Surgical Treatment of Male Postprostatectomy Incontinence: Current Concepts

Clinical characteristics and predictors of long-term postoperative urinary incontinence in patients treated with robot-assisted radical prostatectomy: A propensity-matched analysis

OBJECTIVES

This study aimed to elucidate the clinical characteristics and predictors of long-term postoperative urinary incontinence (PUI) after robot-assisted radical prostatectomy (RARP).

METHODS

This study included patients who underwent RARP at our institution and were stratified into PUI (≥1 pad/day) and continence (0 pad/day) groups at 60 months after RARP. A propensity score-matched analysis with multiple preoperative urinary status (Expanded Prostate Cancer Index Composite urinary subdomains, total International Prostate Symptom Score (IPSS), and IPSS-quality of life scores) was performed to match preoperative urinary status in these groups. Serial changes in urinary status and treatment satisfaction preoperatively and until 60 months after RARP were compared, and predictors of long-term PUI were assessed using multivariate logistic regression analysis.

RESULTS

A total of 228 patients were included in the PUI and continence groups (114 patients each). Although no significant difference in preoperative urinary status was observed between the two groups, the postoperative urinary status significantly worsened overall in the PUI group than in the continence group. Treatment satisfaction was also significantly lower in the PUI group than in the continence group from 12 to 60 months postoperatively. Multivariate logistic regression analysis revealed that age (≥70 years) and biochemical recurrence (BCR) were significant predictors of the long-term PUI group (p < 0.05).

CONCLUSIONS

Patients with long-term PUI had poor overall postoperative urinary status and lower treatment satisfaction than the continence group. Considering the age and risk of BCR is important for predicting long-term PUI when performing RARP.

Post-prostatectomy incontinence: a guideline of guidelines

AIM

To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI).

MATERIALS AND METHODS

The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018).

RESULTS

In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well.

CONCLUSION

This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

Adjustable Male Sling for The Treatment of Postprostatectomy Stress Urinary Incontinence: Intermediate-Term Follow-Up Results

Objective To evaluate the outcomes of adjustable male sling (Argus®) implantation in the management of post-prostatectomy incontinence (PPI) with intermediate-term follow-up results. Materials and methods The data on adjustable male sling surgery between September 2015 and September 2020 were retrospectively analyzed. Patients were preoperatively evaluated with a voiding diary, 24-hour pad test, and validated questionnaire. Functional outcomes were also evaluated using 24-hour pad requirement and pad weight, and the International Consultation on Incontinence (ICIQ-SF) score. Results A total of 16 patients (eight having undergone the transurethral resection of the prostate [TUR-P] and eight radical prostatectomy [RP]) were enrolled in the study. Thirteen patients had moderate (81.25%) PPI, and three patients (18.75%) had severe PPI. With the mean follow-up of 36.9±14.3 months, nine patients (56.2%) were noted as cured and four (25%) as improved, with an overall success rate of 81.2%. At the last follow-up visit, the median number of pads used per day decreased from 3.5 to 1, and the 24-hour pad test result decreased from 300 to 50 gr (p < 0.001 and p < 0.001, respectively). The ICIQ-SF score decreased from the initial mean of 15.8 ± 2.3 to 7.1 ± 6.6 (p < 0.001). When the outcomes were compared according to the etiology, there was no statistically significant difference (p = 0.522). Conclusions Male sling surgery can be performed safely in patients with moderate and severe stress urinary incontinence with low complication and high success rates. The results of TUR-P-related PPI are similar to those of surgery performed due to the etiology of RP.

Transalbugineal Artificial Urinary Sphincter: A Refined Implantation Technique to Improve Surgical Outcomes

The artificial urinary sphincter (AUS) implantation is an effective treatment of post-prostatectomy urinary incontinence (PPI). Still, it may result in troublesome complications such as intraoperative urethral lesion and postoperative erosion. Based on the multilayered structure of the tunica albuginea of the corpora cavernosa, we evaluated an alternative transalbugineal surgical technique of AUS cuff placement with the aim to decrease perioperative morbidity while preserving the integrity of the corpora cavernosa. A retrospective study was conducted in a tertiary referral center from September 2012 to October 2021, including 47 consecutive patients undergoing AUS (AMS800^®) transalbugineal implantation. At a median (IQR) follow-up of 60 (24-84) months, no intraoperative urethral injury and only one noniatrogenic erosion occurred. The actuarial 12 mo and 5 yr overall erosion-free rates were 95.74% (95% CI: 84.04-98.92) and 91.76% (95% CI: 75.23-97.43), respectively. In preoperatively potent patients, the IIEF-5 score remained unchanged. The social continence (0-1 pads per day) rate was 82.98% (CI 95%: 68.83-91.10) at 12 mos and 76.81% (CI 95%: 60.56-87.04) at 5 yrs follow-up. Our technically refined approach to AUS implantation may help to avoid intraoperative urethral lesions and lower the risk of subsequent erosion without compromising sexual function in potent patients. Prospective and adequately powered studies are necessary to achieve more compelling evidence.

Management of Urinary Incontinence Following Radical Prostatectomy: Challenges and Solutions

Urinary incontinence is a common and debilitating problem in patients undergoing radical prostatectomy. Current methods developed to treat urinary incontinence include conservative treatments, such as lifestyle education, pelvic muscle floor training, pharmacotherapy, and surgical treatments, such as bulking agents use, artificial urinary sphincter implants, retrourethral transobturator slings, and adjustable male sling system. Pelvic floor muscle exercise is the most common management to improve the strength of striated muscles of the pelvic floor to try to recover the sphincter weakness. Antimuscarinic drugs, phosphodiesterase inhibitors, duloxetine, and a-adrenergic drugs have been proposed as medical treatments for urinary incontinence after radical prostatectomy. Development of new surgical techniques, new surgical tools and materials, such as male slings, has provided an improvement of outcomes after UI surgery. Such improvement is still ongoing, and the uptake of new devices might lead to even better outcomes after UI surgery.

Therapeutic Efficacy and Mid-Term Durability of Urethral Sphincter Platelet-Rich Plasma Injections to Treat Postprostatectomy Stress Urinary Incontinence

Platelet-rich plasma (PRP) is used for tissue repair and regeneration. Herein, we investigated the therapeutic efficacy and mid-term durability of injections of PRP into the urethral sphincter for the management of postprostatectomy incontinence (PPI). Thirty-nine patients with PPI that were refractory to conservative treatments were prospectively enrolled. They received repeated PRP urethral sphincter injections monthly for a total of four months. The primary endpoint was the Global Response Assessment (GRA) score after treatment. The secondary endpoints included changes in the stress urinary incontinence (SUI) visual analog scale (VAS) from baseline to the end of follow-up and urodynamic parameters from baseline to 3 months. The mean follow-up period after the entire treatment course was 21.0 ± 11.3 (range: 1.6−36.3) months. After PRP injections, the median GRA score with quartiles was 2.0 (1.0, 2.0). The SUI VAS and abdominal leak point pressure significantly improved from 6.9 ± 1.8 to 4.4 ± 2.3, p < 0.001, and from 74.8 ± 37.0 to 115.5 ± 57.9 cmH2O, p = 0.004, respectively, after the fourth PRP urethral sphincter injection. Following PRP urethral sphincter injections, the severity of SUI significantly reduced, indicating efficacy and mid-term durability as a novel treatment for PPI.

Performance of the artificial urinary sphincter implantation in men with urinary incontinence: Results from a contemporary long-term real-world nationwide analysis

PURPOSE

The artificial urinary sphincter (AUS) is one of the most effective surgical treatments for male urinary incontinence regardless of its severity. Current knowledge comes from high-volume centers, but little is known about the performance of this surgery from community practices. This study aims to report contemporary AUS performance in a nationwide observational study in Colombia.

METHODS

Male patients who underwent AUS surgery with AMS 800™ between 2000 and 2020 in more than 17 centers and four cities were identified. Pre, intra, and postoperative characteristics were evaluated, mainly addressing patient reported outcomes measurements in the postoperative period. Retrospective and prospective data collection and descriptive analysis were completed. Kaplan-Meier analysis was used to determine AUS survival rate.

RESULTS

Out of an initial 667 cases, a total of 215 patients met inclusion and exclusion criteria and were included. Mean age was 67 ± 9.4 years, and mean follow-up was 6.0 ± 4.4 years with maximum range of 14 years. The etiology of urinary incontinence was prostate cancer surgery in 141 (81%) of the cases. The rest of the cases were related to benign prostatic disease or spinal cord injury. It is noteworthy that out of 115 patients, only 59 (51.3%) reported previous formal pelvic floor rehabilitation. Subjective severity of urinary incontinence determined by a visual analog scale showed a decrease in 4.5 points after sphincter implantation. Sphincter removal was required in 50 (23.2%) cases. The main reasons for implant removal were urethral erosion and infection. The sphincter survival rate at 2, 5, 8, 10, and 14 years was 76%, 70%, 60%, 57%, and 17%, respectively. Of the subjects at the last follow-up with the device still in place, 80.7% defined their urinary condition as "does not cause or causes minor discomfort," and 99% would recommend the device to a friend or relative in the same condition.

CONCLUSIONS

This series from a community-based practice shows the lack of adherence to clinical practice guidelines and the lack of standardized data collection. In contrast, this study provides real-world data on explantation and revision rates, allows physicians to inform patients and to have clear metrics for a shared decision-making process before the procedure.

European Association of Urology Guidelines on Male Urinary Incontinence

CONTEXT

Urinary incontinence (UI) is a common condition in elderly men causing a severe worsening of quality of life, and a significant cost for both patients and health systems.

OBJECTIVE

To report a practical, evidence-based, guideline on definitions, pathophysiology, diagnostic workup, and treatment options for men with different forms of UI.

EVIDENCE ACQUISITION

A comprehensive literature search, limited to studies representing high levels of evidence and published in the English language, was performed. Databases searched included Medline, EMBASE, and the Cochrane Libraries. A level of evidence and a grade of recommendation were assigned.

EVIDENCE SYNTHESIS

UI can be classified into stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence. A detailed description of the pathophysiology and diagnostic workup has been reported. Simple clinical interventions, behavioural and physical modifications, and pharmacological treatments comprise the initial management for all kinds of UI. Surgery for SUI includes bulking agents, male sling, and compression devices. Surgery for UUI includes bladder wall injection of botulinum toxin A, sacral nerve stimulation, and cystoplasty/urinary diversion.

CONCLUSIONS

This 2022 European Association of Urology guideline summary provides updated information on definition, pathophysiology, diagnosis, and treatment of male UI.

PATIENT SUMMARY

Male urinary incontinence comprises a broad subject area, much of which has been covered for the first time in the literature in a single manuscript. The European Association of Urology Non-neurogenic Male Lower Urinary Tract Symptoms Guideline Panel has released this new guidance, with the aim to provide updated information for urologists to be able to follow diagnostic and therapeutic indications for optimising patient care.

Preoperative nutritional evaluation of prostate cancer patients undergoing laparoscopic radical prostatectomy

Background and objective

Prostate cancer (PCa) is one of the most common malignant tumors in men. Geriatric Nutritional Risk Index (GNRI) is an objective index for evaluating nutritional status of elderly people over 65 years old. The aim of the current study was to explore the correlation and predictive value between GNRI and postoperative recovery and complications in PCa patients undergoing laparoscopic radical prostatectomy (LRP).

Methods

Taking 98 as the GNRI boundary value, 96 PCa patients (aged≥65 y) undergoing LRP in the Department of Urology, Affiliated Hospital of North Sichuan Medical College from January 2018 to December 2020 were grouped into malnutrition group (MNg, 34 patients, 35.4%) and normal nutrition group (NNg, 62 patients, 64.6%). Basic information, laboratory examination indexes, operation conditions, postoperative complications and postoperative recovery indexes of patients were recorded and retrospectively analyzed. Clavien-Dindo Classification System (CDCS) was used to assess postoperative complications. T-test was used to analyze differences between the two groups. ROC curve was generated to determine the predictive value of GNRI for postoperative complications.

Results

Percentage of complications was significantly higher in MNg group compared with that in NNg group (P < 0.01). The average grade based on CDCS was significantly lower in NNg group compared with that in MNg group (P < 0.01). Body weight, Body Mass Index (BMI), preoperative hemoglobin value (HGB), serum albumin (ALB) values of MNg and NNg were significantly positively correlated with GNRI (P<0.01). Incidence and severity of postoperative complications of MNg patients were significantly higher compared with those of NNg patients (P<0.05). Average hospitalization cost of MNg patients was higher in MNg patients compared with that of NNg patients (P<0.05). Duration of post-anesthesia care unit (PACU), duration of antibiotic use and duration of indwelling drainage tube were longer in MNg patients compared with those in NNg patients (P<0.05). Furthermore, volume of indwelling drainage tube was higher in MNg patients compared with that in NNg patients (P<0.05).

Conclusion

GNRI is an effective and reliable tool for evaluation of preoperative nutritional status of prostate cancer patients. The findings showed that GNRI is correlated with postoperative recovery and complications, and is an effective predictive marker.

Long-term outcomes and patient satisfaction after artificial urinary sphincter implantation

PURPOSE

To evaluate long-term functional outcomes of artificial urinary sphincter implantation in men for the treatment of stress urinary incontinence.

MATERIALS AND METHODS

Patients who underwent artificial urinary sphincter implant for non-neurogenic stress urinary incontinence between June 1989 and January 2020 were included in this single-centre retrospective series. All patients with a functional artificial urinary sphincter in situ were contacted to evaluate long-term functional outcomes using validated questionnaires.

RESULTS

A total of 263 patients were included in this retrospective series with a mean follow-up of 61 months. Explant-free survival after 5 years was 75% with a median time to explant of 16.2 years. Revision-free implant survival was 62% after 5 years with a median revision-free implant survival rate of 10.8 years. Previous pelvic irradiation, history of stricture disease and previous artificial urinary sphincter implant were associated with decreased implant survival. Overall social continence rate after 5 years was 60%. Prior radiation therapy, anticoagulation therapy and previous anti-incontinence surgery were associated with a higher incontinence risk. On long-term evaluation of 158 patients with their artificial urinary sphincter currently in situ, 51% were socially continent and 29% reported they were totally dry. Of these patients, 92% indicated to be satisfied with their current continence status.

CONCLUSION

A significant proportion of patients undergoing artificial urinary sphincter implant incontinence needed revision or explant surgery. Long-term continence rates are acceptable but tend to decrease by time. Nonetheless, if patients can maintain a functional AUS in situ, long-term patient satisfaction rates remain high.

Análisis bibliométrico de la incontinencia urinaria masculina. Una mirada de los últimos 20 años

Introducción y Objetivo En las últimas décadas, la incidencia y prevalencia de la incontinencia urinaria han venido en aumento. Existen numerosas publicaciones sobre este tema, se han introducido nuevos dispositivos, y se han modificado las líneas de manejo de esta patología. El objetivo de este estudio es realizar un análisis bibliométrico de las publicaciones sobre incontinencia urinaria masculina en las revistas indexadas.

Métodos Se realizó un análisis bibliométrico descriptivo de corte retrospectivo de la literatura médica disponible en la base de datos Web of Science (WOS) en relación con incontinencia urinaria masculina entre 2002 y 2020. Por medio de la WOS, se obtuvieron las variables a analizar, y se elaboraron tablas y gráficas en el programa Microsoft Office Excel 2017.

Resultados Encontramos un total de 498 publicaciones en 88 revistas. Hubo un crecimiento exponencial de las publicaciones a partir de 2006. Las 3 revistas con mayor porcentaje de publicaciones fueron: J Urol, con 25,2% (125), Neurol Urodyn, con 16,5% (82), European Urology Journal, con 11,1% (55); sólo 5 de las 20 revistas con más publicaciones tuvieron un factor de impacto ≥ 3. El país que tuvo mayor porcentaje fue Estados Unidos con 21,2% (105), seguido por países europeos. En América Latina, el país con mayor número de publicaciones fue Brasil, con 2,6% (13). No se encontraron estudios colombianos con esta búsqueda específica.

Conclusión Este es el primer estudio bibliométrico sobre incontinencia urinaria masculina. Con el tiempo, han aumentado las publicaciones acerca de este tema, y la mayoría está concentrada en revistas de Estados Unidos y Europa. No es predominante la publicación en revistas de alto factor de impacto, y es muy baja la cantidad de publicaciones que aporta Colombia y los demás países latinoamericanos.

Prior Placement of Male Urethral Slings Can Increase the Need for Revision of Artificial Urinary Sphincters

Background: Recurrent stress urinary incontinence (SUI) following male sling can be managed surgically with artificial urinary sphincter (AUS) insertion. Prior small, single-center retrospective studies have not demonstrated an association between having failed a sling procedure and worse AUS outcomes. The aim of this study was to compare outcomes of primary AUS placement in men who had or had not undergone a previous sling procedure. Methods: A retrospective review of all AUS devices implanted at a single academic center during 2000–2018 was performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 19 (14.1%) patients had undergone prior sling procedures. Results: There was no significant difference in demographic characteristics between patients undergoing AUS placement with or without a prior sling procedure. Average follow up time was 28.0 months. Prior sling was associated with shorter overall device survival, with an increased likelihood of requiring revision or replacement of the device (OR 4.2 (1.3–13.2), p = 0.015) as well as reoperation for any reason (OR 3.5 (1.2–9.9), p = 0.019). While not statistically significant, patients with a prior sling were more likely to note persistent incontinence at most recent follow up (68.8% vs. 42.7%, p = 0.10). Conclusions: Having undergone a prior sling procedure is associated with shorter device survival and need for revision or replacement surgery. When considering patients for sling procedures, patients should be counseled regarding the potential for worse AUS outcomes should they require additional anti-incontinence procedures following a failed sling.

Adverse Events Associated With Synthetic Male Slings: An Analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience Database

PURPOSE

We sought to describe and analyze the adverse events associated with synthetic male slings reported to the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

We queried the MAUDE database for all entries including the terms "Male Sling," "InVance," "Virtue," or "Advance" from January 1st, 2009 to December 31st, 2018. We collected and analyzed information about the event type, date received, report source, source type, and manufacturer. We reviewed and categorized the event description text for each medical device report (MDR).

RESULTS

A total of 497 adverse events related to the male sling were identified. The adverse events were classified as injury (95.4%), malfunction (4.2%), and other (0.4%). There were no deaths described. The slings involved were the Advance or Advance XP sling (69.8%), InVance (15.5%), Virtue Quadratic (12.3%), or unknown (2.4%). The 4 most common adverse events described were urinary incontinence (46.7%), sling erosion (9.1%), mechanical malfunction (8.2%), and pain/numbness (8.2%). There was no increase in the number of reports in the years following the FDA warnings for urogynecologic mesh.

CONCLUSION

There was an overall modest number of MDRs related to male slings and the majority of them were reported by the manufacturer. The reporting of adverse events for male slings does not seem to be affected by the controversy and scrutiny towards transvaginal mesh and midurethral slings. Further clinical studies and more objective and detailed databases are needed to investigate the safety of these synthetic slings.

Imaging and Treatment of Complications of Abdominal and Pelvic Mesh Repair

Surgical mesh is used most frequently for tension-free repair of abdominal wall hernias in adults, because the rate of hernia recurrence is lower with mesh than with primary soft-tissue repair. Since the introduction of polypropylene mesh in the middle of the 20th century, many mesh materials and configurations for specific surgical procedures have been developed. In addition to abdominal wall hernia repair, mesh may be used for repair of diaphragmatic hernias, urinary incontinence in women (female slings), genitourinary prolapse (vaginal mesh and sacrocolpopexy), rectal prolapse (rectopexy), and postprostatectomy male urinary incontinence (male slings). General mesh repair complications include chronic pain; fluid collections such as seromas, hematomas, and abscesses; adhesions that may lead to intestinal blockage; erosion into solid or hollow viscera including enterocutaneous fistulizing disease; and mesh failure characterized by mesh shrinkage, detachment, and migration with repair malfunction. Several mesh complications are often diagnosed with imaging, primarily with CT and less frequently with MRI and US, despite variable mesh visibility at imaging. This article reviews the common surgical mesh applications in the abdomen and pelvis, discusses imaging of mesh repair complications, and provides complication treatment highlights.^©RSNA, 2020.

Current Management of Post-radical Prostatectomy Urinary Incontinence

Prostate cancer is the second most common cancer in men worldwide. Radical prostatectomy and radiation beam therapy are the most common treatment options for localized prostate cancer and have different associated complications. The etiology of post prostatectomy incontinence is multifactorial. There is evidence in the literature that anatomic support and pelvic innervation are important factors in the etiology of post-prostatectomy incontinence. Among the many surgical and technical factors proposed in the literature, extensive dissection during surgery, damage to the neurovascular bundle and the development of postoperative fibrosis have a substantial negative impact on the continence status of men undergoing RP. Sparing of the bladder neck and anterior, and possibly posterior, fixation of the bladder-urethra anastomosis are associated with better continence rates. Overactive bladder syndrome (OAB) is multifactorial and the exact role of prostate surgery in the development of OAB is still under debate. There are several variables that could contribute to detrusor overactivity. Detrusor overactivity in patients after radical prostatectomy has been mainly attributed to a partial denervation of the bladder during surgery. However, together with bladder denervation, other hypotheses, such as the urethrovesical mechanism, have been described. Although there is conflicting evidence regarding the importance of conservative treatment after post-prostatectomy urinary incontinence, pelvic floor muscle training (PFMT) is still considered as the first treatment choice. Duloxetin, either alone or in combination with PFMT, may hasten recovery of urinary incontinence but is often associated with severe gastrointestinal and central nervous side effects. However, neither PFMT nor duloxetine may cure male stress urinary incontinence. The therapeutic decision and the chosen treatment option must be individualized for each patient according to clinical and social factors. During the recent years, the development of new therapeutic choices such as male sling techniques provided a more acceptable management pathway for less severe forms of urinary incontinence related to radical prostatectomy. Following this perspective, technological improvements and the emergence of new dedicated devices currently create the premises for a continuously positive evolution of clinical outcomes in this particular category of patients.

A novel management for postprostatectomy urinary incontinence: platelet-rich plasma urethral sphincter injection

Platelet-rich plasma (PRP) is the most innovative blood-derived product used in regenerative medicine. We aimed to investigate the therapeutic efficacy of PRP urethral sphincter injection for the management of postprostatectomy incontinence (PPI). In total, 28 PPI patients with a mean age of 71.8 ± 8.9 years were prospectively enrolled. They received four PRP urethral sphincter injections each month. The clinical outcomes were assessed 3 months after the fourth injection as posttreatment Global Response Assessment (GRA) score, the newly designed visual analogue scale of stress urinary incontinence (VAS of SUI), and in urodynamic parameters. After injections, the posttreatment median GRA with quartiles was 2.0 (1.0, 2.0). Overall, six (21.4%) patients achieved complete continence and pad-free status, 20 (71.4%) achieved successful outcome (GRA score ≥ 2), and 26 (92.9%) showed clinical improvement (GRA score ≥ 1). The VAS of SUI significantly improved from 6.5 (5.0, 8.0) to 3.5 (2.0–5.8) (p < 0.001) as well as abdominal leak point pressure, from 57.5 (50.0, 115.0) to 126.0 (68.3, 150.0), (p = 0.004). After repeated PRP urethral sphincter injections, the SUI severity reduced significantly with high success rates. There was no major adverse event, except three patients with mild hematuria and micturition pain. In conclusion, PRP urethral sphincter injection is safe and effective as a novel management of PPI.

Artificial urinary sphincter: current status and future directions

Urge urinary incontinence (UUI) is one of the most troublesome complications of surgery of the prostate whether for malignancy or benign conditions. For many decades, there have been attempts to reduce the morbidity of this outcome with variable results. Since its development in the 1970s, the artificial urinary sphincter (AUS) has been the “gold standard” for treatment of the most severe cases of UUI. Other attempts including injectable bulking agents, previous sphincter designs, and slings have been developed, but largely abandoned because of poor long-term efficacy and significant complications. The AUS has had several sentinel redesigns since its first introduction to reduce erosion and infection and increase efficacy. None of these changes in the basic AUS design have occurred in the past three decades, and the AUS remains the same despite newer technology and materials that could improve its function and safety. Recently, newer compressive devices and slings to reposition the bladder neck for men with mild-to-moderate UUI have been developed with success in select patients. Similarly, the AUS has had applied antibiotic coating to all portions except the pressure-regulating balloon (PRB) to reduce infection risk. The basic AUS design, however, has not changed. With newer electronic technology, the concept of the electronic AUS or eAUS has been proposed and several possible iterations of this eAUS have been reported. While the eAUS is as yet not available, its development continues and a prototype device may be available soon. Possible design options are discussed in this review.

Argus-T adjustable male sling: A follow-up study on urinary incontinence and patient's satisfaction

AIMS

The use of Argus-T adjustable sling may be a promising alternative option for the treatment of urinary incontinence after radical prostatectomy, however long-term data is lacking. The aim of this study is to evaluate the long-term results of the Argus-T sling on incontinence rates, patient's quality of life and tape-related complications.

METHODS

Patients were eligible if persistent stress incontinence was present ≥12 months after radical prostatectomy. Measurements included 24 h frequency volume micturition list, 24 h pad test, 24 h pad count and quality of life questionnaires. Argus-T adjustable sling was placed with a single perineal route incision approach.

RESULTS

Seventy-eight patients were included, 69 ± 6 years, pre-intervention 24 h urinary loss 212 (75-385) g. Directly after surgery, 63.6% of the patients was completely dry, 79.2% of the patients reported greater than 90% improvement of their urinary loss and 92.2% > 50% improvement. Median follow-up time was 3.2 (2.5-6.1) years. After 5 years of follow-up, 53.3% of the patients were completely dry, 71.5% reported an improvement greater than 90% and 79.6% reported an improvement of greater than 50%. Patients with preoperative urinary loss less than 250 g reported significantly higher improvement of their urinary loss compared to patients with urinary loss ≥250 g (p = .02). Patients satisfaction was still increased after 5 years follow-up (70 ± 21 vs.16 ± 9, p < .001) and patients quality of life remained high (85 ± 20 vs. 88 ± 13, p = .1). Complications were mainly observed directly after surgery. Two patients (2.6%) needed reimplantation of the sling.

CONCLUSION

These data indicate that Argus-T sling is an effective treatment option in obtaining substantial long-term incontinence relief in patients with invalidating moderate stress urinary incontinence after radical prostatectomy.

Therapeutic Efficacy of Urethral Sphincter Injections of Platelet-Rich Plasma for the Treatment of Stress Urinary Incontinence due to Intrinsic Sphincter Deficiency: A Proof-of-Concept Clinical Trial

Purpose

The aim of this study was to investigate the efficacy of autologous platelet-rich plasma (PRP) in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) refractory to medical treatment.

Methods

Thirty-five patients with SUI due to urodynamically proven ISD were prospectively enrolled. Five milliliters of PRP (2.5–5 times the platelet concentration in peripheral blood) was injected into the external sphincter at 5 sites; all patients received 4 injections at monthly intervals. The primary end-point was the change in SUI severity as assessed by a visual analogue scale (VAS of SUI). The secondary-endpoints were the Global Response Assessment score and changes in urodynamic parameters from baseline to 3 months after treatment.

Results

The mean age of patients was 68.7±12 years; the median duration of SUI was 4 years. Five patients had neurogenic SUI, while 30 had nonneurogenic SUI (21 with postprostatectomy incontinence, 6 with previous radical cystectomy, and 3 with other etiologies). Complete dryness was achieved in 7 patients (20.0%) while moderate improvement was observed in 14 (40.0%). The mean VAS of SUI score decreased significantly from 6.57±1.89 to 3.77±2.41 after treatment. The abdominal leak point pressure (ALPP) increased significantly from 98.3±55.8 to 157.3±79.3 cm H₂O. There was no increase of ALPP in neurogenic SUI and less increase of ALPP in patients with failed treatment outcomes. No perioperative adverse events or severe complications occurred.

Conclusions

Urethral PRP injection is safe and effective in increasing urethral resistance and improving SUI. PRP could be an alternative treatment modality for male and female patients with moderate SUI due to nonneurogenic causes.

Urinary retention after AdVance™ Sling: A multi-institutional retrospective study

AIMS

To identify risk factors for urinary retention following AdVance™ Sling placement using preoperative urodynamic studies to evaluate bladder contractility.

METHODS

A multi-institutional retrospective review of patients who underwent an AdVance Sling for post-prostatectomy stress urinary incontinence from 2007 to 2019 was performed. Acute urinary retention (AUR) was defined as the complete inability to void or elevated post-void residual (PVR) leading to catheter placement or the initiation of intermittent catheterization at the first void trial postoperatively. Bladder contractility was evaluated based on preoperative urodynamics.

RESULTS

Of the 391 patients in this study, 55 (14.1%) experienced AUR, and 6 patients (1.5%) had chronic urinary retention with a median follow-up of 18.1 months. In total, 303 patients (77.5%) underwent preoperative urodynamics, and there was no significant difference between average PdetQmax (26.4 vs. 27.4 cmH₂ O), Qmax (16.6 vs. 16.2 ml/s), PVR (19.9 vs. 28.1 ml), bladder contractility index (108 vs. 103) for patients with or without AUR following AdVance Sling. Impaired bladder contractility preoperatively was not predictive of AUR. Time to postoperative urethral catheter removal was predictive of AUR (odds ratio, 0.83; 95% confidence interval, 0.73-0.94; p = .003).

CONCLUSIONS

Chronic urinary retention after AdVance Sling placement is uncommon and acute retention is generally self-limiting. No demographic or urodynamic factors were predictive of AUR. Patients who developed AUR were more likely to have their void trials within 2 days following AdVance Sling placement versus longer initial catheterization periods, suggesting that a longer duration of postoperative catheterization may reduce the occurrence of AUR.

Multicentered Assessment of Clinical Outcomes and Factors Associated With Failure of the Adjustable TransObturator Male System (ATOMS)

OBJECTIVE

To assess postoperative outcomes from the Adjustable TransObturator Male System (ATOMS) and identify factors influencing failure to achieve continence.

PATIENTS AND METHODS

A multicentered analysis was performed on all patients treated for postprostatectomy incontinence using the third-generation ATOMS at 9 Canadian tertiary referral centers. The primary outcome was continence (defined as requiring ≤1 pad postoperatively for patients requiring ≥2 pads preoperatively and 0 pads for those requiring 1 pad preoperatively). Secondary outcomes included improvement (>50% change in pad use), patient satisfaction, explantation, and postoperative complications.

RESULTS

Two hundred and eighty nine patients with a mean age of 68.9 years were analyzed. Pre-operatively mean pad per day use was 4.2 (1-12), 31.5% of patients reported severe incontinence (≥5 pads/day), 33.9% had concurrent radiotherapy and 19.4% had failed previous incontinence surgery. Overall continence rate was 73.3% (n = 212) at a mean follow-up of 19.6 months. More than eighty nine percent (89.3%) (n = 258) of patients experienced >50% improvement, 84.4% (n = 244) of patients were satisfied with the results of surgery. More than seven percent (7.9%) (n = 23) required device explantation. On multivariate Cox regression analysis, concurrent radiotherapy (hazard ratio [H.R.] 2.3, P < .001), diabetes (H.R. 2.2, P = .007) and increased pre-operative pad usage (H.R. 1.1, P = .02) were each associated with failure to achieve continence, while patient age (P = .60), obesity (P = .08), prior urethral stenosis (P = .56), and prior incontinence surgery (P = .13) were not. Radiation therapy was also associated with device explantation (H.R. 2.7, P = .02).

CONCLUSION

ATOMS is a safe and efficacious for treatment of postprostatectomy incontinence. However, patients with prior radiation, increased pre-operative pad use, or diabetes are less likely to achieve continence.

Patient Selection in Surgical Centers of Expertise in the Treatment of Patients with Moderate to Severe Male Urinary Stress Incontinence

<b><i>Objective:</i></b> To analyze decision-making in patients with male urinary incontinence (SUI) in centers of expertise. The artificial urinary sphincter (AUS) remains the gold standard for male patients with moderate to severe SUI but adjustable male slings are a minimally invasive treatment option with good results, hence without a high level of evidence regarding the optimal patient selection. <b><i>Materials and Methods:</i></b> In total, 220 patients (88 AUS; 132 adjustable slings) were investigated from the DOMINO database that underwent surgery between 2010 and 2012 in 5 urological departments that offer adjustable sling systems as well as AUS systems for patients with moderate to severe urinary incontinence. For statistical analysis, the Mann-Whitney <i>U</i> test was used to identify differences between both groups. <b><i>Results:</i></b> Patients selected for an adjustable male sling were less likely to have a neurological disease (5.3 vs. 9.1%; <i>p</i> = 0.030), a prior urethral stricture (22.7 vs. 50.0%; <i>p</i> = 0.001), a prior incontinence surgery (24.4 vs. 45.5%; <i>p</i> = 0.01), or a prior radiation therapy (26.5 vs. 40.1%; <i>p</i> = 0.001). The severity of preoperative incontinence was higher in patients selected for an AUS with a mean pad usage per day of 7.60 versus 5.80 (<i>p</i> &#x3c; 0.001). Mean postoperative pad usage and patients’ subjective perception were comparable in both groups. <b><i>Conclusion:</i></b> In centers offering both options, the decision-making is mainly based upon presence of radiation therapy and previous failed incontinence surgery. Despite the more complex patient cohort selected for an AUS implantation with a possible impact on the postoperative outcome, the functional results seem to be comparable indicating a proper preoperative patient assessment and selection in this cohort.

Daily Pad Usage Versus the International Consultation on Incontinence Questionnaire Short Form for Continence Assessment Following Radical Prostatectomy

Purpose

Continence assessment is an essential component of follow-up after radical prostatectomy (RP). Several methods exist to assess the severity of urinary incontinence (UI). Our study examined the relationship and degree of agreement between International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) scores and the number of pads used in a 24-hour period in the assessment of UI following RP.

Methods

Continence was prospectively assessed in 746 men from a Spanish urology clinic 12 months after RP using the ICIQ-SF and pad usage. The relationship between ICIQ-SF scores and pad usage was assessed using Spearman rank correlation coefficients. The Jonckheere-Terpstra trend test was used to determine whether the ICIQ-SF score and the component question scores increased with increasing pad usage. The Bonferroni-corrected pairwise Wilcoxon rank-sum test was used to determine which pairs of pad usage levels differed. The weighted kappa was used to evaluate the agreement between pad usage levels and ICIQ-SF questions.

Results

The continence rate was 82% using the “no pad usage” definition of continence versus 78% using the definition of an ICIQ-SF score of 0 (P<0.001). Strong positive correlations were observed between the number of pads and the ICIQ-SF total and component question scores (r_s>0.85, P<0.001). The ICIQ-SF total and component question scores increased significantly with increasing pad usage (P<0.001). The ICIQ-SF scores (P<0.018) for all pairs of pad usage levels (0, 1, 2, or 3 or more) differed significantly. The agreement between the ICIQ-SF leakage amount question and pad usage was very good (r_s=0.861, P<0.001).

Conclusions

At 12 months post-RP, 24-hour pad usage was closely correlated with ICIQ-SF, although the continence rate differed depending on the definition used. Higher levels of pad usage were associated with higher questionnaire scores, more leakage, and poor quality of life (interference with everyday life).

Conservative management of urinary incontinence following robot-assisted radical prostatectomy

INTRODUCTION

Robotic assisted radical prostatectomy (RARP) is getting more and more popular becoming the most common radical prostatectomy technique. Unfortunately, a not negligible proportion of patients in whom RARP is performed experience urinary incontinence. We aimed to systematically review the current literature evidence on urinary incontinence conservative treatment after RARP.

EDIDENCE AQUISITION

A systematic literature review search using PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines have been adopted. Population consisted of patients with urinary incontinence after RARP (P), conservative intervention was considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of continence and quality of life (O).

EVIDEDENCE SYNTHESIS

Six studies were included. Four of them investigated the use of pelvic floor muscle training (PFMT). PFMT improved pelvic muscle strength. Continence recovery was faster when guided PFMT was adopted. Moreover, two studies tested the effect of solifenacin on urinary incontinence. One of them, a randomized clinical trial, failed to show shorter time to continence in solifenacin group compared to placebo.

CONCLUSIONS

The use of pads is associated with a detrimental effect on quality of life thus active treatments for UI post-RARP are warranted. PFMT has the main advantage to shorten the time for recovery. The use of solifenacin seems to not offer striking advantages in UI following RARP. Future studies should focus on testing the efficacy of these treatments when used after robotic vs. open radical prostatectomy.

What if artificial urinary sphincter is not possible? Feasibility and effectiveness of ProACT for patients with persistent stress urinary incontinence after radical prostatectomy treated by sling

BACKGROUND

Stress urinary incontinence (SUI) is a major component of the post radical prostatectomy (RP) trifecta. Surgical treatments are sub-urethral slings, artificial urinary sphincter (AUS) and adjustable peri-urethral balloons (PUB) ProACT. All options are imperfect at best and persistent SUI is challenging when AUS is not manageable.

AIMS

This study analyzed the cumulate experience of our 2 centers with offering PUB implantation for SUI post RP in patients with insufficient improvement from slings.

MATERIALS & METHODS

This retrospective study reviewed all patients implanted with second line ProACT. The primary endpoint was continence, defined as 0 pads per day (PPD). The secondary endpoints were 50% decrease in PPD and increases in the Incontinence Quality of Life score (IQOL). Refilling and complications were reported.

RESULTS

Between 2007 and 2016, 26 patients were implanted. Five patients have had adjuvant radiotherapy (18%). The mean follow-up was 36 months (±20; min 14-max 128). All patient presented with persistent SUI, using 2.3 PPD (±1; min 1-max 6), and only one sling was removed due to infection. After ProACT with an average 3 mL refilling (±1.2 min 2-max 6), 18 patients (66.7%) were continent. Eight of the remaining patients (29.6%) were improved; their number of PPD decreased from 2.6 to 1. The average IQOL score of those 8 patients increased by 20 points, from 53.4 up to 74.2 (P = .005). Overall 26 patients (96.3%) were improved. The remaining patient was not implanted because of an intraoperative urethral injury and is considered a failed case (3.7%). He had instead an AUS implantation. Three patients (14.8%) needed PUB replacement.

CONCLUSION

The limited population of patients from both our centers who presented with persistent SUI after RP, despite sling placement, improved with PUB ProACT implantations without significant complications.

The impact of perioperative complications on favorable outcomes after artificial urinary sphincter implantation for post-prostatectomy incontinence

Objective

To investigate the effect of perioperative complications involving artificial urinary sphincter (AUS) implantation on rates of explantation and continence as well as health-related quality of life (HRQOL).

Materials and methods

Inclusion criteria encompassed non-neurogenic, moderate-to-severe stress urinary incontinence (SUI) post radical prostatectomy and primary implantation of an AUS performed by a high-volume surgeon (>100 previous implantations). Reporting complications followed the validated Clavien-Dindo scale and Martin criteria. HRQOL was assessed by the validated IQOL score, continence by the validated ICIQ-SF score. Statistical analysis included Chi (2) test, Mann-Whitney-U test, and multivariate regression models (p <0.05).

Results

105 patients from 5 centers met the inclusion criteria. After a median follow-up of 38 months, explantation rates were 27.6% with a continence rate of 48.4%. In the age-adjusted multivariate analysis, perioperative urinary tract infection was confirmed as an independent predictor of postoperative explantation rates [OR 24.28, 95% CI 2.81-209.77, p=0.004). Salvage implantation (OR 0.114, 95% CI 0.02-0.67, p=0.016) and non-prostatectomy related incontinence (OR 0.104, 95% CI 0.02-0.74, p=0.023) were independent predictors for worse continence outcomes. Low visual analogue scale scores (OR 9.999, 95% CI 1,42-70.25, p=0.021) and ICIQ-SF scores, respectively (OR 0.674, 95% CI 0.51-0.88, p=0.004) were independent predictors for increased HRQOL outcomes. Perioperative complications did not significantly impact on continence and HRQOL outcomes.

Conclusion

Findings show postoperative infections adversely affect device survival after AUS implantation. However, if explantation can be avoided, the comparative long-term functional results and HRQOL outcomes are similar between patients with or without perioperative complications.

Retropubic vs transobturator Argus adjustable male sling: Results from a multicenter study

AIMS

To comparatively analyse outcomes after ARGUS classic and ArgusT adjustable male sling implantation in a real-world setting.

METHODS

Inclusion criteria encompassed: non-neurogenic, moderate-to-severe stress urinary incontinence (≥2 pads), implantation of an ARGUS classic or ArgusT male sling between 2010 and 2012 in a high-volume center (>150 previous implantations). Functional outcomes were assessed using daily pad usage, 24-hour pad testing, and International Consultation on Incontinence (ICIQ-SF) questionnaires. Continence was defined as zero pads per 24 hours. Complications were graded using Clavien-Dindo scale. For multivariate analysis, binary logistic regression models were used (P < .05).

RESULTS

A total of 106 patients (n = 74 [ARGUS classic], n = 32 [ArgusT]) from four centers were eligible. Median follow-up was 44.0 months (24-64). Patient cohorts were well-balanced. We observed a statistical trend in favor of ARGUS classic regarding postoperative urine loss based on standardized 24-hour pad test (71 ± 162 g [ARGUS classic] vs 160 ± 180 g [ArgusT]); P = .066]. Dry rates were 33.3% (ARGUS classic) and 11.8% (ArgusT, P = .114). In multivariable analysis, ArgusT male sling could not be confirmed as an independent predictor of decreased success (OR, 0.587; 95% CI; 0.166-2.076, P = .408). There were no Clavien IV and V complications. Inguinal pain was significantly higher after ArgusT implantation (P = .033). Explantation rates were higher for ArgusT compared to ARGUS classic (14.0 vs 23.3%; P = .371). Longer device survival for the ARGUS classic male sling was observed in Kaplan-Meier analysis (P = .198).

CONCLUSIONS

In the largest comparative analysis of ARGUS classic and ArgusT male sling with the longest follow-up to date, we observed low continence rates with superior functional outcomes and decreased explantation rates after ARGUS classic implantation.

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.

AMS-800 Artificial urinary sphincter in female patients with stress urinary incontinence: A systematic review

AIMS

To perform a systematic review of studies reporting the outcomes of AMS-800 artificial urinary sphincter (AUS) implantation in female patients with stress urinary incontinence (SUI) resulting from intrinsic sphincter deficiency (ISD).

METHODS

A systematic literature search of the Medline and Embase databases was performed in June 2018 in accordance with the PRISMA statement. No time limit was used. The protocol was registered in PROSPERO (CRD42018099612). Study selection and data extraction were performed by two independent reviewers.

RESULTS

Of 886 records screened, 17 were included. All were retrospective or prospective non-comparative case series. One study reported on vaginal AUS implantation, 11 on open AUS implantation, two on laparoscopic AUS implantation, two on robot-assisted AUS implantation and one compared open and robot-assisted implantations. The vast majority of patients had undergone at least one anti-incontinence surgical procedure prior to AUS implantation (69.1-100%). The intraoperative bladder neck injury rates ranged from 0% to 43.8% and the intraoperative vaginal injury rates ranged from 0 to 25%. After mean follow-up periods ranging from 5 to 204 months, the complete continence rates ranged from 61.1% to 100%. The rates of explantation, erosion and mechanical failure varied from 0% to 45.3%, 0% to 22.2% and 0% to 44.1%, respectively.

CONCLUSIONS

AMS-800 AUS can provide excellent functional outcomes in female patients with SUI resulting from ISD but at the cost of a relatively high morbidity. High level of evidence studies are needed to help better define the role of AUS in the female SUI armamentarium.

Clinical results of a dorsally positioned hydraulic ID-sling in male patients with post-prostatectomy-incontinence

PURPOSE

To prospectively evaluate the effectiveness and safety of and the long-term experience with a re-adjustable hydraulic sling (ID-sling) device positioned dorsally to the urethra for the treatment of male post-prostatectomy incontinence (PPI).

MATERIALS AND METHODS

Between September 2007 and November 2009 13 patients with persisting SUI were treated consecutively with an ID-sling™ in two European tertiary centers by a single surgeon. Physical examinations and standardized questionnaires (ICIQ-SF + VAS), pad tests, and 24-h pad number counts were performed at baseline and during follow-up.

RESULTS

The implantation of the hydraulic cuff was uncomplicated in all cases. The ICIQ-SF score diminished from a preoperative mean value of 18 to a mean of five postoperatively. One patient remained completely dry with normal micturition. All patients demonstrated a mild improvement at primary filling but did not show any significant improvement after the second or any subsequent filling. In total, 1/13 (7.7%) patients were completely dry and 5/13 (38.4%) showed improved continence. In 6/13 (46.2%) patients, satisfactory continence results according to subjective criteria, were not achieved. Subsequently, artificial urinary sphincter (AUS) implantation was offered to one patient (7.7%) after 12 months and to ten patients (76,9%) after 24 months.

CONCLUSIONS

The implantation of a dorsally placed hydraulic sling is a not yet standardized and complex procedure, even for the experienced surgeon. To date, this implantation method is not an alternative to other devices. An improved sling design is necessary to simplify the surgical procedure and to improve long-term stability.