Trauma/Reconstruction/Diversion
Francisco Martins, MD (he/him/his)
Department of Urology, University of Lisbon School of Medicine
Sarah Fraumann Faris, MD (she/her/hers)
Associate Professor of Urology
University of Chicago
Course Description: Urinary incontinence is estimated to be prevalent in about 14% of males in the United States. While the exact fraction among these patients suffering from stress urinary incontinence (SUI) is not definitively known, the major etiologies reported for SUI are prostatectomies, with incontinence varying between 2% and 43% (depending on definition, surgical technique and length of follow-up), external beam radiation (1%-16%) and transurethral resection of the prostate (1%-3%). Besides pelvic floor physical therapy, established treatments of SUI are implantation of either male slings or artificial urinary sphincter (AUS). While the majority of patients can be successfully treated with these options and the choice mainly depends on degree of SUI, there are instances in which implantation of these devices is not straightforward and further considerations have to be taken into account. Examples of this include multiple prior AUS erosions, recurrent bladder neck contractures, concomitant radiation cystitis with recurrent hematuria, or decreased urethral viability due to prior radiation or urethroplasty. There is limited information about these topics in the literature or textbooks, especially on how to successfully address SUI in these complex settings, and, hence, many patients may be left untreated despite viable therapeutic options. As the number of patients treated for prostate cancer has increased in the past two to three decades, so will the number of patients who present with complex SUI, making this an emergent and important topic for urologists.
Learning Objectives Summary:
While most SUI patients can be successfully treated with implantation of either a male sling or AUS, depending on severity of incontinence or presence of prior radiation, there is a subset of patients when these procedures are at higher risk of complications. This is especially true for AUS placement. Many of these patients will not be offered an AUS or an AUS replacement after erosion or malfunction due to concerns of further complications. Similarly, patient comorbidities, such as recurrent hemorrhagic cystitis requiring repeated continuous bladder irrigations with large-bore catheters not compatible with an AUS or recurrent bladder neck contractures requiring interventions with cystoscopes of standard size, may prevent urologists form implanting an AUS. There is also a subset of men in whom AUS implantation, usually a second or third one, is simply not feasible due to lack of viable urethral tissue to support it. In all these instances, patients are left incontinent, which severely impacts their quality of life despite the presence of valid treatment options. Unfortunately, some of these unfortunate patients will end up requiring urinary diversion as a last resort. Furthermore, the number of patients with complex incontinence will continue to increase, mainly as a result of late effects of prostate cancer therapy, specifically radiation and/or energy ablative treatments.
As the field of reconstructive surgery continues to emerge rapidly, so has the concern, understanding and development of treatment options for patients with complex male incontinence. The educational aim of this course is to demonstrate the most common clinical presentations of these patients, to delineate treatment strategies and to describe these treatment options.