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Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery
the three treatment options, concluding that up to €711 can be saved per patient by
omitting ES or BFB with preference given to simple PFME (Wille et al. 2003).
There is no conclusion about the optimal timing to start physiotherapy. Starting
with PFME or BFB sessions prior to radical prostatectomy resulted in earlier achievement of continence but did not influence the 1-year continence rates (Sueppel et al.
2001; Parekh et al.2003).
In another study by Bales et al.,preoperative biofeedback starting 2–4 weeks prior
to surgery did not accelerate the return of urinary control and did not improve the
6-month continence rates (Bales et al. 2000).
Pelvic floor muscle training starting at the 7th postoperative day did not show any
differences in early continence rates and continence rates after 1 year compared to no
training (König and Pannek 2001).
Starting with physiotherapy using verbal instructions or electromyographic biofeedback immediately after catheter removal did not show differences in effectiveness,
as all methods yielded comparable continence rates after 1,2, 3,and 6 months assessed
in the 1 h pad test and the numbers of pads per day. The urine loss decreased from 39 g
and 31 g to 3 g and 0 g, respectively after 6 months and the number of pads per day declined from 3.9 and 3.6 to 0.4 and 0.2, respectively (Floratos et al. 2002). However, van
Kampen et al.found a quicker recovery of continence in the first 3 months performing
biofeedback training with an 88% continence rate compared to a continence rate of
only 56% in a control group (van Kampen et al.2000). After a 3 months training starting the 3rd postoperative day, no significant differences were found in a control group
receiving no physiotherapy or when patients underwent either pelvic muscle exercise
or electrical stimulation. Similar results were obtained in men after cystectomy and
orthotopic bladder substitution using ileum-neobladder (Piechota et al. 1999).
Starting with biofeedback 6 weeks after radical prostatectomy could not improve 6month continence rates (Franke et al. 2000). Comparing the results after 24 weeks of
either verbal instructions, pelvic muscle exercise or additional electrical stimulation,
no differences were found in the pad weight test when therapy was initiated 8 weeks
postoperatively (Moore et al. 1999).
However, further research is needed to rule out the optimal timing and protocols
for physiotherapy and the best practices and training methods. Whether the patient
receives the instructions and initial training session from the primary care or home
care physician or in a specialized continence center or rehabilitation clinic may be important,because this may have a decisive effect on the correct execution of the exercises and the motivation and compliance of the patient and the outcome as well.
347
Our Recommendations
We recommend an early onset of physiotherapy with instructions in pelvic floor contractions the day before surgery, repeating this on the 7th postoperative day and then
starting with individual training directly after catheter removal.In this early period, it
is most important that the patient be able to achieve awareness of his pelvic floor muscles and urethral sphincter in order to correctly execute the exercises. Compared to a
simple wait and see strategy,active training has an important psychological aspect for
the patient that should not be underestimated. Physiotherapy starting directly after
catheter removal allows the patient to actively influence his situation, taking responsibility for the time needed to regain continence and improving his motivation and
compliance to do something for his recovery. In our experience, an anticholinergic
25
348
Daniela Schultz-Lampel
medication should also be offered to patients as it has an additional positive effect on
urinary control in the first 3–4 weeks.
We also use the benefit of the German health policy: after discharge from the acute
clinic, the majority of patients are admitted to specialized rehabilitation centers where
they are offered a 3–4 weeks of an intensive training program. Whereas at admission
80% of patients had a second or third degree of incontinence, 33% were completely
continent,39% had a low degree of incontinence and only 28% had a higher degree of
incontinence at time of discharge (Hoffmann et al.2002).
25.2.4.4 Treatment in the Advanced Postoperative Period
Patients who are incontinent 6 months after surgery with no evidence of improvement
will probably not become continent on their own or with conservative methods. More
than 12 months after surgery, 27% of patients suffer from incontinence that makes protection aids necessary (Augustin et al. 2002).
In these cases, further treatment modalities are required depending on the patient’s
complaints and distress. The treatment of persistent stress incontinence is mainly
based on surgery, as it does not respond to physiotherapy and anticholinergic drugs.
While injection therapy with bulking agents is safe and well tolerated,its effect is limited and decreases with time. The best results are achieved by implantation of an artificial sphincter,but with significant complication and revision rates (Table 25.7).
Bulking Agents
After the first injection of Macroplastique,6 of 50 patients were dry and 28 of 50 were
improved.After the second injection, 10 of 40 were dry and 5 additional patients were
improved (Kylmälä et al. 2003). However, in the long-term follow-up, the continence
rates of all injectables dropped to 8%–48%; consequently we no longer recommend
these methods.
Sling Procedures
Sling procedures for male incontinence are attractive as they are easy to perform, inexpensive and nonmechanical.Using autologous or synthetic materials, long-term re-
Table 25.7.
Treatment options in the advanced or late postoperative
period after radical prostatectomy
Incontinence after surgery
Treatment Options after the 1st year
• Incontinence products or devices
• Long-term physiotherapy
• Electrical stimulation
• Bulking agents (injectables)
• Micro-balloons (Pro-Act)
• Sling procedures
• Artificial sphincter
Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery
sults around 50%–70% can be achieved (Schaeffer 2002). However, these techniques
do not play an important role in management of postprostatectomy incontinence.
Artificial Urinary Sphincter
Artificial urinary sphincter placement is the current gold standard of treatment for
persistent postprostatectomy incontinence. Success rates defined as two pads or fewer
per day range from 60% to 80% and patient satisfaction rates go up to 90%.Complete
continence is unusual.Only 4% will become completely dry,whereas 60% will further
require 0–1 pads, 31% 2–3 pads and 4% 3 or more pads per day (Montagne et al. 2001).
Despite its attractiveness, the artificial sphincter is an expensive mechanical device
that can fail requiring re-operations ranging from 50% to 60% (Schaeffer 2002). Regarding these reliable continence rates and complication rates, we would not offer an
artificial sphincter to a man requiring less than two pads per day unless he significantly suffers from his urinary loss.
Micro-Balloons
A new minimally invasive method is the implantation of two paraurethral balloons at
the bladder neck (ProAct) with an adjustable filling status via scrotally implanted
tubes (Fig. 25.3). The early results with a follow-up of 3 years are encouraging: 62% of
patient will become dry and 29% will be improved. The complication rates are low
(Hübner and Schlarp 2003) (Fig.25.3).
349
Fig. 25.3 ProAct – Micro-balloons
25
350
Daniela Schultz-Lampel
25.3 Incontinence After Female Incontinence Surgery
25.3.1 Incidence and Pathophysiology
In the long-term follow-up, continence rates for female incontinence surgery range
from 70% to 90%.So far colposuspension and fascial sling procedures are still the gold
standard of incontinence surgery, but tension-free vaginal tapes have proved to be
equally effective in a follow-up of up to 8 years.
In a study exploring the prevalence and outcome of incontinence surgery in females, Diokno et al.conducted interviews in 45,000 households.From the 24,581 women answering the questionnaire, 4% had a history of incontinence surgery.The initial
surgical success rate was 74% but the satisfaction rate only 67%, whereas the continence rates after 1–2 years improved to 86% after colposuspension and 91% after a
sling procedure. The factors that determined satisfaction were the number of pads,
symptoms of stress incontinence and urge symptoms.Interestingly,53% of patients reported current use of pads or other absorbent devices, indicating a persisting problem
with incontinence (Diokno et al. 2003).
Persisting or de novo urgency or urge incontinence is the most severe cause of incontinence after female incontinence surgery. It occurs in up to 26% of patients after
colposuspension,sling or tension-free tape procedures as well (Tunn et al. 2001; Volkmer et al. 2003; Rezapour and Ulmsten 2001; Croak et al. 2003).
A de novo urge is often related to a hyperelevation of the bladder neck, false sling or
tape position or tape dislocation (Fischer et al. 2002a, b; Nguyen 2002; Scapero and
Nitti 2002).
In up to 27% of patients, an additional obstruction occurs after incontinence surgery with incomplete voiding or urinary retention despite attempting a tension-free
placement of the tape. In most of these cases, a preoperative detrusor hypocontractility is found. Usually the micturition resolves within the first 10 days after surgery. An
obstructive urinary retention making intermittent catheterization necessary occurs in
up to 6% of patients (Croak et al.2002).
Fig. 25.4 TVT localization with perineal ultrasound
Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery
In a study by Sevestre et al.,persistent stress incontinence was found in 14% of patients, whereas 18% of failures had urge incontinence and 21% had de novo urgency
without incontinence (Sevestre et al.2003).
However, there are no conclusive data about rates of persisting pure stress incontinence after the various incontinence procedures in females.As in patients with a preoperative hypotonic urethra of less than 10 cm of water in the urethral pressure profile, continence rates after colposuspension and tension-free tapes do not exceed
50%–80%, and other sling procedures will only be slightly better (Rezapour and Ulmsten 2001; McGuire and Lytton 2002). It can be assumed that in this case postoperative
persisting stress incontinence will be roughly 20%–30%.
Additionally, urinary tract infections may be responsible for deterioration of continence after incontinence surgery. A urinary tract infection developed in 23% after colposuspension despite antibiotic prophylaxis and 81% of infections occurred after the
7th day (Chilaka and Mayne 1998).
25.3.2 Diagnostic Work-up
As in males suffering from incontinence after radical prostatectomy,the preoperative
communication between patient and physician with thorough information on expected outcomes, including dysuric or incomplete voiding and incontinence during the
first 4 weeks, may help to decrease dissatisfaction with postoperative results (Croak et
al. 2003). Interestingly a longer recovery time was not associated with decreased satisfaction.
A careful history can already distinguish the circumstances of urine loss, whether it
is due to stress, urge or mixed incontinence. A bladder diary, stress test and pad test
should complete and document these subjective data.
A urine analysis is mandatory to exclude a urinary tract infection deteriorating urinary control.
Physical examination including vaginal examination is performed to test the postoperative healing and the capability of pelvic floor muscle contraction.
Ultrasound of post-void residual urine is necessary to detect obstruction and retention.Perineal or transvaginal ultrasound are excellent tools to identify the localization of a sling or tape and is also an excellent instrument to evaluate the effect of pelvic floor muscle contraction on the urethra and bladder (Fig. 25.4).
Cystoscopy is performed when hyperelevation of the bladder neck and tape erosion
or perforation are suspected.
Urodynamic studies are usually indicated when postoperative complaints will be
unchanged 4–8 weeks postoperatively and are mandatory before each surgical reintervention (Table 25.8).
351
25.3.3 Treatment in the Early Postoperative Period
Supplying the patient with incontinence devices adapted to the degree of incontinence
is the first step in early postoperative treatment.
Anticholinergic drugs should be tried for at least 4 weeks in case of urgency or urge
incontinence.
Pelvic floor muscle exercise,biofeedback and electrical stimulation are further options to improve the continence status.
352
Daniela Schultz-Lampel
25
Table 25.8.
Diagnostic work-up in incontinence after female incontinence-surgery
Diagnostic work-up
• History: urgency, urge or stress incontinence, dysuria
• Bladder diary
• Stress test
• Pad test
• Urine/urine culture
• Physical examination: PFM contraction
• Ultrasound: residual urine
• Perineal or vaginal ultrasound: tape localization
• Cystoscopy: sling perforation or erosion
• Urodynamic studies
PFM pelvic floor muscles.
If urgency and urge incontinence persist 4 weeks after surgery a local infiltration of
the anterior vaginal wall with local anesthetic drugs can rule out patients who will improve from a surgical vaginal urethrolysis.
Midline tape lysis or vaginal urethrolysis within the first 4 weeks after placement of
the tape succeeded in resolving obstruction in 65%–87% and resolving urgency or
urge incontinence in 16%–69%, with a low rate of de novo stress incontinence in
13%–19% (Petrou and Young 2002 Fischer et al. 2002a, b; Carey et al.2003; Croak et al.
2003; Scapero et al. 2003). From 800 tension-free vaginal tapes, 45 had to be cut, 40%
due to retention, 51% due to sensory urge and 9% due to combined pathology. The tape
incision was usually performed about 8 weeks postoperatively (Fischer et al. 2002a, b).
25.3.4 Treatment in the Advanced Postoperative Period
In urgency or urge incontinence resistant to pharmacotherapy or not suitable for
urethrolysis,a trial of injection of botulinum A toxin in the detrusor muscle or a neuromodulation of the sacral nerves may be justified.
A recurrent incontinence surgery should not be performed earlier than at least
3 months after the preceding operation.Whether classical sling procedures or tensionfree vaginal tapes should be preferred in this situation cannot definitively be answered
(Wilson et al. 2003). An advantage of the new transobturatory approach may be that
this technique will bypass the former region of surgery.
In worst cases,implantation of an artificial urinary sphincter may also be an option
in female stress incontinence.
25.4 Conclusion
Urinary incontinence is common after radical prostatectomy and not as rare as could
be expected after female incontinence surgery.
As incontinence improves with time, invasive treatment options should be withheld
in the early postoperative period.
However, patients should be offered therapeutic methods that improve their quality of life and accelerate the recovery period to regain continence.In this context,phys-
Chapter 25 Postoperative Management of Urinary Incontinence After Urologic Surgery
iotherapy is the most important therapeutic approach in the early postoperative period. However, the value of the different methods such as simple pelvic floor muscle exercise, biofeedback training, electrical stimulation or combination therapies remain
uncertain.
Accurate preoperative information on possible postoperative bladder dysfunctions
or incontinence can improve patient’s satisfaction and quality of life.
However, the most important point is to prevent postoperative incontinence with
thorough preoperative work-up and careful surgical techniques.
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