More on age and urinary continence post-radical prostatectomy


We commented on Friday last week on a paper by Wallerstedt et al. addressing factors affecting risk for urinary continence after radical prostatectomy. One reader had asked us whether we could provide more details about the age breakdown and the rates of urinary incontinence in the patients studied by the Swedish research team.

Dr. Wallerstedt kindly provided us with a copy of the full text of this paper early this morning, and we thank her for this courtesy. In the tables below you can find: (a) a breakdown of the continence rates of the patients by age group at 3 and 12 months post-surgery (continence being defined as no more than one change of pad per day) and (b) a breakdown of the patients’ pad use by age group at 12 months post surgery.

So this first table clearly shows the increase in risk of incontinence at 3 and 12 months post-surgery compared to age at surgery, with nearly a third of all men aged 65 or older requiring at least two changes of pad during a 24-hour period at 12 months:

IT1

The second table needs to be interpreted with a little care because the data in the columns are not additive. In other words, for the men aged 40 to 45 years at the time of surgery, 96/118 (81 percent) were using no pads at 12 months; 22/118 were using a pad at least some of the time; of those 22 men, 15 changed their pad at least twice a day (and therefore met the criteria for incontinence); of those 15 men, 9 were changing pads at least three times a day; etc. Conversely, among those who were 70 to 80 years old at surgery, only 72/145 (50 percent) were pad free and of the 73 still using a pad at 12 months post-surgery, 55/145 or 38 percent met the criteria for incontinence.

IT2

What is very clear from these two tables is that, even in men < 55 years of age, there is a significant risk for some degree of incontinence post-surgery, and that for men in their 60s at the time of surgery the risk for a clinically significant degree of incontinence at 12 months is well over 20 percent.

Wallerstedt and her colleagues note that these data appear to correlate reasonably well to data from prior studies of the relationship between age and risk for incontinence post-surgery.

11 Responses

  1. Mike:

    Do you have tables showing incontinence by age that was not caused by RP? I think it’s worth noting that age-related incontinence is much higher than we are aware …

  2. I totally disagree with the above status results. In my case, when I had my prostate removed, I needed to change at least 12 times in a 24-hour period. Why, Because I could not not stand the wetness and odor.

  3. Sitemaster, again, you are great at providing edifying data for those visual learners. Thanks.

    On another note, I am real negative on radiation … after reading about issues patients have years afterwards. My neighbor, who had brachytherapy from a top San Diego doctor, just went back to the hospital with bleeding complications. This is his third time dealing with it. Why are so many people enamored with radiation as a prostate cancer solution when it is not without baggage. What percent of radiation patients NEVER have side effects?

  4. Dear Mr. Garcia:

    It may well be that in the first few days and weeks after RP that a patient has significant incontinence of the type you describe (particularly if his catheter is removed too early or he has a bad surgeon). However, these are data taken at 3 and 12 months post-surgery among > 1,000 men who were generally treated by rather good surgeons.

  5. Dear Elucidated1:

    One of the problems with quality when it comes to prostate cancer therapy is that we commonly hear about the bad results but we much less frequently hear about the good results because the men who are satisfied with their treatment tend to go back (satisfied) to their original lives and not participate in this type of discussion.

    I don’t have any way to know what percentage of men treated with radiation therapy (or indeed any other form of therapy) “NEVER have side effects?” I don’t even have a way to be able to know with accuracy the percentage of men treated with radiation therapy who were completely satisfied with their treatment … even if they did have some minor side effects. What I do know is that over the years I have spoken to a lot of men who have had either surgery or radiation and who will generally say that they were “satisfied” or “very satisfied” with their treatment. Of course this doesn’t necessarily mean that they ought, necessarily, to be “satisfied” or “very satisfied” … but nevertheless they are.

    Over the years we have heard patients from the brachytherapy group, the proton radiation therapy group, the cryotherapy group, and most recently the HIFU group all praise the quality and outcomes of these forms of therapy to the skies. Also over the years, we have seen data published by reputable physicians suggesting that significant rates of side effects and complications are associated with all of these forms of treatment. My take-away from all of this is that the ways we currently go about the treatment of prostate cancer are not exactly associated with a high probability for high overall quality of outcome. However, I also know of no way to treat prostate cancer today that does not come with such risks … with, of course, the exception of active monitoring for as long as possible, which is one of the reasons that I recommend this form of management to men with low-risk disease.

    I know of no form of radical treatment for prostate cancer that has not, quite regularly, been associated with bad outcomes for individual patients. Am I sorry for those patients? Of course I am, but hopefully no one will suggest that I haven’t tried to warn them going in. The real problem is that all too often patients don’t hear what they need to hear (even if they are told things very specifically) or they simply don’t do enough homework beforehand.

  6. Sitemaster, thanks so much for following up on my questions so very quickly — the additional incontinence info is very instructive.

    I had to comment on the last paragraph of your response to Elucidated1. Undoubtedly, some patients aren’t sufficiently attentive to doctors’ warnings, don’t do their homework, or suffer from selective (in)attention.

    But I think you’re letting the doctors off too easily. The doctor is responsible for communicating the necessary information, including red flags, to the patient in a reasonably effective and unbiased way. I’ve been on active surveillance for 2.5 years and have seen, in my prostate cancer odyssey, a dozen or so doctors, some of them world-renowned. One was a jerk, one less experienced than I would have preferred, and another was at an institution that gave me pause, but I have a good deal of admiration for almost all of them. Most were knowledgeable, some evidently caring and a couple or three, mirabile dictu, were both.

    Nonetheless, I can honestly say that every one of those doctors oversold his specialty, be it surgery, seeds, external beam, active surveillance, or whatever, in comparison with those of his peers. Doctors tend to be both arrogant and defensive to a degree and insufficiently attentive to their role as service providers. (I’m a lawyer — ask me how often I keep a client waiting more than 5 minutes.) Very few doctors are equipped to listen to the needs and values of an individual patient or to evaluate what the patient knows or doesn’t know or hears or doesn’t hear.

    All too often, one gets a mostly mechanical download of rote information, with canned warnings and disclaimers that, simply by virtue of their ubiquity and presentation, have a soporific, rather than a warning, effect. Sometimes, it seems as if the doctor himself doesn’t really want to hear the warnings. We all want to feel like we’re doing good work and that our are outcomes are a little better than they are. It’s also understandable that frightened patients may not be sufficiently attentive to warnings — it’s hard to apply probabilities (especially those below 0.5, much less, unspecified or considerably lower ones) to your own, individual fate, and if you substitute worst-case scenarios for healthy denial, you’ll likely become paralyzed. And then there are patients who are stuck with a poor outcome and seek to minimize their issues. You can see the phenomenon on Amazon any day — if they’re not outraged, people understandably tend to rate their costly lemon as an apple, if not a peach.

    I don’t have a ready solution to any of these problems, many of which have systemic causes. If I were to single out one issue, it’s simply that patients are disadvantaged by the paucity of truly honest brokers. It ought to be easy to find an independent, unbiased, knowledgeable doctor who can help one navigate and decide between prostate cancer specialists and options — but it ain’t.

  7. Dear PC Aguy:

    I do regularly criticize the medical profession for lack of clarity. If you take the one comment above out of that context, then yes, it is fair to suggest that I was “letting the doctors off the hook.” However, I would (gently) submit to you that for the many dozens of times I have probably pointed out on this blog (over the past 4+ years) that doctors don’t do a very good job of offering clear and neutral guidance to their patients, this is (I think) at most the second time I have pointed out that patients also have some serious responsibilities too. (To continue Latin discourse, however, I do regularly advise patients that caveat emptor.)

  8. The most truthful answer about treatment outcome a physician can give is, “I do not know.”

    The answer a patient is most uncomfortable with is, “I do not know.”

  9. ‘The answer a patient is most uncomfortable with is, “I do not know,” ‘ i.e., ignorance is bliss, … until you are no longer ignorant.

  10. Dear Chris O’Neill:

    I absolutely disagree with your last comment. The fact that a patient is going to feel uncomfortable when told the truth is no reason for a physician not to tell the truth. The wise patient’s response to “I don’t know” is not to accept ignorance but to ask what the physician does feel as sure as he can about.

  11. My statement didn’t come out the way I meant it to. I was thinking, the patient prefers to be ignorant that the physician does not know. Sorry it’s probably too confusing to be helpful.

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