CONCEPTS IN CANCER CARE
| POSTPROSTATECTOMY URINARY INCONTINENCE —Elise De, MD, Assistant Professor of Surgery, Urological Institute
of Northeastern New York, Albany
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| Introduction: types of male incontinence—intrinsic sphincteric deficiency (ISD; usually idiopathic); urge urinary incontinence;
mixed incontinence; incontinence rates following—radical retropubic prostatectomy (RRP) 2% to 78% (depending
on definition of incontinence); transurethral resection of prostate (TURP) 1% to 2% (associated with
compromised internal sphincter and damaged external urethral sphincter); evaluation—history; physical examination;
when planning surgery, perform urodynamic evaluation, ie, cystometrography; uroflometry
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| Options for managing ISD: conservative options—should be discussed during patient consultation; improve quality of
life in men waiting for definitive therapy; candidates with—mild incontinence (ie, 1-3 pads per day) can receive bulbourethral
sling or bulking agents; severe incontinence can receive AMS 800 artificial urinary sphincter (AUS), double-
cuff, or transcorporeal sphincters
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| Injection therapy: collagen—achieves 20% overall postprostatectomy dry rate at 12 mo; indicated in men who have minimal
incontinence, refuse other forms of surgery, require preoperative temporizing measure, or are too ill for surgery;
Macroplastique—silicone polymer; in Europe, equalled efficacy of AUS for minimal incontinence; Durasphere—
implantable beds; difficult to use
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| Male bulbourethral sling: candidates have—mild incontinence; failed injection therapy; normal detrusor compliance or
function; areflexia; commitment to performing clean intermittent postoperative catheterization; limited manual or
mental capacity; refused implantation of AMS 800 AUS; poor candidates have—severe urinary incontinence; undergone
prior AUS implantation or intense irradiation; absolute contraindications—severe osteoporosis; infectious
complications; osteomyelitis; obstruction; standard male sling—placement similar to that used with female pubovaginal
sling; approach more difficult in men with previous hematoma, lymphocele, or anastomotic leak; associated with
56% dry rate and 27% revision rate
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 | InVance sling: bone-anchored; provides compression and partial outlet obstruction; achieves continence rate of 75% to
85%; to assess outcome—check retrograde leak point pressure with perfusion sphincterometry; use cough test in patients
under spinal anesthesia
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| AMS 800 AUS: improvements—transition to narrow cuff backing reduced erosion and reoperation rates; kink-resistant tubing;
better connection system; sterile technique—avoids catastrophic infection; mandates 10-min scrub for patient, 5-min
scrub for staff, and double gloving
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| Standard 2-incision (perineal and inguinal) technique: retract exposed urethra and bulbocavernosus muscle laterally; to avoid
perforating urethra at septum, carefully dissect between urethra and corporal body; use 2-cm aperture to facilitate visualization
and fitting of measurement tape; dissect toward bulb; reservoir placement—inguinal or midline incision (midline
preferred in men who have undergone prior surgery); requires use of isotonic filling solutions (injectable saline reduces error
risk); pass tubing; place pump, make connections, and deactivate device; place 12- to 14-F Foley catheter for 24 hr; patient
must spend 3 to 6 wk at home before device activated
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| Single transverse penoscrotal incision technique: place 3- to 4-cm incision below penoscrotal junction; retract scrotum to reach
urethral bulb; theoretically, approach eliminates discomfort, facilitates visualization of interface between urethra and corpora,
and facilitates pump placement in obese men; points—if patient had anastomotic leak or hematoma postprostatectomy,
be prepared to perform double-incision technique; trim excess tubing to decrease bulk; small scrotum or inflexible
scrotal wall complicates exposure
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| Observations: results—approach provides better results than sling procedure for severe incontinence; special cases—
perform cystoscopy preoperatively; with contracture, perform transurethral resection (TUR) and place AUS 3 mo later
with confirmation of stability; with refractory stricture, place UroLume device; when other options fail, close bladder
neck with or without augmentation; bottom line—patient satisfaction uniformly good
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| Problems: early postoperative complications include—urinary retention (managed with brief catheterization); scrotal hematoma
(managed conservatively); scrotal urinoma (surgery necessary to find unrecognized urethral injury); long-term
complications—erosion; persistent incontinence or infection; pump migration and leaks; erosion—risk factors include
previous surgery, radiation exposure, prior erosion, steroid use, and urethral catheterization; with single-cuff system, infection
risk may require removing entire device (surgeon can reimplant device later); with double-cuff system, if 1 cuff erodes,
convert implant to single-cuff system; role of radiation in erosion debatable; persistent incontinence following initial
placement—may indicate insufficient urethral compression; to manage, downsize cuff or place tandem cuffs; additional
factors—with detrusor overactivity, evaluate situation before operating to alter device; if incontinence recurs after period
of successful control, patient may have accidentally deactivated device and requires reeducation on proper use; manage
fluid loss from system by exploration and replacement; clogged resistor or cuff atrophy requires surgical repair; bottom
line—with double-cuff technique, patient satisfaction remains high
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| Infection: mandates removal of device; conservatively, device can be replaced at 3 to 6 mo; Mulcahy salvage
protocol—rate of salvage 87%; uses 7-step antibiotic irrigation procedure; requires all drapes and instruments be
changed; once new device in place, close without drains and administer long-term antibiotic therapy
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| Transcorporeal AUS placement: indications include poor coaptation of proximal cuff at bulb, prior erosion, and urethral
damage at optimal cuff site; points—84% of men require ≤1 pad per day at 17 mo; penile prosthesis cannot be used to
manage erectile dysfunction
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| BLADDER CANCER MANAGEMENT: HIGHLIGHTS FROM THE SOCIÉTÉ INTERNATIONALE D’UROLOGIE
(SIU) CONSENSUS CONFERENCE —Mark Soloway, MD, Professor and Chairman, Department of Urology,
University of Miami School of Medicine, Miami
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| Diagnosis, staging, and epidemiology: bladder cancer more common in men; risk factors—cigarette smoking; occupation;
chronic urinary tract infection (UTI); schistosomiasis; radiation exposure; point—relatively stable mortality rates mandate
investigation into risk and screening; recommended grading system—does not categorize papilloma as cancer; classifies
tumors as low-grade or high-grade; must be used by pathologist; make sure pathology report—incorporates information
pertinent to grading system; indicates whether pathologic specimen contains muscle tissue; upper tract evaluation—
unnecessary in patients with low-grade Ta disease; periodic monitoring recommended for high-grade tumors; diagnosis—
fluorescent cystoscopy (data insufficient to recommend use); TUR (minimally invasive and underutilized); bladder perforation
(prognosis poor, especially when located intraperitoneally); bladder perforations—unacceptable; adversely affect
prognosis; avoid bladder perforations by—not overdistending bladder; being careful when in diverticulum; assessing obturator
reflex; not going deep when managing Ta lesion; reducing cautery current during surgery; staging—do not subdivide
T2a and T2b, and T3a and T3b disease; with transitional cell carcinoma (TCC) of prostate, prognostic differences
mandate subdividing disease in urethra, ducts, and stroma; with high-grade tumor—improve staging accuracy with second
TUR at 1 to 4 wk after initial resection
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| Markers: early detection in high-risk population—helps prevent progression; may reduce cost; depends on developing
markers with high positive and negative predictive value, ie, ideal marker simple, reliable, and accurate; hematuria—
inexpensive and sensitive marker; poor specificity limits screening value; urinary cytology—ideal for detecting high-
grade disease; bladder wash provides better yield than voided cytology; markers approved by Food and Drug Administration
(FDA)—blood tumor antigen (BTA); urinary nuclear matrix protein 22 (NMP22); UroVysion test; points—
patients with Ta disease do not require cystoscopic evaluation every 3 mo; markers more sensitive than cytology for low-
grade disease, less sensitive than cytology for high-grade disease
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| Low-grade Ta disease: identifiable on endoscopy; when managing low-grade disease—office cauterization with fulguration
indicated when cytology negative and Ta disease suspected; routine upper tract imaging and mucosal biopsy unnecessary;
administer intravesical chemotherapy (ie, mitomycin and epirubicin) post-TUR to decrease risk for additional
tumor (approach contraindicated if bladder perforated); bacillus Calmette-Guérin (BCG) contraindicated
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| High-grade Ta disease and carcinoma in situ (CIS): associated with 20% risk for progression; determining timing and selection
of treatment difficult; errors in clinical judgment may kill patient; cystectomy—at diagnosis, associated with 95% cure
rate; postponed too long, reduces cure rate by 30% to 40%; indicated for patient with high-grade disease following early failed
BCG therapy; intravesical chemotherapy—mandatory in recovery room after TUR and for patient with solitary high-grade
Ta lesion; once pathology report confirms presence of high-grade Ta or T1 disease or CIS, perform second TUR and administer
BCG; CIS—initial treatment involves cystectomy vs continued BCG therapy and monitoring; if management fails, perform
cystectomy
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| T1 disease: pathologic specimen must contain muscle tissue; continuous flow resection critical for performing good endoscopy;
emphasize importance of complete TUR and re-resection 4 wk later; administer single-dose intravesical chemotherapy
after TUR; maintenance BCG—standard approach; duration unclear; upper tract monitoring—necessary;
intervals unclear; pathology report—helps quantify and substage T1 disease; indicates depth of tumor penetration into
lamina propria; patients with high-risk T1 disease—require cystectomy; do not get BCG or second TUR
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| Muscle-invasive disease: improvement in survival rates minimal
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| T2 disease: treatment selection difficult; problem areas—delayed treatment adversely affects survival, ie, many patients with
muscle-invasive cancer have treatment delayed due to misdiagnosis; many older patients with muscle-invasive bladder cancer
never offered cystectomy, ie, data suggest only 5% of patients 75 to 80 yr of age in United States undergo cystectomy;
survival rates have remained in 30% to 40% range over past 30 yr
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| Management: chemotherapy provides modest improvement in outcomes; surgery—perioperative mortality <3% for major
medical centers; need for more extensive lymph node dissection under investigation; prostate-sparing surgery not considered
standard practice; partial cystectomy infrequently used; upper tract monitoring—high-risk tumors cannot be identified
at right time, regardless of frequency of monitoring program
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| Urinary diversion: factors to consider when selecting approach include patient’s age, tumor status, comorbidity, motivation,
and renal function; contraindications to continent diversion—poor patient motivation; poor potential for maintaining
intermittent catheterization; neobladder—free refluxing neobladder preferred option, ie, if afferent limb relieves
pressure on upper tract, err on side of having no obstruction; potential complications manageable; ileum bowel segment
of choice for forming orthotopic neobladder; points—most patients who wake up at night are continent; in most cases,
nocturnal incontinence cannot be altered by neobladder; hypercontinence—can occur; not worst problem to have, ie, almost
everyone adapts well to clean intermittent catheterization (CIC) to avoid appliance; ileal conduit—preferred in
older individuals; complication rate equals that of orthotopic neobladder
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| Transitional cell cancer (TCC) of prostate: high-grade tumor at bladder neck or multifocal CIS—biopsy prostatic
urethra; differentiate disease going from bladder to prostate from disease starting in urothelium and entering ducts and
stroma; options—invasion into prostatic substance (initiate chemotherapy; survival poor with cystectomy alone); stromal
invasion (treat with cystoprostatectomy and possibly chemotherapy); noninvasive CIS of urothelium (consider TUR
followed by BCG); invasion into ducts (cystoprostatectomy preferred; TUR and BCG possible); caveat—data on proper
management of TCC of prostatic urothelium limited: neoadjuvant chemotherapy—data suggest cisplatin-based chemotherapy
administered prior to cystectomy provides modest benefit and decreases morbidity; should be considered in anyone
with high-risk disease (recommendation based on dramatic increase in pT0 rate seen with neoadjuvant
chemotherapy)
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| Bladder preservation: benefits quality of life; problems—tendency to understage bladder cancer; lack of randomized trials;
factors favoring bladder preservation—T2 disease (as opposed to T3 or T4 disease); small tumor; no hydronephrosis;
options—combination of chemotherapy and radiation therapy acceptable; evidence supporting use of neoadjuvant
chemotherapy inadequate
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| Metastatic disease: points—combination of gemcitabine (Gemzar) and cisplatin probably equals efficacy of methotrexate,
vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) with less toxicity; high-dose MVAC may be better
than standard MVAC; carboplatin less effective than cisplatin for treating patients who have urothelial cancer;
recommendation—if patient has good renal function, encourage medical oncologist to avoid carboplatin and administer
cisplatin with gemcitabine or in MVAC
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| Radiation therapy: acceptable when used concurrently with chemotherapy and thorough TUR to treat select patients; not
contraindicated by CIS; approach in high-risk patients considered candidates for cystectomy—initiate neoadjuvant
chemotherapy, reevaluate situation, and administer full-dose radiation therapy with cisplatin; survival rates equal those
seen with radical cystectomy
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| Additional concerns: squamous cell carcinoma—chemotherapy role minor; perform cystectomy and urinary diversion;
adenocarcinoma—approach approximates that used for squamous cell carcinoma; partial cystectomy acceptable for
urachal adenocarcinoma; small cell carcinoma—incidence increasing; if diagnosed on TUR, treat with chemotherapy followed
by cystectomy or radiation
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Educational Objectives
| The goal of this program is to educate the listener about current concepts in the management of urologic cancer. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Assess current alternatives for managing postprostatectomy incontinence.
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| 2. Perform successful artificial urinary sphincter implantation and bulbourethral sling surgery to control postprostatectomy
incontinence.
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| 3. Review current Société Internationale d’Urologie (SIU) consensus conference guidelines for managing bladder cancer.
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| 4. Discuss SIU recommendations for the diagnosis and staging of bladder cancer.
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| 5. Use SIU guidelines to implement appropriate treatment protocols for all stages of bladder cancer.
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Discussed on This Program
BCG, intravesical (Bacillus Calmette-Guérin) [Pacis, TheraCys, TICE BCG]
Carboplatin [Paraplatin]
Cisplatin (CDDP) [Platinol-AQ]
Doxorubicin [Adriamycin PFS, Adriamycin RDF]
Epirubicin HCl [Ellence]
Gemcitabine HCl [Gemzar]
Methotrexate (amethopterin; MTX) [Methotrexate LPF, Rheumatrex Dose Pack, Trexall]
Mitomycin (mitomycin-C; MTC) [Mutamycin]
Vinblastine sulfate (VLB) [Velban]
Suggested Reading
Anger JT et al: Anastomotic contracture and incontinence after radical prostatectomy: a graded approach to management.
J Urol 173:1143, 2005; Fassi-Fehri H et al: Treatment of postoperative male urinary incontinence by InVance prosthesis:
preliminary results. Prog Urol 14:1171, 2004; Gousse AE et al: Two-stage management of severe postprostatectomy bladder
neck contracture associated with stress incontinence. Urology 65:316, 2005; Manoharan M, Soloway MS: Optimal
management of the T1G3 bladder cancer. Urol Clin North Am 32:133, 2005; Nieder AM et al: Cystoprostatectomy and
orthotopic ileal neobladder reconstruction or management of bacille Calmette Guerin-induced bladder contractures. Urology
65:909, 2005; Petrou SP: Treatment of postprostatectomy incontinence: is the bulbourethral sling a viable alternative
to the artificial urinary sphincter? Curr Urol Rep 3:360, 2002; Schaal CH et al: Longitudinal urethral sling with prepubic
and retropubic fixation for male urinary incontinence. Int Braz J Urol 30:307, 2004; Soloway MS: Where are the ‘poster
boys’ for bladder cancer? BJU 91:769, 2003;
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. De gave her scientific presentation at Current Concepts in Men’s Health 2005, presented August 12 to 14, 2005 in
Bolton Landing, New York, by Albany Medical College and the Urological Institute of Northeastern New York; Dr. Soloway
gave his scientific presentation at the 60th Annual Meeting of the Canadian Urological Association held June 26 to
29, 2005 in Ottawa, Canada. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the
production of this program.
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