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AUA 2020

AUA 2020: Crossfire: Controversies in Urology: Are Urodynamics Needed in the Workup of Post-Prostatectomy Incontinence? Pros and Cons of Artificial Urinary Sphincter

(UroToday.com) As part of the Crossfire Controversies in Urology session at the AUA 2020 Virtual Annual Meeting, a group of panelists discussed the pros and cons of whether urodynamics are needed in the workup of post-prostatectomy incontinence under the guidance of moderator Jaspreet Sandhu, MD. Dr. Sandhu notes that in the Incontinence After Prostate Treatment: AUA/SUFU Guideline, statement 9 states that clinicians should evaluate patients with incontinence after prostate treatment with a history, physical exam, and appropriate diagnostic modalities to categorize the type and severity of incontinence and degree of bother (Clinical Principle). Additionally, guideline statement 15 notes that clinicians may perform urodynamic testing in a patient prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling (Clinical Recommendation, Grade C). As such the current evaluation algorithm is detailed and is as follows:

EvaluationAlgorith_Crossfire_AUA2020.png

Timothy Boone, MD, PhD, discussed the pro standpoint of utilizing urodynamics prior to an artificial urinary sphincter in men with post-prostatectomy incontinence. Dr. Boone notes that there are several important questions that he asks patients when deciding if they are the ideal candidate for an artificial urinary sphincter:

  • Describe your pads and activity of daily living?
  • Do you use pads at night while sleeping?
  • Do you ever leak sitting or with urgency?
  • Do you want surgery to help manage your incontinence?

If the patient is a good historian with clear stress urinary incontinence symptoms and minimal to no supine incontinence at night, Dr. Boone feels that no pre-artificial urinary sphincter urodynamics are required. Additionally, they must have good hand function and cognition, with no concurrent neurologic disease. Dr. Boone performs cystoscopy for every post-prostatectomy incontinent patient prior to an artificial urinary sphincter and leaves their bladder full, has them stand, and then cough. Dr. Boone does utilize urodynamics for patients that are poor historians, those with mixed symptom with urgency incontinence, all patients that have been radiated, and post-TURP patients. He feels that this helps set expectations post-artificial urinary sphincter regarding overactive bladder and possible urinary urgency incontinence.

Dr. Boone acknowledges that for many years, measuring the Valsalva Leak Point Pressure (VLPP) was the urodynamics of choice to confirm intrinsic sphincter deficiency causing post-prostatectomy incontinence, but notes that this is used much less commonly today. Definitive literature to support or reject the value of urodynamic testing to predict successful continence following artificial urinary sphincter placement does not exist. Previous literature does suggest that the success of continence after an artificial urinary sphincter is much more likely with normal compliance and low amplitude detrusor overactivity. In another study, Ko and colleagues found that in a single-center study of 130 patients (30% with a prior history of XRT), a capacity <300 mL and history of XRT predicted de novo overactive bladder with reduced quality of life.1 Additionally, 37% had de novo overactive bladder after an artificial urinary sphincter, which increased to 70% at nine months of follow-up.

Dr. Boone’s group previously assessed pre-operative urodynamic testing among 61 men with post-prostatectomy incontinence, finding that 30% of men were “strain voiders”, however, the outcomes with artificial urinary sphincter placement were not influenced by detrusor underactivity.2 In another study from Dr. Boone, overactive bladder symptoms before artificial urinary sphincter placement did not impact overall continence results.3 De novo overactive bladder developed in 23% of men with pure stress urinary incontinence pre-artificial urinary sphincter, and 71% of men with pre-artificial urinary sphincter overactive bladder continued with symptoms after device placement. Furthermore, overactive bladder with anticholinergic use pre-artificial urinary sphincter predicted post-artificial urinary sphincter use of medication.

Dr. Boone concluded his pro-artificial urinary sphincter discussion with the following take-home messages:

  • Urodynamic testing may help plan treatment in patients with confounding symptoms and a history of radiation therapy
  • Cookie-cutter medicine is not good for men with post-prostatectomy incontinence
  • In most cases, even though the urodynamic testing reveals a deviation from “normal”, outcomes with treatment using the artificial urinary sphincter tend to be good

Ouida Lenaine-Westney, MD, then provided the con argument for urodynamic testing prior to artificial urinary sphincter placement for men with post-prostatectomy incontinence. She notes that the guidelines are not definitive on the use of urodynamics in the evaluation of these men:

  • Artificial Urinary Sphincter – Report of the 2015 Consensus Conference4: Urodynamics should be carried out at the discretion of the clinicians in cases where it will help with diagnosis or counseling and follow-up. Poor bladder compliance may pose a risk of upper tract damage after an artificial urinary sphincter and should be followed closely (Grade C Recommendation)
  • Incontinence and Prostate Treatment – AUA/SUFU Guideline (2019)5: Guideline Statement 15 says that clinicians may perform urodynamic testing in a patient prior to surgical intervention for stress urinary incontinence in cases where it may facilitate diagnosis or counseling (Clinical Recommendation, Grade C).
  • 6th International Consultation on Incontinence (2017)6: Multichannel urodynamics may be useful prior to invasive treatment for incontinence (Level of evidence 3, Grade C Recommendation).

Dr. Lenaine-Westney notes that the purpose of urodynamics in the presumptive artificial urinary sphincter patient is not to document incontinence in this specific population but to identify adverse storage factors such as irreversible small capacity, poor compliance, and intractable detrusor overactivity. Theoretically, it is also used to diagnose conditions that portend a poor prognosis for artificial urinary sphincter efficacy and longevity. In a study from Dr. Boone’s group, 129 patients with post-prostatectomy incontinence underwent multichannel video-urodynamic evaluations before virgin artificial urinary sphincter implantation [7]. The presence of adverse preoperative urodynamic features, such as poor bladder compliance <10 mL/cm, the presence of detrusor overactivity, early sensation of bladder filling at <75 mL, an early first desire to void at <125 mL, reduced cystometric capacity of <200 mL, low abdominal leak point pressure of <30 cm H2O, low peak flow of <10 mL/s, low detrusor pressure at the peak flow of <10 cm, or a bladder contractility index of <100, did not negatively affect the post-artificial urinary sphincter daily pad use. Thus, the need for urodynamics in these patients is likely not necessarily required.

Dr. Lenaine-Westney’s recommendations for patients with detrusor activity is to treat these overactive bladder patients preoperative to assess responsiveness but to not deny them an artificial urinary sphincter if they have concomitant stress urinary incontinence. This is supported by the Artificial Urinary Sphincter: Report of the 2015 Consensus Conference that suggests that detrusor overactivity should be treated before surgery, but does not constitute a contraindication for artificial urinary sphincter implantation (Grade D Recommendation) [4].

The typical index patient is the uncomplicated post-prostatectomy patient with no post-operative complications, no history of radiation, no history of neurogenic bladder, who is dry at night, and has no overactive bladder symptoms. In Dr. Lenaine-Westney’s opinion, there is no indication for pre-operative urodynamics in this patient. Urodynamics should be performed in high-risk patients, which includes those with neurogenic diagnoses (dementia, multiple sclerosis, CVA), salvage prostatectomy patients with complications (ie. urethral stricture, anastamotic leak), or those with total incontinence (complete storage failure).

In this debate regarding the utility of urodynamics for post-prostatectomy incontinence prior to the artificial urinary sphincter, Dr. Lenaine-Westney concluded with the following summary points:

  • Urodynamics rarely changes the planned operative treatment for these patients
  • Urodynamics is most helpful in identifying what has gone wrong post-implant rather than predicting whether a storage related problem will occur
  • Judicious use of urodynamics in specific situations may be helpful, but there should not be a blanket application of urodynamics to all patients
Presented by: Jaspreet S. Sandhu, MD, Memorial Sloan Kettering Cancer Center, New York, NY; Timothy Boone, MD, PhD, Houston Methodist, Houston TX; Ouida Lenaine-Westney, MD, MD Anderson Cancer Center, Houston, TX

Written By: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27-28, 2020. 

References:

  1. Ko KJ, Lee CU, Kim TH, et al. Predictive Factors of De Novo Overactive Bladder After Artificial Urinary Sphincter Implantation in Men with Post-Prostatectomy Incontinence. Urology 2018 Mar;113:215-219.
  2. Gomha MA, Boone TB. Voiding Patterns in Patients with Post-Prostatectomy Incontinence: Urodynamic and Demographic Analysis. J Urol 2003 May;169(5):1766-1769.
  3. Lai HH, Boone TB. Implantation of Artificial Urinary Sphincter in Patients with Post-Prostatectomy Incontinence, and Preoperative Overactive Bladder with Mixed Symptoms. J Urol 2011 Jun;185(6):2254-2259.
  4. Biardeau X, Aharony S, et al. Artificial Urinary Sphincter: Report of the 2015 Consensus Conference. Neurourol Urodyn. 2016 Apr;35 Suppl 2:S8-S24.
  5. Sandhu JS, Breyer B, Comiter C, et al. Incontinence after Prostate Treatment: AUA/SUFU Guideline. J Urol 2019 Aug;202(2):369-378.
  6. Averbeck MA, Woodhouse C, Comiter C, et al. Surgical Treatment of Post-Prostatectomy Stress Urinary Incontinence in Adult Men: Report From the 6th International Consultation on Incontinence.  Neurourol Urodyn 2019 Jan;38(1):398-406.
  7. Lai HH, Hsu EI, Boone TB. Urodynamic Testing in Evaluation of Postradical Prostatectomy Incontinence Before Artificial Urinary Sphincter Implantation. Urology 2019 Jun;73(6):1264-1269.