Risk Of Postoperative Incontinence Research Articles

Influence of Early Apical Release on Outcomes in Endoscopic Enucleation of the Prostate: Results From a Multicenter Series of 4392 Patients

ObjectiveTo evaluate outcomes after laser Endoscopic enucleation of the prostate (EEP) stratified by whether early apical release (EAR) was performed or not. MethodsWe retrospectively reviewed patients with clinical benign prostatic hyperplasia who underwent EEP with holmium or thulium fiber laser in 8 centers (January 2020-January 2022). Exclusion criteria: previous prostate/urethral surgery, prostate cancer, pelvic radiotherapy, concomitant lower urinary tract surgery. One-to-one propensity score-matching was performed between patients with EAR versus no EAR, with covariates including age, prostate volume, diabetes mellitus, hypertension, preoperative indwelling catheter, IPSS, Qmax, enucleation and laser types. Multivariable logistic regression analyses were performed to evaluate independent predictors of 30-day postoperative complications and urinary incontinence. ResultsEAR was performed in 2094 of 4392 included patients. The matched cohort consisted of 787 patients per arm. Total operation time was significantly longer in the EAR group (median 75 vs 67 minutes, p=0.004). Early complications were higher in the EAR group (18.6% vs 12.5%, p=0.001), while postoperative incontinence rates were similar (14.1% vs 13.1%, p=0.61). Multivariable regression analysis showed that 3-lobe enucleation and operation time were significant predictors of postoperative complications; preoperative indwelling catheterization, higher prostate volume, and en-bloc enucleation were associated with higher odds of postoperative incontinence. Limitation: retrospective nature. ConclusionsPerforming EAR during EEP is associated with a greater incidence of early complications, which was mainly driven by higher rates of postoperative hematuria and perioperative transfusion. The risk of postoperative incontinence and its duration are not affected by EAR.

Outcome of different surgical procedures for fistula-in-ano: a single centre-based study

Background: Fistula-in-ano is an abnormal communication between anal canal/rectum and perianal skin. It is considered to be chronic sequelae of cryptoglandular perianal abscess. Surgical treatment is the standard of care. However, the surgical techniques have evolved over time in order to give a satisfactory non-recurring result without jeopardising continence mechanism. Our aim was to study the feasibility and outcome of various surgical procedures done for fistula-in-ano.Methods: This study was conducted in colorectal division of department of general surgery SKIMS Srinagar, from 2017-2019. All patients underwent a surgical procedure which was deemed feasible for a particular case. Pre-operative data and post-operative outcome/complications were studied over a mean follow up of 12 months. Final inferences were drawn after analysing the data using various statistical tools.Results: Fistula-in-ano has male predominance (8:1), with intersphincteric fistula being the commonest type (48%) in our study. Majority of our patients underwent fistulectomy (72.5%) with or without Seton placement. Over a mean follow up of 12 months, only 19 patients (15.32%) developed recurrence. Incontinence was observed in 15 patients (12.09%). The risk of recurrence was observed to be directly related to the complexity of fistula.Conclusions: Fistulectomy is safe and effective for low intersphincteric and trans-sphincteric fistulas with acceptable rates of recurrence. Benefit of radical excision in high fistulas with multiple secondary tracts should be carefully weighed against risk of post-operative incontinence.

Real world outcomes of lateral internal sphincterotomy vs botulinum toxin for the management of chronic anal fissures

BackgroundLateral internal sphincterotomy (LIS) remains the gold standard surgical approach for the management of chronic anal fissures (CAF). The procedure however, is complicated by the risk of postoperative incontinence. Intrasphincteric Botulinum Toxin (BT) has gained popularity as an alternative approach, despite being inferior to LIS with regards to cure rates. In the real world, patients at high risk for postoperative incontinence are likely to be offered BT as a preliminary procedure. The aim of this study was to explore the real-world outcomes of LIS and BT for a cohort of CAF patients. Methods251 consecutive patients treated with either BT or LS for CAF by a single surgeon were reviewed. Patients were offered BT as a preliminary procedure if they had risk factors for faecal incontinence, whereas all other patients underwent LIS. Primary outcomes included rates of recurrence and faecal incontinence. ResultsLIS was superior to BT with regards to recurrence rates throughout the mean follow up period of five years (5% vs 15%, p = 0.012). A total of 17 patients experienced a minor degree of flatal incontinence at the 6-week follow up, although there was no difference between LIS and BT (7% vs 6%, p = 1.000). Four LIS patients (2%) continued to experience some minor incontinence to flatus at the 12-month follow up and were managed with biofeedback. ConclusionFor patients with CAF, individualizing the treatment approach according to risk factors for incontinence could mitigate this risk in LIS. High risk patients should be offered BT as a preliminary procedure.

Réfection d’anastomose urétro-vésicale par voie extra-péritonéale laparoscopique robot-assistée pour sténose anastomotique post-prostatectomie radicale

Urethro-vesical anastomosis stenosis following radical prostatectomy is a rare complication but represents a challenging situation. While the first-line treatment is endoscopic, recurrences after urethrotomies require a radical approach. We present the updated results of our patient's cohort treated by pure robotic anastomosis refection. This is a retrospective, single-center study focusing on one surgeon's experience. Patients presented an urethro-vesical stricture following a radical prostatectomy. Each patient received at least one endoscopic treatment. The procedure consisted of a circumferential resection of the stenosis, followed by a re-anastomosis with well-vascularized tissue. We reviewed the outcomes in terms of symptomatic recurrences and continence after the reconstructive surgery. From April 2013 to May 2020, 8 patients underwent this procedure. Half of the patients had previously been treated with salvage radio-hormonotherapy. The median age was 70 years (64-76). The mean operative time was 109minutes (60-180) and blood loss was 120cc (50-250). One patient had an early postoperative complication, with vesico-pubic fistula. The average length of stay was 4.6 days (3-8). Mean follow-up was 24.25 months (1-66). Half of the patients experienced a recurrence at a median time of 8.25 months (6-11) after surgery. Five patients experienced incontinence of which 3 required an artificial urinary sphincter implantation. Extra-peritoneal robot-assisted urethro-vesical reconstruction is feasible and safe to manage bladder neck stricture after radical prostatectomy. The risk of postoperative incontinence is high, justifying preoperative information. III.

German S3 guidelines: anal abscess and fistula (second revised version).

The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men. This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature. Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate. In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

Operative strategy for fistula-in-ano without division of the anal sphincter.

The treatment of perianal fistulas is diverse because no single technique is universally effective. Fistulotomy remains the most effective way of eradicating the pathology but it renders the patient at some risk of faecal incontinence, which many patients are reluctant to take. There are no data in the literature to indicate the healing rate of perianal fistulas when using an operative strategy that routinely avoids division of any part of the anal sphincter. The aim of this paper is to present the long-term results with an operative strategy that aims to avoid division of any part of the anal sphincter complex when treating all types of perianal fistulas, thereby minimising/eliminating the risk of postoperative incontinence. We report 54 consecutive cases of anal fistula that presented electively and as an emergency. Patients with known or subsequently diagnosed inflammatory bowel disease or malignancy were excluded from the study. Overall, 46 patients (37 male and 9 female) with a median age at presentation of 42 years (range: 19-73 years) were treated by lay-open of the subcutaneous tract of the perianal fistula and insertion of a loose seton for the part of the fistula tract related to the sphincter complex. The types of fistula treated were intersphincteric (89%), transsphincteric (4%) and high suprasphincteric (7%). The median length of time that the seton was left in place was 7 months (range: 1.5-24 months). The healing rate was 86% with a recurrence rate of 19% and a median follow-up duration of 42 months. Patients who are reluctant to take any risk of faecal incontinence could be treated using an operative strategy that routinely avoids division of any part of the anal sphincter complex as this has a recurrence rate that compares well with other treatment modalities.

Cryptoglandular anal fistulas.

Cryptoglandular anal fistula arises in 2 per 10 000 persons per year and is most common in young men. Improper treatment can result in fecal incontinence and thus in impaired quality of life. This S3 guideline is based on a systematic review of the pertinent literature. The level of evidence for treatment is low, because relevant randomized trials are scarce. Anal fistulae are classified according to the relation of the fistula channel to the sphincter. The indication for treatment is established by the clinical history and physical examination. During surgery, the fistula should be probed and/or dyed. Endo-anal ultrasonography and magnetic resonance imaging are of roughly the same diagnostic value and may be useful as additional studies for complex fistulae. Surgical treatment is with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter, and occlusion with biomaterials. Only superficial fistulae should be laid open. The risk of postoperative incontinence is directly related to the thickness of sphincter muscle that is divided. All high anal fistulae should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterials yields a lower cure rate. This is the first German S3 guideline for the treatment of cryptoglandular anal fistula. It includes recommendations for the diagnostic evaluation and treatment of this clinical entity.

Surgisis Fistula Plug: The United States Experience

Anorectal fistulae are a heterogeneous group of disorders that can cause significant pain, social impairment, hygienic problems, and, rarely, sepsis. Surgery is the mainstay of treatment for anorectal fistulae, yet no one procedure is universally efficacious and safe. Simple fistulae can often be treated by simple fistulotomy, but complex fistulae present a more complicated scenario—effective surgical treatment options are compromised by increased risk of incontinence. Likewise, safe treatment alternatives have low risk of postoperative incontinence but low success rates. The Surgisis AFP appears to be an effective and safe treatment alternative for complex fistula, including Crohn's fistula, based on initial reports.

Lokale Anwendung von Nitroglycerin-Salbe zur Behandlung von Analfissuren. Eine Alternative zur chirurgischen Therapie?

Patients suffering from anal fissures are commonly treated by lateral sphineterotomy. This surgical treatment includes the risk of postoperative incontinence, especially in young women with a possible vaginal delivery in their future. Glyceryl trinitrate, a nitric oxide donor, was shown to be effective to induce reversible chemical sphineterotomy. Nitric oxide is an important neurotransmitter mediating relaxation of the internal anal sphincter. The clinical evidence for therapeutic adequacy was examined in a prospective randomized study.

THE SIGNIFICANCE OF THE OPEN BLADDER NECK ASSOCIATED WITH PELVIC FRACTURE URETHRAL DISTRACTION DEFECTS

As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.

Changes of Urodynamic Findings after Radical Retropubic Prostatectomy

Objectives: We wanted to evaluate the urodynamic changes of radical retropubic prostatectomy in patients with localized prostate cancer and identify specific factors that could influence the postoperative continence status. Methods: Sixty-six consecutive patients (mean age 68 years) were studied urodynamically within 1 week before surgery, and 44 of them at a mean 7.6 months after radical intervention. Results: Complete urinary continence was achieved in 37/44 men (84.1%) after 6 months and in 43/44 patients (97.7%) 1 year after surgery. Stress incontinence of varying degree improved with time. Seven patients demonstrated a moderate incontinence 4 months after radical prostatectomy and 1/7 was still incontinent after 1 year. Mean flow rate, maximum detrusor pressure, maximum urethral closure pressure (at rest and voluntary contraction of the sphincter) and functional urethral length showed significant changes after surgery. Detrusor instability, which was present in 31.8% of the 66 patients preoperatively, was not responsible for any case of postoperative incontinence. The urethral pressure profile was significantly reduced in all patients after surgery. Conclusions: The present study indicates that there are no preoperative alterations in bladder function such as detrusor instability to identify patients at risk for postoperative incontinence. Postoperative incontinence seems to depend upon sphincteric deficiency as expressed by the reduced pressures in the sphincteric mechanism.

Urinary Incontinence after Prostatectomy in Dogs

Eleven dogs with prostatic disease were treated by total prostatectomy. Urinary incontinence persisted in three of nine dogs, two of which were also incontinent before surgery. The incidence of postoperative incontinence may be reduced by undermining the prostatic capsule to preserve as much prostatic urethra as possible. The risk of postoperative incontinence appeared greater if there was prostatic neoplasia or preoperative urinary incontinence.