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Urologia 2015 ; 82 ( 1 ): 42-45 DOI: 10.5301/uro.5000064

original article

ISSN 0391-5603

Urinary incontinence and neuropathy after radical prostatectomy: diagnosis and treatment Bernardo Ventimiglia, Matilde Sigona, Agata Di Dio, Tiziana Puglisi, Giuseppe Costantino Department of Surgery, Urology Clinic, Neurourology and Urodynamics, University of Catania, Catania - Italy

Abstract Introdution and Objective: The urinary incontinence after radical prostatectomy is secondary to neuropathy with various degrees from neurapraxia to neurotmesis. We propose to apply therapeutic and rehabilitative models appropriate to the diagnosis and to evaluate the results. Materials and Methods: We examined 79 homogeneous patients with urinary incontinence after radical prostatectomy. After having defined the diagnosis by a urodynamic examination, the study of pudendal nerve somatosensoryevoked potentials (SEPs) and perineal electromyography (EMG), patients were divided into four groups (A; B; C; D) and submitted to different clinical drug protocols and rehabilitation. After 3 months, patients were reevaluated. Results: Twenty-eight patients with idiopathic overactive bladder (Group A) have been treated with anticholinergics: two unchanged (7%); 14 improved (50%); and 12 recovered (43%). Sixteen patients with overactive bladder and sphincter incompetence (Group B) have practiced physiokinesis therapy (FKT) of pelvic floor and anticholinergic therapy: one unchanged (6%); eight improved (50%); and seven recovered (44%). Fourteen patients with perineal incompetence to continence (Group C) have been treated with FES, FKT of pelvic floor, and Biofeedback: three patients were unchanged (21%); five improved (36%); and six recovered (43%). Twenty-one patients with sphincter denervation (Group D) performed FES, FKT of pelvic floor, and Biofeedback: 16 unchanged (76%); five improved (24%); and zero recovered (0%). Of these 16 patients, six non-responders have placed a transobturator tape (TOT) sling and four an artificial sphincter. Conclusions: A therapy adherent to the diagnosis increases success rate. Keywords: FKT of pelvic floor, Neuropathy, Radical Prostatectomy, Rehabilitation, Urinary Incontinence

Introduction Urinary incontinence (UI) frequently occurs after radical prostatectomy (RP) despite the improvement in surgical techniques and a better understanding of pelvic anatomy and micturition neurophysiology. According to several articles from 1995 to 2013 examined by our meta-analysis, not subject to this publication (Tab. I), UI varies between 2% and 87% in patients undergoing RP. This wide range depends on the definition of the different parameters and varying degrees of UI itself (1). Furthermore, the patient population examined is often not homogeneous due to other possible causal factors or predisposing factors (previous transurethral resection of prostate “TURP”, preoperative radiotherapy, neurodegenerative disease, obesity, cervicoAccepted: March 18, 2014 Published online: January 6, 2015 Corresponding author: Bernardo Ventimiglia Neurourology and Urodynamics, University Hospital “Policlinico-Vittorio Emanuele” Via Plebiscito 628 Catania 95124, Italy [email protected]

urethral obstruction, tumor recurrence, and so on). Scientific literature has demonstrated that UI after PR has different clinical aspects certainly not due to a single type of urodynamic pattern. This seems to be due to side effects of dissection techniques and/or coagulation adopted on the nerve plexus. The pathogenesis of UI after RP has not been clearly defined yet. Scientific literature recognizes sphincter incontinence as the main cause, but in reality, it is more often than not a mixed picture in which it coexists in a mixed framework with other alterations. Thanks to the improvement of the urodynamic test, the overactive bladder (OB) has been increasingly recognized. Leach (2), for example, in 2004 found OB to be the sole cause in 50% of patients. Moreover, even if our meta-analysis of the pathogenesis in scientific literature underlines the multifactorial genesis of UI following RP and the presence of different clinical presentations, not enough attention is paid to the neuronal injury after surgery. In particular, we compared seven articles that recognize the same three dysfunctions: OB, sphincter incompetence, and a mixed incontinence. They all use urodynamic evaluation, but only one uses a neurophysiological test (8). So, our study aims to clarify the type of incontinence through urodynamic results and to specify, if possible, the basic neurological damage by a neurophysiological examination. © 2015 Wichtig Publishing

Ventimiglia et al

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Table I - Digest of meta-analysis Year

Authors

No. of patients

Protocol

Medium time

1995

OB

SPH.INC MIX INC

Other

Chao-Mayo (3)

74

Urodynamic test

3.8 years

4.0%

57.0%

1997

Hammerer and Huland (4)

82

Urodynamic test

Presurgery; after 6-8 weeks; after 6 months

41.0%

59.0%

1998

Ficazzola-Nitti (5)

60

Urodynamic test



3.0%

67.0%

23.0%

7.0%

1999

Groutz and coll. (6)

83

Urodynamic test

2.7 years

3.6%

32.5%

12.0%

51.9%

2005

Kielb and Clemens (7)

146

Urodynamic test

4.1 years

0.7%

65.0%

13.0%

21.4%

2010

Ventimiglia et al (8)

51

Urodynamic test; Pudendal SEPs; Perineal EMG.

After 8-24 months

35.0%

37.0%

28.0%

2013

Chung et al (9)

264

Urodynamic test

32.6 months

27.0%

17.0%

39.0%

56.0%

OB = overactive bladder; SPH.INC = sphincter incompetence; MIX INC = mixed incontinence.

After having defined a qualitative and quantitative diagnosis, we applied a rehabilitation protocol offering several options for treatment.

Materials and Methods Between January 2005 and December 2012, we selected 79 consecutive patients with UI after RP (39 laparoscopic, 40 retropubic), average age is 66 years (range 51-77), and time span of 4-24 months after surgery. The patients reported a positive pad test (range between 3 and 12 pads/day). All patients with tumor recurrence, previous radiotherapy, TURP, or bladder outlet obstruction (BOO) were excluded. During the evaluation phase, all patients performed: • • •



clinical evaluation (urological history, pad test, clinical examination of pelvic floor, research of muscle synergies, and reversal of perineal control, “pc-test”); urodynamic test (urodynamic equipment Pico Menfis 3000) with previous eradication of any urinary infection; study of somatosensory-evoked potentials (SEPs) of the pudendal nerve (stimuli 5/s; filters 20-200 Hz; analysis time 100 ms (10)) recorded in Cz, Fz comparative to peroneal, and external sciatic popliteal nerves; perineal electromyography (EMG) with computerized frequency analysis (Medelec S92) with needle electrodes.

We consider signs of neuroapraxia to be due to a transient functional impairment that involves myelin: the reduction in nerve conduction velocity directly, which is evident by the analysis of SEP, and the reduction of the contractile strength of the pelvic floor in perineal EMG indirectly. The assonotmesis, due to an axonal injury, is characterized in SEP by a reduction in the nerve conduction amplitude and latency, in EMG by a reduction in amplitude and number of PUM (motor unit potential) during a maximal voluntary contraction, and by an increase in the average duration of individual action potential. In the neurotmesis, the conduct of the potential is extremely slow or stopped and there are signs of spontaneous © 2015 Wichtig Publishing

activity by denervation such as fasciculations, fibrillation, and Jasper’s potentials in EMG. Having reached an accurate diagnosis of UI, we performed an appropriate treatment on the basis of the specific urodynamic and neurophysiological results. Our rehabilitive protocol involves the use of:  Behavioral therapy for all incontinent patients: eating habits, body weight, physical activity, postural attitude, and breathing;  Anticholinergic therapy in case of an OB: we use Solifenacina 5 mg or Fesoterodina 4 mg based on personal response to these drugs;  Physiokinesis therapy of pelvic floor (FKT) in case of perineal incompetence or perineal denervation. It is thus divided into: a) acquisition: awareness of the perineum and anus muscle activity; b) muscle balance and co-contraction: elimination of synergies between agonist and antagonist; c) training : isometric and isotonic exercises in supine, sitting, quadruped, standing position, improving phasic and tonic fibers of the pelvic floor; d) automation: strengthening of the reflex contraction of the pelvic floor after increased intra-abdominal pressure;  Visual feedback by perineal surface EMG in case of perineal incompetence or perineal denervation, but it is contraindicated in case of OB;  Functional electrical stimulation (FES) of the pubococcigeal muscle through surface electrodes with a frequency of 10-40 Hz and double resting time compared with the working one. We adopted this technique with the same indications of Biofeedback: in case of perineal incompetence or perineal denervation, but it is contraindicated in case of OB;  Cunningham penile clamp (Grade of Recommendation C of guidelines on UI therapy-ICS 2013) in order to perform the pelvis perineal physiotherapy without UI;  Acid Alpha Lipoic (300 mg) for the neuroapraxia (11, 12).

Neuropathy after radical prostatectomy

44 Table II - Urodynamic diagnosis and perineal neuropathy

Table III - Clinical and rehabilitative protocols

Group A

Group A 28 patients

Overactive bladder Normal perineal muscles 28 patients (35%)

Group B

Group C

Group D

Overactive bladder

Normal bladder

Normal bladder

Perineal Perineal Perineal incompetence incompetence denervation (Neuroapraxia) (Assonotmesis) (Neurotmesis) 16 patients (20%)

14 patients (18%)

21 patients (27%)

After 3 months, patients were revalued (13). The Pad test was repeated and the outcome measures were 0, recovered; 1-2, improved; and more than 2, unchanged.

Results The urodynamic and neurophysiological tests, performed on 79 patients, showed four different clinical groups, called A, B, C, D, as summarized in Table II. Group A consisted of 28 patients and showed an OB (120 cc average leak point) and a valid contraction of perineal muscles, while the neurological tests were negative. The 16 patients in group B had an OB and a perineal incompetence to continence. This is demonstrated by a rapid depletion of contractile perineal force using perineal EMG with an analysis of frequency. In the 14 patients in group C, there was only a perineal incompetence with a normal bladder. At EMG, there was a severe loss of ability to articulate the pelvic floor that indicated a low threshold of muscle fatigue. The 21 patients in group D had a short bladder compliance; the pudendal SEPs showed a severe reduction in the amplitude and velocity of nerve conduction, detected in Cz-Fz, and during the perineal EMG, some Jasper’s potentials appear. Therefore, our diagnostic protocol suggests four different types of UI: in group A, there is an idiopathic OB, while in group B, it is associated with a perineal functional deficit; in group B, there is a moderate to severe degree of neurapraxia that involves the pudendal nerve plexus; in group C, each bladder parameter is normal, while it is clear that there is an axonotmesis that impairs the function of the pelvic floor; in group D, the neurotmesis determines a complete perineal deficit to continence and consequently a reduced bladder compliance. We associated four clinical categories with four different treatment protocols (Tab. III). The patients in group A were treated with anticholinergic drugs (Solifenacin 5 mg/day: 22 patients; Fesoterodin 4 mg/ day: six patients). This group gained a success rate of 93%, divided as follows: 12 patients recovered (43%) [pad test negative], 14 improved (50%) [pad test 1-2/day]; and only two patients unchanged (7%) [pad test >2] after 3 months of pharmacological treatment. The patients in group B with a mixed incontinence were treated with anticholinergic (Solifenacin 5 mg/day: 14 patients; Fesoterodin 4 mg/day: two patients), alpha lipoic acid 300 mg for 4 weeks, and session of FKT for 6 weeks. In this group, we noticed that seven patients recovered (44%) [pad

Group B 16 patients

Group C 14 patients

Behavioral therapy and FES and FKT and Biofeedback 14 patients 22 patients and Solifenacin 5 mg; Solifenacin 5 mg; Cunningham 2 patients 6 patients (6 weeks) Fesoterodin 4 mg Fesoterodin 4 mg and ac. Alpha lipoic 300 mg (4 weeks) and FKT (6 weeks) Behavioral therapy and pharmacological therapy:

Behavioral therapy and pharmacological therapy:

Group D 21 patients Behavioral therapy and FES and FKT and Biofeedback (6 weeks) and Cunningham (6 weeks)

test negative], eight patients improved (50%) [pad test 1-2/ day], and one unchanged (6%) [pad test >2]. The patients in group C, with perineal incompetence without bladder anomalies, were subjected to 12 sessions of FES with individual stimulation parameters, FKT, and Biofeedback with physiatric monitoring for 6 weeks. Moreover, they practiced daily home FKT and the use of Cunningham’s penile clamp. The results of this group were six patients recovered (43%) [pad test negative], five patients improved (36%) [pad test 1-2/day], and three unchanged (21%) [pad test >2]. Group D with sphincter lesion and a reduction of bladder compliance was treated as patients in group C. None of the patients have recovered (0%), five have improved (24%) [pad test 1-2/day], and 16 remain unchanged (76%) [pad test >2]. Among these nonresponder patients, six were treated by placement of a Sling TOT (transobturator tape), four with the placement of an artificial urinary sphincter, and six refused further surgical procedures.

Discussion In scientific literature, there are a lot of authors who have attempted diagnosis and rehabilitation treatment of UI after RP. Previous studies have clearly established the importance of FKT associated or not with FES and Biofeedback, in the recovery of UI. In particular, Van Kampen (14) in 2000 with his case-control study, in which he compared patients treated with FKT and patients with placebo, underlined the effectiveness of rehabilitation in order to recover an early continence. Filocamo (15) in 2005 agreed with this assumption, thanks to his accurate follow-up of incontinent patients. Otherwise, the meta-analysis of Hunter (16) and Mac Donald (17) in 2007 noted an excessive variability in incontinent patients in previous studies about the benefit of FKT. On the one hand, in 2008, Moore (18) defined the obtained findings with a physiatric guide similar to the obtained findings with oral or written rules; on the other hand, Overgard (19) in 2008 and Marchiori (20) in 2010 reaffirmed the effectiveness of rehabilitation. Moreover, Dora (21) in 2008 and Ribeiro (22) in 2010 stimulated the use of Biofeedback with their study. Lastly, Khoder (23) in 2011 took the benefit of FKT for granted. © 2015 Wichtig Publishing

Ventimiglia et al

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In our opinion, these studies are characterized and limited by the uniformity of treatment and the absence of neurophysiological evaluation that could explain the reason why some patients did not respond despite the fact that they were treated with the same treatment and follow-up period of time. The use of pelvic SSEP, indeed, identified the histological injury type in different patients: in group B, there are several degrees of neurapraxia; in group C, there is likely Wallerian degeneration after axonotmesis, and both injuries are treatable with rehabilitation; in group D, neurotmesis is a more serious damage leading to surgical intervention. Therefore, the urodynamic test in group A showed that sometimes there is no indication of physiatric treatment, but only of a pharmacologic one. Considering this, our study associates different urodynamic and neurophysiological frameworks with different therapeutic protocols and results obtained after treatment, which in turn justify the neurophysiological classification. In fact, patients who had a neurapraxia or an axonotmesis have showed an improvement or a recovery in about 90% of patients, whereas only 24% of patients with neurotmesis showed an improvement. In our study, patients come to our attention after having been operated on by surgeons with different learning curves and from different centers. Therefore, we cannot formulate a plausible statistical evaluation about the differences of morbidity between patients undergoing a retropubic and laparoscopic RP. Otherwise, the clinical results are influenced by the time elapsed after the operation: as expected, the best results were obtained in patients treated less than 8 months after surgery. However, our study does not have a randomized design; treatment groups are unbalanced because they reflect neurophysiopathological classification. The sample size of patients examined is not so large, but we are going to extend our protocols to other incontinent patients.

5.

Conclusions

17.

Our study has shown that in patients with UI after RP, a clear urodynamic and neurophysiological diagnosis is useful in order to improve clinical and therapeutic protocols. Also, the choice to undergo an early rehabilitation process gives better and more stable clinical results long range.

Disclosures Financial support: The authors have no financial disclosures to make. Conflict of interest: The authors have no conflict of interest.

6.

7. 8. 9. 10. 11. 12. 13. 14.

15. 16.

18.

19.

20.

References 1.

2. 3. 4.

Sacco E, Prayer-Galetti T, Pinto F, et al. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term followup. BJU Int. 2006;97(6):1234-1241. Leach GE. Incontinence treatment options for post-prostatectomy. Reprinted from PCRI Insights May 2004 vol. 7, no. 2. Chao R, Mayo ME. Incontinence after radical prostatectomy: detrusor or sphincter causes. J Urol. 1995;154(1):16-18. Hammerer P, Huland H. Urodynamic evaluation of changes in urinary control after radical retropubic prostatectomy. J Urol. 1997;157(1):233-236.

© 2015 Wichtig Publishing

21. 22.

23.

Ficazzola MA, Nitti VW. The etiology of post-radical prostatectomy incontinence and correlation of symptoms with urodynamic findings. J Urol. 1998;160(4):1317-1320. Groutz A, Blaivas JG, Chaikin DC, Weiss JP, Verhaaren M. The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study. J Urol. 2000;163(6): 1767-1770. Kielb SJ, Clemens JQ. Comprehensive urodynamics evaluation of 146 men with incontinence after radical prostatectomy. Urology. 2005;66(2):392-396. Ventimiglia B, Tsirgiotis A, Coco T, et al. Urinary incontinence after prostatectomy. Neurophysiological and urodynamic diagnosis Urologia 2011;78(2):1-4-37. Chung DE, Dillon B, Kurta J, et al. Detrusor underactivity is prevalent after radical prostatectomy: a urodynamic study including risk factors. Can Urol Assoc J. 2013;7(1):33. D’Alpa F, Ventimiglia B, Scrofani A, Grasso A. Pudendal nerve SEPs in myelopathies. Acta Neurol (Napoli). 1987;9(2): 139-146. Mijnhout GS, Alkhalaf A, Kleefstra N, Bilo HJ. Alpha lipoic acid: a new treatment for neuropathic pain in patients with diabetes? Neth J Med. 2010;68(4):158-162. Han T, Bai J, Liu W, Hu Y. A systematic review and meta-analysis of α-lipoic acid in the treatment of diabetic peripheral neuropathy. Eur J Endocrinol. 2012;167(4):465-471. Minaldi G, Ventimiglia B, Finocchiaro M, et al. Sexual activity and urinary incontinence in women. Urologia. 2009;76:203-206. Van Kampen M, De Weerdt W, Van Poppel H, De Ridder D, Feys H, Baert L. Effect of pelvic-floor re-education on duration and degree of incontinence after radical prostatectomy: a randomised controlled trial. Lancet. 2000;355(9198): 98-102. Filocamo MT, Li Marzi V, Del Popolo G, et al. Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. Eur Urol. 2005;48(5):734-738. Hunter KF, Glazener CM, Moore KN. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2007;2(2):CD001843. MacDonald R, Fink HA, Huckabay C, Monga M, Wilt TJ. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int. 2007;100(1):76-81. Moore KN, Valiquette L, Chetner MP, Byrniak S, Herbison GP. Return to continence after radical retropubic prostatectomy: a randomized trial of verbal and written instructions versus therapist-directed pelvic floor muscle therapy. Urology. 2008;72(6):1280-1286. Overgård M, Angelsen A, Lydersen S, Mørkved S. Does physiotherapist-guided pelvic floor muscle training reduce urinary incontinence after radical prostatectomy? A randomised controlled trial. Eur Urol. 2008;54(2):438-448. Marchiori D, Bertaccini A, Manferrari F, Ferri C, Martorana G. Pelvic floor rehabilitation for continence recovery after radical prostatectomy: role of a personal training re-educational program. Anticancer Res. 2010;30(2):553-556. Dora G, Rizzi E, Bosatta P, et al. The use of biofeedback in recovery of urinary incontinence after radical retropubic prostatectomy. Urologia. 2011;78(2):1-4-37. Ribeiro LHS, Prota C, Gomes CM, et al. Long-term effect of early postoperative pelvic floor biofeedback on continence in men undergoing radical prostatectomy: a prospective, randomized, controlled trial. J Urol. 2010;184(3):1034-1039. Khoder WY, Trottmann M, Stuber A et al. Early incontinence after radical prostatectomy: a community based retrospective analysis in 911 men and implications for preoperative counseling. Urol Oncol; 2013 Oct 31 (7) 1006-11.

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Urinary incontinence and neuropathy after radical prostatectomy: diagnosis and treatment.

The urinary incontinence after radical prostatectomy is secondary to neuropathy with various degrees from neurapraxia to neurotmesis. We propose to ap...
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