0022-5347/95/1533- 1038$03.00/0 THE JOURNAL OF UROLOGY Copyright 0 1995 by AMEUlw UROLOOICAL ASSOCLkTION, L C .

Vol. 153, 1038, March 1995 Printed in V.S.A.

Editorial

POST-PROSTATECTOMY INCONTINENCE: THE IMPORTANCE OF BLADDER DYSFUNCTION

In 1987 we published a review of our post-prostatectomy incontinence experience, which examined the urodynamic findings in 38 men.' A suggested treatment algorithm in- cluded in that article focused on the importance of specific treatment being directed by the urodynamic findings. In the article by Goluboff et al in this special issue of the Journal (page 1034) a number of critical points are emphasized re- garding these urodynamic findings. As the number of radical prostatectomies performed continues to increase, we are called upon to evaluate and treat greater numbers of men with post-prostatectomy incontinence. In a recent review of 840 Medicare beneficiaries treated with radical prostatec- tomy between 1988 and 1990 more than 60% reported some problem with wetness and 30% required some form of pro- tection for the incontinence.2 Goluboff et al again remind us to avoid the false assumption that most of these men have sphincteric damage and stress incontinence. In fact, in their experience with 56 men only 5% (3 men) had stress inconti- nence alone. In our previously reported experience with 107 men with post-prostatectomy incontinence only approxi- mately a third had stress incontinence The majority of men had either high pressure bladder dysfunction (detru- sor instability with or without decreased compliance) or stress incontinence in conjunction with high pressure blad- der dysfunction. This observation strongly supports the need for detailed urodynamic studies before instituting any inva- sive treatment for the incontinent man following prostatec- tomy.

Should either periurethral injection therapy or placement of an artificial sphincter be performed in men with a signif- icant component of bladder dysfunction, which was present in more than 60% of men with post-prostatectomy inconti- nence in our experience and in 95% of men reported on by Goluboff et al, the operative results will clearly be suboptimal as the continued or exacerbated high bladder pressures ex- ceed the iatrogenically elevated outlet resistance. After care- ful urodynamic study, surgical intervention (an artificial sphincter) was required in 54% of our patient population with a success rate of 90%. Conversely, 84% of those treated with anticholinergic therapy alone had significant improve- ment in incontinence as bladder dysfunction was ~ontrolled.~ Why should this bladder dysfunction be such a major con- tributor to incontinence following prostatectomy?

To provide some additional information regarding this question we prospectively evaluated 26 men with detailed urodynamic studies before and 3, 6 and 12 months after radical retropubic prostatectomy? At each interval after sur- gery the majority of men with incontinence had a major component of bladder dysfunction that occurred de novo fol- lowing the radical prostatectomy. Further study is required to define the exact cause of this change in bladder function. Are the etiologies different in incontinent men following transurethral resection of the prostate versus after radical prostatectomy? As suggested by Goluboff et al, does aging have a significant role in the bladder dysfunction? Is there some iatrogenic denervation that occurs during radical pros- tatectomy that contributes to de novo postoperative changes in bladder function? As we strive to answer these questions, hopefully we will be able to improve our ability to predict preoperatively those at risk for this devastating postopera- tive complication. In the future we may be able to modify our surgical technique to help minimize this complication and to offer effective nonsurgical and surgical treatment to carefully selected individuals to improve their quality of life after prostatectomy.

Gary E. Leach Department of Urology Kaiser Permanente Medical Center Los Angeles, California

REFERENCES

1. Leach, G. E., Yip, C. and Donovan, B. J.: Post-prostatectomy incontinence: the influence of bladder dysfunction. J. Urol., 138 514, 1987.

2. Fowler, F. J., Barry, M. J., Lu-Yao, G., Roman, A,, Wasson, J. and Wennberg, J.: Patient-reported complications and fol- low-up treatment after radical prostatectomy. Urology, 42 622, 1993.

3. Leach, G. E. and Yun, S. K.: Post-prostatectomy incontinence: parts I and 11. Neurourol. Urodyn., 11: 91, 1992.

4. Foote, J., Yun, S. K. and Leach, G. E.: Post-prostatectomy incon- tinence: pathophysiology, evaluation, and management. Urol. Clin. N. h e r . , 1 8 229, 1991.

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