Do early injections of bulking agents following radical prostatectomy improve early continence?

A national study of artificial urinary sphincter and male sling implantation after radical prostatectomy in England

OBJECTIVES

To consider the provision of post-radical prostatectomy (RP) continence surgery in England.

MATERIALS AND METHODS

Patients with an Office of Population Census and Surveys Classification of Interventions and Procedures, version 4 code for an artificial urinary sphincter (AUS) or male sling between 1 January 2010 and 31 March 2018 were searched for within the Hospital Episode Statistics (HES) dataset. Those without previous RP were excluded. Multivariable logistic regressions for repeat AUS and sling procedures were built in stata. Further descriptive analysis of provision of procedures was performed.

RESULTS

A total of 1414 patients had received index AUS, 10.3% of whom had undergone prior radiotherapy; their median follow-up was 3.55 years. The sling cohort contained 816 patients; 6.7% of these had received prior radiotherapy and the median follow-up was 3.23 years. Whilst the number of AUS devices implanted had increased each year, male slings peaked in 2014/2015. AUS redo/removal was performed in 11.2% of patients. Patients in low-volume centres were more likely to require redo/removal (odds ratio [OR] 2.23 95% confidence interval [CI] 1.02-4.86; P = 0.045). A total of 12.0% patients with a sling progressed to AUS implantation and 1.3% had a second sling. Patients with previous radiotherapy were more likely to require a second operation (OR 2.03 95% CI 1.01-4.06; P = 0.046). Emergency re-admissions within 30 days of index operation were 3.9% and 3.6% fewer in high-volume centres, for AUS and slings respectively. The median time to initial continence surgery from RP was 2.8 years. Increased time from RP conferred no reduced risk of redo surgery for either procedure.

CONCLUSION

There is a volume effect for outcomes of AUS procedures, suggesting that they should only be performed in high-volume centres. Given the known impact of incontinence on quality of life, patients should be referred sooner for post-prostatectomy continence surgery.

Surgical treatment of post-prostatectomy stress urinary incontinence in adult men: Report from the 6th International Consultation on Incontinence

AIMS

To report the recommendations of the 6th International Consultation on Incontinence (ICI) on post-prostatectomy urinary incontinence.

METHODS

The 6th ICI committee on surgical treatment of urinary incontinence in men assessed and reviewed the outcomes of surgical therapy and updated the prior recommendations published in 2013. Articles from peer-reviewed journals, abstracts from scientific meetings, and literature searches by hand and electronically formed the basis of this review. The resulting guidelines were presented at the 2016 ICI meeting in Tokyo, Japan.

RESULTS

Voiding diary and pad tests are valuable for assessing quantity of leakage. Cystoscopy and/or urodynamics may be useful in guiding therapy depending on the type of incontinence and presumed etiology. Artificial Urinary Sphincter (AUS) is the preferred treatment for men with moderate to severe stress urinary incontinence (SUI) after RP. Male slings are an acceptable approach for men with mild to moderate SUI. Much discussion centers on the definition of moderate SUI. Injectable agents have a poor success rate in men with SUI. Options for recurrent SUI due to urethral atrophy after AUS implantation include changing the pressure balloon, downsizing the cuff and increasing the amount of fluid in the system. Infection and/or erosion demand surgical removal or revision of all or part of the prosthesis.

CONCLUSIONS

Although there are several series reporting the outcomes of different surgical interventions for PPUI, there is still a need for prospective randomized clinical trials. Recommendations for future research include standardized workup and outcome measures, and complete reporting of adverse events at long-term.

Surgery for Male Urinary Incontinence: Where are we now and what is in the Pipeline?

Male stress urinary incontinence, which has radical prostatectomy as the main aetiology, affects about 39% of the adult male population and is one of the complications of radical prostatectomy with the greatest impact on the quality of life of patients. There are a wide range of treatments for stress urinary incontinence available to the urologist, ranging from conservative treatments to surgical treatments, from minimally invasive procedures to the implant of artificial sphincter prosthesis. The aim of this work is to define the state-of-the-art of surgical treatments for male stress urinary incontinence, analyzing the most recent studies in the literature and evaluating the available scientific evidence.

Treatment outcomes of transurethral macroplastique injection for postprostatectomy incontinence

PURPOSE

We investigated the efficacy of transurethral injection of Macroplastique bulking agent (Uroplasty) for male stress urinary incontinence (SUI) after prostate surgery.

MATERIALS AND METHODS

This retrospective review included men with SUI treated by transurethral injection for symptoms resulting from prostate surgery. Patients were evaluated at 1 month and 6 months after injection by determining the number of pads used per day and changes in incontinence symptoms. Treatment success was defined as use of 1 pad or fewer per day combined with subjective symptom improvement.

RESULTS

The study population comprised 30 men with a mean age of 66.1±5.3 years. Of the 30 patients, 24 (80.0%) underwent prostate cancer surgery and the remaining 6 (20.0%) underwent surgery for benign prostatic hyperplasia. The preinjection pad number was 2.9±1.9 pads per day. After injection treatment, the mean follow-up period was 9.3±12.7 months and the success rate was 43% (13/30) at 1 month and 32% (6/19) at 6 months. Injection was more likely to result in a successful outcome in patients with no preinjection radiation treatment history and higher abdominal leak point pressure (ALPP) than in those with a previous history of radiation treatment and lower ALPP, although this result was not statistically significant. Acute urinary retention occurred in 5 patients (17%).

CONCLUSIONS

Transurethral Macroplastique injection treatment is a relatively non-invasive treatment method for male SUI with a success rate of 43% at 1 month and 32% at 6 months. Patients with a higher ALPP and no previous history of radiation therapy may experience better treatment outcomes.

Current trends in the management of post-prostatectomy incontinence

One of the annoying complications of radical prostatectomy is urinary incontinence. Post-prostatectomy incontinence (PPI) causes a significant impact on the patient's health-related quality of life. Although PPI is stress urinary incontinence caused by intrinsic sphincter deficiency in most cases, bladder dysfunction and vesicourethral anastomotic stenosis can induce urine leakage also. Exact clinical assessments, such as a voiding diary, incontinence questionnaire, pad test, urodynamic study, and urethrocystoscopy, are necessary to determine adequate treatment. The initial management of PPI is conservative treatment including lifestyle interventions, pelvic floor muscle training with or without biofeedback, and bladder training. An early start of conservative treatment is recommended during the first year. If the conservative treatment fails, surgical treatment is recommended. Surgical treatment of stress urinary incontinence after radical prostatectomy can be divided into minimally invasive and invasive treatments. Minimally invasive treatment includes injection of urethral bulking agents, male suburethral sling, and adjustable continence balloons. Invasive treatment includes artificial urinary sphincter implantation, which is still the gold standard and the most effective treatment of PPI. However, the demand for minimally invasive treatment is increasing, and many urologists consider male suburethral slings to be an acceptable treatment for PPI. The male sling is usually recommended for patients with persistent mild or moderate incontinence. It is necessary to improve our understanding of the pathophysiologic mechanisms of PPI and to compare different procedures for the development of new and potentially better treatment options.

The treatment of stress incontinence in men: part 2 of a series of articles on incontinence

BACKGROUND

Stress incontinence in men is a rare, usually iatrogenic condition. Its prevalence can be expected to rise in the future because of the increasingly common performance of radical prostatectomy. Most men who have undergone prostatectomy experience a transient disturbance of urinary continence. Such disturbances are only rarely due to structural damage to the sphincter apparatus and therefore have a good prognosis for spontaneous recovery.

METHOD

Selective literature review.

RESULTS

Pelvic floor training and/or pharmacotherapy can be used for more rapid restoration of subjectively satisfactory urinary continence. If the sphincter is intact, continence can also be regained in the early postoperative period through the submucosal injection of bulking agents. Incontinent patients whose urinary sphincter is dysfunctional because of denervation or direct injury to striated muscle can now be treated with a variety of surgical techniques. The implantation of an artificial sphincter is the gold standard of therapy. Properly selected and informed patients can also be treated with minimally invasive procedures, such as the creation of a male suburethral sling, although the experience with such procedures to date has not been extensive.

CONCLUSION

Post-prostatectomy incontinence has a good prognosis and should thus be treated conservatively at first. If it nonetheless persists, surgical treatment is indicated for patients who choose it after being fully informed about their options.

An adjustable continence therapy device for treating incontinence after prostatectomy: a minimum 2-year follow-up

OBJECTIVE

To evaluate the efficacy and safety of the ProACT (Uromedica, Inc., MN, USA) balloon device, an alternative for the surgical management of incontinence after prostatectomy.

PATIENTS AND METHODS

The initial patients who received this device at our institution were evaluated, using urodynamics at baseline and at 6 months. Perioperative variables were recorded and pad usage, volume adjustments, an estimate of Incontinence Quality of Life (I-QoL) and adverse events were recorded at baseline, and 1, 3, 6, 12 and 24 months after surgery.

RESULTS

In all, 37 patients were treated on this protocol between November 2001 and March 2005. Of these, 30 had had radical prostatectomy and seven holmium laser enucleation of the prostate. The mean (range) pad usage decreased from 2.81 (1-12) at baseline to 0.7 (0-4) pads at 24 months, and the I-QOL increased from 49.7 (4.5-77) to 81.3 (13.6-100) over the same period. At 24 months, 62% of 34 men were pad-free and 81% required one pad or less. Bilateral explantation was required in three patients (11%) for infection (one) and balloon migration (two). All other adverse events were mild and transient.

CONCLUSIONS

The ProACT balloon device is an acceptable therapy for the surgical management of incontinence after prostatectomy.

Long-term results and patients' satisfaction after transurethral ethylene vinyl alcohol (Tegress) injections: a two-centre study

Tegress is ethylene vinyl alcohol which is non-allergenic and permanent. The aim of the study was to evaluate efficacy, feasibility and safety of transurethral Tegress in women with urodynamic stress incontinence in a two-centre setting. Approximately 33 female patients with urodynamic stress incontinence were prospectively included in the study. Preoperatively, the patient's history, gynaecological examination and multichannel urodynamics were performed. On follow-up, the patient was asked to use a visual analogue scale to measure her contentness and underwent uroflowmetry and a cough test. Median follow up was 51 months. About 15 women considered themselves as completely continent, and 23 (69%) were either satisfied or very satisfied. Pad test was positive in 18 (54.5%) patients, and cough test was positive in 20 (60.6%). Patients' satisfaction did not correlate with objective dryness. Ethylene vinyl alcohol is a bulking agent with a success rate of approximately 45% after 51 months.

Adjustable Continence Therapy (ProACT™): Evolution of the Surgical Technique and Comparison of the Original 50 Patients with the Most Recent 50 Patients at a Single Centre

OBJECTIVES

The desire for an adjustable surgery for male stress urinary incontinence that avoids further surgery has produced a percutaneous adjustable device. The adjustable continence therapy (ProACT) consists of two balloons, placed bilaterally at the bladder neck after prostatectomy. Titanium ports, attached via tubing to each balloon are placed in the scrotum allowing for volume adjustments of the balloons at any time perioperatively and postoperatively. This paper examines the evolution of the technique and the impact of this progression on patient outcomes.

METHODS

Two groups, one representing the first 50 patients, the second consisting of the last 50 patients are compared for changes in pad use and incontinence quality of life (I-QOL) with a mean follow-up of 23 mo (range: 1-46 mo) in group 1 and 20 mo (range: 18-24) in group 2. A comparison of complications and retreatment is summarised.

RESULTS

Pad usage was reduced significantly in both groups (p<0.001). Overall, group 2 patients obtained more consistent outcomes compared to group 1 (80% vs. 60% dry or >50% improved). I-QOL improved in both groups although more significantly in group 2 (p = 0.005). Operative time was reduced in group 2. The rate and range of complications experienced in group 1 as the technique evolved decreased dramatically in group 2.

CONCLUSIONS

The evolution of technique and expertise has facilitated an efficient surgical implantation procedure with reproducible and effective objective and subjective outcomes. The implantation of this device is now conducted in >100 centres across Europe.