A Valsalva leak-point pressure of >100 cmH2O is associated with greater success in AdVance™ sling placement for the treatment of post-prostatectomy urinary incontinence

Contemporary male slings for stress urinary incontinence: advances in device technology and refinements in surgical techniques

Synthetic male sling (MS) is considered an effective surgical treatment to restore male stress urinary incontinence. The modern MS can be categorised into adjustable or non-adjustable types, while the surgical techniques can be divided into retropubic or transobturator approaches. This narrative review paper evaluates the contemporary MS devices in the current commercial market regarding clinical outcomes and refinements in surgical techniques. Scientific advances in device design and technology, coupled with further surgical refinements will enhance the clinical outcomes and improve the safety profile of MS surgery. The newer generation of modern MS not only provides direct compression of the bulbar urethra but also allows for proximal urethral relocation by realigning the mobile sphincter complex to provide further urethral sphincter complex coaptation. Strict patient selection, use of MS with proven clinical records, adherence to safe surgical principles and judicious postoperative care are critical to ensure a high continence rate, good patient satisfaction and low postoperative complications.

Valsalva leak point pressure (VLPP) greater than 70 cm H2O is an indicator for sling success: a success prediction model for the male transobturator sling

INTRODUCTION AND OBJECTIVES

Urodynamic studies are often performed in the evaluation of post-prostatectomy urinary incontinence (PPUI). The male transobturator sling (TOS) is a minimally invasive treatment for PPUI. Others have reported their results with a specific Valsalva leak point pressure (VLPP) that predicts a good outcome with the male TOS. Our objective was to determine the relationship of the pre-operative VLPP on the success rate of the male TOS in a high-volume, single center. We hypothesized that a higher pre-operative VLPP better predicts successful outcomes.

METHODS

We reviewed patients undergoing a male TOS placement from 2006 to 2012 at our institution. Patients who underwent TOS placement were identified using our patient data portal (DEDUCE). Demographic, urodynamic, and follow-up data were extracted by chart review. Post-operative success was defined by the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g per 24 h. Cox and linear regression models were performed.

RESULTS

290 patients were included. All patients underwent a radical prostatectomy for prostate cancer and presented with PPUI. Mean age at surgery was 66.3 (± 7.4) years and 84% were Caucasian. Median time to follow-up was 5 months (IQR 1-15). A linear regression model shows an inverse prediction curve for sling failure versus VLPP (p = 0.02). The hazard ratio for failure with a VLPP of ≤ 70 cm H₂O compared with a VLPP of > 70 cm H₂O, adjusted for pelvic radiation and 24-h pad weight was 0.5 (95% CI 0.2-0.98).

CONCLUSION

Patient selection is imperative in the success of the male TOS for patients with PPUI. In our cohort of patients with PPUI, those with a pre-procedural VLPP of > 70 cm H₂O were 50% less likely to fail after TOS placement versus those with a VLPP ≤ 70 cm H₂O. In our practice, we use these data to support the use of VLPP cut off of 70 cm H₂O as an indicator for success to help in the evaluation and counseling of patients.

Impact of preoperative factors on recovery of continence after artificial urinary sphincter implantation in postprostatectomy incontinence

Background

The purpose of this study was to determine the influence of preoperative factors on the recovery of continence after artificial urinary sphincter (AUS) implantation in postprostatectomy incontinence.

Materials and methods

Seventy-two patients who underwent AUS implantation between April 2006 and March 2020 were analyzed. The clinical features and preoperative urodynamic parameters were correlated with the postoperative continence rate using linear and logistic regression analysis. The recovery of continence was defined by the patient requiring no use of a protective urine pad during the 24 hours.

Results

Of the 72 patients, 57 (79.2%) recovered continence (dry group), while 15 (20.8%) were wearing more than 1 pad per day (wet group) on the last follow-up visit. In the clinical characteristics, only the interval between radical prostatectomy and AUS (in months) showed a statistically significant difference (35.4 ± 26.2 in the dry group, 22.7 ± 12.2 in the wet group, p = 0.009). Other preoperative clinical features such as the underlying disease, surgical methods, size of prostate, tumor stage, and radio nor hormonal therapy did not present statistically significant differences.

Of the preoperative urodynamic parameters, only the abdominal leak point pressure (ALPP) showed statistical significance when related to surgical outcomes by 88.6 ± 33.6 in the dry group and 66.1 ± 29.6 in wet the group (P = 0.024). The number of patients for whom ALPP was higher than 80 cm H₂O was 61.4% in the dry group and 20% in the wet group (95% confidence interval: 1.612-25.11). Other preoperative UDS features including detrusor underactivity, maximum urethral closure pressure, and others were not statistically significant.

Conclusions

The interval between RP and AUS, as well as the preoperative ALPP, can be possible predictive factors for the surgical outcomes of AUS implantation. In addition, an ALPP of >80 cm H₂O has a high degree of predictability for success of AUS surgical outcomes in post-RP incontinence.

The male sling for stress urinary incontinence: tips and tricks for success

Urethral slings are a good treatment option for mild male stress urinary incontinence. There are many different sling options, but herein our group describes our techniques with the Advance® and Virtue® slings. More important than technique, we strongly think that patient selection is paramount to sling success. We only offer slings to patients who have low 24 hour pad weights, high Valsalva leak point pressure, and no history of pelvic radiation. Still, like with any surgery, we recommend that the surgeons implant the device that they are most comfortable with along with their chosen techniques.

A novel human cadaver model to investigate a retrourethral transobturator male sling procedure

Purpose

To develop a cadaver model for the assessment of a male transobturator male sling (retrourethral transobturator sling [RTS], AdVance™; Boston Scientific, USA) to investigate its effect on a simulated abdominal and retrograde leak point pressures (ALPP, RLPP) and the urethral pressure profile (UPP).

Materials and Methods

Three fresh frozen human male cadaver specimens were obtained. A suprapubic tube was inserted into the bladder and connected to a digital manometer to measure bladder pressure. Manual suprapubic pressure was then applied to generate an increase in intraabdominal pressure and measure a simulated ALPP. Subsequent measurements of RLPP and UPP were recorded. All measurements were undertaken prior to and following insertion of a RTS.

Results

The placement of the RTS consistently increased the simulated ALPP for all three cadaver specimens when compared to baseline measures. No leaks occurred at simulated ALPP's of 170 cm H₂O for specimen 1, 160 cm H₂O for specimen 2, and 170 cm H₂O for specimen 3. There was minimal or no change in the RLPP's and UPP's following insertion of the RTS when compared to respective baseline.

Conclusions

A model using fresh unfixed cadavers that incorporates a simulated measurement of ALPP is feasible for male stress urinary incontinence surgical intervention investigations.

Male Slings for Postprostatectomy Incontinence: A Systematic Review and Meta-analysis

CONTEXT

Male slings are recommended by the European Association of Urology guideline for the treatment of mild to moderate postprostatectomy incontinence. However, none of them has been proved to be superior to the others, and there are no defined guidelines to preference of a given sling model.

OBJECTIVE

To evaluate and compare the efficacy and safety of the different types of male slings in the treatment of postprostatectomy incontinence.

EVIDENCE ACQUISITION

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. A systematic literature search in the databases of PubMed, Embase, and Cochrane using the keywords "incontinence," "prostatectomy," and "male sling/system" was conducted in June 2018. Studies in English with at least 15 patients and a minimum follow-up of 12 mo were included. As the primary endpoint, we assessed the cure rate of the different sling types. As secondary endpoints, we assessed the improvement rate, subjective cure rate, overall complication rate, explantation rate, risk factors for failure, and effect on patients' quality of life.

EVIDENCE SYNTHESIS

The literature search identified 833 articles. A total of 64 studies with 72 patient cohorts were eligible for inclusion. Fixed slings were implanted in 55 (76.4%) of the patient cohorts. The objective cure rate varies between 8.3% and 87% (pooled estimate 0.50, 95% confidence interval [CI] 0.45-0.56, I²=82%). Subjective cure was achieved in 33-94.4%. Adjustable slings showed objective cure rates between 17% and 92% (pooled estimate 0.61, 95% CI 0.51-0.71, I²=88%). The subjective cure rate varies between 28% and 100%. In both types of slings, pain was the most common complication, but chronic painful conditions were really rare (1.3% in fixed slings and 1.5% in adjustable slings). The most common complication after pain was urinary retention in fixed slings, and infection and consequential explantation in adjustable slings.

CONCLUSIONS

Both fixed and adjustable slings are beneficial for the treatment of postprostatectomy incontinence. Although adjustable slings might lead to higher objective cure rates, they might be associated with higher complication and explantation rates. However, at present, due to significant heterogeneity of the data, this cannot be said with certainty. More randomized controlled trials with long-term follow-up and the same definition for continence are needed.

PATIENT SUMMARY

Fixed and adjustable slings are effective treatment options in mild to moderate postprostatectomy incontinence.

International Consultation on Incontinence 2016; Executive summary: Urodynamic testing

AIMS

The International Consultation on Incontinence has published an update of the recommendations for the diagnosis and management of urine incontinence (ICI2016). This manuscript summarizes the consultations committee-recommendations with regard to urodynamic assessment.

METHODS

Expert consensus on the basis of structured evidence assessment has been the basis of the consultations publication and has been summarized by the committee for this manuscript.

RESULTS

Patients that are not satisfied with their initial management on the basis of their reported signs and symptoms of urinary incontinence, as well as all patients with neurological abnormalities that are potentially relevant for the function of the lower urinary tract, may very likely profit from objective diagnosis and staging and grading of their dysfunction, with urodynamic testing, regardless their age, vulnerability and/or comorbidities. The principles and technical innovations as well as the principal recommendations for the utilization of (invasive) urodynamic assessment for women, men, children, and vulnerable elderly, with or without neurogenic lower urinary tract dysfunction with urinary incontinence are provided in this abbreviated ICI recommendations-document.

CONCLUSIONS

The ICI2016 committee on urodynamics presents an executive summary of the most important reasons and recommendations for the use of urodynamic investigations for patients with urinary incontinence.

Functional follow-up after Advance® and Advance XP® male sling surgery: assessment of predictive factors

PURPOSE

To evaluate the efficacy of the Advance^® and AdvanceXP^® slings in men with stress urinary incontinence (SUI) post-radical prostatectomy and to identify predictive factors for outcome.

METHODS

Included were male patients with SUI following radical prostatectomy who had a positive "repositioning test", 24 h-pad weight (PW) test < 400 g and who were continent at night and at rest. Urgency was defined as a sudden compelling desire to pass urine, which was difficult to defer. The cure rate was defined as no pad use.

RESULTS

From February 2008 to October 2014, 24 AdVance^® and 70 AdVance XP^® were implanted. The median (range) follow-up was 49 (12-102) months. The overall cure rate was 77%. The preoperative 24 h PW was significantly related to the continence outcome (p = 0.044). A total of 12 patients (13%) presented with postoperative AUR, which was significantly related to abnormal voiding detrusor activity (p = 0.036). Twenty-two patients (23%) had postoperative urgency (16% "de novo"), which was significantly related to preoperative urgency (p = 0.003). During follow-up, a degree of deterioration of continence was observed in five patients who were classed as cured initially. To date, no reports of urethral sling erosion have been made.

CONCLUSIONS

The AdVance^® and AdVanceXP^® slings are safe and effective in relieving SUI following post-radical prostatectomy. There were no differences between the two slings in terms of efficacy, urgency or postoperative AUR. There was a moderate rate of "de novo "urgency and low rate of loss of continence during follow-up.

Recent research on the role of urodynamic study in the diagnosis and treatment of male lower urinary tract symptoms and urinary incontinence

Although evidence shows that urodynamic study may not improve outcomes, it can be used to evaluate men with lower urinary tract symptoms (LUTSs) which have not been adequately delineated and treated. In young men with LUTS not responding to treatment based on clinical examination, or elderly men with LUTS and incontinence, a complete urodynamic evaluation is mandatory to understand the pathophysiology underlying LUTS, such as bladder outlet obstruction (BOO), detrusor overactivity, and detrusor underactivity. Preoperative urodynamic study-proven BOO is a predictor of a successful surgical outcome. An urodynamic study should be performed when patients with LUTS are planning to undergo surgical treatment for benign prostatic obstruction.

Hypothesis That Urethral Bulb (Corpus Spongiosum) Plays an Active Role in Male Urinary Continence

The proximal urethral bulb in men is enlarged, surrounds the bulbous urethra, and extends dorsally towards the perineum. During intercourse engorgement takes place due to increased blood flow through the corpus spongiosum. Antegrade ejaculation is facilitated by contraction of the bulbospongiosus muscles during climax. Micturition during sexual stimulation is functionally inhibited. Supporting the bulb may indirectly facilitate continence in a certain subset of patients with postprostatectomy incontinence. During physical activity with increased abdominal pressure, reflex contraction of the pelvic floor muscles as well as the bulbospongiosus muscles occurs to support sphincter function and limit urinary incontinence. Operations to the prostate may weaken urinary sphincter function. It is hypothesized that the distal urinary sphincter may be supported indirectly by placing a hammock underneath the urethral bulb. During moments of physical stress the "cushion" of blood within the supported corpus spongiosum helps to increase the zone of coaptation within the sphincteric (membranous) urethra. This may lead to urinary continence in patients treated by a transobturator repositioning sling in patients with postprostatectomy incontinence. This paper describes the possible role of the urethral bulb in male urinary continence, including its function after retroluminal sling placement (AdVance, AdVance XP® Male Sling System, Minnetonka, USA).

Evaluation and Management of Postprostatectomy Incontinence: A Systematic Review of Current Literature

CONTEXT

Radical prostatectomy is the most common reason for male stress urinary incontinence. There is still uncertainty about its diagnostic and therapeutic management.

OBJECTIVE

To evaluate current evidence regarding the diagnosis and therapy of postprostatectomy incontinence (PPI).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in October 2015 using the Medline database.

EVIDENCE SYNTHESIS

Diagnosis and conservative treatment of PPI are currently mostly based on expert opinions. Pelvic floor muscle training is the noninvasive treatment of choice of PPI. For invasive management of moderate to severe PPI, the artificial urinary sphincter is still the treatment of choice, but an increasing number of adjustable and nonadjustable, noncompressive as well as compressive devices are used more frequently. However, no randomized controlled trial has yet investigated the outcome of one specific surgical treatment or compared the outcome of different surgical treatment options.

CONCLUSIONS

The level of evidence addressing the surgical management of PPI is still unsatisfactory. Further research is urgently needed.

PATIENT SUMMARY

Incontinence after the removal of the prostate (postprostatectomy incontinence) is the most common cause of male stress urinary incontinence. First-line therapy is physiotherapy and lifestyle changes. If no satisfactory improvement is obtained, various surgical treatment options are available. The most commonly used is the artificial urinary sphincter, but other treatment options like male slings are also available.

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure

PURPOSE

We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis.

RESULTS

A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31).

CONCLUSION

In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.