Correlation of abdominal leak point pressure with objective incontinence severity in men with post-radical prostatectomy stress incontinence

Assessment of the Impact of Pentafecta Parameters Affecting the Quality of Life of Patients Undergoing Laparoscopic Radical Prostatectomy

Prostate cancer is being detected in increasingly younger men. These patients expect to preserve their current quality of life and quickly recover after treatment. Medical technology and surgical techniques are advancing along with the growing expectations of patients. In addition, the universal method of assessing the quality of outcomes after operations is constantly being researched. As of today, biochemical remission alone, after radical prostatectomy, is insufficient for the patient. Therefore, multi-parametric evaluation methods are being developed, such as trifecta, which assesses biochemical remission, continence, and erectile function. The improvement over the trifecta is the pentafecta, which additionally evaluates postoperative complications and infiltration of surgical margins. Our study was conducted within a group of patients who were surgically treated for prostate cancer in 2017 at the Clinic of Urology and Urological Oncology of the Pomeranian Medical University. We recruited 237 men for the study. From that group, 131 men met the criteria to be included in the analysis. Maintaining continence (87.78%) is the easiest pentafecta parameter to obtain and will have the greatest impact on quality of life in the future. Maintaining biochemical remission (82.44%) is the second most important aspect for the patient. Retaining erectile function is the most difficult pentafecta parameter to obtain (29.01%) while having little impact on the quality of life. Negative surgical margins (66.41%) showed a negligible impact on the quality of life. The occurrence of complications (32.07%) has a negative impact on the quality of life of patients, but only during the treatment of complications.

Standing cough test stratification of moderate male stress urinary incontinence

PURPOSE

Patient-reported history of pads per day (PPD) is widely recognized as a fundamental element of decision-making for anti-incontinence procedures. We hypothesize that SUI severity is often underestimated among men with moderate SUI. We sought to compare patient history of incontinence severity versus objective in-office physical examination findings.

MATERIALS AND METHODS

We retrospectively reviewed our single-surgeon male SUI surgical database from 2007-2019. We excluded patients with incomplete preoperative or postoperative data and those who reported either mild or severe SUI, thus having more straightforward surgical counseling. For men reported to have moderate SUI, we determined the frequency of upgrading SUI severity by recording the results of an in-office standing cough test (SCT) using the Male Stress Incontinence Grading Scale (MSIGS). The correlation of MSIGS with sling success rate was calculated. Failure was defined as >1 PPD usage or need for additional incontinence procedure.

RESULTS

Among 233 patients with reported moderate SUI (2-3 PPD), 89 (38%) had MSIGS 3-4 on SCT, indicating severe SUI. Among patients with 2-3 PPD preoperatively, sling success rates were significantly higher for patients with MSIGS 0-2 (76/116, 64%) compared to MSIGS 3-4 (6/18, 33%) (p <0.01).

CONCLUSIONS

Many men with self-reported history of moderate SUI actually present severe SUI observed on SCT. The SCT is a useful tool to stratify moderate SUI patients to more accurately predict sling success.

Refined nomogram incorporating standing cough test improves prediction of male transobturator sling success

AIMS

To develop a decision aid in predicting sling success, incorporating the Male Stress Incontinence Grading Scale (MSIGS) into existing treatment algorithms.

METHODS

We reviewed men undergoing first-time transobturator sling for stress urinary incontinence (SUI) from 2007 to 2016 at our institution. Patient demographics, reported pads per day (PPD), and Standing Cough Test (SCT) results graded 0-4, according to MSIGS, were assessed. Treatment failure was defined as subsequent need for >1 PPD or further procedures. Parameters associated with failure were included in multivariable logistic models, compared by area under the receiver-operating characteristic curves. A nomogram was generated from the model with greatest AUC and internally validated.

RESULTS

Overall 203 men (median age 67 years, IQR 63-72) were evaluated with median follow-up of 45 months (IQR 11-75 months). A total of 185 men (91%) were status-post radical prostatectomy and 29 (14%) had pelvic radiation history. Median PPD and SCT grade were both two. Eighty men (39%) failed treatment (use of ≥1 PPD or subsequent anti-incontinence procedures) at a median of 9 months. History of radiation (P = 0.03), increasing MSIGS (P < 0.0001) and increasing preoperative PPD (P < 0.0001) were associated with failure on univariate analysis. In a multivariable model with AUC 0.81, MSIGS, and PPD remained associated (P = 0.002 and <0.0001 respectively, and radiation history P = 0.06), and was superior to models incorporating PPD and radiation alone (AUC 0.77, P = 0.02), PPD alone (AUC 0.76, P = 0.02), and a cutpoint of >2 PPD alone (AUC 0.71, P = 0.0001).

CONCLUSIONS

MSIGS adds prognostic value to PPD in assessing success of transobturator sling for treatment of SUI.

Management of Male and Female Neurogenic Stress Urinary Incontinence in Spinal Cord Injured (SCI) Patients Using Adjustable Continence Therapy

Introduction

Artificial urinary sphincter (AUS) is an option for the treatment of neurogenic stress urinary incontinence (nSUI), but complications and re-operation rates are high, and there is no clear indication from guidelines ( 1 ). The aim of our study is to evaluate the effectiveness of a less invasive continence device in neurogenic population: Adjustable Continence Therapy ProACT/ACT®.

Methods

We retrospectively includedpatients with spinal cord injuries in this study, complaining of nSUI and treated at our Institution with Pro-ACT/ACT® implantation. Diagnosis of nSUI was achieved with clinical history data collection and video-urodynamic testing.

Results

We treated 13 males and 3 females by proACT/ACT device, mean age 47.5 years (range 27-71). Fifteen implantations were performed bilaterally under spinal anesthesia and under fluoroscopic control; in one male patient, only the right balloon was implanted. Mean refilling number was 2.8 (range 0-6), and mean final volume was 3.6 ml. No patient reported any perioperative complications according to Clavien-Dindo. Follow-up was 37 months (range 7-156). Five patients (31%) underwent device explantation for deflate in one case, erosion or migration in three cases (18%), and infection in one case. About 43.75% of patients were dry and 18.75% improved more than 50% their urine loss, 37.5% of patients improved less than 50%, and no one reported worsening of incontinence.

Conclusions

Implantation of proACT/ACT® device is safe and a minimally invasive procedure also in neurological patients, with a relative low rate of intra and postoperative complications. Efficacy is good, although slightly lower than the results in non-neurological patients.

Artificial Urinary Sphincter: Report of the 2015 Consensus Conference

PURPOSE

The AMS800™ device, by far the most frequently implanted artificial urinary sphincter (AUS) worldwide, is considered to be the "gold-standard" when male incontinence surgical treatment is contemplated. Despite 40 years of experience, it is still a specialized procedure with a number of challenges. Here, we present the recommendations issued from the AUS Consensus Group, regarding indications, management, and follow-up AMS800™ implantation or revision.

MATERIALS AND METHODS

Under ICS auspices, an expert panel met on July 10, 2015 in Chicago, IL, USA in an attempt to reach a consensus on diverse issues related to the AMS800™ device. Participants were selected by the two co-chairs on the basis of their practice in a University hospital and their experience: number of implanted AUSs according to AMS (American Medical System Holdings Inc., Minnetonka, MN) records and/or major published articles. Topics listed were the result of a pre-meeting email brainstorming by all participants. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short evidence-based presentation, when possible.

RESULTS

A total of 25 urologists were invited to participate, 19 able to attend the conference. The present recommendations, based on the most recent and relevant data available in literature as well as expert opinions, successively address multiple specific and problematic issues associated with the AMS800™ trough a eight-chapter structure: pre-operative assessment, pre operative challenges, implantation technique, post-operative care, trouble-shooting, outcomes, special populations, and the future of AUSs.

CONCLUSION

These guidelines undoubtedly constitute a reference document, which will help urologists to carefully select patients and apply the most adapted management to implantation, follow-up and trouble-shooting of the AMS800™.

The artificial urinary sphincter and male sling for postprostatectomy incontinence: Which patient should get which procedure?

Surgery is the most efficacious treatment for postprostatectomy incontinence. The ideal surgical approach depends on a variety of patient factors including history of prior incontinence surgery or radiation treatment, bladder contractility, severity of leakage, and patient expectations. Most patients choose to avoid a mechanical device, opting for the male sling over the artificial urinary sphincter. The modern male sling has continued to evolve with respect to device design and surgical technique. Various types of slings address sphincteric incompetence via different mechanisms of action. The recommended surgery, however, must be individualized to the patient based on degree of incontinence, detrusor contractility, and urethral compliance. A thorough urodynamic evaluation is indicated for the majority of patients, and the recommendation for an artificial urinary sphincter, a transobturator sling, or a quadratic sling will depend on urodynamic findings and the patient's particular preference. As advancements in this field evolve, and our understanding of the pathophysiology of incontinence and mechanisms of various devices improves, we expect to see continued evolution in device design.

Surgery for postprostatectomy incontinence: which procedure for which patient?

Surgery remains the most effective treatment for postprostatectomy incontinence. Over the past two decades, this surgery has evolved with respect to both operative technique and sling design, and various devices are now available that have different mechanisms of action, such as the artificial urinary sphincter, retroluminal sling or quadratic sling. The choice of device, however, should be individualized according to the circumstances of each patient. The optimal surgical treatment depends on a variety of patient-related factors, including the degree of urine leakage as assessed by incontinence pad weight test results, bladder contractility, urethral compliance, history of radiation exposure or prior incontinence surgery, and patient preference--given the choice, most patients opt for a sling procedure over an artificial sphincter to avoid implantation of a mechanical device. Athorough urodynamic evaluation is, therefore, necessary for the majority of patients. An artificial urinary sphincter, retroluminal sling or quadratic sling might be the most appropriate choice for a particular patient, depending on their specific urodynamic findings. Progress in this field continues, and several new devices are in development.

Urodynamic evaluation before and immediately after robot-assisted radical prostatectomy

OBJECTIVE

To evaluate continence status and mechanism of urinary incontinence immediately after robot-assisted radical prostatectomy (RARP) by performing urodynamic evaluation.

METHODS

A total of 87 patients with localized prostate cancer who underwent RARP were included. Filling cystometry, urethral pressure profilometry, and abdominal leak point pressure (ALPP) tests were performed before and immediately after RARP.

RESULTS

The mean urine loss ratio (ULR), calculated by dividing the total urine volume by the weight of urine loss after RARP, was 17.8%. Nerve-sparing (NS) surgery significantly affected ULR compared with non-NS surgery. In the comparison between preoperative and postoperative results, the mean maximal cystometric capacity (MCC) and maximal closure urethral pressure (MUCP) decreased from 341 mL and 84.6 cm H2O to 250 mL and 35.6 cm H2O, respectively. No urine leakage was observed in ALPP test preoperatively; however, urine leakage was observed postoperatively in 75 patients (86%), with a mean ALPP of 47.7 cm H2O. Multivariate analysis revealed that MCC, MUCP, and ALPP after RARP were predictive factors for ULR. Linear correlations were found between ULR and MUCP and between ULR and ALPP after RARP. NS status and MUCP after RARP (r=0.247; P=.021) and the ALPP (r=0.254; P=.018) were significantly correlated.

CONCLUSION

In urodynamic evaluation immediately after RARP, MCC, MUCP, and ALPP were found to predictive factors for urinary incontinence. The NS procedure contributed to continence status after RARP.

Urodynamics for postprostatectomy incontinence: when are they helpful and how do we use them?

Urodynamics is indicated for the evaluation of postprostatectomy incontinence unless an artificial urinary sphincter placement is the preferred option, as in cases of severe incontinence, prior radiation, or previous male sling or artificial urinary sphincter placement--when male sling is unlikely to achieve efficacy. Urodynamics should be performed only when there is a question it can answer that would affect treatment choice or outcome. Urodynamic findings of detrusor underactivity, overactivity, and reduced compliance are important considerations in deciding how best to treat postprostatectomy incontinence.

Lack of association between the ICIQ-SF questionnaire and the urodynamic diagnosis in men with post radical prostatectomy incontinence

PURPOSE: To analyze the correlation between the "International Consultation on Incontinence Questionnaire-Short Form" (ICIQ-UISF) survey and the urodynamic findings in men with urinary incontinence (UI) following radical prostatectomy (RP). METHODS: 88 men who presented post-RP UI for a minimum of 1 year were enrolled prospectively. All answered the ICIQ-UISF survey and underwent urodynamic testing. Patients were divided in 3 Groups according to their urodynamic diagnosis: Group 1, patients with sphincteric incontinence (SI) alone; Group 2, patients with mixed UI (SI + Bladder Dysfunction (BD)); and Group 3, patients with BD alone. Data were analyzed using SPSS v16.0 software. RESULTS: There were 51 men in Group 1 (57.9%); 30 in Group 2 (34%); and 7 (7.9%) in Group 3. BD was found in 37/88 patients (42%), but it was the main cause of UI in only 14 patients (15.9%). There was no statistically significant difference among the mean ICIQ-UISFs values from groups 1, 2, or 3 (p>0.05). The symptoms of stress incontinence correlated with the urodynamic finding of SI (r = 0.59), and complaints of urinary urgency correlated with the presence of detrusor overactivity (DO) (r = 0.37), but these complaints did not predict the main cause of UI. CONCLUSION: The etiology of UI following RP cannot be predicted by the ICIQ-UISF survey. Symptoms of stress and urge incontinence predict the findings of SI and DO on urodynamic tests, but they cannot ascertain the main cause of UI. Urodynamic testing remains the gold standard to assess the etiology of post-RP UI.

The Male Perineal Sling: Assessment and Prediction of Outcome

PURPOSE

The male perineal sling has become an option for treating male stress incontinence. We evaluated its overall efficacy and determined preoperative parameters that could predict success.

MATERIALS AND METHODS

A total of 62 men with stress incontinence were prospectively evaluated and underwent a male perineal sling. Preoperatively 24-hour pad weight, urodynamics and a number of validated incontinence questionnaires were completed. At a minimum of 3 months of followup 24-hour pad weight and questionnaires were repeated. Success was assessed using the 1 question Patient Global Impression of Improvement. The Patient Global Impression of Improvement was compared to a number of other subjective and objective measures of outcome. Finally, preoperative parameters were evaluated to determine predictors of outcome.

RESULTS

As determined by the Patient Global Impression of Improvement, the success rate was 58%. The only preoperative factor predictive of success was 24-hour pad weight. An individual had a 71% chance of successful surgery if preoperative pad weight was less than 423 gm. There was a statistically significant difference between successes and failures in terms of postoperative pad weight and certain questionnaires, including the UCLA/RAND Prostate Cancer Index urinary function score, International Consultation on Incontinence short form, Incontinence Impact Questionnaire, Urogenital Distress Index and International Prostate Symptom Score. The overall complication rate was 21% and the reoperation rate was 14.5%.

CONCLUSIONS

The male perineal sling can be an effective surgical treatment for stress incontinence in the appropriate patient. The procedure is most successful in patients with lesser objective degrees of incontinence. The Patient Global Impression of Improvement is an effective tool for assessing outcome for this population.

Do Clinical or Urodynamic Parameters Predict Artificial Urinary Sphincter Outcome in Post-Radical Prostatectomy Incontinence?

OBJECTIVES

To determine whether urodynamic or clinical parameters can predict artificial urinary sphincter (AUS) outcome in patients who were incontinent after radical prostatectomy (RP). Incontinence after RP is secondary to intrinsic sphincter deficiency, but urodynamics have been advocated before AUS placement to detect factors that could limit surgical success.

METHODS

We reviewed all AUSs placed for RP incontinence from January 1995 to December 2004. The preoperative clinical parameters and urodynamic parameters were correlated with surgical success using linear and logistic regression analysis, respectively. Surgical failure was defined as requiring more than one pad per day.

RESULTS

The data from 86 patients (mean age 72 years) were analyzed. Of these 86 patients, 15 (17%) were wearing more than 1 pad per day at the last follow-up visit; 11 patients (13%) considered their operation a failure; and 20 patients (24%) had postoperative urgency. The presence of detrusor overactivity (P = 0.92), low first sensation (P = 0.52), low bladder compliance (P = 0.38), and bladder capacity less than 300 mL (P = 0.58) in patients did not predict for AUS failure compared with patients without these findings. No clinical parameters were found that demonstrated a statistical association with the number of pads per day. Older patients considered themselves less improved (P = 0.012) than did younger patients.

CONCLUSIONS

No evidence has shown that patients who are incontinent after RP who have detrusor overactivity, a low first sensation, decreased compliance, or a low bladder capacity have worse post-AUS outcomes than other patients. Older patients tended to have decreased perceived improvement. We found no clinical or urodynamic parameter that would be a contraindication to AUS placement for post-RP incontinence.

Comparison between reduction in 24-hour pad weight, International Consultation on Incontinence-Short Form (ICIQ-SF) score, International Prostate Symptom Score (IPSS), and Post-Operative Patient Global Impression of Improvement (PGI-I) score in patient evaluation after male perineal sling

AIMS

We assessed the utility of three self-assessment instruments: the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the post-operative Patient Global Impression of Improvement (PGI-I) score, and the International Prostate Symptom Score (IPSS) by correlating them with an objective outcome, the change in 24-hr pad weight, after a male perineal sling.

METHODS

Twenty-six men with urodynamically confirmed stress incontinence underwent a male perineal sling. Patients were evaluated pre-operatively and post-operatively with a 24-hr pad test, IPSS and ICIQ-SF. Patients also completed the PGI-I post-operatively. Changes in study parameters were compared via the paired t-test, and correlations were performed using Spearman's rho.

RESULTS

There were significant reductions in 24-hr pad weight (-274 g, P < 0.001), percentage 24-hr pad weight (54.2%), ICIQ-SF score (-6.3, P < 0.001), and the three ICIQ-SF subscores (-1.2, -1.7, -3.4 for Questions 3, 4, and 5, respectively, P < 0.001 for all). The change in total ICIQ-SF score and the post-operative PGI-I score correlated strongly with percentage reduction in 24-hr pad weight (r = -0.68, P < 0.001; r = -0.81, P < 0.001, respectively) and with each other (r = 0.79, P < 0.001). The change in all three ICIQ-SF subscores correlated significantly with percentage reduction in 24-hr pad weight and with post-operative PGI-I score. There was no significant change in the IPSS or the voiding or storage subscores, and none correlated with any other study parameter.

CONCLUSIONS

This study validates the construct validity of the ICIQ-SF and PGI-I in the assessment of treatment for male stress incontinence and should make clinicians confident in comparing studies of incontinence treatment utilizing the change ICIQ-SF score, the post-operative PGI-I score, and percentage reduction in 24-hr pad weight as outcome measures.

A urodynamics protocol to optimally assess men with post-prostatectomy incontinence

AIMS

To propose a urodynamic protocol to comprehensively assess all parameters of post prostatectomy incontinence (PPI).

METHODS

Sixty men with a history of PPI after radical prostatectomy prospectively underwent a standardized video urodynamics protocol. A 7F urethral catheter was used for standard cystometry, abdominal leak point pressure (ALPP), and pressure flow measurements. The International Continence Society nomogram classified obstruction and further classification of obstruction was based on fluoro voiding cystourethrography and non-invasive flow rates (free Qmax).

RESULTS

Twenty-four (40%) men had detrusor overactivity with 8 (13%) also having detrusor overactivity incontinence. Only one patient had impaired compliance. All men had urodynamic stress incontinence, but 21 (35%) men demonstrated it only after removal of the urethral catheter. For men leaking with and without the urethral catheter, the respective ALPP was significantly different, 86.3 and 67 cmH2O, respectively (P = 0.002). The men who leaked only in the absence of the urethral catheter had significantly higher ALPP measurements, P < 0.001. After reclassification using the fluoroscopic images of the bladder outlet and free Qmax, only 13.3% patients were obstructed.

CONCLUSIONS

The proposed urodynamic protocol allows for an optimal assessment of bladder and sphincter dysfunction and outlet obstruction in men with PPI.