BackTable / Urology / Podcast / Transcript #11

Podcast Transcript: Evaluation & Management of Post-Prostatectomy Incontinence

with Dr. Steve Hudak and Dr. Aditya Bagrodia

Dr. Aditya Bagrodia interviews urologist Dr. Steve Hudak from UT Southwestern Medical Center about post-prostatectomy incontinence. They cover an array of topics including, incontinence evaluation, managing patient expectations, kegel exercises and pelvic floor therapy, and slings vs. artificial urinary sphincters. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Pre-Prostatectomy Optimization and Initial Evaluation of Post-Prostatectomy Incontinence

(2) Timing of Surgical Intervention and Recommendation of Sling Versus Sphincter

(3) Patients with Bladder Neck Contracture, Radiation History, and Upcoming Radiation

(4) Short-Term Patient Expectations and Perioperative Management

(5) Catheterization and Cystoscopy in Artificial Urinary Sphincter (AUS) Patients

(6) Long-Term Patient Expectations and Device Lifespan

(7) Navigating a Positive Preoperative Urine Culture

(8) Critical Operative Steps to Minimize Complications

(9) Evaluation and Management of Common Complications

(10) Advice to Trainees and the Future of the Field

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Evaluation & Management of Post-Prostatectomy Incontinence with Dr. Steve Hudak and Dr. Aditya Bagrodia on the BackTable Urology Podcast)
Ep 11 Evaluation & Management of Post-Prostatectomy Incontinence with Dr. Steve Hudak and Dr. Aditya Bagrodia
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[Aditya Bagrodia]
Hello, everyone. And welcome back to the BackTable urology podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is Aditya Bagrodia as your host this week. And I'm very excited to introduce our guest today, Steven Hudak, from the UT Southwestern Department of Urology.

Steve is our recently minted program director, which we're all very excited about. He's been an absolute thought leader in trauma/reconstruction and prosthetics over the last decade or so. A lot of fascinating and important work on some of the particular challenges and clinical scenarios we meet in military personnel. And I really couldn't be happier to introduce Steve to the show. So welcome, Steve. How's the morning going?

[Steve Hudak]
Thanks, Aditya. It's great to be with you. Morning is going great, excited to be here.

(1) Pre-Prostatectomy Optimization and Initial Evaluation of Post-Prostatectomy Incontinence

[Aditya Bagrodia]
All right. All right. So despite the fact that there's been tremendous progress, technological advances, and surgical management of prostate cancer, of course, stress incontinence is something that we see. And today, we're really hoping to dig in with Steve on some of the nuances, tips and tricks as we guide patients through the post-prostatectomy incontinence journey. So Steve, maybe I'll just start out with leading up to surgery, anything you recommend to surgeons performing prostatectomy in terms of prepping their patients for surgery?

[Steve Hudak]
Yeah, that's great. So I think expectation management is huge. It's not probably appropriate to overpromise outcomes from the beginning. I think it's important to prepare patients for, basically, the certainty of some degree of urinary leakage certainly immediately after catheter removal. And so that way their expectations are set, they're not surprised and disappointed if there is some leakage when the catheter comes out. And if they happen to be more continent than most, well, then they're going to be very pleased with that. So I think that trying to set the stage for quality of life expectations from the beginning are important.

But then I think it's very reasonable to not be doom and gloom about it. And let them know that over the course of the first six months to a year after the radical prostatectomy that the majority of men will regain continence to the degree of needing one pad per day or less. And it's probably only about 10 to 20% of men that will need further treatments for ongoing incontinence after radical prostatectomy.

So I think setting that stage early on, under-promise, over-deliver, but then not being too pessimistic with the long term and then probably concluding it with letting them know that if they are in that 10 to 20%, there are good, safe, well-tested and proven options both surgical and nonsurgical to improve that control, and secondarily, their quality of life.

[Aditya Bagrodia]
Perfect, perfect. Certainly in my end, I absolutely agree with that philosophy of trying to set realistic expectations, perhaps even under-promise and over-deliver, hopefully, and in addition I’ll have them start doing Kegel exercises. So I think here in our practice, typically patients are going to be doing Kegels, essentially, as soon as a catheter comes out and they're comfortable. You're going to see patients from the community, as well as internally, if they've been doing Kegels for 8 to 12 weeks without any meaningful improvement...what are your thresholds? What are your thoughts on pelvic floor physical therapy?

[Steve Hudak]
So I think that this is a resource that's very valuable. Unfortunately, it's not available in all communities. A good pelvic floor physical therapist that will work with an incontinent male can be difficult to find. And so certainly if there's one available at your practice or in your community, I think it is particularly important, especially if they seem to be struggling a little bit with the mechanics of pelvic floor physical therapy, obviously, it's hard without complex measuring devices to really know this...but you can try to assess if they really have captured the physical aspect of a Kegel. It's a foregone conclusion that guys will just know how to do it, but if they seem to be struggling with it, I think in this group it's particularly helpful. So if you have the combination of, like you said, a couple three months out and they don't seem to be making any progress, they feel like they're struggling with the mere act of a Kegel exercise, especially if that resource is available, I think there's a lot to gain and very little to lose by getting a physical therapist involved.

[Aditya Bagrodia]
Couldn't agree more. Yeah, and we really are, I think, blessed to have tremendous physical therapists that are really, really experts at what they do. And I think there's also a growing body of videos and so forth, even on YouTube that I'll often direct patients towards that can help make sure that they're being done properly. So let's say that they've gone through some lifestyle changes - decreasing caffeine, seeing a physical therapist - and they're still not quite where they want to be. And this is, I'm guessing, a lot of the patients that come into your door. Tell us a little bit about your intake and evaluation of these patients.

[Steve Hudak]
Yeah, that's great. So I think you bring up a good point in terms of different types of referrals and different types of practices that people have. I mean, certainly, I consider some of the incontinence surgeries well within the realm of a well-trained general urologist. So it's possible that there are still doctors in smaller practices that may care for the patient throughout the entire experience from pre-op evaluation, radical prostatectomy, post-op care and even surgical care for incontinence. So, I think that's a different setup for someone that's going to see them all the way along, compared to someone that may be in a bigger practice that focuses their surgical care on post-operative care of prostate cancer patient survivorship, prosthetics, et cetera. So sometimes, where you identify that patient matters. Many times those of us that do this work exclusively really won't see the patient until a year or sometimes longer out. So it's very, very different than seeing someone that's three or six months out.

I think regardless of your perspective, when you're seeing them within the first year, I think what's more important than a specific month cutoff is really their trajectory. So for example, if someone perhaps had a wide resection for aggressive prostate cancer, they're six months out and they've really seen no meaningful improvement over the last several months despite pelvic floor physical therapy, I don't think there's anything that's magical that's really going to happen in those next six months are any clear cutoff that has to happen. So I think it's the combination of timeframe, whatever disease parameters - certainly if it was a salvage procedure after radiation, then obviously, they're much more likely to fail conservative management - so pre-op and peri-op information is important. Time from surgery, trajectory of improvement are all important. And then digging deep into that history, I think, is necessary at the first visit.

I think, as a side note to that, I'd say that there are a couple of different ways to work through the evaluation. And the AUA guidelines leave a lot of latitude depending on a urologist's practice. Philosophically, I like to do the evaluation for interested patients in two steps, two separate visits. And it comes from the fact that when we think about the viewpoint of a patient that had a surgical treatment and then now has a problem, it's not necessarily a drastic complication like something that leaves them in the hospital for longer or a prolonged surgical leak or an infection. But in their mind, it's going to be I wasn't incontinent (or I was continent), and then I had this surgery and now I'm not continent.

So I personally don't like to go in there guns blazing and say, I'm "Dr. Hudak. I'm your surgeon. We're going to fix this with more surgery on the first day." I like to use that first visit, rather, to take a good history, use the 15 or 20 minutes in that appointment, really, to get to know their problem and to allow them to be comfortable with the plan of evaluating it, not jumping directly into surgery. So that first visit for me, again, is a history, a gaining of a two-way rapport, and then a little bit of education about the options that are available. If it appears to be pure or at least mixed stress incontinence, I'll give them some online and in-print materials about the options, and then leave it at that. I don't do an invasive physical exam, I don't do any invasive testing on that first visit. I do the history, I give them some information, and then if they're interested I'll set up a very short-term follow-up where we'll do a cystoscopy, some provocative maneuvers, a physical examination, and a residual check.

[Aditya Bagrodia]
Perfect. Any questionnaires that you use as a standard part when you're in taking these patients just to give some objective data to quantify symptom severity?

[Steve Hudak]
I don't find them to be clinically helpful. I certainly think they're relevant if we're doing well-designed research, but clinically helpful? Certainly I don't. The main things that I ask them are when do you leak, when do you not leak, what are your activity levels? And then basic flow dynamics stuff - do you have a good stream, blood in the urine, bladder infections? So I think the “when do you leak?” is important, obviously, because if it's an obvious classic stress case, they'll say, well, when I cough, when I lift. But sometimes they'll just say, "You know, Doc, when I'm up and walking around, I just will check my pad later and it'll be wet." And so that can be hard to characterize. In which case, the second question, when do you not leak, is important. So I think that patients that are dry all night is a pretty reliable indicator for this being a stress problem. I think patients that say “yeah, I'm wet but I can still feel that urge and walk to the bathroom, get to the toilet, and get a stream going.” I think that's a pretty reliable indicator of it not being a kind of an urge predominant problem.

And so, I think kind of a give and take of what causes it, what doesn't cause it, and then an overall assessment of their activity. I mean, there are younger men that will leak several pads a day but are still working full time, they still go to the gym, they still run. And that's very different than someone that may be homebound because of the degree of incontinence. And so, I think an assessment of that, and that's why I take that first visit to really have a conversation to get into those three things. And to me, that conversation is more helpful on a patient to patient basis than any printed questionnaires.

[Aditya Bagrodia]
Got it. Yeah. It sounds like it almost ultimately culminates in a bit of a bother impact on life and type of activities. Pad weights, bladder diaries - are those things that you prefer to get or is it kind of in the same camp of good for research, maybe not as clinically impactful?

[Steve Hudak]
Yeah, same camp there, definitely those are very, very helpful if we're trying to do studies to evaluate this in large groups. Fortunately, there was a study that came out several years ago that really looked at pad weights and compared it to things that might be more easy to assess. And they found strong correlation, not just pad counts but pad weights compared to the combination of pad count, pad type, and assessment of how soaked it is when they change, and then the overall quality of life impact.

And this makes a lot of sense. So, a man may say, I leak two pads per day, and another man may say I leak four pads per day. And you would, obviously, think it might be hard to compare those. But if you dig into that and ask them what type of pad and how soaked are they and how much does it bother you, that man that leaks four pads per day might say, "I use a thin pad liner. It's barely damp when I change it. I'm very active, and it's very bothersome to me." And then compare that to the man that uses a full thickness depends type pull up undergarment twice a day that's fully soaked, it doesn't cause him bother and he barely leaves the house. And so you can see how just digging into it with some very simple questions will provide a lot more information than a simple pad count, and is a lot less cumbersome for you, for your patient, and for your office in terms of weighing the pads.

[Aditya Bagrodia]
Absolutely. And I think it's something we all come across clinically. What if they complain about climacturia specifically? Any thoughts on how that interfaces with general stress incontinence or even if it's a bit of an isolated symptom?

[Steve Hudak]
I like to dig into it a little bit. I think this term is becoming more mainstream, certainly, among urologists and secondarily, just to the available information that patients can get is becoming more of a thing that they know about. That being said, I rarely have a patient that comes in using that exact term. And so, I think it's important to be very, I guess, probing. And it can be difficult but obviously you'll generate a rapport with patient but be a bit probing as to whether it's incontinence during the physical act of sex, which is obviously an act that's can be straining and can cause a true stress environment, or is it simply isolated to leakage during the time of climax? And so, I think evaluating that and digging into that and then seeing is this just another other manifestation of the stress or is it isolated climacturia, and then combining that with any further information they gave you to really see, is it totally isolated climacturia or is this something that will just be treated in combination with other aspects of their overall picture of stress incontinence?

[Aditya Bagrodia]
Okay, super helpful. Quick comment on Cunningham clamps, condom caths....I feel like this is like, even over the course of my relatively finite career, something that's been coming across my desk less and less common, but a quick comment would be great.

[Steve Hudak]
We see very few men that are going to be successful with either of these in the long term. There are some anatomical considerations, obviously, you need a protuberant phallus to apply any of these, especially a condom catheter, given the fact that it's not just a single point fixation. And so, what I'll do for these miscellaneous devices is I'll refer the patients to a third party website where they know they can purchase them and try them on their own.

And I've actually learned a lot from my patients in these over the years, particularly for nonsurgical candidates or patients that are averse to surgery, sometimes they'll come in with handouts and pictures of, "Hey Doc, I saw this or that." And I've just been really surprised with what patients can find out on their own, those that are motivated.

But for those that are seeking these options, I give them a third party website that I trust where they don't have to... Obviously, if you Google “penis clamp” there can be some interesting things that come up onto their screen. So, I point them in the right direction if this is what they want. And there's different types of undergarments that are more discreet than just going to the grocery store. So there's really a wealth of information that's out there. As far as specific use of these, the one caveat that I would put in is that I think a Cunningham clamp is very, very helpful to serve as almost a test run, so to speak, compared to an artificial urinary sphincter. And when you think about it, that makes sense. It's a compressive device that the patient controls.

It's obviously different with regards to where it is anatomically, but I found it particularly helpful for the very severely incontinent male that perhaps doesn't even void because he's leaking so severely. And you'll see these patients particularly in the post-radiation, post-prostatectomy setting that they just basically are wet all the time. And so, for these patients it could be difficult, especially the radiated ones, to know do they have bladder dysfunction, or really bad sphincter dysfunction, or both?

And so, many clinics will have just the classic Cunningham clamp in their office. You can give them one and show him how to use it, tell him to not wear it 24 hours a day, and apply it. And if they can go two, three, four hours without severe urgency and discomfort, I found that this is a really good provocative maneuver that costs basically nothing and requires very little to no invasiveness to then see if it's a simulation to see if they have the appropriate bladder capacity to be successful with a sphincter.

(2) Timing of Surgical Intervention and Recommendation of Sling Versus Sphincter

[Aditya Bagrodia]
Nice to know how you're incorporating that into part of the evaluation. So I think we've touched on some critical aspects here - conservative management options, fairly comprehensive it would seem like. And now we're beyond nonsurgical options. You touched base on timing how trajectory is probably a little bit more important than like a magical one year cutoff. So maybe, without putting words in your mouth, the earliest would be in that six-month timeframe. If you're plateauing close to a year, then it's probably reasonable to start thinking about surgical correction. Is that fair?

[Steve Hudak]
Yeah, definitely fair. I think the reason that trajectory matters so much is that even severe leakers, if they're improving, you may presume, “well, man, this gentleman is at six months out. He's still using five pads per day” ... But if he's improving, there's the possibility that he could perhaps, if not resolve completely, kind of tip from a more severe leaker into a more mild leaker. And that's important because if he kind of, over that timeframe may still need surgery, but tilts into a sling candidate, and you would operate on him too soon before he plateaued, I think that might be a missed opportunity to potentially employ a less invasive option. But that'll still certainly fall within that plateau situation.

And so, I agree with what you said. If they flat line, if they've maximized pelvic floor maneuvers, then whether it's 7 months, 12 months, or 15 months - it doesn't really matter. And in that same vein, if someone is continuing to improve - it's 16, 18 months - and they are patient, and are happy with their course, there's no need to leap in early. I mean, clearly, if you're much beyond two years, I think it's probably not helpful waiting. But I think it all comes back to that trajectory more so than the specific timeframe.

[Aditya Bagrodia]
Absolutely, absolutely. And so now, as we start thinking about interventions here, can you tell us how you organize (A) what are the comprehensive set of tools that are available to you? And (B) what are the patient specific and degree of continence specific factors that may be guiding your conversation and leading your recommendation?

[Steve Hudak]
So, I'd bring it back to what I mentioned before about it really being a two-step, two-visit evaluation. And so, within that first visit, of course, the history but also an assessment as to what their general thoughts are certainly their medical status, obviously, if it's early on, if they were healthy enough to undergo a robotic prostatectomy they're going to be healthy enough to undergo any of the surgical incontinence procedures (provided everything went well after the prostate). But really assessing where they're at with regards to what they might want to do or what they want to try.

If they have even an inkling of interest in the surgical options at that first visit, I will offer them usually within a week or two a follow-up for a little bit more of the secondary evaluation. And that's where we will really begin to stratify or I guess complete the stratification, for the options that are available. So on that visit, we'll come in, we'll get a urinalysis, do a cystoscopy.

During the cystoscopy, of course, looking through the urethra into the bladder. You do a full cystoscopy like you normally would. Once in a while, you'll detect the guy that had a bladder tumor without really any other inciting symptoms or signs, which I think obviously is an important find. It's nice not to find that on the day of surgery. That's rare but, again, it'll be important to find. Sometimes you'll see a subclinical bladder neck contracture, certainly less common in this era of robotics. So to eliminate those two, probably most frequent occult bladder pathologies is important.

We'll fill the bladder 200 or 300 cc's and then withdraw the scope to the level of the proximal bulbar urethra. We'll look at the sphincter. It'll be on the screen, so the patient will have some feedback. And I'll ask them to contract their pelvic floor to do a Kegel exercise to use whatever lexicon that they're comfortable with. And then we'll watch together how that sphincter closes. You'll see a couple of patterns. One, you'll see complete and firm and sustained sphincter closure. And that's favorable. Sometimes you'll see a complete closure that immediately fatigues almost like a wink that it closes but then immediately can't be sustained. And then less commonly, you'll see what's called a sector defect where only part of the sphincter, half of the sphincter, will contract due to a structural problem with the sphincter itself. And then less commonly, they won't be able to contract it at all. So it's good to quantify that cystoscopically. It's good for the patient to see it to say if it doesn't squeeze much at all, they'll be able to see that and they'll be able to better understand the anatomical problem.

And then what I'll do, particularly for those that have not been radiated and may be more mild to moderate leakers, I want to try to simulate what a sling would do. And so it's a little bit cumbersome, but you prepare the patient for it and then basically place pressure and have your assistant help you by holding the scope, and then place firm pressure behind the scrotum, right in the mid perineum to assess the mobility of the proximal bulbar and membranous complex. A favorable response to this would be when you apply manual pressure in this area, you don't see compression of the bulb, but you rather see complete coaptation or reproduction of the membranous closure. So this suggests a favorable response to the mechanics of a sling, which basically improves the passive closure of the membranous urethra. It's a little bit hard to illustrate this verbally in this format, but it's something that's an easy test to do. So that's favorable when you apply that compression and you see closure of the membranous urethra without the patient volitionally doing it.

Then you remove the scope, do a simple cough test while lying down. If they don't leak, I stand them up. If they are passively continent when standing with a full bladder, I think this is important, and then I'll have them cough again. And then finally, we'll have a urinal and have them begin to start their stream. And once they’ve got a full stream going, I'll have them interrupt the stream. So it's the combination really of those maneuvers that will help stratify them between the two most common surgical techniques, mainly a sling and a sphincter.

[Aditya Bagrodia]
Got it. And I can actually appreciate why this needs to happen in a couple of different visits. It sounds like a true wealth of information on the history side in visit, A, and certainly on the examination side on the second visit. And I know that this is not going to be binary, Steve, but as you alluded to, it's generally slings versus sphincters. What are your main decision points that are driving that?

[Steve Hudak]
So yeah, you're exactly right, incontinence severity is a continuum. And so things that we consider are the severity of leakage as assessed by that four-question aspect that we talked about before, the response to the provocative maneuvers that I just mentioned. The most important historical, I guess, caveat is radiation or not. We're pretty much limiting our conversation here to post-prostatectomy. And that's very appropriate because, really, that's the overwhelming majority of male stress incontinence patients that we treat.

And then getting into more subtleties in terms of the age of the patient, their overall functional status, their goals, and tying all that together. And it'll create, like I said, somewhat of a continuum, but really it’ll tease out patients that are clearly not candidates for one or the other. So for example, if you have a patient that has severe arthritis of the hands or bad neuropathy of their hands and they have a difficult time typing on a keyboard, holding a pen, they're going to really struggle with using an artificial sphincter. And relying on someone else to operate that sphincter for them it's just not a sustainable thing. So those sorts of problems would eliminate someone from an artificial sphincter candidacy.

Conversely, someone that's radiated, someone that has a high post-void residual, which we'll check after that provocative maneuvers, once they complete their voiding, as I mentioned, those are not going to be patients that are going to be well suited for a sling. And so, incontinence severity is the final aspect of that. If someone leaks one or two pads per day, they're minor pads, they're not soaked very much...I'm loath to put a sphincter in those men, particularly if they're younger, because the likelihood of needing a revision is much higher in younger men just due to their life expectancy. And then the opposite side of that, patients that have gravity-type incontinence are never going to do well with the sling.

So, I do what I can to put them into those that are clearly in one camp or the other, and to whittle it down to those that may be candidates for both. So this would be the functional man in his 60s or early 70s that's in reasonably good health, that leaks three or four pads per day, that has favorable metrics on cystoscopy as we discussed, that really is a candidate for either operation. And then we can get further into that discussion if you'd like. But that's really the main group that requires some more complex decision-making for those that could really go either way.

(3) Patients with Bladder Neck Contracture, Radiation History, and Upcoming Radiation

[Aditya Bagrodia]
Perfect. So you'd mentioned with the cysto, you get a lot of information even potentially around strictures, bladder neck contracture. I'm just going to ask you briefly a couple of timing questions for some of these scenarios. So history of bladder neck contracture that you incised, what's your timeframe before you consider doing any type of procedure?

[Steve Hudak]
So back up just a second and I think, really, there are two, I guess, general categories of bladder neck contracture patients that we'll see. Like I said, fortunately, this is much, much less common than when I was a resident, when I feel out the junior resident in the endo suite was doing TUIBNCs literally every OR day back in the open prostatectomy era. And thankfully, this has changed the game with regards to the frequency of these. And so, in the current era, if you will, there are two categories as I would place them that we see. Some are subclinical or asymptomatic bladder neck contracture where basically patient says they have a good stream, they might empty completely, their only complaint is the incontinence. And you do the preoperative cystoscopy and there's perhaps a 12 or 14 French bladder neck contracture that you can't scope through. So this is entirely different than the other category of patient that perhaps may be radiated or had an unfortunate hematoma with a distraction after their prostatectomy that goes into urinary retention or is severely symptomatic.

So the reason these two patients are different is that, obviously, a patient that has no symptoms from it and has no voiding problems - they don't have infections, they're not in retention - this is a patient that really the only reason we need to treat these is to be able to get a catheter in to perform the operation. So for those, I'll have no problem with doing a balloon dilation at the time, particularly if it's like a 12, 14 French. Do a balloon dilation at the time of the sphincter or the sling, the catheter is in, we do the operation, take the catheter out as we normally would - and the likelihood of that progressing to a urinary retention situation is effectively nil. That will likely go back to its previous state of 12 or 14 French and it'll resume being no problem to the patient.

However, if the patient is in urinary retention, it needs to have a more aggressive incision of that contracture. I think this is a different thing altogether. And the last thing that you want to do is do that endoscopic procedure, put the sphincter in immediately or soon after, and then risk them going back into retention in the short term and now you're having to sort out how to manage that instrument, their fresh sphincter, likely need a suprapubic tube. And so those two camps are very, very different with how to plan the timeframe.

[Aditya Bagrodia]
Got it, appreciate you distinguishing those types of bladder neck contractures.

[Aditya Bagrodia]
And just a quick timing question, I'm just going to almost ask you kind of rapid fire. So if they've had a prostatectomy, and based on pathology or PSA, if postoperative radiation is planned, how do you approach that? I mean, of course, you want to look at degree of incontinence and whether they're continuing to improve. But broad strokes, would you want to get your sling or sphincter in before or after radiation?

[Steve Hudak]
So certainly, we always want to get it in before radiation, especially if it's a sling because slings don't work well after radiation. So if it's a guy that leaks two or three pads per day and he's presumed to require radiation, then it's best to get it in ahead of time. There's not good data to say that it won't fatigue after the radiation. But I've noted that the rearrangement, the structural rearrangement that we see with the sling is possible and favorable before radiation and not after radiation.

And so, basically, if radiation is imminent, it's a high risk patient. He's several months out and basically they're hoping to radiate sooner than later. I don't want to delay that part of their cancer care to do the surgery. What's much more common is a patient may have early biochemical recurrence, a PSA is 0.07, but they’re really waiting for it to truly be defined as a true biochemical occurrence so radiation is not yet imminent, so to speak. In those cases, I confirm with the radiation oncologist, but in those cases, I definitely do the surgery if radiation is not yet planned. So I hope that answers that timeframe question. I don't delay it if it's planned. But if it's presumed but not planned, then I certainly do it. Because six weeks after the surgery, I'm okay with them proceeding with radiation if need be.

[Aditya Bagrodia]
Okay. And what if they've been radiated? Is there a certain amount of time you'd like to wait? So this is prostatectomy, the other edge of salvage radiation, is there a minimum time that you'd like to wait?

[Steve Hudak]
I like to wait three months. I think it's probably not really clearly defined. I think the radiation oncologists are usually in support of that. And so if they're a severe leaker and they're motivated, many times they like to just get back into the routine after the day after day grind of radiation. So it's rare that I see a patient that's really begging to have that place in the first month or two after they’ve completed their radiation. And so, allowing them to restore a baseline, making sure that they don't have any early cystitis after radiation. And so, usually in the three to six-month mark after radiation is complete is the time that we'll start looking into getting back and getting ready for the sphincter.

[Aditya Bagrodia]
And post-salvage prostatectomy patients, oftentimes, of course, there's anatomy characteristics, there's tissue quality characteristics, there can be fairly pronounced incontinence. Do you generally say, “Yeah, this is not going to likely improve with more conservative management, let's get it in early if they're having incontinence” or, give a little bit of time for the tissue to really repair and heal as much as it's going to?

[Steve Hudak]
Again, a lot of this depends on the motivation of the patient. If they had radiation, obviously, their prostate cancer surgeon going into the salvage prostatectomy is virtually always going to be very realistic with the fact that they're going to leak afterwards. And so, if they come in guns blazing at three months, I'd probably say, hey, let's wait till six months, do some physical therapy just to make sure. But I have no need to wait longer than that for patients that are in the salvage prostatectomy scenario that are simply not improving. Like what I'd said previously, there's no sense in waiting for a year on these guys. And I'm not really worried at the six-month mark that there's going to be any issues with healing at that point in time, provided there wasn't any early difficulty getting the catheter out and healing the anastomosis after the prostatectomy.

(4) Short-Term Patient Expectations and Perioperative Management

[Aditya Bagrodia]
Okay. So we've made it through some scenarios that we've seen and we're making decisions. Tell us a little bit about managing patient expectations. Perhaps we start out with a sphincter. And how does that kind of thought go in terms of what does this look like a couple of days after surgery, a few weeks after surgery, in terms of durability and efficacy?

[Steve Hudak]
Yeah. So this is important. I think the most important thing for them to know is that it doesn't work right away. Namely that when you place an artificial sphincter, we leave it in a deactivated state and let them heal for about six weeks or so. At which point they're going to be just as incontinent as they were the day before surgery. And so, if you're busy rushing through the counseling, you may overlook that and they'll be surprised for those first six weeks. So, that's the first thing, is they're going to continue to be incontinent for the first six weeks after surgery.

Perioperatively, virtually all of these are now done in the outpatient setting. I found that in the first phase of my career that I'd leave a catheter in, keep them overnight, but really I realized that we weren't doing a darn thing for him in that overnight stay. And so there's not much to be gained from that really at all. What I'll do is I'll use a lot of local anesthetic before I place the prosthesis to make sure that I don't poke any of the components, do a bilateral pudendal block, do a regional block in the area of the regulating balloon placement muscular incision, and then a skin block. Multimodal analgesia from anesthesia, send them home on NSAIDs if not contraindicated, Tylenol, and perhaps just a few narcotics if needed as a last resort. And patients do very, very well being discharged on the day of surgery. I leave it maximally deactivated, and so I've not had a problem with urinary retention. And so I take the catheter out in the operating room and they don't go home with one. I think if you size your sphincter cuffs a bit snug or don't deactivate it completely, some surgeons will note some early postoperative retention in which case they might send them home with a catheter. I've never seen that, and so I don't like them going home with a catheter for that reason.

So now they're going home the day of surgery, we tell them to take it easy, don't lift anything heavy so they don't herniate their balloon to their muscular incision. They'll have some swelling and some bruising. But really, they're on their feet at home, wearing their pad, if they were using a clamp before they can go back to doing that. And really the recovery from a patient impact standpoint is really only bothersome probably for a week or two depending on the stamina of the patient.

I'll see him back at that six-week mark, clearly earlier if they're having any wound questions, but we'll see him back at six weeks. We'll activate the device. I do that early in the day, because we need to activate it and also prove that they're able to use it. And so we'll do that early in the day. And then I'll invite them to either stay in the clinic, have a cup of coffee, or go to a nearby coffee shop or restaurant just to make sure that they can fill their bladder and activate it, operate it on their own and empty their bladder. Because the last thing we want to do is this is the last patient slot of the day, and then now it's 8:00 at night, they can't work it or are struggling with it and they end up in an ER, God forbid. And worst case scenario, someone that doesn't know much about sphincters ends up putting a catheter in on the first day of its use. So I think an early process of doing that early in the day, tell them that I'll be in the office and they can bop back if they're having any issues with it and needing more coaching provides them some confidence and really provides me some security to know what they've went through is not all for naught in that first period.

(5) Catheterization and Cystoscopy in Artificial Urinary Sphincter (AUS) Patients

[Aditya Bagrodia]
We've all come across this...catheters and patients, whether they're getting heart caths or orthopedic surgeries, et cetera. Just a quick, your strategy for patients that require catheters after AUS?

[Steve Hudak]
So the company used to provide a MedicAlert bracelet in with the patient education packet. That isn't always available now, but they will provide an information card where the patient could just send that in and they'll send them an information bracelet. And so, basically they can wear this like they would any other MedicAlert bracelet. It basically says “artificial sphincter, don't place catheter, call urology.” So I think education is important. And this will protect them if there is any circumstances where they'd be incapacitated, or the nurse will ask them are they wearing any jewelry so it'll be the last thing that they take out in the holding area if they're getting a hip replacement or a hearth surgery or something like that.

And in those cases, the surgeon at the procedure that they're having absolutely wants to have a catheter, they'll call the urologist. We'll deactivate the device. We'll place a 12 French catheter and just leave it in overnight, take it up next morning. If they're still in the ICU and need to I&O’s monitored, then a condom cath works fine in that circumstance or just close nursing care. And then, God forbid, it is a more dire situation where they need to have catheter drainage for much longer due to their illness or what have you, then in those cases a percutaneous suprapubic tube with ultrasound guidance is probably the safest thing to do. And it's a bit of a frustration, but it's much more important than leaving a prolonged catheter across that sphincter.

[Aditya Bagrodia]
You'd mentioned earlier that, as a part of your evaluation, it gives you some information in terms of whether there may be a bladder tumor or not. Something, again, that comes across my desk periodically....patient with history of sphincter developed hematuria, suggestive of a bladder tumor. You got to go in there and get a pathologic diagnosis. Any advice for urologists that come across that state?

[Steve Hudak]
These are tough situations. I think going into it, this is now converted from a quality of life situation to yet again another cancer operation. So, I think informing the patient that the most important thing here is evaluating, diagnosing, and hopefully treating their presumed bladder cancer. Technically, maximally deflating and deactivating the device. In terms of scope selection, if it is just a small tumor that can be cold-cup biopsied, I know it's frustrating for the urologist but trying flexible scopes if he can. And then ablating the area if that's appropriate from a sampling standpoint.

If it's too large of a tumor, then obviously that's not going to be practical. But again, using a smaller non-continuous flow rigid scope will be helpful. There are certainly the possibilities of going in perineally and decoupling the cuff - I think that this should really be used really only in select scenarios and I wouldn't recommend this the first time around. And then obviously, if a patient has high-risk non-muscle invasive bladder cancer, perhaps this is an individual that just may not be the greatest candidate for bladder preserving modalities because now we're fighting against not only the cancer risk of bladder preserving therapies but also that every time you go back into the urethra, threatening that artificial sphincter. So, this certainly deserves a three-way discussion between the urologist managing the cancer, the urologist that may be managing his incontinence, and the patient.

(6) Long-Term Patient Expectations and Device Lifespan

[Aditya Bagrodia]
Perfect. So, just backing up a step before we jump into some of the operative considerations, let's maybe stick to sphincters. So Dr. Hudak, once this is in, I'm going to be bone dry for the rest of my life. Is that a reasonable expectation for the patient?

[Steve Hudak]
It's a great question. And I know I skipped through it before. When you mentioned expectations, I jumped into short-term. But you're exactly right. With long-term expectations, I make it very clear that being bone dry is certainly a goal that we all strive for but it's not something that can be specifically targeted. We don't do the operation any differently in a man that wants to be bone dry versus one that would be perfectly happy with one pad per day.

And so, I tell them that when that is the outcome, everybody is very, very pleased. I talk to them about the well-established outcomes-based research, and that 90% of men have substantial improvement in their incontinence, most of whom use one pad per day or less are happy that they did it, would do it again given the chance, and would recommend it to any friend or close loved one.

And so I think that that number really drives home the point with regards to patient reported outcome expectations without saying, "Hey, we're going to put the sphincter in and you're going to be dry." I tell them 9 out of 10 times you'd be very pleased with this. I say most guys like to have a security liner just because they're used to it. And if at some point in time you find that that's not needed down the road, then that's an added bonus. And I think this is the appropriate level of expectation management that men end up being very comfortable with.

[Aditya Bagrodia]
And is that going to be the same for a patient receiving a sling?

[Steve Hudak]
Sling is a little bit different. Okay. So again, it all comes down to patient selection. That's an all-comers number for men that undergo an artificial sphincter. For those that undergo a sling, it really depends on how severe their incontinence is. So if they're in that moderate three to four pads per day group, their success rate is lower. And the outcomes of artificial sphincter eclipse sling in this moderate leakage group, and there are a growing number of complications now that are supporting this. But a man that wears one pad per day is going to have better outcomes.

The boilerplate numbers that I share with patients for sling is if we look at a large group of well-selected sling patients, half of them will be dry. About 30% of them will be improved with a higher quality of life and higher activity level. And about 10 to 20% of them are going to be no different. And so all-comers, again, it gets close to that 90% - albeit with a greater proportion that we can and can’t say that they will be bone dry. But an important aspect of that counseling session is of those 10 to 20% that fail, so to speak, they're no worse. And their outcomes with subsequent sphincter are no different than had they never underwent a sling.

So given the less invasive aspects of a sling, I tell them that if they're on the fence, so to speak, other than the aspects of going through the surgery, there's very little to lose by attempting a sling. And there's a lot to gain if it's successful, given the fact that it's a passive continence outcome, it doesn't require any manipulation every time they urinate and its failure rate is far different. It's not a mechanical device so it's not going to erode, in fact, or break down.

[Aditya Bagrodia]
Got it. And I know that this is obviously going to be patient-specific, but if they do "fail" their sling, is your general strategy to put in a sphincter at that point?

[Steve Hudak]
It depends. You got to dig back into the history really to demonstrate the nature of a failure. And so, you'd certainly do that history exam, repeat the system, make sure there's nothing bizarre going on. Get a PVR and make sure there's no retention due to the sling, which in the short term is reasonably common and the long term is almost never seen.

But yeah, to oversimplify it, if it is just persistent stress incontinence after a sling that's bothersome for them, I personally would go back to proceed with an artificial sphincter. There are small reports of a repeat sling. But to me, it just doesn't make a lot of sense if one thing didn't work to do that same thing again. And so, yes, in that patient, I would proceed to a sphincter. And again, there's good data to suggest that placing a sphincter after a sling is no more difficult for the surgeon and the outcomes are no more different for the patient than an aversion scenario.

[Aditya Bagrodia]
Perfect. And you kind of mentioned lifespan as well as device function. For patient receiving sphincter, is there the clock starts at the time of placement?

[Steve Hudak]
Yeah, certainly. It's a mechanical device, obviously. So, the mechanical aspects of it can break down. The tubing can break. The pressure regulating balloon, which is just a thin-lined elastic silicone balloon, if you will, the tension in that balloon provides the pressure within the cuff, that can fatigue with time. And so, if you look at the data, the half-life of these devices is somewhere between 7 and 10 years. And so I think it's important for patients to know. So if it's a man in his mid-70s, there's a good possibility that this may be the only device that he ever needs. That being said, if it's a man in his 50s, I tell him that almost undoubtedly that to undergo a sphincter basically guarantees that he will have a series of operations over the remainder of his lifespan.

And again, speaks for borderline candidates, the potential importance of sling because it almost buys him more time on the clock, especially if it's successful. But yeah, it's usually early complications being worried about an infection, which is rare, urethral erosion, which will occur in somewhere between 2 to 10% of men, depending on their prior history. But if they make it through, not encountering those in the early post-operative period, they can expect somewhere around seven years before they even really have to worry about device failure.

(7) Navigating a Positive Preoperative Urine Culture

[Aditya Bagrodia]
Yeah, I think that's super valuable across the age spectrum and health spectrum. But certainly for younger patients, that may be considering some type of intervention. So you mentioned ev urinalysis, if that's positive, obviously, they would have a culture and have that treated. Is that your general practice?

[Steve Hudak]
That's a tough-y. It's pretty controversial. I mean, clearly, if patients have symptomatic cystitis this is a patient we would treat like anybody else. We're not going to operate on someone that has symptomatic cystitis. But what you commonly see in chronically wet men, likely due to the breakdown in their normal host defense mechanism which is a dry outlet, is they'll be chronically colonized. And so, this is controversial. If someone is asymptomatic, their UA shows no pyuria, and their preoperative culture shows 50,000 colony forming units of a single speciated pan-sensitive E. coli, the reflex thing that we see amongst our trainees is to give them two weeks of antibiotics leading up into their surgery. I'm not going to necessarily say that that's wrong, but you're not going to cure, at least immediately, the host defense problem that they have. And so in my experience, it's perfectly reasonable just to give them appropriate culture sensitive antibiotics around the time of their operation, and what this does is it treats the problem that they have perioperatively without modifying their bacterial milieu and then hopefully not breeding for resistant organisms. So that's my personal opinion. I've had great success with that. I think to study that is hard. We've looked at, nationwide, the practices among reconstructive urologists and found managing this problem is across the board. So there's clearly no consensus, ut I just would invite people to be thoughtful about their maneuvers there and not reflexive, particularly if it's an asymptomatic colonization without any pyuria.

[Aditya Bagrodia]
Okay. So, kind of a standard case, preoperative antibiotics, is there a go-to that you use for your reconstructive cases?

[Steve Hudak]
Yes. So for any prosthetic case, so an artificial sphincter or an IPP, if there's no allergies I'll do a gram of vancomycin and then 5 milligrams per kilogram, ideal body weight dosed, of gentamicin, just that single dose on the way into the OR. And if it's a sling, I'll just do Ancef.

[Aditya Bagrodia]
Okay. And you continue those postoperatively?

[Steve Hudak]
Nope, just a single dose. The modern prosthetics are coated with InhibiZone. So, that releases the minocycline and the rifampin locally into the tissues. And so, that treats two things - it treats the patient internally but it also treats the patient externally. Many times we talk about infection risks, they'll be like, "Doc, why don't you give me antibiotics?" And I said, "You're getting antibiotics internally." And so that I think is effective on both arms, so to speak.

(8) Critical Operative Steps to Minimize Complications

[Aditya Bagrodia]
Perfect. And just a little bit about some of your critical intraoperative considerations, there's going to be a whole host of patient-specific factors post-radiation, obesity. But maybe starting with sphincter, what's the crux of the matter as you're deciding what size goes in? Is it sizing of the cuff that's really going to drive the outcome here or potentially drive complications? Can you tell us a little bit about the most critical aspects of the case?

[Steve Hudak]
Yes. I think having good urethral exposure is important. I think, once upon a time, people would place artificial sphincters through a penoscrotal approach, and that's largely been abandoned. So I think getting the patient into a good lithotomy position, using a self-retaining retractor and really getting good exposure of that most proximal bulb right before it makes the turn toward the urogenital diaphragm, getting good exposure of that part of the urethra. Careful, sharp dissection circumferentially. Particularly dorsally, this can be hard to see, so having a good assistant, having good surgical lighting, I like to use loop magnification, I think it's an error to just shove a right angle back there and hope that it's in the right spot. So I like to do this under direct visualization. This is something that's easily taught. Most programs now have urologists that are doing higher volume urethroplasty, so it's really no different than that part of the exposure.

And then getting an adequate measurement of the circumference of that corpus spongiosum urethral complex. It's debatable whether you undersize, oversize, make them a bit tighter, a bit more loose, I like to just right size them. So get an accurate measurement of the circumference and then put a cuff around it that fits that size. If they measure, for example, 4.3 centimeters, I'll round up to 4.5 especially to the 4.5 size cuff as those come in only half centimeter sizes. Especially in radiated patients, I don't like to make it too tight. I think with that, you allow lower risks of erosion and lower risks of urinary retention.

So I think adequate exposure, precise measurement, and then accurate sizing based on that. Although there's some controversy, there are certainly those that want to make it a little bit tighter. But you have to anticipate the possibility of higher risks of retention and erosion, if you choose that approach.

[Aditya Bagrodia]
Okay. And how about for slings, if you could just, again, highlight where you think the battle is won with that operation?

[Steve Hudak]
Yeah, the most difficult part of this operation or the most, I guess, foreign part of this operation for those that don't do urethral surgery every day, is identification and dissection of the most proximal bulb and division of the central tendon, basically all the way down to the urogenital diaphragm. And so, for those that do urethroplasty a lot, this is no big deal. But for those that may be inexperienced with urethroplasty, this is a scary step because you're actually dissecting parallel between the corpus spongiosum and the rectum. And so, making your incision all the way down to the anal verge with appropriate draping of the anal area, good exposure, anterior retraction of the corpus spongiosum, posterior retraction of the bulbospongiosus muscle, and then just careful division of that urogenital or that central tendon all the way to the UGD, that's really the most difficult part of the dissection.

That needle passage or the trocar passage, if you will, is something that's really..the learning curve on that is just a couple of cases, probably shorter in those that are used to doing it. For female, transobturator slings, the redesign of the sling over the past several years is a larger circle on that helix making it easier to get around the descending ramus. So that's pretty straightforward. I think really, once you figure out and become comfortable with that posterior dissection of the central tendon..this is really a straightforward operation, something that I definitely would replace in the camp of a general urologist.

(9) Evaluation and Management of Common Complications

[Aditya Bagrodia]
Perfect. So you mentioned more, I guess, feared complications, infection and erosion where hardware has got to come out. Broad strokes, once you've done your device removal, about how long do you give things before you'd be comfortable with reestablishing the evaluation, repeating a cysto and potentially putting in another device?

[Steve Hudak]
Yeah. A quick word of mention about slings there. If you scope them at the time, the likelihood of having a sling erosion into the urethra is effectively nil. This has not even really ever really been reported in any substantial numbers. And the reason that I mentioned that is that due to the widespread visibility of the mesh problem amongst the female incontinence and prolapsed market, your patients will ask about this. They'll say I saw this commercial about sling use for incontinence, what's the deal? And so I think being mindful of the fact that the male urethra is different than the female urethra, the male genitalia is different than the female genitalia, and so as such, the performance of the male sling is different with regards to erosion and infection. And this is something that... sling explant is effectively almost really never needed.

With regards to artificial sphincter erosion and infection, I use the three-month cutoff. Sometimes this might be longer if the patient has a longer prolonged course - if they develop a fistula after a urethral erosion, and sphincter explant. So if they do well after that, the catheter is in for a few weeks, comes out, the VCUG shows the urethra is healed... I'll scope them at three months, and then if they're so motivated at that point in time, proceed with a salvage sphincter placement at that point.

[Aditya Bagrodia]
Yeah. And I mean, of course, we get into the less common scenarios, previously placed sling or sphincter post-radiation, fistula. And I think that's a little bit outside of the scope of what I'd wanted to touch base on today. But common troubleshooting, you've got a sphincter in, something doesn't quite seem like it went like you would have potentially imagined, what's your -- cysto or urinalysis or culture, maybe UDS if there's some component of mixed incontinence? But actually, in terms of interrogating the device and not committing to a full-blown comprehensive replacement, what are common things that you see that can oftentimes be managed a little less intensively?

[Steve Hudak]
Yeah. One thing is to make sure that they're just operating the system right. Sometimes they'll inadvertently deactivate the device and won't know it. And if they hadn't seen you in a while or seeing perhaps another urologist that may not be comfortable or familiar with the device, they may have never reactivated it correctly. So something simple of just interrogating the pump.

Something else that can be done easily in the office is standing them up doing a cough test, seeing if it's true stress leakage. Another thing is placing an ultrasound probe over the area of the pressure regulating balloon. If you have an abdominal probe, you can easily locate this. The cross sectional diameter of a full pressure regulating balloon should be about three and a half centimeters. So if you either can't locate it or just see kind of the hub, the echogenic hub but no hypoechoic fluid-filled balloon next to it, you know that there's a fluid leak somewhere. If you don't have the ultrasound equipment in your office, it's easy to do a non-contrast stone protocol, a CT scan of the pelvis to see if the device is empty.

And so that puts you into a couple of categories. If it's empty, then you know it's a leak. If it's full but they still have stress incontinence, then it may be a problem with the bladder or a problem with the coaptation at the level of a cuff, in which case more invasive evaluation - cystoscopy, sometimes urodynamics - will be needed at that point. But the combination of an exam, a cough test, and some imaging of the balloon can give a lot of information with very little effort.

(10) Advice to Trainees and the Future of the Field

[Aditya Bagrodia]
Really appreciate that, Steve. And a recurrent theme that's occurred to me over the course of our time together is that while this can be a straightforward procedure, I think you've really highlighted that there is a lot of nuance, there are a lot of patient-specific factors, incontinence-specific factors, perioperative considerations, post-operative things that can be done that really elevate this from an okay outcome to a perfect, or as close to perfect, outcome as we can hope for. And I certainly appreciate you walking us through this entire journey and how it goes in your practice. And I'd like to think that most of my patients never required this operation, none of us are immune and I can certainly say that my patients that have had procedures with Steve have been extremely, extremely pleased with the whole experience. So before we wrap up, Steve, any just thoughts, recommendations for trainees, urologists as they think about post-prostatectomy incontinence?

[Steve Hudak]
Yeah. I mean, I think, as trainees are learning about this or well-rounded general urologists or perhaps looking to get into this aspect of the field, I think this is well within the arm's reach of well-trained urologists, especially for the first time cases. As we get into more salvage cases or re-operative cases, those of us that do this frequently are happy to accept those patients, but really, this is something that is available to everybody. And there's a big problem in the field with men having this problem and not knowing that this option is available. So, there are a number of efforts to get visibility of this problem out to urologists, out to non-urologists ,and out to patients to realize that good options exist that can really dramatically improve the quality of life among patients.

And there's also innovation underway. The sling has been redesigned over the last several years. And even on the horizon, there's the eAUS that's in development that I expect will be present, I'm being told will be on the market within the next 5 to 10 years. So if we're counseling patients about an artificial sphincter in a man that's in his 50s, I am at the point of telling him that we're going to give this a go, we've got a good option available, but who knows, a decade from now when you get your revision, there's going to be new technology available that may allow you to really do some exciting things like modulating the pressure that allows you to crank up the control when you're out running and turn it down at night when you want your urethra to rest. And so, I mean, I think that there are exciting aspects of this field that are within arm's reach away which will kind of evolve and improve in the generations to come.

[Aditya Bagrodia]
Well, that's exciting. I think we see examples of this across urology. The AMS has obviously been the workhorse for a long, long time as it pertains to sphincters. And I think there's been some new technological advances as you described which, again, are probably not things we're going to get to be able to comprehensively run through. But it sounds like the slings are getting better there. We're getting more data. We're understanding what the limitations are and opportunities for improvement. Well, Steve, again, I really appreciate you sharing the wealth of knowledge. I certainly learned a lot and hope that our leadership does as well. So thank you, thank you, and thanks to our listenership.

[Steve Hudak]
Thanks a lot, Aditya. It was a pleasure to be with you.

Podcast Contributors

Dr. Steve Hudak discusses Evaluation & Management of Post-Prostatectomy Incontinence on the BackTable 11 Podcast

Dr. Steve Hudak

Dr. Steven Hudak is a practicing Urologist and an Associate Professor in the Department of Urology at UT Southwestern Medical Center.

Dr. Aditya Bagrodia discusses Evaluation & Management of Post-Prostatectomy Incontinence on the BackTable 11 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2021, July 14). Ep. 11 – Evaluation & Management of Post-Prostatectomy Incontinence [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Articles

Topics

Artifical Urinary Sphincter (AUS) Surgery Procedure Prep
Cystoscopy Procedure Prep
Pelvic Floor Therapy Procedure Prep
Post-Prostatectomy Incontinence Condition Overview
Prostatectomy Procedure Prep
Sling Surgery Procedure Prep