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Management of Post-Prostatectomy Incontinence
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Hann-Chorng KuoTaiwan
Moderator
ACU Lecture: Videourodynamic Study for Precision Diagnosis and Management of Lower Urinary Tract DysfunctionVideourodynamic Study in the Precision Diagnosis and Management of Lower Urinary Tract Dysfunctions
Hann-Chorng Kuo, M.D.
Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
As a urologist, we are dealing with patients with lower urinary tract symptoms everyday. We did transurethral resection of the prostate (TURP) for elderly men with bothersome lower urinary tract symptoms (LUTS). We put a suburethral sling for women with stress urinary incontinence (SUI). We prescribed alpha-blocker for those who had difficulty in urination. We add antimuscarinics for patients with urgency urinary incontinence. Our seniors always told us these treatments are effective in treating patients with LUTS. However, patients still had LUTS after TURP, women still complained of urgency and dysuria after anti-incontinence surgery. Medication based on storage or emptying LUTS do not work all the time. Why? Because symptoms are not reliable, a large prostate does not indicate bladder outlet obstruction (BOO), and SUI is not solely a result of urethral incompetence. Therefore, in diagnosis and management of LUTS, we need precision medicine to direct an accurate pathophysiology of LUTS, and to guide an appropriate management based on the bladder and bladder outlet dysfunction. When we encounter patients who have LUTS refractory to the treatment based on our initial diagnosis, when we are treating patients who have complicated storage and emptying LUTS, when we are not sure patients could benefit from the invasive procedures for their LUTS, or patients who had both lower and upper urinary tract dysfunctions, videourodynamic study (VUDS) is an essential investigation for diagnosis and management of LUTS. In additional to benign prostate hyperplasia (BPH) and BOO, male patients with emptying LUTS might result from detrusor underactivity (DU), bladder neck dysfunction (BND), urethral sphincter dysfunction, or a hypersensitive bladder, which is not related with the prostate. Patients with BPH and LUTS might have latent neurogenic lesion, such as minor stroke, Parkinson's disease, or early dementia, causing LUTS. TURP without known the neurological disease might exacerbate LUTS after surgery. Mixed SUI comprises intrinsic sphincter deficiency (ISD) and detrusor overactivity (DO). The overactive bladder (OAB) symptoms may also result from an incompetent bladder outlet. Without comprehensive VUDS, we might cure the SUI, but OAB remains after placing a mid-urethral sling. Bladder pain is the cardinal symptoms of interstitial cystitis. However, bladder pain perceived by the patient might also originate from BOO or pelvic floor fascitis. VUDS can help in discrimination. DU and low compliant bladder and ISD could result in complicated storage and emptying LUTS. Large post-void residual (PVR) should alert us to investigate whether it is originated from low compliance or ISD. Dysfunctional voiding (DV) and BND in women with emptying LUTS. OAB symptoms are not always coming from the DO. BOO such as BND, DV, or urethral stricture might exist in men and women without voiding symptoms. Urinary difficulty in women is usually a result from low detrusor contractility, due to DU, or through inhibitory effect from a poorly relaxed pelvic floor or urethral sphincter. A simple bladder neck incision can effectively restore spontaneous voiding in men or women with dysuria due to DU or BND. However, a tight BN is necessary to predict a successful treatment outcome. Patients with central nervous system (CNS) disorders or spinal cord injury usually have complicated LUTD, including DO, BND, DV, detrusor sphincter dyssynergia (DSD), and vesicoureteral reflux (VUR). Management of LUTS in CNS disorders or SCI patients should know the current bladder and bladder outlet dysfunctions. Pediatric incontinence, children with myelomeningocele, DV, or recurrent urinary tract infection are complicated and need precision diagnosis before treatment. Especially when surgery is planned. Lower urinary tract dysfunctions is a dynamic condition. The bladder and bladder outlet dysfunction might change with time. Although VUDS is considered as an invasive investigation with radiation exposure, the advantages in accurate diagnosis and guiding management outweigh these disadvantages.
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Lewis ChanAustralia
Speaker
Imaging of Male Pelvic Floor Structure and the Natural Course of Pelvic Floor Remodeling after ProstatectomyLower urinary tract symptoms and incontinence are common issues in the ageing population. It is well recognised that radical prostatectomy can have significant impact on urinary continence and quality of life in men who have undergone surgery for prostate cancer. The causes of post prostatectomy incontinence can be multifactorial and urodynamic studies in men prior to prostatectomy have shown a high prevalence of bladder dysfunction. This presentation covers the role of dynamic ultrasound in studying the male pelvic floor and the changes observed following prostatectomy.
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Yen-Chuan OuTaiwan
Speaker
ARUS–PRUS Partnership Ceremony: A New Chapter in Asia Robotic Urology CollaborationDear colleagues and friends,
It’s a great honor to witness the signing of this partnership between the Asian Robotic Urology Society (ARUS) and the Philippines Robotic Urology Society (PRUS).
This marks the beginning of a new chapter in regional collaboration—one that emphasizes shared training, joint research, and mutual support to advance robotic urology across Asia. PRUS brings energy, expertise, and vision to this partnership, and ARUS is proud to walk alongside you as we work toward higher standards and better outcomes for our patients. Let us move forward together—with unity, purpose, and innovation.
Congratulations to both ARUS and PRUS!Aquablation Revolutionizing BPH Treatment: A New Era of Minimally Invasive Therapy-Tungs' Taichung Metroharbor Hospital ExperienceIntroduction
Aquablation is a waterjet ablation therapy for benign prostatic hyperplasia (BPH) that has gained significant attention. While its efficacy, durability, and safety have been established across various prostate sizes (30–150 mL), local data on its efficacy, safety, and learning curve in Taiwan remain limited. Our team have been performed 85 cases between March 2024 and July 2025. This lecture presents the learning curve observed in the first 50 patients who underwent Aquablation for BPH, highlighting its role in revolutionizing BPH treatment.
Materials and Methods
We conducted a retrospective review of 50 consecutive patients who underwent Aquablation between March 2024 and February 2025, dividing them into two groups: Group I (first 25 cases) and Group II (subsequent 25 cases). Assessments included IPSS, QoL, uroflowmetry parameters (voiding volume, Qmax, Qmean, PVR), operative time, hemoglobin drop, Clavien-Dindo grade ≥2 complications, hospital stay, and urethral catheter duration.
Results
Patients in Group II were younger and had smaller prostates. Aquablation was successfully performed in all cases. IPSS, QoL, voiding volume, Qmax, and Qmean improved significantly and were sustained for three months, while PVR improved only in Group I. Operative time was significantly shorter in Group II, and hemoglobin drop was greater in Group I. Complication rates, hospital stay, and catheter duration were similar between groups.
Conclusions
Aquablation provided significant and immediate improvements in voiding parameters and symptoms, with sustained PVR benefits in larger prostates. Surgeon proficiency improved after 25 cases. Overall, Aquablation proved safe and effective, even in an unselected patient population. Aquablation represents a promising advancement that could transform the therapeutic landscape for BPH—particularly if costs are reduced.Experience of 100 Consecutive Hugo Robotic Radical ProstatectomiesIntroduction and background:
Dr. Ou’ surgical team of Tungs’ Taichung MetroHarbor Hospital performed the first Hugo robotic radical prostatectomy on May 9, 2023. In 2023, we published the results of the first series of 12 Hugo robotic radical prostatectomies performed. In 2024, we published a comparison of 30 Hugo robotic radical prostatectomies and 30 Da Vinci robotic radical prostatectomies. Professor Ou is the Hugo robotic arm instructor recognized by Medtronic. Many Southeast Asian doctors come to this Hospital to observe the surgery and learn.
Material and Methods:
We prospectively collected data for retrospective analysis and statistics from May 9, 2023 to April 30, 2025, performing 100 consecutive Hugo robotic radical prostatectomies. We compared the surgical results of 1-50 cases (group 1) and 51-100 cases (group 2). The data analyzed included basic information, age, risk of anesthesia, BMI , prostate-specific antigen, clinical stage, and Gleason score grade. The two groups were compared in terms of surgical difficulty, receipt of neoadjuvant hormonal therapy, obesity, prostate volume >70 g, prostate protrusion more than 1 cm into the bladder neck, previous transurethral resection of prostate, history of abdominal surgery, extensive pelvic lymphadenectomy, salvage radical prostatectomy, and time from biopsy to radical prostatectomy less than 6 weeks. The two groups were compared in terms of robotic console time, blood loss, blood transfusion rate, and surgical complications. We compared the two groups in terms of postoperative pathological staging and grade, the proportion of tumor, and the proportion of urinary control at one month and three months.
Results:
The study showed that the age of patients in the second group was slightly higher, but the statistical p value was 0.058, which did not reach statistical difference. The second group of patients had significantly higher rates of stage III, stage IV, lymph node and bone oligometastasis, with a p value of 0.021. The rate of neoadjuvant hormonal therapy received by the second group was 16 percent, which was statistically significant compared with 2 percent of the first group (p = 0.021). The rates of other surgical difficulty factors were the same between the two groups. The average blood loss of patients in the second group was 156 CC, which was significantly less than the 208 CC in the first group. The operation time and surgical complications were comparable between the two groups. The cancer volume of the second group of patients was significantly reduced compared with that of the first group (3.30±2.93 versus 5.09±5.24, p value=0.049). The reason was that more patients in the second group received neoadjuvant hormonal therapy, which significantly reduced the cancer. Both groups of patients had very good urinary control after surgery.
Conclusion:
We conclude that Hugo robotic radical prostatectomy is an effective and feasible method with extremely low complications and good recovery of urinary control function after surgery. After the experience of the first 50 operations, the surgeon will choose patients with higher difficulty, especially those receiving neoadjuvant hormone therapy, to perform the operation.Total Solution of Maintenance of Urinary and Sex Function during Robotic Radical ProstatectomyBackground:
Robotic-assisted radical prostatectomy (RARP) has become a preferred surgical approach for localized prostate cancer due to its minimally invasive nature and precision. However, the preservation of urinary continence and sexual function remains a significant postoperative challenge. Traditional outcomes have focused heavily on oncological safety. Yet, contemporary perspectives emphasize a more holistic view—embodied in the concept of the “Pentafecta,” which includes continence, potency, negative surgical margins, biochemical recurrence-free survival, and absence of perioperative complications.
Objective:
This presentation introduces a comprehensive and integrative approach aimed at maximizing functional outcomes—particularly urinary continence and erectile function—through a modified pubovesical complex-sparing RARP under regional hypothermia, supplemented with real-time nerve imaging, neurovascular preservation strategies, and biological enhancement techniques.
Methods:
We present data and experience from Tungs’ Taichung MetroHarbor Hospital (TTMHH), including a series of 3780 robotic procedures performed between December 2005 and July 2025. Among these, 100 cases were completed using the Hugo™ RAS system and 21 with the da Vinci SP™ platform. Our modified technique builds upon Dr. Richard Gaston’s pubovesical complex-sparing method, with the addition of localized hypothermia (24°C), near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG), and application of dehydrated human amnion/chorion membrane (dHACM). In selected cases, nerve grafting with Axogen® technology was applied.
Results:
Initial results indicate a significantly improved early return of continence (95% by 16 weeks) and promising erectile function recovery, particularly in patients who received adjunctive therapies such as phosphodiesterase inhibitors or vacuum erection devices. The precision afforded by robotic technology enabled preservation of
prostate capsular arteries and accessory pudendal arteries. Localized hypothermia contributed to reduced tissue edema, minimized neural trauma, and improved nerve recovery. The use of ICG-NIRF allowed real-time identification of critical vascular landmarks, enhancing nerve-sparing accuracy. Preliminary analysis suggests our technique is both feasible and reproducible.
Conclusion:
The modified pubovesical complex-sparing RARP under hypothermia, augmented with vascular imaging and biologic materials, offers a promising paradigm for functional preservation in prostate cancer surgery. This total solution approach not only protects neurovascular integrity but also accelerates recovery of continence and potency.
Continued accumulation of clinical cases and controlled comparative studies are warranted to further validate the efficacy and long-term benefits of these techniques.
Significance:
This strategy reflects a patient-centered evolution in robotic prostate surgery, merging surgical innovation with anatomical preservation and technological augmentation. It represents an epic collaboration of surgical precision, team-based care, and thoughtful application of biomedical advances to improve quality of life outcomes in prostate
cancer patients.Total Solution of Maintenance of Urinary and Sex Function during Robotic Radical Prostatectomy
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Chung-Cheng WangTaiwan
Speaker
Ureteral Stent and SelectionUreteral stents are widely used in urology for the management of obstructive uropathies, including urologic or non-urologic malignancy, radiation therapy, ureteral calculus, infection, surgical or nonsurgical trauma, or congenital factors. An untreated ureteral obstruction could result in urinary tract infection, abdominal or flank pain, and a deterioration of renal function. Despite their widespread utility, the selection of an appropriate ureteral stent remains a complex clinical decision involving multiple variables including patient-specific factors, disease pathology, duration of stenting, and the desired balance between drainage efficacy and patient comfort.
Advancements in stent technology have led to the development of a variety of stent types, distinguished by their material composition (e.g., polyurethane, silicone, and hydrophilic-coated polymers), design features (e.g., double-J, multi-length, tail stents), drug-eluting capabilities, reinforced metallic stent, and biodegradable stents. Each design aims to optimize certain aspects of performance such as resistance to encrustation, migration, infection, and stent-related symptoms.
Key considerations in stent selection include indwelling time, risk of infection or encrustation, patient anatomy, and comorbidities or prior urologic surgery. For short-term use, polyurethane or co-polymer stents are often preferred due to their balance of flexibility and cost-effectiveness. In contrast, silicone stents may be more appropriate for long-term indwelling due to their superior biocompatibility and reduced encrustation rates. Drug-eluting stents are emerging as promising options in cases of recurrent infection or tumor-associated obstruction. Softer materials, tapered tips, and biodegradable stents aim to reduce stent-related lower urinary tract symptoms.
Recently, we reported the efficacy and safety of Allium metallic ureteral stents in treating 13 patients with refractory ureteral strictures. The median (IQR) age of the patients was 63 (46–76) years. The median (IQR) follow-up was 15 (13.5–21) months. Treatment success and improvement were noted in 9 (69.2%) and 3 (23.1%) patients, respectively. Compared to the preoperative levels, the median (IQR) serum creatinine levels were significantly improved at 3 months after the operation [1.6 (1.25–2.85) vs. 1.2 (1.05–2.05), p = 0.02] and at the last visit [1.6 (1.25–2.85) vs. 1.2 (1.05–1.8), p = 0.02]. Stent migration and encrustation were noted in three (23.1%) and one (7.7%) patients, respectively. The preliminary results showed that Allium ureteral stents were safe and effective for patients with refractory ureteral strictures.
In conclusion, as technology continues to evolve, the future of ureteral stenting lies in personalized device selection based on real-time patient feedback, predictive analytics, and enhanced biomaterials. Further clinical trials and comparative studies are essential to establish evidence-based guidelines that can assist clinicians in making the most appropriate stent choices for optimal outcomes
Fixed and Adjustable Male Slings: Key Techniques for Primary Implantation and Troubleshooting in Challenging CasesMale slings have emerged as an effective surgical solution for stress urinary incontinence (SUI) following radical prostatectomy, offering an alternative to artificial urinary sphincters, particularly in patients with mild to moderate incontinence. Among the available options, fixed and adjustable male slings represent two major categories, each with distinct mechanisms of action, implantation techniques, and postoperative management considerations.
Fixed male slings work by repositioning and compressing the bulbar urethra against the pubic ramus to restore continence. These slings rely on proper patient selection—typically individuals with preserved sphincter function, low-volume leakage, and no prior pelvic radiation. Key technical considerations include precise dissection of the perineal space, adequate urethral mobilization, tension-free sling placement, and symmetric anchoring of the arms. Avoidance of over-tensioning is crucial to prevent postoperative urinary retention and perineal discomfort.
Adjustable male slings offer intraoperative or postoperative modification of sling tension to accommodate varying degrees of incontinence or suboptimal initial outcomes. These slings are particularly useful in patients with higher degrees of incontinence, previous pelvic surgery, or radiation. The implantation techniques vary but generally involve positioning a cushion or compressive element under the urethra, with external or subcutaneous access ports for saline adjustment. Mastery of device calibration, port placement, and infection prevention are critical to long-term success.
Challenging cases—such as those involving prior sling failure, prior pelvic radiation, fibrosis, or altered anatomy—require tailored strategies. In irradiated patients, tissue integrity and healing potential are compromised, often necessitating the use of adjustable systems with minimal tissue dissection or the combination of sling and bulking agents. In reoperative fields, precise identification of tissue planes and modified dissection techniques are required to prevent urethral injury or inadequate compression. Troubleshooting sling failure involves assessing continence status, sling positioning via imaging or endoscopy, and determining whether revision, adjustment, or conversion to an artificial urinary sphincter is most appropriate.
Postoperative complications including infection, urethral erosion, urinary retention, and persistent incontinence can be mitigated by proper surgical technique, patient education, and regular follow-up. Management of these complications should be proactive and individualized, balancing intervention timing with patient expectations and functional goals. In this topic, we will share our experiences to avoid these complications and increase the successful outcome.
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TICC - 2F 201DE
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