By: Dan Sperling, MD

Urinary incontinence means the involuntary leaking of urine. It is “one of the most commonly reported and distressing side effects of prostate cancer treatment.”[i] The most prevalent types following surgery to remove prostate cancer (radical prostatectomy or RP) are stress incontinence (leakage during a cough, sneeze or physical activity) and urge incontinence or overactive bladder (feeling like you have to go to the bathroom and sometimes not making it there in time). The severity of post-RP incontinence varies from a few drops or spurts to regular dribbling requiring the use of pads or adult diapers. Urologic surgeons recognize that incontinence after radical prostatectomy is a “highly problematic” condition that affects “many aspects of quality of life, and healthcare providers must be aware of this.”[ii] In fact, published peer-reviewed articles suggest that doctors know this. According to a 2016 urology journal article, “Stress urinary incontinence (SUI) is a degradation of the quality of life factor in the consequences of radical prostatectomy.”[iii]

How long does incontinence last, and how frequently does it linger? Those are hard numbers to pin down because published studies are not always apples-to-apples in terms of how the study was designed, which definitions of incontinence they use, and varying follow-up periods. A 2016 review of 61 high quality papers examined incontinence rates at 12 months (one year) after RP. The authors acknowledged that there were variances in patient populations based on age and clinical factors, as well as a mix of surgeons’ levels of experience; in order to analyze incontinence data, the authors “included only outcome data obtained using objective measures or reliable and valid measurement instruments. In detail, the definition of continence was the use of no pad at all, 0–1 pads per day, or no leak measured by a validated questionnaire including the International Consultation of Incontinence Questionnaire-Urinary Incontinence…”[iv] Thus, it’s evident that the same standard of continence was not equal across the studies, with the strictest definition being the use of no pad at all. Taking that into account, the authors state that an “acceptable incontinence rate” is 10% at 12 months, and calculated that their data pool averaged 10-15% rates at 12 months. They hypothesize that two of the studies with unusually high rates of 25-30% for the same period may have been the product of operations performed by “under-experienced surgeons.”

A more discouraging report out of Washington University analyzed data from 589 cases of men who completed a pre-surgery questionnaire on medical history and lifestyle factors, and whose self-reported incontinence was recorded at their first post-RP clinical visit (approximately 6 weeks) and again at 58 weeks after surgery. The study team used the strict definition of continence as no pad use at all. Not all men who completed the questionnaire and had surgery showed up for the post-treatment clinical visits, so the data reflects a drop in sample size. The purpose of the study was to determine if some men were more at risk of post-surgery incontinence, and they found that men who were both obese and inactive had the highest rates. Their findings were:

• At 6 weeks, 59% were incontinent (rates were roughly comparable for obese and nonobese men)
• At 58 weeks, 22% were incontinent (this far out from treatment, men who were obese and inactive had the highest rates at 41%).

Urologic surgeons are continually striving to reduce incontinence side effect rates because they know that urine leakage is a high price to pay for “getting all the cancer out.” (This is the goal of RP, though long-term success rates range from just over 90% to below 75%.) One approach is to identify patients who might be at greater risk of post RP-incontinence, such as pre-existing urinary difficulties, anatomic abnormalities, or obesity/inactivity. Another approach is technologic improvements like robotic-assisted RP. Statistics generally reflect somewhat lower incontinence rates for robotic-assisted RP (2-15%), and highly experienced robotic surgeons claim that lifelong permanent incontinence after robotic surgery is rare for their patients. Still, a noted urologist with the University of California/Irvine Department of Urology states that “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.”[v]

The physical discomforts, hygiene issues, and emotional toll of long-term (more than 18 months) post-surgery incontinence can completely discourage patients. There are procedures that can be done and many give the patients the relief and success they are looking for. These procedures include installing a sling that supports and puts pressure on the urethra to help retain urine until the bladder is emptied; injection of a bulking agent to make the urethra narrower so it can close off the flow; and surgical placement of an artificial urinary sphincter that holds urine back until operated by the patient.

Perhaps the most important recommendation for urologists discussing prostate cancer treatment options with their newly diagnosed patients is to evaluate the patient’s current urinary status, and discuss what’s important to him regarding quality of life (urinary and sexual). The physician needs to be familiar with health factors that place the patient at risk of post-RP leakage, including age, weight, body mass index and exercise – and to be frank with the patient if they are not favorable. Being honest about the range of success/side effect rates for each treatment is important. Equally valuable is recommending that the patient to do his own research on side effect risks for each treatment helps empower the patient to weigh his options. Finally, encouraging attendance at a support group will help patients hear real life stories, as will enrolling in an online discussion forum. Patients deserve complete education, not unpleasant surprises after major surgery.

And, speaking of well-rounded information, many patients are still not told about the use of multiparametric MRI to identify the presence of a tumor, in-bore MRI guided biopsy for the greatest accuracy with minimal needles, and the option of focal therapy such as our Focal Laser Ablation which destroys the tumor while preserving healthy gland tissue as well as potency and continence. We owe it to patients to fully inform patients of all options, be it for detection, diagnosis or treatment.

[i] Wolin K, Luly J, Sutcliffe S, Andriole G, Kibel A. Risk of Urinary Incontinence Following Prostatectomy: The Role of Physical Activity and Obesity. J Urol. 2010 Feb; 183(2): 629–633.

[ii] Seo HJ, Lee NR, Son SK, Kim DK et al. Comparison of Robot-Assisted Radical Prostatectomy and Open Radical Prostatectomy Outcomes: A Systematic Review and Meta-Analysis. Yonsei Med J. 2016 Sep;57(5):1165-77. doi: 10.3349/ymj.2016.57.5.1165.

[iii] Pic G, Terrier JE, Ozenne B, Morel-Journel N et al. [Impact of anastomotic strictures on treatment of post-prostatectomy stress incontinence by artificial urinary sphincter]. Prog Urol. 2016 Oct 7. pii: S1166-7087(16)30570-X. doi: 10.1016/j.purol.2016.09.063. [Epub ahead of print]

[iv] Seo et al., Ibid.

[v] http://www.urology.uci.edu/prostate/Continence.html