The AdVance male sling as a minimally invasive treatment for intrinsic sphincter deficiency in patients with neurogenic bladder sphincter dysfunction: a pilot study

Current Surgical Treatment for Neurogenic Lower Urinary Tract Dysfunction in Patients with Chronic Spinal Cord Injury

This study aimed to present a comprehensive literature review of the efforts of a spinal cord injury workgroup in Taiwan regarding urologic surgery for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI). Surgical procedures should be viewed as a final option for managing patients with SCI who have persistent symptoms and complications that cannot be resolved by other means. Surgeries can be grouped according to their purpose: reducing bladder pressures, reducing urethra resistance, increasing urethra resistance, and urinary diversion. The choice of surgery depends on the type of LUTD based on urodynamic tests. Additionally, cognitive function, hand motility, comorbidities, efficacy of surgery, and related complications should be considered.

Efficacy and Safety of Surgical Treatments for Neurogenic Stress Urinary Incontinence in Adults: A Systematic Review

CONTEXT

Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI).

OBJECTIVE

To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management.

EVIDENCE ACQUISITION

A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

EVIDENCE SYNTHESIS

A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively.

CONCLUSIONS

The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques.

PATIENT SUMMARY

Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence.

First experience with ATOMS system implant in neurogenic stress urinary incontinence

AIM

To evaluate efficacy and safety of ATOMS implant in neurogenic patients with stress incontinence performing clean intermittent catheterization (CIC).

METHODS

We included all patients with neurogenic sacral/subsacral lesion and stress urinary incontinence, treated with ATOMS implant between January 2018 and March 2019. All patients received anamnesis, 24-hour pad test and pad count, physical examination, video urodynamic evaluation, Qualiveen questionnaire. All patients were followed up at 12 months after implantation. Patients were considered "continent" when dry or when wearing a security pad (social continence).

RESULTS

We treated eight male patients with a median age of 25 years, four affected by myelomeningocele, and four by cauda equine syndrome. The median preoperative 24-hour pad test was 225 g (interquartile range [IQR]: 180-275). During the surgical procedure, we did not fill the cushion to prevent postoperative urethral injuries when performing CIC in the early postoperative time. At a 12-month follow-up, we had a significant reduction in postoperative 24-hour pad test (median value: 7.5 g; IQR: 0-16.25; P < .05). All patients reached continence. We had a significant reduction in the Qualiveen scores (P < .05). Patients demonstrated to be satisfied with the results of the intervention at the PGI-I questionnaire. The only complications were four cases of temporary scrotal edema (Clavien-Dindo 1) treated with conservative therapy. All patients resumed CIC without urethral traumatism nor catheter insertion difficulties. We had no cases of device infection nor device removal.

CONCLUSIONS

Implantation of ATOMS device seems to be an effective and safe minimally invasive procedure also in neurological patients with a low rate of postoperative complications.

A comparison of the treatment recommendations for neurogenic lower urinary tract dysfunction in the national institute for health and care excellence, European Association of Urology and international consultations on incontinence guidelines

AIMS

Healthcare guidelines are an important vehicle in establishing up-to-date evidence based medicine (EBM) in clinical practice. Due to varying development processes, clinical guidelines created by different institutions can often contain contrasting recommendations. This can have implications for optimal and standardized patient care across management settings.

METHODS

The similarities and differences of treatment recommendations made in the National Institute for Health and Care Excellence (NICE), The European Association of Urology (EAU), and the International Consultation on Continence (ICI) guidelines for neurogenic lower urinary tract dysfunction (NLUTD) were assessed.

RESULTS

The guidelines generally agree on their approach to conservative management, including behavioral therapies, and catheterization techniques. There was discrepancy on the benefit of using an alpha blocker in NLUTD and bladder outlet obstruction (BOO) and administering Botulinum toxin A (Onabotulinum-A) in NLUTD. The highest degree of divergence was seen in recommendations for surgical treatments, where the EAU made gender-specific recommendations, and gave continent urinary diversion higher preference than given in the NICE and ICI guidelines.

CONCLUSIONS

In the absence of high-quality clinical evidence, many of the recommendations made across all three guidelines are based on expert opinion. NICE, the EAU and ICI have similarities but they place differing emphasis on costs and expert opinion, which translated in notably different recommendations. It is evident that increased research efforts, possibly in the form of prospective registries, pragmatic trials, and resource utilization studies are necessary to improve the underlying evidence base for NLUTD, and subsequently the strength and concordance of recommendations across guidelines.

[Male neurogenic stress urinary incontinence treated by artificial urinary sphincter AMS 800™ (Boston Scientific, Boston, USA): Very long-term results (>25 years)]

OBJECTIVE

The aim of the study was to report the very long-term functional outcomes of artificial urinary sphincter (AUS) in male neurological patients.

MATERIAL AND METHODS

Male neurological patients diagnosed with stress urinary incontinence due to sphincter deficiency and undergoing AUS (AMS 800^®) implantation between 1985 and 1992 were enrolled. Continence, defined by no pad/condom usage, explantation and revision rates were reported.

RESULTS

Fourteen patients with a median age of 27.3 years (IQR: 27.3-40.8) were included: four had a spinal cord injury and ten a spina bifida. Prior continence surgery was reported by 6 patients (42.9 %). Artificial urinary sphincter was implanted in a peribulbar (n=4) or periprostatic position (n=10). Median follow-up was 18.3 years (IQR: 10.1-20.3). At last follow-up, all patients were alive. Three native devices were still in place, eight were revised (four of them were secondarily explanted) and three were explanted due to erosion or infection. The 5-, 10-, 15-, 20-year explantation-free survival rates were respectively 85.7, 62.3, 52.0, 39.0 %. The 5-, 10-, 15-, 20-year revision-free survival rates were respectively 78.6, 42.9, 28.6, 7.1 %. At last follow-up, 50 % patients were continent.

CONCLUSION

In the very long run, AUS provided a 50 % continence rate in male neurological patients but the revision rates were important.

LEVEL OF EVIDENCE

4.

Heterogeneity in reporting on urinary outcome and cure after surgical interventions for stress urinary incontinence in adult neuro-urological patients: A systematic review

AIMS

To describe all outcome parameters and definitions of cure used to report on outcome of surgical interventions for stress urinary incontinence (SUI) in neuro-urological (NU) patients.

METHODS

This systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study protocol was registered and published (CRD42016033303; http://www.crd.york.ac.uk/PROSPERO). Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov were systematically searched for relevant publications until February 2017.

RESULTS

A total of 3168 abstracts were screened. Seventeen studies reporting on SUI surgeries in NU patients were included. Sixteen different outcome parameters and nine definitions of cure were used. Six studies reported on objective outcome parameters mainly derived from urodynamic investigations. All studies reported on one or more subjective outcome parameters. Patient-reported pad use (reported during interview) was the most commonly used outcome parameter. Only three of 17 studies used standardized questionnaires (two on impact of incontinence and one on quality of life). Overall, a high risk of bias was found.

CONCLUSIONS

We found a considerable heterogeneity in outcome parameters and definitions of cure used to report on outcome of surgical interventions for SUI in NU patients. The results of this systematic review may begin the dialogue to a future consensus on this topic. Standardization of outcome parameters and definitions of cure would enable researchers and clinicians to consistently compare outcomes of different studies and therapies.

AdVance male sling

The AdVance sling (American Medical Systems, Minnetonka, MN, United States of America) is a synthetic transobturator sling, which is a safe and effective minimally invasive treatment for mild to moderate stress urinary incontinence (SUI) in male patients. This article provides a step-by-step description of our technique for placement of the AdVance male sling, including details and nuances gained from surgical experience, advice for avoidance of complications and discussion on management of complications and sling failures. Patient selection is very important, including exclusion and preoperative treatment of urethral stenosis and bladder dysfunction. Previous pelvic radiation is a poor prognostic factor. In brief, the steps of sling placement are: (I) mobilization of the corpus spongiosum (CS); (II) marking and mobilization of the central tendon; (III) passage of the helical trocar needles exiting at the apex of the angle between the CS and inferior pubic ramus; (IV) fixation of the broad part of the sling body to the CS at the previous mark; (V) cystoscopy during sling tensioning; (VI) placement of a Foley urethral catheter; (VII) Subcutaneous tunnelling of the sling arms back toward the midline; (VIII) wound closure. The most common early postoperative complication is urinary retention but long-term retention is extremely rare. Management of sling failures include placement of an artificial urinary sphincter, repeat AdVance sling, urethral bulking agent or ProACT device.

Treatment of stress urinary incontinence in men with spinal cord injury: minimally invasive=minimally effective?

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To assess the outcome of minimally invasive treatment of stress urinary incontinence with alloplastic slings in patients with neurogenic lower urinary tract dysfunction.

SETTING

Switzerland.

METHODS

The patient database of a tertiary urologic referral center was screened for male patients with SCI who underwent implantation of a suburethral sling between June 2009 and December 2015. Patient characteristics and bladder management details were collected by chart review.

RESULTS

Sixteen patients were identified. Of those, 13 received a transobturator tape (TOT) and three underwent implantation of an retropubic adjustable system (RAS). In the TOT group, nine patients became continent, one patient was improved and three patients remained unchanged. Three patients underwent minor revisions due to impaired wound healing. In the RAS group, no patient improved and one RAS had to be removed due to severe wound infection; in a second patient, an abscess with destruction of the urethra occurred.

CONCLUSIONS

In our experience, alloplastic slings seem to be an effective minimally invasive treatment option in male patients with SUI due to SCI. TOT seem to be more effective than RAS and was associated with less severe complications. The selection criteria for the optimal patient and the optimal sling have to be further defined.

Managing adult urinary incontinence from the congenitally incompetent bladder outlet

PURPOSE OF REVIEW

Treatment of urinary incontinence in adult patients with congenital incompetent bladder outlet (exstrophy-epispadias complex, cloacal anomalies, or neurogenic bladder secondary to myelomeningocele) is a challenging surgical problem. In this review article, we summarize and highlight recent studies in the management of incontinence in this patient population.

RECENT FINDINGS

The literature regarding management of urinary incontinence in this patient population is scarce. Injection of bulking agents to the bladder neck, artificial/autologous slings, artificial urinary sphincters, bladder neck reconstruction, bladder neck closure, or a combination of these are the cornerstone of management. Augmentation cystoplasty is a major adjunct procedure that can help increase continence rate and success of surgery in select patients. The level of evidence on bladder neck procedures for this patient population is low because of significant limitations, including small sample, heterogeneity of primary diagnosis/surgical techniques, variable definitions of continence, and the retrospective nature of most studies in this field.

SUMMARY

Standard options for treatment of urinary incontinence in the congenitally incompetent bladder outlet procedure remain unchanged. There is no single reproducible procedure to accomplish the goal of renal preservation and continence in these patients, and often patients require multiple procedures to achieve continence. Most importantly, the pediatric and adult urologist should continue to work toward achieving a well tolerated and efficient transition of care. There is a need to standardize data acquisition and reporting of outcomes. Although randomized control studies would be ideal, because of the small number of patients with these conditions, this may not be practical. Collaboration and continued discussion among experts in the field is needed to gain a better understanding of the optimal management strategy in this growing patient population.

Management options for sphincteric deficiency in adults with neurogenic bladder

Neurogenic bladder is a very broad disease definition that encompasses varied disease and injury states affecting the bladder. The majority of patients with neurogenic bladder dysfunction do not have concomitant intrinsic sphincteric deficiency (ISD), but when this occurs the challenges of management of urinary incontinence from neurogenic bladder are compounded. There are no guidelines for surgical correction of ISD in adults and most of the literature on treatment of the problem comes from treatment of children with congenital diseases, such as myelomeningocele. Our goal, in this review, is to present some of the common surgical options for ISD [including artificial urinary sphincters, bladder slings, bladder neck reconstruction (BNR) and urethral bulking agents] and the evidence underlying these treatments in adults with neurogenic bladder.

Surgical treatment of neurogenic stress urinary incontinence: A systematic review of quality assessment and surgical outcomes

BACKGROUND

There are many opinions but little firm knowledge about the optimal treatment of neurogenic stress urinary incontinence (NSUI).

OBJECTIVE

To scrutinize the quality and surgical outcomes of the available treatment modalities in the published literature.

EVIDENCE ACQUISITION

A systematic review of the published literature from Pub Med and Web of Science was undertaken for studies describing surgical treatment of NSUI between 1990 and 2013. A checklist of criteria of methodological and reporting quality of interventions in urological publications was applied to assess quality of the retrieved publications. Surgical outcomes of success, failure, and reoperation were calculated. Statistical analyses included one-way ANOVA and post-hoc tests to determine significant differences between groups.

EVIDENCE SYNTHESIS

Thirty studies were identified with Level 3 evidence. The quality of reporting was 43-81%, with significantly higher quality noted in studies published after 2002 (64% vs. 45%, P < 0.0001). None of the studies followed a randomized controlled trial (RCT) design. Three primary surgical procedures were used in 29 of 30 studies: artificial urinary sphincter (AUS), urethral slings, and urethral bulking agents. One study used a ProACT device. AUS was considered more successful than urethral bulking agents (77 ± 15% vs. 27 ± 20%, P = 0.002). Urethral bulking agents reported higher failures than urethral sling procedures (49 ± 16% vs. 21 ± 19%, P = 0.016) and AUS (21 ± 19% vs. 10 ± 11%, P < 0.002).

CONCLUSIONS

The quality of evidence obtained from non-RCTs is modest. Surgeries for NSUI have relatively high success rates but also high complication rates in this highly heterogeneous population. More studies using modern techniques are required to update our knowledge.