The “best” way to measure post-treatment levels of urinary continence

A new paper published by researchers from Sweden’s prestigious Karolinska Institute and related institutions makes it increasingly clear that — to date — we haven’t been able to work out (let alone consistently use) a really good way to measure real urinary continence after radical prostatectomy.

There has been a not unreasonable assumption that, if men reported no use of pads at all at a specific time post-surgery, they could be reasonably considered to be fully continent. However, the article by Wallerstedt et al. has now clearly shown that there is wide variation in the use of urinary pads among men who give the same answer when questioned about whether they have bother from urinary leakage.

The problem, of course, is that without a really accurate and consistently applied method for measurement of urinary leakage after radical prostatectomy, surgeons may be misleading themselves and their patients about the quality of surgical outcomes. This means that newly diagnosed patients may be selecting surgery as a first-line treatment option with a misguided understanding of their probability of total continence post-treatment.

Wallerstedt and her colleagues assessed data from a  consecutive series of 1,411 men who had a radical prostatectomy at Karolinska University Hospital between 2002 and 2006. The patients were aksed to respond to a study-specific questionnaire that dealt with pad status, urinary leakage, and bother from urinary leakage. They report the following key data:

  • Completed questionnaires were received from 1,179/1,411 men (83.6 percent) with a follow-up of greater than 1 year.
    • 411/1,179 men (34.9 percent) had had an open radical prostatectomy.
    • 768/1,179 men (65.1 percent) had had a robot-assisted, laparoscopic radical prostatectomy.
  • Median age at time of surgery was 63 years (range, 37 to 78 years).
  • The average (median) follow-up period was 2.2 years.
  • A small amount of urinary leakage was clearly associated with a significant risk of urinary bother.
    • 46/775 men reporting no pad use at all (5.9 percent) also reported moderate or much urinary bother.
    • 514/775 men reporting no pad use at all (66.3 percent) also reported no urinary leakage.
    • 255/775 men reporting no pad use at all (32.9 percent) also reported little urinary leakage.
    • 38/123 men reporting use of a security pad (30.9 percent) also reported moderate or much bother.
    • 14/123 men reporting use of a security pad (11.4 percent) also reported no urinary leakage.
    • 101/123 men reporting use of a security pad (82.1 perecent) also reported little urinary leakage.
    • The risk of bother from urinary leakage was 5.2 times higher in the safety pad use group vs the zero pad use group.
  • Unsurprisingly, as the number of pads being used increased, there was a higher risk of urinary bother.

What is also worth noting is that, in this large, consecutive series of patients treated at a major academic medical center, of those who responded to the questionnaire, less than half (514/1,179 men; 43.6 percent) reported both no pad use and no urinary leakage at all after at least 1 year of follow-up.

In their conclusions, the authors write that:

The bother from urinary leakage can be considered more clinically important than the actual grade of urinary leakage. Thus, to evaluate urinary incontinence we recommend measuring urinary leakage and the bother from urinary leakage.

They go on to point out what we have suggested above — that to be able to compare incontinence rates post-surgery from different patient series and populations with accuracy means the use of identical definitions of continence and incontinence and the use of the same questions when assessing urinary leakage and urinary bother, as well as pad use.

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