Post‐prostatectomy stress urinary incontinence: What treatment for which patient?

Editorial Comment: This is a summary article written by the “committee” assigned to consider this problem at the International Consultation on Incontinence-Research Society meeting held in June 2009. The overall conclusion is that it is not possible at this time to answer which treatment is suitable for which patient; this will require good quality research with adequate followup duration, consistent definition, and standardized tools for pre-management and post-management evaluations. The following topics are discussed: 1) prediction (the degree of pelvic floor development is related to the recovery of continence 3 months after surgery but data further on are lacking); 2) protective or rehabilitative effect of pelvic floor muscle exercises (“relatively weak evidence based as to efficacy and how best to deliver such training”); 3) pharmacological management (expectation that to be effective, some urethral sphincter activity must remain; “well conducted, multicenter, [randomized controlled trials] with long-term followup would be needed to adequately judge duloxetine treatment but there is no agreement whether such trials are warranted”); 4) bulking agents (“Although the procedure seems to be easy to perform and patients are initially satisfied, results are of short durability. The present evidence does not appear to warrant additional research, and the overall strategy of bulking agents may have limited scope in [post-prostatectomy incontinence]”); 5) adjustable compressive balloon therapy (current case series report high initial improvement levels with high necessity of volume readjustment; “additional [randomized controlled trials] comparing adjustable balloons to [artificial urinary sphincter] with long-term followup would be beneficial”); 6) slings and tapes, both nonadjustable and adjustable (relatively high “success”—dry or improved—rates reported with series followed 2 to 4 years); 7) artificial urinary sphincter (relatively high success rate, longest followup; current reports cited which predict superior efficacy in men with higher incontinence grades but “the efficacy of the [artificial urinary sphincter] is partly counteracted by purchase price, operation time, and surgical or mechanical complications. Consequently there is an increasing tendency towards treating lower incontinence grades with alternative techniques, but only time will tell whether this is beneficial to the treated patients”).