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Prävention der postoperativen Harninkontinenz

Prevention of postoperative urinary stress incontinence

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Zusammenfassung

Ein nicht unerheblicher Anteil der Prävalenz der männlichen Inkontinenz geht auf eine postoperative Belastungsinkontinenz nach operativer Therapie des Prostatakarzinoms zurück. Dabei wird die postoperative Inkontinenzrate nach radikaler Prostatektomie je nach Autor und Patientenkollektiv zwischen 2,9% und 87,0% angegeben. Hierbei spielen patientenbezogene Faktoren, wie „Body-Mass-Index“, Patientenalter, Nebenerkrankungen, Prostatagröße und präoperative Kontinenz, aber auch die Art und Weise der Datenerhebung und Klassifikation der Inkontinenz eine Rolle. Allerdings zeigen Untersuchungen der letzten Jahre, dass die angewendete Operationstechnik einen entscheidenden Einfluss auf die postoperative Kontinenz des Patienten ausübt. Dem Erhalt des muskulären urethralen Sphinkters (Rhabdosphinkter, äußerer Schließmuskel) kommt dabei die entscheidende Rolle zu. Weitere anatomische Strukturen und deren Erhalt tragen allerdings zusätzlich zur postoperativen Kontinenz bei. Dazu gehören v. a. der Blasenhalserhalt, nervenschonende Operationsverfahren und die Rekonstruktion des vesikourethralen Übergangs.

In den letzten Jahren wurden diesbezüglich verschiedene Modifikationen der Operationstechnik auf ihre spezifischen Auswirkungen auf die postoperative Kontinenz untersucht. Die Auswertung dieser Studien zeigt v. a. eine deutliche Verbesserung der postoperativen Frühkontinenz und eine deutlich kürzere Zeitspanne bis zum Erreichen der vollen Kontinenz. Die Langzeitergebnisse zeigen dahingegen keine signifikanten Vorteile für die beschriebenen Modifikationen in Bezug auf die Kontinenz gegenüber der Standardoperation.

Die bisher vorliegenden Studien zeigen nur geringe Auswirkungen der beschriebenen präventiven Maßnahmen auf die postoperative Kontinenz mit insgesamt großer Bandbreite der publizierten Kontinenzraten. Zur Evaluierung der genauen Auswirkungen der präventiven Modifikationen der Operationstechnik sind weitere, v. a. größere und randomisierte Studien notwendig, um die effektivsten Modifikationen zu identifizieren. Dabei scheint es wahrscheinlich, dass schlussendlich Kombinationen dieser präventiven, operativen Maßnahmen zu einer deutlichen Verbesserung der postoperativen Kontinenzraten führen werden.

Abstract

Postoperative stress incontinence following operative treatment of prostate cancer represents a considerable percentage of overall male incontinence. Postoperative incontinence following radical prostatectomy ranges between 2.9 and 87% depending on author and patient characteristics. Especially patient-related factors such as body mass index, age, size of prostate, preoperative incontinence, and concomitant diseases as well as classification of incontinence and modality of data collection influence postoperative continence rates. However, recent publications demonstrate the important impact of different operative techniques with regard to postoperative continence.

The preservation of the muscular urethral sphincter is of particular importance. Nevertheless, the preservation of further anatomical structures contributes to postoperative continence. Preservation of bladder neck, nerve sparing, and reconstruction of the vesicourethral junction are operative techniques to prevent postoperative incontinence. In the last decade different modifications of the operative technique have been investigated regarding specific effects on postoperative continence.

The interpretation of these studies investigating these operative techniques showed improvement in early continence with shorter period of time to continence. Long-term follow-up revealed no significant advantages for these modifications with regard to continence compared to the standard procedure. To evaluate the long-term effects of certain modifications to prevent incontinence, randomized and well powered studies are necessary. It seems to be most likely that a combination of these preventive modifications will lead to improved postoperative continence rates.

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  1. Urologische Klinik, Universitätsklinik Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    M.A. Reiter, A. Haferkamp & M. Hohenfellner

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  1. M.A. Reiter
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  2. A. Haferkamp
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  3. M. Hohenfellner
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Correspondence to M.A. Reiter.

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Reiter, M., Haferkamp, A. & Hohenfellner, M. Prävention der postoperativen Harninkontinenz. Urologe 49, 489–497 (2010). https://doi.org/10.1007/s00120-010-2267-y

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