Treatment of post-prostatectomy urinary incontinence and erectile dysfunction: there is insufficient utilisation of care in German cancer survivors

[Structural health care reality in the surgical treatment of male stress incontinence in Germany]

BACKGROUND

Stress urinary incontinence in men is predominantly iatrogenic after radical prostatectomy or transurethral interventions. Current studies show that there is a deficit in the availability of surgical therapy not only in Germany. The aim of this study is to investigate in more detail the structural health care situation of surgical treatment of male stress incontinence in Germany.

MATERIALS AND METHODS

The evaluation of the surgical therapy of male stress incontinence in Germany is based on the OPS (Operationen- und Prozedurenschlüssel-German procedural classification) codes from hospital quality reports from 2011-2019.

RESULTS

From 2012-2019, the number of male incontinence surgeries declined from 2191 to 1445. The number of departments performing incontinence surgeries decreased from 275 to 244. In the multivariate analysis, a high number (≥ 50) of radical prostatectomies/year (RPE/year) is an independent predictor of a high-volume centre (≥ 10 procedures/year; odds ratio [OR] 6.4 [2.3-17.6]; p < 0.001). The most significant decrease was in sling surgery (from 1091 to 410; p < 0.001). Here, the number of cases decreased especially in departments that implanted a high number of slings (≥ 10 slings/year; -69%; -62.4 ± 15.5 surgeries/year; p = 0.007). In addition, the number of departments implanting slings decreased over the investigated time period (from 34 to 10; p < 0.001). This particularly affected departments that also had a low number of RPE/year (from 9 to 0; -100%).

CONCLUSION

The situation of surgical treatment of male stress urinary incontinence in Germany shows a clear decline in sling implantation, especially in small departments. On the one hand, this reflects the increasingly differentiated indications for sling implantation. On the other hand, it raises the suspicion that a gap in care has developed, as the decline was not compensated for by other surgical therapies.

[Urinary incontinence after radical prostatectomy: risk factors and utilisation of care]

Stress urinary incontinence is a relevant risk of radical prostatectomy (RP), which significantly affects patients' quality of life. The risk of developing stress urinary incontinence depends on pre-, intra- and postoperative factors. In particular, intraoperative factors regarding different surgical techniques are often focused on in order to improve continence rates. If stress urinary incontinence develops after RPE, patients affected should be treated adequately. In this respect, there are indications of healthcare insufficiencies in Germany. On the one hand, these include deficits in the use of incontinence materials. On the other hand, surgical treatment of stress urinary incontinence after RPE is insufficient.

Insufficient utilization of care in male incontinence surgery: health care reality in Germany from 2006 to 2020 and a systematic review of the international literature

PURPOSE

Data suggest that the utilization of care in male incontinence surgery (MIS) is insufficient. The aim of this study was to analyse the utilization of care in MIS from 2006 to 2020 in Germany, relate this use to the number of radical prostatectomies (RP) and provide a systematic review of the international literature.

METHODS

We analysed OPS codes using nationwide German billing data and hospitals' quality reports from 2006 to 2020. A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).

RESULTS

MIS increased by + 68% from 2006 to 2011 (1843-3125; p = 0.009) but decreased by - 42% from 2011 to 2019 (3104-1799; p < 0.001). In 2020, only 1435 MISs were performed. In contrast, RP increased from 2014 to 2019 by 33% (20,760-27,509; p < 0.001). From 2012 to 2019, the number of artificial urinary sphincters (AUSs) changed minimally (- 12%; 1291-1136; p = 0.02). Sling/sling systems showed a decrease from 2011 to 2019 (- 68% 1632-523; p < 0.001). In 2019, 63% of patients received an AUS, 29% sling/sling systems, 6% paraurethral injections, and 2% other interventions. In 2019, few high-volume clinics [n = 27 (13%)] performed 55% of all AUS implantations, and few high-volume clinics [n = 10 (8%)] implanted 49% of retropubic slings.

CONCLUSION

MIS have exhibited a relevant decrease since 2011 despite the increase in RP numbers in Germany, indicating the insufficient utilization of care in MIS. The systematic review shows also an international deficit in the utilization of care in MIS.

Evaluation of the effect of levator ani muscle contraction on post-prostatectomy urinary incontinence using cine MRI

AIM

Post-prostatectomy urinary incontinence (PPI) is the greatest concern for urologists after radical prostatectomy (RP). It is thought that PPI is composed of multiple factors including static and dynamic components. The purpose of this study is to show visually levator ani muscle (LAM) contraction during pelvic floor muscle contraction and to evaluate the dynamic differences in its contraction between men with and without PPI.

METHODS

This study was a case-control study of the urinary continent or incontinent men. It investigated whether LAM contraction was involved in urinary leakage based on examination of LAM contraction by cine magnetic resonance imaging.

RESULTS

The LAM contracted from the coccyx to the pubis in the same manner before and after surgery. The degree of contraction of the LAM in post-prostatectomy groups was smaller than that in the healthy adult group. The contraction distances of each part of the pelvic floor were decreased by 50%-70% in the incontinence group compared to those in the continence group. The bladder neck moved 2.5-fold further in the continence group and the direction of movement was more vertical than in the incontinence group. Urethral compression was attenuated by about 40% in the incontinence group compared to that in the continence group.

CONCLUSIONS

RP can cause damage to the LAM. LAM contraction is reduced after RP compared with that in healthy adult men. In men with PPI, the reduced muscle contraction might not compress the urethra sufficiently when abdominal pressure is raised. Pelvic floor muscle training might provide a meaningful method for the recovery of LAM contraction in patients with PPI.

[Health care reality of urological endoprosthetics in Germany from 2006 to 2016]

Hintergrund

Die Behandlung von Harninkontinenz und erektiler Dysfunktion verbessert die Lebensqualität vieler Patienten. Insbesondere die Endoprothetik mit Sphinkter- und Penisprothesen erzielt hierbei sehr gute Ergebnisse, wenn konservative Therapieoptionen ausgeschöpft sind. Ziel dieser Studie ist eine Darstellung der Entwicklung und aktuellen Versorgungslage der Sphinkter- und Penisprothesenimplantation in Deutschland.

Material und Methoden

Wir führten eine Analyse der Diagnosis-Related-Groups-Abrechnungsdaten in Deutschland im Zeitraum von 2006 bis 2016 durch. Die Versorgungslage im Jahr 2016 beschrieben wir auf Basis der Qualitätsberichtsdaten der deutschen Krankenhäuser.

Ergebnisse

Von 2006 bis 2012 stieg die Zahl der implantierten Sphinkterprothesen in Deutschland von 739 auf 1112 (p < 0,001) und die Zahl der implantierenden Kliniken von 129 auf 206 (p < 0,001). Von 2012 bis 2016 fielen die Fallzahlen auf 980 und die Zahl der Kliniken auf 198. Im Jahr 2016 implantierten 168 (88 %) urologische Kliniken 1–9 Sphinkterprothesen und 23 (12 %) Kliniken ≥ 10 Sphinkterprothesen. Die 10 Top-Kliniken (≥20 Sphinkter) implantierten 34 % (283/839) aller Sphinkter. Von 2006 bis 2013 stieg die Zahl der implantierten Penisprothesen kontinuierlich von 263 auf 503 (p < 0,001) sowie die Zahl der implantierenden Kliniken von 71 auf 107 (p < 0,001). Von 2013 bis 2016 stagnierte die Fallzahl (p = 0,9) und die Zahl der implantierenden Kliniken (p = 0,5). Der Anteil implantierter Penisprothesen im Rahmen von Geschlechtsumwandlungen stieg von 17 % im Jahr 2006 auf 25 % im Jahr 2016 (p = 0,03). Im Jahr 2016 implantierten 83 (85 %) urologische Kliniken 1–6 Penisprothesen und 14 (15 %) Kliniken ≥ 7 Prothesen. Die 7 Top-Kliniken (≥20 Prothesen/Jahr) implantierten 232/448 (52 %) der Prothesen.

Diskussion

Der Versorgungsstand der urologischen Endoprothetik in Deutschland zeigt eine deutliche Zentrenbildung, aber auch eine große Zahl von Kliniken mit geringer Fallzahl. Seit 2012/2013 zeigt sich eine Stagnation der Fallzahlen von Penis- und Sphinkterprothesenimplantationen, die in Zusammenschau mit den Prostatektomiefallzahlen eine Unterversorgung vermuten lässt.

Zusatzmaterial online

Die Online-Version dieses Artikels (10.1007/s00120-021-01444-5) enthält weitere Tabellen zu Fallzahlen von Sphinkterprothesen und Penisprothesenimplantationen. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.