Response to Lin et al. 'RE: urinary incontinence recovery and surgical techniques in endoscopic enucleation of the prostate'.
Journal
BJU international
ISSN
1464-410X
Date Issued
2024-10-09
Author(s)
Abstract
Transient urinary incontinence (UI) is a common yet troublesome complication following endoscopic enucleation compared with resection and vaporisation of the prostate [1]. Therefore, urologists are increasingly exploring various surgical techniques to minimise its occurrence and improve patient recovery. Our study, titled ‘Prospective study of urinary incontinence recovery following endoscopic enucleation of the prostate’, recorded the surgical methods used by five surgeons. These methods were categorised into two groups: original en bloc (retrograde) and anteroposterior dissection techniques. We adopted a one-lobe approach in both methods, although variations in technique were applied based on individual cases as surgeons aimed to reduce UI. Lin et al. emphasised the importance of preserving the anterior fibromuscular stroma (AFS) to prevent postoperative transient UI [2]. The AFS extends from the bladder neck to the prostate apex, connecting to the external sphincter. During enucleation, the surgical plane is established between the transitional zone and the AFS. To protect the AFS, incisions are made at the 11- and 1-o’clock positions, extending from the bladder neck to the apex, potentially leaving the anterior transitional zone intact. In our study, 25 patients in the retrograde group and 29 in the anteroposterior group underwent preservation of the 11- to 1-o’clock position to reduce UI. In the retrograde group, the mean International Consultation on Incontinence Questionnaire – Urinary Incontinence-Short Form (ICIQ-UI-SF) scores at 1 week, and 1, 2, and 3 months were 6.71 vs 7.56, 4.29 vs 4.68, 2.54 vs 3.12, and 1.30 vs 1.88, respectively, for the traditional vs preservation techniques (subgroup analysis from Fig. 2 in the original submission). In the anteroposterior group, the respective scores were 4.50 vs 4.75, 2.83 vs 2.17, 1.92 vs 1.31, and 1.04 vs 0.31. Severe UI occurred in 34 (22.1%) vs five (20%) and nine (8.3%) vs three (10.3%) patients in the retrograde and anteroposterior groups, respectively (Table 1). Our findings did not show a significant benefit from preserving the 11- to 1-o’clock position. However, the anteroposterior technique appeared more effective in reducing transient UI compared to the retrograde method, although this benefit was observed only within the first 2 months postoperatively. This may be attributed to the early apical release and reduced sphincter traction associated with the anteroposterior technique in our cohort, which was absent in the retrograde approach. Large prostate adenoma enucleation techniques vary but protecting the external sphincter is critical [3, 4]. Cutting between 1 and 11 o’clock to preserve sphincter mucosa may reduce UI. Early sphincter-adenoma separation is also essential. Some surgeons prefer a top-down approach, cutting between 10 and 2 o’clock. While preserving the adenoma at 1 and 11 o’ clock may minimise sphincter damage, our study did not find a significant improvement in UI outcomes. Our study also assessed different types of transient UI using the ICIQ-UI-SF, including stress, urgency, mixed, continuous, and other forms of UI. Solely focusing on stress UI or relying on verbal inquiries risks underestimating the patient's condition. It is therefore essential to carefully evaluate the definitions and diagnostic methods of each type when comparing their severity in clinical practice. The authors declare no relevant conflicts of interest regarding this study.
SDGs
Type
letter