Stress urinary incontinence in the prostate cancer survivor

The Role of Educational Level and Cognitive Status in Men Undergoing Artificial Urinary Sphincter Implantation

OBJECTIVE

To examine the relationship between education level, cognitive function of patients and the success/ revision rates of artificial urinary sphincter (AUS) implantation in men with postprostatectomy incontinence.

METHODS

Between January 2010 and March 2018, 163 patients (mean age, 68 ± 6.8 years) with moderate-to-severe stress urinary incontinence who underwent AUS implantation were retrospectively examined. Demographic data, body mass index, comorbidities, surgical technique, previous strictures, and radiation therapy were recorded. Incontinence was measured by daily pad use and evaluated by International Consultation on Incontinence Questionnaire-short form. Patients' overall improvement was assessed using the Patient Global Impression of Improvement questionnaire. Education level was determined using the International Standard Classification of Education. Cognitive status was assessed using the Mini-Mental State Examination. Treatment success was defined as the need for ≤1 pad/day at last follow-up.

RESULTS

AUS was successful in 77.3% of patients. The International Consultation on Incontinence Questionnaire-short form score improved significantly from 19.9 ± 2.9 to 4.4 ± 5.4 (P = .001). The median outcome reported subjectively on the Patient Global Impression of Improvement scale was 2.1 ± 1.5 (1-7) and self-reported as "much better." Patients' education level had statistically no significant relationship with AUS success and revision rates. Similarly, there was no significant relationship between cognitive status, educational level and the need for revision of AUS (P >.05). However, patients with moderate cognitive impairment and a body mass index >30 showed significantly lower AUS success rates (P <.05).

CONCLUSION

AUS implantation is safe and effective treatment option especially for nonobese and cognitively intact patients of all educational levels.

Treatment of male stress urinary incontinence with the adjustable transobturator male system: Outcomes of a multi-center Iberian study

AIM

To evaluate effectiveness and safety of the adjustable transobturator male system (ATOMS) for male stress urinary incontinence (SUI).

MATERIAL AND METHODS

A retrospective multicenter study was conducted in nine Iberian institutions using a board-approved database for 215 patients intervened between 2012 and 2017, with no case excluded. Continence status, patient satisfaction, number, and grade of complications (Clavien-Dindo) and factors affecting dry rate at adjustment were evaluated. Multivariate analysis defined the population at best success rate. Incontinence recurrence due to device failure and/or explant was evaluated and Kaplan-Meier curve for durability performed.

RESULTS

Adjustment was achieved at a mean 1.4 ± 1.9 fillings. Dry-rate after adjustment was 80.5% (96.2% mild and 75.3% moderate-severe), 121 (56.3%) used no pads, and 52 (24.2%) a security pad with urine loss under 10 mL. Mean basal daily pad-test and pad-count decreased from 484 ± 372.3 mL and 3.9 ± 2 pads to 63.5 ± 201.2 mL and 0.9 ± 1.5pads (both P < 0.0001). Satisfaction rate was 85.1% (94.3% mild and 82.1% moderate-severe). Factors associated to dryness were: lesser severity of SUI (P < .0001), absence of radiotherapy (P = 0.0002) and device generation (P = 0.05). Multivariate analysis revealed absence of radiation (OR = 3.12; 1.36-7.19), mild (OR = 19.61; 3.95-100), and moderate (OR = 2.48; 1.1-5.59) SUI were independent predictors. Complications presented in 33(15.35%); 66.7% grade 1, 9.1% grade 2, and 24.2% grade 3. At 24.3 ± 15 mo mean follow-up device was explanted in seven (3.25%) and SUI worsened after adjustment in nine (4.2%). Dry-rate at follow-up was 73% and durability of device in dry patients at adjustment was 89.8% (82.9-94) at 2-years.

CONCLUSIONS

This study confirms ATOMS device is safe and achieves high treatment efficacy and patient satisfaction in a multicenter setting. Significantly better results are achieved in less severe and non-irradiated cases. Durability of the device is reassuring in the short-term.

Artificial urinary sphincter for urinary incontinence after radical prostatectomy: a historical cohort from 2004 to 2015

This study aimed to retrospectively evaluate a cohort of patients with prostate cancer and persistent urinary incontinence after radical prostatectomy. From January 2004 to December 2015, eighty-six individuals were identified to have received an AUS implant, provided by a private nonprofit HMO operating in Belo Horizonte, Brazil. On total, there were 91 AUS implants, with a median interval between radical prostatectomy and AUS implant of 3.6 years (IQR 1.9 to 5.5). The rate of AUS cumulative survival, after a median follow-up of 4.1 years (IQR 1.7-7.2 years), was 44% (n=40). The median survival of AUS implants was 2.9 years (IQR 0.5-7.9 years). Thirty-seven AUS implants (40.7%) resulted in grade III surgical complications. There were 5 deaths at 2.1, 4.7, 5.7, 5.7 and 6.5 years of follow-up, but none due to causes directly associated to the AUS implant. Persistent severe incontinence was documented in 14 (15.3%) additional patients. From the 51 AUS implants which resulted in grade III surgical complications or persistent severe incontinence, 24 (47.1%) underwent surgical revisions. Explantation of the sphincter or its components was observed in 6 cases (25.0%). Mechanical failure, described as fluid loss and/or inability to recycle the AUS device, was observed in 4 devices (16.7%). In conclusion, although AUS implants are recommended as the gold-standard treatment of severe urinary incontinence after prostatectomy, the observed high rates of malfunction and grade III adverse events are a matter of concern warranting further assessment on the safety and efficacy of these devices.

Review Article: Past, Present and Future of Cancer Survivorship and the Importance of the Urologist

INTRODUCTION

Cancer survivorship is a concept that focuses on the complete medical and holistic care of the patient with cancer from the time of diagnosis to the time of death. In 2015 the number of cancer survivors in the United States was expected to exceed 14.5 million people and a significant portion of these patients have malignancies that affect the genitourinary health of the survivor. In this review we describe the concept of cancer survivorship and review the important role of the urologist in cancer survivor care.

METHODS

A literature search concerning cancer survivorship and urogenital neoplasms was performed. We systematically searched Medline® from inception until July 2015 with the objective of identifying studies specifically targeting broad survivorship care concerns for genitourinary neoplasms. We also included nonsystematically identified publications, and governmental and agency produced reports that are currently available through various government entities and organizations.

RESULTS

Systematic searching yielded 35 articles and 7 reports for inclusion in our literature review. Urology relevant Medline findings were categorized into review articles, biopsychosocial aspects of cancer care, guidelines or society recommendations, diet and exercise related materials, models or coordination of care, or other. We found that the development of guidelines and recommendations for survivorship care in urology has been limited by the quality of the studies published to date.

CONCLUSIONS

More patients are surviving cancer and living with the consequences of treatment of the primary disease. Awareness of the components of survivorship will be critical as more national organizations require specific survivorship care programs to address these issues. Given that a large number of cancer survivors in the United States have survived urological malignancy or have urological side effects of treatment, the urology community must be familiar with the global concept of survivorship.

Pubic symphysis osteomyelitis in the prostate cancer survivor: clinical presentation, evaluation, and management

OBJECTIVE

To describe pelvic bone osteomyelitis in the prostate cancer survivor, to report on clinical presentation and treatment, and to suggest an algorithmic approach to managing this syndrome complex.

MATERIALS AND METHODS

A retrospective chart review from January 2011 to June 2014 was performed to identify prostate cancer patients with pubic symphysis osteomyelitis at a tertiary-care academic medical center with emphasis on genitourinary cancer survivorship. Data on clinical presentation and outcomes were reviewed.

RESULTS

Ten patients were diagnosed with having osteomyelitis of the pubic symphysis with or without extension into the pubic rami. Three patients had associated rectal fistulas. Four patients had radical prostatectomy, 5 patients received radiotherapy, and 1 patient received high-intensity focused ultrasound as the primary treatment for prostate cancer. The most common presenting symptoms were pelvic and suprapubic pain, difficulty in walking, and recurrent urinary infections at a median of 7 years after prostate cancer treatment (range, 1.5-16 years). Eight of the 10 patients underwent pubic bone debridement with urinary and fecal diversion when needed. Two patients continue to be managed conservatively with suppressive antibiotics owing to low disease burden. Complete resolution of symptoms was noted in patients undergoing operative intervention, without any pelvic ring instability due to pubic bone resection.

CONCLUSION

The combination of pelvic pain, difficulty with ambulation, and recurrent infections in a prostate cancer survivor should prompt investigation for pubic bone osteomyelitis-a poorly recognized syndrome complex that is best managed in a multidisciplinary setting.