Patient predictors of postprostatectomy incontinence

In this video, Ricardo M. de Oliveira Soares, MD, discusses patient-specific predictors of post prostatectomy incontinence. Soares is a urologist at Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Transcription:

There is way more than surgery to [predict] why some people get incontinence and others don't. There are different factors that make patients more at risk, and I always discuss them with my patients. For example, patients who are older have higher risk. Patients that have a high [American Society of Anesthesiology] score are going to have worse results. Patients with a higher [body mass index] [are also at higher risk]. Obviously, in the US, obesity is a big problem. Sometimes, it's a little difficult to extrapolate the results from Europe and Asia to the American population, because the bodies are not the same. That's why it's important to know your own results. I know my results over the past 5 years here in the US, and those are what I quote to my patients. Whenever you're talking about the risk of incontinence, you should know your own data and not cite a specialist who has done a [large amount] of cases. That's very important to know. Prostate size is another factor. Patients with larger prostates are going to have a slightly higher risk of incontinence. The bladder neck is going to be bigger, there's more difficulty in sparing the surrounding structures and also having a good view of the apex to spare that membranous urethra. It's easier with small prostates to get a good sparing of the urethra. Patients who have a higher score on questionnaires such as the International Consultation on Incontinence Questionnaire and International Prostate Symptom Score tend to have more problems, particularly [if they have] overactive bladder, because obviously that is not going to be resolved with a prostatectomy. If a patient has had previous surgery such as transurethral resection of the prostate or holmium laser enucleation of the prostate, that also increases their risk of incontinence. Another factor is the stage of the cancer. If the cancer is more advanced, you need to remove more surrounding tissues around the prostate. To get extra safety margin, you remove more nerves and more arteries, and therefore the sphincter innervation and blood supply are going to be compromised, increasing the risk of incontinence. Even if the patient becomes continent, they tend to have a more delayed recovery. In terms of imaging, there's been studies showing either on MRI or the transperineal ultrasound showing that number 1 is obviously the membranous urethra length. For someone who has a very long urethra, the reconstruction is probably going to be easier. It has been shown that for each extra millimeter that you have in the urethra, there is a 5% increase of recovery of continence, and that's predictive at 6 and 12 months. Another parameter is the thickness of the levator ani muscle. That obviously is a surrogate for the patient's fitness, and it has been shown to weave in with other types of cancer surgery. With less muscle mass, the patient's going to have higher risk of complications. For men with bladder cancer, the thickness of the psoas muscle is a surrogate, but in the case of prostate cancer, the thickness of levator ani is a surrogate for fitness, and the thicker it is, the faster recovery the patient is going to have. There have been studies [looking at whether] if the bladder neck shape of the apex is overlapping the urethra makes a difference, but there was nothing conclusive in regards to those parameters.

This transcription was edited for clarity.