
recurrent cases this is still unclear.If the patient opts for surgery therapy must be chosen individually. No general recommendations can be given. There are no data on recurrent TVT operations in patients who had a failed TVT operation before.Generally
a different type of surgery (e.g., colposuspension) should be considered if one method
has failed. It is absolutely not clear if new transobturatorial tapes will work after TVT
has failed. In cases of persistent or recurrent stress urinary incontinence after colposuspension,a second colposuspension is only useful if the bladder neck is still mobile.
A suburethral tape such as TVT might be successful.
In unclear cases of postoperative urinary incontinence, a fistula should be kept in
mind and excluded if necessary.
337
쐽 Prolapse surgery: is anatomy restored and function preserved?
It is very important to keep in mind that the restoration of anatomy does not automatically include that function is restored as well. Patients might develop dyspareunia,
anal incontinence and/or urinary incontinence after prolapse surgery.Women should
be advised to come back in case of any problems.Dyspareunia might occur after posterior repair or after mesh implantation.New symptoms of anal incontinence require
a work-up of the posterior compartment and conservative or surgical treatment.
Masked stress urinary incontinence might become unmasked after prolapse surgery.Minimally invasive surgery such as TVT implantation is mostly the treatment of
choice for those patients.
쐽 How can the result of surgery be preserved?
There are no data that prove that anything can be done to improve long-term results
after surgery.However, women should be advised to avoid heavy lifting and straining
during defecation. Local estriol might be useful, as explained above. Whether pelvic
24
338
Ursula M. Peschers, Ralf Tunn
floor exercises are useful is unknown. Nevertheless, the patient should perform pelvic
floor exercises if they are able to contract the pelvic floor muscles. Physiotherapy is also useful to teach the correct way of lifting to avoid sudden intra-abdominal pressure
rises.
Chapter 25
Chapter 25 Postoperative Management of Urinary Incontinence
Postoperative Management
of Urinary Incontinence
After Urologic Surgery
Daniela Schultz-Lampel
339
25
Contents
25.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 340
25.2 Incontinence After Radical Prostatectomy . . . . . . . . 340
25.2.1 Incidence and Pathophysiology . . . . . . . . . . . . . . 340
25.2.2 Information and Education Before Discharge
from the Hospital . . . . . . . . . . . . . . . . . . . . . . 342
25.2.3 Diagnostic Work-up . . . . . . . . . . . . . . . . . . . . 342
25.2.4 Treatment in the Early Postoperative Period . . . . . . . 345
25.2.4.1 Incontinence Products and Appliances . . . . . . . . . . 345
25.2.4.2 Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . 346
25.2.4.3 Physiotherapy: Pelvic Floor Muscle Exercise,
Biofeedback,Electrical Stimulation . . . . . . . . . . . . 346
25.2.4.4 Treatment in the Advanced Postoperative Period . . . . 348
25.3 Incontinence After Female Incontinence Surgery . . . . 350
25.3.1 Incidence and Pathophysiology . . . . . . . . . . . . . . 350
25.3.2 Diagnostic Work-up . . . . . . . . . . . . . . . . . . . . 351
25.3.3 Treatment in the Early Postoperative Period . . . . . . . 351
25.3.4 Treatment in the Advanced Postoperative Period . . . . 352
25.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . 352
References . . . . . . . . . . . . . . . . . . . . . . . . . . 353
25
340
Daniela Schultz-Lampel
25.1 Introduction
Urinary incontinence after urologic surgery is a disappointing experience for both patient and surgeon. However, bladder dysfunction and especially incontinence can occur after pelvic surgery such as radical prostatectomy, transurethral prostatectomy
(TUR-P), cystectomy with orthotopic bladder substitution, or even after incontinence
surgery.Because of their clinical relevance, this article will focus on two items: incontinence after radical prostatectomy and persisting incontinence after female incontinence surgery.In the early postoperative period, up to 97% of patients are incontinent
after radical prostatectomy and also up to 30% of females experience urgency or incontinence after incontinence surgery.
Although continence improves with time in most cases, we should offer patients
therapeutic methods to accelerate the regaining of continence and to ameliorate their
quality of life.
In addition, accurate preoperative information about the possibility of postoperative bladder dysfunction and incontinence is mandatory as it improves patient’s satisfaction rate and quality of life.A thorough preoperative diagnostic work-up and careful surgical techniques are obligate prerequisites to prevent incontinence.
25.2 Incontinence After Radical Prostatectomy
Radical prostatectomy for treatment of localized prostate cancer has become one of
the most frequently performed urologic surgeries. Irrespective of a retropubic, perineal or laparoscopic approach and despite improved nerve-sparing and sphincterpreserving techniques, incontinence remains a significant concern for patients and
surgeons.
25.2.1 Incidence and Pathophysiology
Estimates of postoperative incontinence rates vary dramatically, ranging from 0.5% to
87%, depending on a number of factors relating to study design, including definition
of continence, assessment methods, time since surgery and the patient’s vs the
surgeon’s reporting (Palmer et al. 2000;Alivizatos et al.2003; Krupski et al. 2003; Young
et al. 2003).
The early continence rates directly after removal of the catheter are low and at that
time up to 97% of patients lose urine. Retropubic and perineal approaches tend to
have better early continence rates than the laparoscopic approach – especially in the
early learning phase. However, in the 1 year follow-up,all three approaches have similar continence rates (Wille et al. 2003;Anastaridis et al. 2003; Egawa et al. 2003; Kirschner-Hermann and Jakse 2002) (Table 25.1).
The median time to regain continence ranges somewhere around 3 months depending on the definition of continence and on patient’s age and comorbidity (Abbas
et al. 2002; Young et al. 2003). Median time to regain continence was 1.4 months in
patients younger than 55 years, 3.0 months in patients between 55 and 64 years and
3.3 months in patients older than 64 years. In healthy patients, continence was
achieved after 1.4 months,whereas when there were one or two comorbidities or more
than two comorbidities, regaining continence took 3.3 months and 3.5 months,respec-
Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery
Table 25.1. Comparison of continence rates of retropubic,perineal and laparoscopic radical prostatectomy
Continence rates after surgery Retropubic Perineal Laparoscopic
1 day after catheter removal 21% 40–91% 3%
After 3 months 59%–63% 29%
After 6 months 84% 55% 47%
After 12 months 86%–93% 65%–99% 72%–93%
Wille et al. (2003): retropubic; Anastariadis et al. (2003): laparoscopic; Egawa et al. (2003):retropubic + laparoscopic; HJ Keller, personal communication: perineal; Kirschner-Hermanns and
Jakse (2002): perineal.
tively. A further delay in regaining continence was seen after postoperative radiation
(Young et al. 2003). Eighty-nine percent of patients achieved final continence status
6 months postoperatively (Fontaine et al. 2000).At the end of the 1st year after surgery,
continence rates rose to around 90%, leaving 5%–15% of patients requiring a longterm treatment (Table 25.2).
Intrinsic sphincter deficiency resulting in urinary stress incontinence is the primary cause of incontinence and can be found in 57%–100% of incontinent patients after radical prostatectomy (Comiter et al.2003). However, in the early postoperative period, up to two-thirds of patients suffer from initial urgency (Fontaine et al.2000) and
detrusor pathologies such as bladder instability or low compliance bladder influence
continence in 13% and 25% of cases,respectively, in the long run.A mixed incontinence
with bladder and sphincter dysfunction is the cause of incontinence in up to one-third
of patients (Oehlschläger et al. 1999; Pfister et al. 2002; Gomha and Boome 2003) (Table 25.3).
341
Table 25.2. Factors determining time to regain continence after radical prostatectomy
Incontinence after surgery
• Early incontinence rates 80%–97%
• Time to regain continence 3 months
Age <55 years 1.4 months
Comorbity None 1.4 months
• Overall continence rates >1 year 13%–99%
Incontinence requiring treatment 5%–15%
Wille et al.(2003); Anastariadis et al. (2003); Parekh et al.(2003); Alivizatos et al.(2003).
a
Young et al. (2003); Smith and Milam (2002); Abbas et al. (2002); Kielbl et al.(2001); Melchior
et al. (2000).
55–64 years 3.0 months
>64 years 3.3 months
1–2 3.3 months
>2 3.5 months
a
342
Daniela Schultz-Lampel
Table 25.3. Pathophysiology of incontinence after radical prostatectomy
Pathophysiology of incontinence after surgery
Intrinsic sphincter deficiency 57%–100%
Bladder instability 4%–13%
Low compliance bladder 11%–25%
Mixed incontinence 28%–31%
Initial urgency 66%
Chao and Mayo (1995); Oehlschläger et al. (1999); Fontaine et al. (2000); Comiter et al. (2003);
Gomha and Boone (2003).
25
25.2.2 Information and Education Before Discharge
from the Hospital
Although the patient receives preoperative information about the diagnosis of prostate cancer and possible treatment options and side effects, little is retained of the preoperative education because of the overwhelming nature of the diagnosis. Therefore
the early concerns of men in the early weeks after radical prostatectomy are:
쐽 The lack of knowledge on the postoperative recovery period
쐽 The knowledge gaps on catheter care, postoperative pain, incontinence
and erectile dysfunction
쐽 The lack of health care professional support
These information deficits severely affect the quality of life and healthy postoperative
rehabilitation (Moore and Estey 1999).
Most of the patients are discharged from the hospital only with protective padding
and for most of them this is a catastrophe. Only 37% and 61% of men in two studies
(Fitch et al.2000; Palmer et al. 2003, respectively) believe they had received enough information to prepare them to cope with urinary incontinence. Therefore accurate and
comprehensive information and instructions on protective aids, diapers,pads, special
devices for men, urine drainage sheaths, penile clamps and practical tips and instructions on how to use these devices are mandatory before the patient leaves the hospital
(Fig. 25.1).Admission to specialized rehabilitation clinics, continence advisers or continence clinics as well as communication with local chapters of support groups may also help to regain continence more completely.
25.2.3 Diagnostic Work-up
After an appropriate interval to allow for improvement, the patient should undergo a
thorough evaluation to assess the contribution of the various causes of incontinence
and should be managed using a sequential treatment approach (Wahle 2000). However,there is no consensus on the appropriate interval and the best therapy.
When the patient is not satisfied with his continence status before discharge from
the hospital, we directly perform a noninvasive diagnostic work-up taking the his-
Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery
Fig. 25.1 Variety of incontinence products: protective aids,diapers, pads,urine drainage sheaths,
penile clamps
343
tory, urine analysis, bladder diary, stress and pad test, physical examination and
ultrasound to quantify the urinary loss, and repeat this work-up after 4–6 weeks if
there is no improvement. More invasive methods such as cystoscopy, including a
video sphincter test or urodynamic studies, are usually not performed before the first
3 months after surgery, but are mandatory when operative interventions are planned
(Table 25.4).
Table 25.4.
Diagnostic work-up in postprostatectomy incontinence
Diagnostic work-up
Before discharge and repeated after 4–6 weeks:
• History: urinary control,number of pads
• Bladder diary
• Stress test
• Pad test
• Urine/urine culture: exclusion of UTI
• Physical examination: PFM contraction
• Ultrasound: residual urine, PFM contraction
After 3 months
• Cystoscopy
• (Video) sphincter test
• Urodynamic studies
UTI urinary tract infection, PFM pelvic floor muscles.
344
Daniela Schultz-Lampel
25
Table 25.5.
Questionnaire (modified
according to Salomon et al.
2003)
1. Do you leak urine during the day?
• Never
• Sometimes (less than once a week
• Often (at least once a week)
• All the time
2. Under what circumstances do you leak urine?
• Never
• During intense effort (sport, lifting heavy things,etc.)
• During moderate effort (climbing stairs)
• During slightest effort (coughing, laughing, etc.)
3. Do you wear pads during the day?
• Never
• As a precaution
• Not more than one pad per day
• More than one pad per day
4. Do you leak urine during your sleep?
• Never
• Sometimes (less than once a week)
• Often (at least once a week)
• All night
5. Do you use pads at night?
• Never
• As a precaution
• Not more than one pad per day
• More than one pad per day
A careful history, favorably completed by a questionnaire (Table 25.4), inquiring
about total urinary control, the circumstances of urinary leakage and the number of
pads used during the day (Kielb et al. 2001; Salomon et al. 2003), a bladder diary, a
stress test and a pad test are prerequisites to quantify urine loss.
A urine analysis is mandatory to exclude a urinary tract infection deteriorating urinary control.
A physical examination should test the capability of pelvic floor muscle contraction.
Ultrasound is necessary to check post-void residual urine and is also able to show
if contraction of the pelvic floor can be performed correctly.
Cystoscopy is normally not necessary within the first 3 months, unless obstructive
voiding patterns indicate a stricture of the anastomosis. The most important value of
cystoscopy is the possibility of sphincter evaluation. A video sphincter test, enabling
the patient to watch the procedure of actively contracting his sphincter under cystoscopic view, provides the physician with a quantification of sphincter damage and
makes the patient aware of his urethral sphincter and can also be used as a biofeedback mechanism during continence training.
Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery
Urodynamic studies are only indicated in small bladder capacity, suspicion of detrusor hyperactivity or low compliance bladder,and are usually not performed in the
first 6 months after surgery. The value of urethral pressure profiles and leak-point
measurements is controversial (Comiter et al.2003).
25.2.4 Treatment in the Early Postoperative Period
Because incontinence improves with time after surgery,invasive surgical interventions
should be withheld initially. Improvement continues for at least 1 year after surgery,
However, if there is still substantial leakage at 6 months postoperatively, few men will
regain total urinary control, and investigation and intervention seem warranted
(Moorehouse et al.2001; Smith and Milam 2002). The early treatment relies on behavioral management,including patient education and information,supportive care with
continence devices, pharmacotherapy, continence training with pelvic floor muscle
exercises and/or biofeedback mechanisms and electrical stimulation (Table 25.6).
25.2.4.1 Incontinence Products and Appliances
Spontaneous recovery of normal urinary control can take more than 1 year. Therefore,
in the early period after surgery protective devices should be offered to the patient to
improve his quality of life and provide a safe feeling in his social environment.
The most important considerations when selecting incontinence products or devices are that any device used must not leak and must be discreet, easily managed,and
must be able to be changed without others noticing it. The volume and frequency of
urine leakage, the mobility, the manual dexterity and the patient’s preferences determine the choice of the products. Special disposable absorbent products for men may
not be suitable or fit in the early postoperative phase but may be an option when continence has improved. Men with a higher degree of incontinence may profit from urinals or urine drainage sheaths. External fixed compression devices such as penile
clamps or penile tapes were already presented in 1750 but recently there has been a
trend back toward these devices in special cases.However,this form of passive urethral
compression should not be applied for longer than 2–3 h/day and is therefore reserved
for patients doing sports (Madjar et al.2001).
345
Table 25.6.
Treatment options in the
early postoperative period
after radical prostatectomy
Incontinence after surgery
Treatment options in the 1st year
• Watchful waiting
• Patient education + support
• Protective devices, pads,diapers
• Pharmacotherapy (anticholinergic drugs)
• Physiotherapy (PFME,BFB)
• Electrical stimulation
• No invasive surgery before the 1st year after surgery!!!
PFME pelvic floor muscle exercises,BFB biofeedback.
25
346
Daniela Schultz-Lampel
25.2.4.2 Pharmacotherapy
Anticholinergic drugs can help to increase the bladder volume after surgery, as 66% of
patients have associated urgency in the early postoperative period. Administration of
trospium chloride in addition to continence training in the first 3–4 weeks after surgery significantly improved the degree of incontinence, the number of pads, voiding
frequency and bladder volume (Otto et al.2002).
25.2.4.3 Physiotherapy: Pelvic Floor Muscle Exercise,
Biofeedback, Electrical Stimulation
Different physiotherapeutic approaches such as pelvic floor muscle exercises (PFME),
biofeedback (BFB),electrical stimulation (ES) or a combination of these methods have
been used for conservative treatment of incontinence after radical prostatectomy
(Fig. 25.2). The reports of the efficacy of these continence training methods are discrepant because trials are often not randomized and controlled. In the Cochrane Review,Moore et al. detected only five randomized studies in a review period from 1980
to 1999.They concluded that it was not possible to reliably identify or rule out a useful
effect of these methods and that men’s symptoms tended to improve with time irrespective of management of incontinence (Moore et al. 2001).Several studies could not
show any significant differences concerning early and late continence rates.Especially
in severe incontinence, physiotherapy had limited benefit.
In a recent prospective, randomized study comparing the effect of PFME, ES and
BFB on urinary incontinence after radical retropubic prostatectomy, Wille et al. could
not see any significant difference in continence rates after 3 and 12 months in any of
Fig. 25.2 Biofeedback and electrical stimulation devices
Соседние файлы в папке @xirurgi_2025