The Artificial Urinary Sphincter After a Quarter of a Century: A Critical Systematic Review of Its Use in Male Non-neurogenic Incontinence

Noninvasive Urinary Incontinence Control Device

Urinary incontinence (UI) is affecting a large number of men and women around the world and it lowers the quality of life dramatically. A large number of treatments have been introduced, but they require invasive surgeries associated with infections and loss of privacy. In this paper, a novel device is introduced which is designed for permanent or temporary treatment of incontinence in men and women, providing more convenience and control. This design provides a urethral stent having a magnetically controlled valve for patients suffering from incontinence due to diseases like bladder sphincter dyssynergia and neurogenic bladder. The new device provides an effective way for controlling the urination time and voiding the bladder, with a simple design, easy to insert, remove, and operate. In this paper, first a review on the urinary system diseases causing incontinence is presented, and then treatment options, indications for their use, and relevant clinical observation are discussed. Finally, the new device is introduced and its characteristics and applications are addressed.

Incontinence after radical prostatectomy: Anything new in its management?

INTRODUCTION

With the increasing number of radical prostatectomies (RP) performed, male stress urinary incontinence (SUI) has become common. The artificial urinary sphincter (AUS) is the gold standard to treat SUI post-RP, but new devices have recently been developed. We review the recent studies on the treatment of SUI post-RP; we also describe the surgical techniques, mechanisms of action and results of these new procedures.

METHODS

We conducted a literature review search in the PubMed/Medline and Embase databases. Our search was restricted to recent articles. We included studies even if the urinary incontinence was due to sphincter deficiency after RP in non-neurologic patients.

RESULTS

We found 8 cohort studies for the surgical procedure: 3 studies concerning slings, 1 involving balloons adjustable implant, and 4 involving new devices. The only randomized controlled trial (RCT) was a pharmacologic clinical trial comparing duloxetine to placebo. The social continence rates were analyzed for 6 studies and were up to 66%.

CONCLUSION

New minimally invasive surgical procedures have emerged as the main alternative to AUS, with social continence rates up to 60% despite just 1 RCT studying the pharmacologic approach. There is an urgent need for well-designed clinical trials to clarify the role of new surgical alternatives in the management of SUI post-RP. New technologies should continue to be evaluated and compared with the AUS, which remains the gold standard.

A state-of-the-art review on the evolution of urinary sphincter devices for the treatment of post-prostatectomy urinary incontinence: past, present and future innovations

An artificial urinary sphincter (AUS) is the only mechanical device that closely simulates the function of a biological urinary sphincter. Over the past four decades, advances in mechanical design, applications of new technology and lessons learned from clinical experience have made AMS 800 device the standard of care in post-prostatectomy urinary incontinence. While the current AMS 800 device provides an effective, safe and durable option, it is not without its limitations and complications. Newer and innovative AUS-like devices are designed to rectify some of AMS 800 device problems, but, like any mechanical device, they too have their own shortcomings. Emerging novel therapies such as nanotechnology-driven device and stem cell therapy are attractive, but are not commercially available or have no proven long-term outcome. The following article provides a critical review on the past, present and future innovations in designing the ideal urinary sphincter to treat post-prostatectomy urinary incontinence.

Transcorporal artificial urinary sphincter implantation as a salvage surgical procedure for challenging cases of male stress urinary incontinence: surgical technique and functional outcomes in a contemporary series

OBJECTIVES

To describe the surgical technique of transcorporal artificial urinary sphincter (AUS) implantation. To assess the efficacy of the AUS on continence and erectile function.

PATIENTS AND METHODS

A prospective evaluation was conducted between December 2007 and October 2012 at a tertiary referral centre of all male patients treated by transcorporal AUS (AMS800™, AmericanMedicalSystems, Minnetonka, MN, USA) implantation for stress urinary incontinence (SUI) recurrence, after failure of previous anti-incontinence surgery. Functional urinary outcomes were assessed according to daily pad use, the Urinary Symptom Profile questionnaire, and International Consultation on Incontinence Questionnaire - Short-Form. Erectile function was evaluated using the five-item International Index of Erectile Function (IIEF-5) questionnaire and patient satisfaction was assessed by Patient Global Impression of Improvement questionnaire. Data were collected by telephone interview.

RESULTS

A total of 23 patients were included. Their mean (sd; range) age was 70 (7; 60-85) years. Of these, 18 patients had urethral atrophy and/or erosion after placement of AUS (11 patients), male sling (four patients) or both (three patients), and five patients had severe urethral atrophy after pelvic radiation therapy. The implantation of the AUS with transcorporal cuff placement was successful in all patients, with no peri-operative complications. Follow-up data over 1 year were available for 17 patients. After a median (sd; range) follow-up of 20 (15; 2-59) months, eight patients were perfectly dry (no pad use and no symptoms), five achieved social continence (less than one pad/day), and four still had SUI (required two or more pads/day). Among six patients who had good preoperative erectile function and were sexually active, four had no decrease in their IIEF-5 score.

CONCLUSIONS

Transcorporal AUS cuff placement is a useful alternative for challenging cases of male SUI after failure of previous surgical treatment, urethral atrophy or erosion. Erectile function can be maintained despite dissection of the corporal body.

The two-year outcome of the I-Stop TOMS™ transobturator sling in the treatment of male stress urinary incontinence in a single centre and prediction of outcome

PURPOSE

The aim of this study was to present the results of the 2 year outcome of I-Stop TOMS™ transobturator sling for post-prostatectomy (UIPP) minor to moderate male urinary incontinence treatment.

MATERIALS AND METHODS

A prospective, single center study, including 26 patients with minor to moderate IUPP and operated on using a suburethral sling (MS) TOMS™ (four arms) was performed. UIPP assessment was made preoperatively and 1 year postoperatively, using validated questionnaires (SF36 and ICIQ), number of pads daily, and the 24 hours Pad-test (LPT). Telephone follow-up evaluation was performed in 21 patients over a 2 years period following surgery.

RESULTS

Radical prostatectomy was performed 48.4 months earlier and average patient age was 67.3 years. Preoperatively, the mean number of pads used daily was 2.3 with an average weight loss of 207.1grams at LPT. At 1 year, ICIQ and SF36 scores significantly improved. Weight loss in the LPT as well as the number of pads significantly decreased (P<0.05). At 1 year, 13 patients were cured, 12 were improved, one reached improvement criteria, and 96.2% using a pad daily maximum. With more than a 2 year follow-up, 10/21 patients were dry, nine improved and two failed, and 90.5% using 0 to 1 pad per day.

CONCLUSIONS

The transobturator TOMS™ male sling is a simple and well-tolerated procedure permitting a significant improvement of UIPP, with 50% of patients achieving complete continence at 1 year postoperatively, these good results continued beyond 2 years.

LEVEL OF EVIDENCE

4.