Five-Year Results of a Prospective Multicenter Trial: AdVance XP for Postprostatectomy-Incontinence in Patients with Favorable Prognostic Factors

Mitigating infections in implantable urological continence devices: risks, challenges, solutions, and future innovations. A comprehensive literature review

PURPOSE OF REVIEW

Stress urinary incontinence is a growing issue in ageing men, often following treatment for prostate cancer or bladder outflow obstruction. While implantable urological devices offer relief, infections are a significant concern. These infections can lead to device removal, negating the benefits and impacting patient outcomes. This review explores the risks and factors contributing to these infections and existing strategies to minimize them. These strategies encompass a multifaceted approach that considers patient-specific issues, environmental issues, device design and surgical techniques. However, despite these interventions, there is still a pressing need for further advancements in device infection prevention.

RECENT FINDINGS

Faster diagnostics, such as Raman spectroscopy, could enable early detection of infections. Additionally, biocompatible adjuncts like ultrasound-responsive microbubbles hold promise for enhanced drug delivery and biofilm disruption, particularly important as antibiotic resistance rises worldwide.

SUMMARY

By combining advancements in diagnostics, device design, and patient-specific surgical techniques, we can create a future where implantable urological devices offer men a significant improvement in quality of life with minimal infection risk.

AdVance™ male sling for stress urinary incontinence: Long-term follow-up and patient satisfaction

Objectives

To evaluate long-term effects, complications and satisfaction among patients treated with AdVance™ and AdVance™ XP slings (AS) at a Norwegian specialist care hospital.

Materials and Methods

Patients who had an AS implanted due to stress urinary incontinence (SUI) 2009-2016 were identified retrospectively. Demographic and perioperative data were extracted from electronic patient files. We did a patient-reported outcome measure (PROM) survey with the Expanded Prostate Cancer Index Composite (EPIC-26) urinary domain and a Satisfaction Questionnaire (SQ) 2018-2020. Cure was defined as use of ≤1 pad/day.

Results

The AS was implanted in 165 patients, mainly due to mild to moderate SUI (median leakage 112 g, range 13-589 g/24 h). Preoperative urodynamics showed mild detrusor overactivity (DO) in 11 patients. At 6-week follow-up, 148 patients (90%) were cured. The most common complication was urinary retention (N = 38), transient in 32 patients (range 1-42 days). Two patients were later operated with division of the sling due to persistent retention. During clinical follow-up of up to 12 years, 27 patients were reoperated due to persistent/recurrent incontinence. The PROM survey was sent to 125 patients and 115 (92%) replied at median 73 (20-134) months postoperatively. Ninety-one (79%) used ≤1 pads/day, 97 (85%) were satisfied, one patient-reported pain. Regression analyses showed that failure (>1 pad/day) was significantly associated with a higher amount of leakage preoperatively and at the 6-week follow-up. Total cure rate in the complete cohort was 64% at median 73 (20-134) months follow-up.

Conclusions

The AS shows good and persistent long-term results in patients with mild to moderate SUI. The only identified risk factor for long-term failure was higher amount of leakage preoperatively. The incidence of high body mass index (BMI), DO and previous radiotherapy was low and not significantly associated with failure but is still considered risk factors.

Surgical Management of Male Stress Incontinence: Techniques, Indications, and Pearls for Success

Purpose

Male stress urinary incontinence (SUI) has detrimental and long-lasting effects on patients. Management of this condition is an evolving field with multiple options for surgical treatment. We sought to review the pre-operative evaluation, intra-operative considerations, post-operative care, and future directions for treatment of male SUI.

Methods

A literature review was performed using the PubMed platform to identify peer-reviewed, English-language articles published within the last 5 years pertaining to management of male stress urinary incontinence with an emphasis on devices currently on the market in the United States including the artificial urinary sphincter (AUS), male urethral slings, and the ProACT^TM system. Patient selection criteria, success rates, and complications were compared between the studies.

Results

Twenty articles were included in the final contemporary review. Pre-operative workup most commonly included demonstration of incontinence, PPD, and cystoscopy. Definition of success varied by study; the most common definition used was social continence (0-1 pads per day). Reported rates of success were higher for the AUS than for male urethral slings (73-93% vs 70-90%, respectively). Complications for these procedures include urinary retention, erosions, infections, and device malfunction. Newer treatment options including adjustable balloon systems and adjustable slings show promise but lack long-term follow-up.

Conclusion

Patient selection remains the primary consideration for surgical decision-making for management of male SUI. The AUS continues to be the gold standard for moderate-to-severe male SUI but comes with inherent risk of need for revision. Male slings may be a superior option for appropriately selected men with mild incontinence but are inferior to the AUS for moderate and severe incontinence. Ongoing research will shed light on long-term results for newer options such as the ProACT and REMEEX systems.

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.

Long-term Functional Outcomes and Patient Satisfaction After AdVance and AdVanceXP Male Sling Surgery

BACKGROUND

Transobturator male sling has gained increasing acceptance for the treatment of male urinary incontinence. Several prospective trials have demonstrated the safety and efficacy of the AdVance and AdVanceXP slings.

OBJECTIVE

To evaluate long-term functional outcomes after AdVance or AdVanceXP sling implant for non-neurogenic male stress urinary incontinence and identify factors associated with a higher risk for incontinence or decreased satisfaction.

DESIGN, SETTING, AND PARTICIPANTS

Patients who underwent AdVance or AdVanceXP implant surgery between June 2007 and April 2018 were retrospectively included in this single-institution, consecutive series.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

In April 2020, patients were recontacted to evaluate long-term functional outcomes and satisfaction by standardized, validated questionnaires.

RESULTS AND LIMITATIONS

A total of 216 patients were included in this study; 172 of them could be contacted for the assessment of long-term patient reported outcomes. The median follow-up period was 49 mo. Overall social continence (ie, needing no more than one pad per 24 h) at 5-yr follow-up was 66% (confidence interval [CI]: 58-73%). In an ideal population (ie, needing no more than four pads per 24 h and naïve for pelvic radiotherapy, prior incontinence surgery, or urethral stricture surgery), 5-yr social continence rates were markedly better and reached 79% (CI: 69-85%). Overall social continence rates tended to decrease at 10-yr follow-up to 42% (CI: 33-52%). Overall, totally dry rate at 5-yr follow-up was 53% (CI: 46-60%), which again was significantly better in the ideal population (62%, CI: 51-70%). According to the Patient Global Improvement Indices score, 71% (CI: 63-78%) of patients indicated to be satisfied after 5 yr, which improved to 77% (CI: 67-85%) in the ideal patient population. In a multivariate analysis, prior pelvic radiotherapy and previous incontinence or urethral stricture surgery were associated with decreased continence rates and patient satisfaction.

CONCLUSIONS

In general, long-term continence rates and patient satisfaction after AdVance and AdVance XP sling surgery are acceptable but deteriorate significantly as time from surgery progresses. Especially patients with a history of pelvic radiotherapy, prior incontinence surgery, or urethral stricture surgery should be counseled properly about their higher risk for sling failure.

PATIENT SUMMARY

In this report, we investigated long-term outcomes after Advance and AdvanceXP sling implant for male stress urinary incontinence. We found that, in general, continence and patient satisfaction are acceptable but deteriorate significantly as time from surgery progresses. Patients with previous pelvic radiotherapy, incontinence surgery, or urethral stricture surgery are at higher risk for sling failure.

ATOMS (Adjustable Transobturator Male System) Is an Effective and Safe Second-Line Treatment Option for Recurrent Urinary Incontinence after Implantation of an AdVance/AdVance XP Fixed Male Sling? A Multicenter Cohort Analysis

(1) Background: This study examined outcomes of second-line ATOMS implantation after failure of the fixed male sling (FMS) AdVance/AdVance XP. (2) Methods: A retrospective multicenter cohort analysis was carried out in men implanted with an ATOMS between 2011 and 2020 after failure of an AdVance/AdVance XP. Success was assessed on the basis of objective (dryness, 0-1 pad/24 h or >20 g/24 h pad test) and subjective results (PGI-I). We performed the Wilcoxon rank sum test, Fisher's exact test, logistic regression, and multivariate analysis. (3) Results: The study included 88 patients from 9 centers with a mean age of 71.3 years. No Clavien-Dindo > II complications occurred within the first 3 months after ATOMS implantation. A total of 10 cases (9%) required revision in the ensuing clinical course. After a mean follow-up of 42.5 months, 76.1% achieved social continence, and 56.8% used no pads at all. Mean urine leakage/24 h dropped from 422 g (3.9 pads) to 38 g (0.69 pads) and the mean ICIQ-SF decreased from 16.25 to 5.3 (p < 0.0001). PROMs (patient-reported outcome measures) showed improvement in 98.9% of cases, and 63.6% gave a "very much better" PGI-I rating. Multivariate analysis identified a lower probability of achieving maximum satisfaction for the following factors: the AdVance XP as first-line therapy (OR 0.35), a lower ICIQ-SF question 1 (OR 0.26), status post-irradiation (OR 0.14), and more severe pain prior to ATOMS implantation (OR 0.51). (4) Conclusions: Implantation of an ATOMS is an effective and safe second-line treatment option for recurrent urinary incontinence after implantation of an AdVance/AdVance XP sling. High patient satisfaction was demonstrated in a long-term follow-up.

Age at surgery is not a prognostic factor for the AdVance-XP male sling efficacy: A post-hoc analysis of a prospective 7-year multicentric study

OBJECTIVE

To evaluate the factor age at the surgery on long-term postoperative outcomes in patients with postprostatectomy incontinence (PPI) after AdVance XP transobturator male sling implantation.

METHODS

A total of 115 male patients with PPI, who had undergone AdVance XP sling implantation, were included. Patients had PPI with endoscopically confirmed good sphincteric-contractility and a positive coaptive response. Kruskal-Wallis test with Dunn post-hoc tests were used to analyze the postoperative outcome differences between the patient groups aged less than 66, 66-75, and over greater than 75 years. Outcome measures were the 24 h pad test, the number of daily pads used, the International Consultation on Incontinence Questionnaire short form (ICIQ-SF), International Quality of Life Score (IQOL), Patient Global Impression of Improvement (PGI-I), International Index of Erectile Function-5 (IIEF-5), International Prostate Symptom Score (IPSS), and Visual Analog Scale scores. Observation time points were 3, 6, 12, 24, 36, 48, 60, and 84 months after surgery.

RESULTS

Between the age groups, there was no difference in the success rate of the procedure (defined as 0 pads/24 h and less than 5 g in the 24-h pad test) at any point in time. Subjective parameters measures using the ICIQ-SF, PGI-I, IQOL, and IPSS scores showed no differences between the two cohorts. Only erectile function (IIEF-5 score) was lower in older patients in comparison to the cohort aged less than 66 years (p < 0.05 at 3, 6, 12, 24, 36, and 48 months).

CONCLUSIONS

The present study complements the European multicentre AdVance XP follow-up study. Here, we show that age at surgery does not affect the objective success, subjective success, or the complication rate. Thus, we do not recommend factoring in chronological age into surgical selection criteria for the AdVance XP implantation.

[Alloplastic material in the treatment of urinary incontinence]

Surgery for urinary incontinence is indicated after failure of conservative treatment with pelvic floor therapy. Different sling systems are the established treatment option for urinary incontinence for female and male patients. Tension-free vaginal tapes represent the standard of care in the surgical treatment of female stress urinary incontinence. In male patients with mild or moderate stress urinary incontinence, fixed repositioning slings or adjustable compressive slings represent minimally invasive alternatives to the artificial urinary sphincter. The use of surgical mesh material has been widely discussed within the last years. The current US Food and Drug Administration warning was focused on the use of transvaginal mesh implants in female patients with pelvic organ prolapse. Within the current debate, surgery for stress urinary incontinence and surgery for pelvic organ prolapse have often not been differentiated. With this ongoing discussion about the use of foreign material in reconstructive surgery, laparoscopic colposuspension might be performed more often in the near future.