Male synthetic sling versus artificial urinary sphincter trial for men with urodynamic stress incontinence after prostate surgery (MASTER): study protocol for a randomised controlled trial

Current status of the adjustable transobturator male system (ATOMSTM) for male stress urinary incontinence

Male stress urinary incontinence is a debilitating condition, which can occur after prostate surgery. In persistent cases, surgery is indicated and a number of options are available. This includes one of the male slings, Adjustable transobturator male system (ATOMSTM, A.M.I, Austria). There are now an increasing number of studies published. This review provides an overview of the current status of this implant device including technical considerations, surgical outcomes and potential advantages and disadvantages compared to alternatives such as the artificial urinary sphincter.

A modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for male stress urinary incontinence: a pilot study

OBJECTIVES

The aim of this study was to demonstrate the feasibility of a modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for the treatment of male urinary incontinence and to preliminarily evaluate the short-term clinical efficacy of this technique.

PATIENTS AND METHODS

The clinical data of patients treated with the modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique using a Pelvimesh pelvic floor repair patch as a sling were collected. The primary evaluation criteria were surgery-related indicators and daily urinal pad usage before and after treatment, and the secondary evaluation criteria were the corresponding incontinence scores and the results of surgery-related questionnaires.

RESULTS

After 1-12 months of follow-up, seven patients were clinically cured. Follow-up 1 month after surgery showed that one patient (14.3%) used one pad daily, and six patients (85.7%) did not need pads. The incontinence quality of life questionnaire (I-QOL) scores at 3 days and 1 month postoperatively were 89.4 ± 2.5 and 88.1 ± 6.7, respectively, which were significantly higher than the preoperative scores (31.5 ± 18.9) (P < 0.05). The scores of the International Continence Control Association Incontinence Questionnaire Short Form (ICI-Q-SF) at 3 days and 1 month postoperatively were 3.2 ± 0.9 and 4.2 ± 1.7, respectively, which were significantly lower than the preoperative scores of 19.4 ± 5.0 (P < 0.05). In addition, the results of the surgery-related questionnaires were positive. No serious complications occurred in any of the patients.

CONCLUSION

The modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for the treatment of male urinary incontinence patients is safe, effective, minimally invasive, and has few complications. However, further validation in large sample, randomized, comparative, and longer-term follow-up studies is still needed.

Modified Sling Midurethral Suspension+Hemolock Fixation Technique for Male Urinary Incontinence: A Pilot Study

OBJECTIVE

To demonstrate the feasibility of a modified midurethral sling+hemolock fixation technique for treating male urinary incontinence. This study aims to provide a preliminary assessment of the short-term clinical efficacy of this technique.

METHODS

We collected the clinical data of patients treated with modified sling midurethral suspension+ hemolock fixation technique. The primary evaluation criteria were surgery-related indicators and daily urinal pad usage by patients before and after treatment, and the secondary evaluation criteria were the corresponding incontinence scores and the results of surgery-related questionnaires.

RESULTS

Follow-up 1-7months, eight patients achieved a clinical cure. Follow-up 1month after surgery showed that two patients (25.0%) used one pad daily and six patients (75.0%) did not need pads. The incontinence quality of life questionnaire (I-QOL) scores were (86.0 ± 7.0) and (89.0 ± 3.0) at three postoperative days and one postoperative month, respectively, which were significantly higher than the preoperative scores (26.0 ± 6.0) (P <.05). The scores of the International Continence Control Association Incontinence Questionnaire Short Form (ICI-Q-SF) at three postoperative days and one postoperative month were (4.0 ± 2.0) and (4.0 ± 1.0), respectively, which were significantly lower than the preoperative scores of (18.0 ± 1.0) (P <.05). Besides, the results of the surgery-related questionnaires were positive.

CONCLUSION

The short-term efficacy of the modified sling midurethral suspension+ hemolock fixation technique for the treatment of male urinary incontinence patients is safe, effective, minimally invasive, and has few complications. However, further validation in large samples, randomized, comparative, and longer-term follow-up studies is still needed.

Efficacy of electrical pudendal nerve stimulation versus pelvic floor muscle training in treating postradical prostatectomy urinary incontinence: study protocol for a randomised controlled trial

INTRODUCTION

Urinary incontinence (UI) is one of the main complications of radical prostatectomy. Electrical pudendal nerve stimulation (EPNS) has been used to treat stress UI based on its mechanism of passive pelvic floor muscle contraction reported in the previous research. However, there are no studies comparing the effects of EPNS and active pelvic floor muscle training (PFMT) in the treatment of postradical prostatectomy UI (PPUI). Here, we describe the protocol for a randomised controlled trial to evaluate the efficacy of EPNS in treating PPUI compared with PFMT.

METHODS AND ANALYSIS

This study is designed as an open-label randomised controlled trial with blinded assessment and analysis. A total of 90 eligible men will be randomly allocated to two groups. The treatment group (n=45) will receive EPNS while the control group will perform PFMT by doing the Kegel exercise. Forty EPNS treatment sessions will occur over a period of 8 weeks. The primary outcome measure will be improvement rate, and the secondary outcome measures, the number of pads used, 24-hour pad test, and International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form will be compared between baseline and the study endpoint. The International Consultation on Incontinence Questionnaire-Lower Urinary Tract Symptoms Quality of Life and care compared as the quality of life and satisfaction outcomes between groups.

ETHICS AND DISSEMINATION

This protocol has been approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (approval no. 2021 KL-040-02). Written informed consent will be obtained from each participant. The results of the study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2200055461.

The "Minimal-Touch" Technique for Artificial Urinary Sphincter Placement: Description and Outcomes

OBJECTIVE

The study aimed to describe "minimal-touch" technique for primary artificial urinary sphincter placement and evaluate early device outcomes by comparing it with a historical cohort.

MATERIALS AND METHODS

We identified patients who underwent primary artificial urinary sphincter placement at our institution from 1983 to 2020. Statistical analysis was performed to identify the rate of postoperative device infection in patients who underwent minimal touch versus those who underwent our traditional technique.

RESULTS

526/2601 total procedures (20%) were performed using our "minimal-touch" approach, including 271/1554 patients (17%) who underwent primary artificial urinary sphincter placement over the study period. Around 2.3% of patients experienced device infection after artificial urinary sphincter procedures. In the "minimal-touch" era, 3/526 patients (0.7%) experienced device infection, including 1/271 (0.4%) of those with primary artificial urinary sphincter placement. In comparison, 46/2075 patients (2.7%) experienced device infection using the historical approach, with 29/1283 (2.3%) of primary artificial urinary sphincter placements resulting in removal for infection. Notably, 90% of device infections occurred within the first 6 months after primary placement. The difference in cumulative incidence of device infections at 12 months did not meet our threshold for statistical significance for either the total cohort of all AUS procedures (primary and revision) or the sub-group of only those patients undergoing primary artificial urinary sphincter placement (Gray K-sample test; P=.13 and .21, respectively).

CONCLUSION

The "minimal-touch" approach for artificial urinary sphincter placement represents an easy-to-implement modification with potential implications on device outcomes. While early results appear promising, longer-term follow-up with greater statistical power is needed to determine whether this approach will lower the infection risk.

Early activation of artificial urinary sphincter for stress incontinence is safe: A pilot study

Background:

Artificial urinary sphincter (AUS) activation is usually deferred until 6 weeks following insertion. However, this timeframe for activation is based on traditional dogma. This study aims to assess the feasibility, efficacy and safety of earlier activation of AUS.

Methods:

A prospective database was established on consecutive patients undergoing AUS implantation (AMS-800 Boston Scientific) from March 2019 to March 2022 by a single fellowship-trained urologist. Early activation was defined as <30 days from the date of implantation.

Results:

Twenty-one patients were included in the study with a median follow-up of 34 (range: 3–96) months. The most common indication for AUS insertion was post-prostatectomy stress urinary incontinence ( n = 19, 90%). All 21 patients had their AUS successfully activated and used before 30 days, with a median of 14 (range: 9–28) days. Median (range) pre-operative continence pad numbers were 3 (2–6) and 0 (0–1) at 4 weeks post-operatively. Median (range) pad weight per day was 600 g (190–1310 g) pre-operatively and 6 g (0–6 g) at 4 weeks post-operatively. There were no adverse events associated with early activation.

Conclusion:

To our knowledge, this is the first description of the early activation of the AMS-800 AUS device. Our preliminary experience indicates early activation is safe and acceptable for patients.

Level of evidence:

II

Space-time distribution of urinary incontinence outpatient production in men, Brazil, 2010-2019

OBJETIVE

To estimate the temporal trend and spatial distribution of urinary incontinence outpatient production in men in Brazil.

METHODS

This was an ecological time series study of Brazil and its regions, from 2010-2019, using data from the Brazilian National Health System Outpatient Information System. Prais-Winsten regression was used to analyze the temporal trend in Brazil as a whole and by region. The autoregressive integrated moving average model was used to forecast the trend until 2024.

RESULTS

In 2010, 3,457 outpatient appointments for urinary incontinence in men were registered, rising to 16,765 in 2019, revealing a rising temporal trend [annual percentage change = 50.37%; 95% confidence interval (95%IC) 37.54;63.62]; and a forecast of growth for the period 2020-2024 (final ARIMA model: 1, 1, 0). The spatial distribution of urinary incontinence rates varied between the country's macro-regions.

CONCLUSION

There was a rising temporal trend in urinary incontinence outpatient production in men in Brazil between 2010-2019 with growth forecast until 2024. The highest rates occurred in the Southeast region and the highest increase was found in the Southern region.

Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT

BACKGROUND

Stress urinary incontinence is common in men after prostate surgery and can be difficult to improve. Implantation of an artificial urinary sphincter is the most common surgical procedure for persistent stress urinary incontinence, but it requires specialist surgical skills, and revisions may be necessary. In addition, the sphincter is relatively expensive and its operation requires adequate patient dexterity. New surgical approaches include the male synthetic sling, which is emerging as a possible alternative. However, robust comparable data, derived from randomised controlled trials, on the relative safety and efficacy of the male synthetic sling and the artificial urinary sphincter are lacking.

OBJECTIVE

We aimed to compare the clinical effectiveness and cost-effectiveness of the male synthetic sling with those of the artificial urinary sphincter surgery in men with persistent stress urinary incontinence after prostate surgery.

DESIGN

This was a multicentre, non-inferiority randomised controlled trial, with a parallel non-randomised cohort and embedded qualitative component. Randomised controlled trial allocation was carried out by remote web-based randomisation (1 : 1), minimised on previous prostate surgery (radical prostatectomy or transurethral resection of the prostate), radiotherapy (or not, in relation to prostate surgery) and centre. Surgeons and participants were not blind to the treatment received. Non-randomised cohort allocation was participant and/or surgeon preference.

SETTING

The trial was set in 28 UK urological centres in the NHS.

PARTICIPANTS

Participants were men with urodynamic stress incontinence after prostate surgery for whom surgery was deemed appropriate. Exclusion criteria included previous sling or artificial urinary sphincter surgery, unresolved bladder neck contracture or urethral stricture after prostate surgery, and an inability to give informed consent or complete trial documentation.

INTERVENTIONS

We compared male synthetic sling with artificial urinary sphincter.

MAIN OUTCOME MEASURES

The clinical primary outcome measure was men's reports of continence (assessed from questions 3 and 4 of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) at 12 months post randomisation (with a non-inferiority margin of 15%). The primary economic outcome was cost-effectiveness (assessed as the incremental cost per quality-adjusted life-year at 24 months post randomisation).

RESULTS

In total, 380 men were included in the randomised controlled trial (n = 190 in each group), and 99 out of 100 men were included in the non-randomised cohort. In terms of continence, the male sling was non-inferior to the artificial urinary sphincter (intention-to-treat estimated absolute risk difference -0.034, 95% confidence interval -0.117 to 0.048; non-inferiority p = 0.003), indicating a lower success rate in those randomised to receive a sling, but with a confidence interval excluding the non-inferiority margin of -15%. In both groups, treatment resulted in a reduction in incontinence symptoms (as measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form). Between baseline and 12 months' follow-up, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score fell from 16.1 to 8.7 in the male sling group and from 16.4 to 7.5 in the artificial urinary sphincter group (mean difference for the time point at 12 months 1.30, 95% confidence interval 0.11 to 2.49; p = 0.032). The number of serious adverse events was small (male sling group, n = 8; artificial urinary sphincter group, n = 15; one man in the artificial urinary sphincter group experienced three serious adverse events). Quality-of-life scores improved and satisfaction was high in both groups. Secondary outcomes that showed statistically significant differences favoured the artificial urinary sphincter over the male sling. Outcomes of the non-randomised cohort were similar. The male sling cost less than the artificial sphincter but was associated with a smaller quality-adjusted life-year gain. The incremental cost-effectiveness ratio for male slings compared with an artificial urinary sphincter suggests that there is a cost saving of £425,870 for each quality-adjusted life-year lost. The probability that slings would be cost-effective at a £30,000 willingness-to-pay threshold for a quality-adjusted life-year was 99%.

LIMITATIONS

Follow-up beyond 24 months is not available. More specific surgical/device-related pain outcomes were not included.

CONCLUSIONS

Continence rates improved from baseline, with the male sling non-inferior to the artificial urinary sphincter. Symptoms and quality of life significantly improved in both groups. Men were generally satisfied with both procedures. Overall, secondary and post hoc analyses favoured the artificial urinary sphincter over the male sling.

FUTURE WORK

Participant reports of any further surgery, satisfaction and quality of life at 5-year follow-up will inform longer-term outcomes. Administration of an additional pain questionnaire would provide further information on pain levels after both surgeries.

TRIAL REGISTRATION

This trial is registered as ISRCTN49212975.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 36. See the NIHR Journals Library website for further project information.

Acupuncture for prostatectomy incontinence: study protocol for a multicenter single-blind randomized parallel controlled trial

BACKGROUND

Urinary incontinence is a common complication post radical prostatectomy. Acupuncture is considered an effective treatment for post-prostatectomy incontinence (PPI), but the evidence is still limited. We propose to evaluate the effectiveness of acupuncture in a rigorously conducted trial.

METHODS

Twenty hospitals will recruit 340 participants with urinary incontinence after radical prostatectomy in China from April 2021 to April 2022. Participants will be randomly allocated to acupuncture or sham acupuncture with a 1:1 ratio using computerized simple random sampling. The study plan consists of 1-week baseline, 6-week treatment, and 18-week follow-up. Eighteen 30-min sessions of acupuncture or sham acupuncture treatment will be provided between weeks 1 and 6. The primary outcome is the change in the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF) score at the week 6 from the baseline. Secondary outcomes include the change in volume of urine leakage at weeks 4 and 6 from a baseline measured using the 1-h pad test; 72-h incontinence episode frequency based on a 72-h voiding diary; change in the Expanded prostate cancer Index Composite scale (EPIC-26); change in the Self-Rating Anxiety Scale; weekly consumption of pads; and the severity of urinary incontinence based on a 72-h bladder diary and self-assessment of the therapeutic effect. The safety of acupuncture will also be assessed.

DISCUSSION

This trial will help to identify whether acupuncture is effective for PPI, and, if so, whether it exerts a therapeutic rather than a placebo effect.

TRIAL REGISTRATION

www.Chictr.org.cn ChiCTR2100042500 . Retrospectively registered on 22 January 2021.

Efficacy and safety of onabotulinumtoxin A injection in male patients with detrusor overactivity after stress urinary incontinence surgery

INTRODUCTION AND OBJECTIVE

The use of onabotulinumtoxin A (BoNT-A) injection in male patients with detrusor overactivity (DO) after stress urinary incontinence (SUI) surgery has been scarcely described. Our aim was to assess results of this treatment in this specific population.

MATERIALS AND METHODS

Retrospective analysis of men with previous SUI surgery who had been treated with a first injection of 100 U BoNT-A because of DO since 2010 in our department. Treatment response was assessed with the Treatment Benefit Scale: 1) greatly improved; 2) improved; 3) not changed; 4) worsened after treatment (Treatment Benefit Scale 1 or 2: treatment response). Complications were classified according to the Clavien-Dindo classification. Treatment continuation was considered present if, at the last visit, patients had received a BoNT-A injection within the preceding 12 months. Pre- and post-treatment urodynamic variables were compared.

RESULTS

Eighteen patients were included, median age 71.1 (59.1-83.5) years. Twelve (66.7%) patients reported response to treatment. Two (11.1%) complications were detected: urinary retention requiring clean intermittent catheterization (Clavien-Dindo 2). No complications related to previous SUI surgery were detected. Fifteen (83.3%) patients had a follow-up >12 months (median follow-up 57 [15-89] months) and all of them had discontinued treatment at the end of follow-up. Urodynamic studies showed significant improvement in terms of DO and bladder compliance.

CONCLUSION

Although most men with DO after SUI surgery respond to intradetrusor BoNT-A injection, all of them discontinue treatment due to personal reasons. It is a safe procedure, with urinary retention requiring clean intermittent catheterization being the most frequent complication.

Efficacy and safety of onabotulinumtoxin A injection in male patients with detrusor overactivity after stress urinary incontinence surgery

INTRODUCTION AND OBJECTIVE

The use of onabotulinumtoxin A (BoNT-A) injection in male patients with detrusor overactivity (DO) after stress urinary incontinence (SUI) surgery has been scarcely described. Our aim was to assess results of this treatment in this specific population.

MATERIALS AND METHODS

Retrospective analysis of men with previous SUI surgery who had been treated with a first injection of 100U BoNT-A because of DO since 2010 in our department. Treatment response was assessed with the Treatment Benefit Scale: 1) greatly improved; 2) improved; 3) not changed; 4) worsened after treatment (Treatment Benefit Scale 1 or 2: treatment response). Complications were classified according to the Clavien-Dindo classification. Treatment continuation was considered present if, at the last visit, patients had received a BoNT-A injection within the preceding 12 months. Pre- and post-treatment urodynamic variables were compared.

RESULTS

Eighteen patients were included, median age 71.1 (59.1-83.5) years. Twelve (66.7%) patients reported response to treatment. Two (11.1%) complications were detected: urinary retention requiring clean intermittent catheterization (Clavien-Dindo 2). No complications related to previous SUI surgery were detected. Fifteen (83.3%) patients had a follow-up>12 months (median follow-up 57 [15-89] months) and all of them had discontinued treatment at the end of follow-up. Urodynamic studies showed significant improvement in terms of DO and bladder compliance.

CONCLUSION

Although most men with DO after SUI surgery respond to intradetrusor BoNT-A injection, all of them discontinue treatment due to personal reasons. It is a safe procedure, with urinary retention requiring clean intermittent catheterization being the most frequent complication.

Evaluation of the 24-h pad weight test as continence rate assessment tool after artificial urinary sphincter implantation for postprostatectomy urinary incontinence: A Swedish retrospective cohort study

AIM

Patient-reported pad-count as continence rate assessment tool after artificial urinary sphincter (AUS) implantation is common. However, lack of standardized continence definition using this method results in heterogeneous published efficacy outcomes. Data on 24-h pad weight tests (PWT) after primary AUS implantation for postprostatectomy urinary incontinence (PPUI) is scarce. Our aim was to evaluate the 24-h PWT as an efficacy assessment tool and correlate it to qualitative outcomes using validated questionnaires.

METHODS

This retrospective, single center, follow-up cohort study, evaluated 180 patients who underwent primary AUS implantation for PPUI from 2005 to 2018. Voiding diaries, 24-h PWT, validated patient satisfaction and quality of life (QoL) questionnaires were collected pre-operatively and at 3-6 months postactivation, using the institution's Electronic Medical Records.

RESULTS

The median preoperative and postoperative 24-h PWT values were 494 (interquartile range [IQR]: 304-780) and 7 (IQR: 0-25) g respectively with a significant improvement in urinary leakage of 489.5 g 99.1% (p < 0.001). Median preoperative and postoperative I-QoL results increased from 33.5 (IQR: 19.3-63.6) to 86.4 (IQR: 73.9-94.3) points, with a significant 52.9 points improvement in QoL (p < 0.001). Similarly, the median preoperative and postoperative ICIQ-SF values decreased from 20 (IQR: 17-21) to 5 (IQR: 3-9) points, showing a significant improvement of 15 points (p < 0.001). We also found a significant correlation between PWT and patient satisfaction.

CONCLUSION

The 24-h PWT provides a reliable and objective assessment of continence rates, with a strong correlation to qualitative outcomes, after primary AUS implantation for PPUI. Its use could help reduce reported outcome heterogeneity across studies.

Outcomes of a Noninferiority Randomised Controlled Trial of Surgery for Men with Urodynamic Stress Incontinence After Prostate Surgery (MASTER)

BACKGROUND

Stress urinary incontinence (SUI) is common after radical prostatectomy and likely to persist despite conservative treatment. The sling is an emerging operation for persistent SUI, but randomised controlled trial (RCT) comparison with the established artificial urinary sphincter (AUS) is lacking.

OBJECTIVE

To compare the outcomes of surgery in men with bothersome urodynamic SUI after prostate surgery.

DESIGN, SETTING, AND PARTICIPANTS

A noninferiority RCT was conducted among men with bothersome urodynamic SUI from 27 UK centres. Blinding was not possible due the surgeries.

INTERVENTION

Participants were randomly assigned (1:1) to the male transobturator sling (n = 190) or the AUS (n = 190) group.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was patient-reported SUI 12 mo after randomisation, collected from postal questionnaire using a composite outcome from two items in validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form questionnaire (ICIQ-UI SF). Noninferiority margin was 15%, thought to be of acceptable lower effectiveness, in return for reduced adverse events (AEs) and easier operation, for the sling. Secondary outcomes were operative and postoperative details, patient-reported measures, and AEs, up to 12 mo after surgery.

RESULTS AND LIMITATIONS

A total of 380 participants were included. At 12 mo after randomisation, incontinence rates were 134/154 (87.0%) for male sling versus 133/158 (84.2%) for AUS (difference 3.6% [95% confidence interval {CI} -11.6 to 4.6], pNI = 0.003), showing noninferiority. Incontinence symptoms (ICIQ-UI SF) reduced from scores of 16.1 and 16.4 at baseline to 8.7 and 7.5 for male sling and AUS, respectively (mean difference 1.4 [95% CI 0.2-2.6], p =  0.02). Serious AEs (SAEs) were few: n = 6 and n = 13 for male sling and AUS (one man had three SAEs), respectively. Quality of life scores improved, and satisfaction was high in both groups. All other secondary outcomes that show statistically significant differences favour the AUS.

CONCLUSIONS

Using a strict definition, urinary incontinence rates remained high, with no evidence of difference between male sling and AUS. Symptoms and quality of life improved significantly in both groups, and men were generally satisfied with both procedures. Overall, secondary and post hoc analyses were in favour of AUS.

PATIENT SUMMARY

Urinary incontinence after prostatectomy has considerable effect on men's quality of life. MASTER shows that if surgery is needed, both surgical options result in fewer symptoms and high satisfaction, despite most men not being completely dry. However, most other results indicate that men having an artificial urinary sphincter have better outcomes than those who have a sling.

Longer is better than shorter: The added value of the seven-day pad test in the post-radical prostatectomy urinary incontinence

AIMS

To investigate the feasibility and reliability of the seven-day pad test (7DPT), the correlation between 7DPT and 24-hour pad test (24HPT), and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire, and the different categorization by the severity of each pad test. Pad weighting tests have been recommended in the evaluation of post-radical prostatectomy urinary incontinence severity, being considered the 24HPT gold standard. Some authors consider that the longer the testing, the better assessment. We propose a self-filled pad weight, the 7DPT.

METHODS

A prospective study of incontinent male patients after radical prostatectomy. We carried out the study in two phases. All patients underwent urodynamic study. The first phase evaluated the feasibility and reliability of 7DPT. The second evaluated the correlation between 7DPT, 24HPT, and ICIQ-SF questionnaire in a larger sample.

RESULTS

First phase: 32 patients were recruited. Test-retest reliability was excellent, with good agreement between mean 7DPT and 24HPT. The number of pads and mean 7DPT showed a good correlation. Second phase: 72 patients were screened, 51 (71%) met inclusion criteria. Mean 7DPT and 24HPT showed a strong association. Mean 7DPT and 24HPT correlated moderately with ICIQ-SF score. 7DPT and 24HPT agreement with ICIQ-SF groups was slight. As 7DPT captures better days with maximum urinary leakage, up to 12 patients would have been misclassified according to 24HPT (number need to treat for 7DPT was seven).

CONCLUSIONS

7DPT is a feasible and reliable tool to evaluate post-radical prostatectomy urinary incontinence, with a strong correlation with the 24HPT and moderate with the ICIQ-SF.

The AdVance™ male sling: does it stand the test of time?

INTRODUCTION

There is minimal data published on the longevity of the transobturator retrobulbar male sling (AdVance™). We aimed to determine the efficacy, the complication rate and need for salvage SUI surgery in the medium to long term for male sling insertion.

MATERIALS AND METHODS

We performed a retrospective review of all patients undergoing male sling insertion at a single centre between 2009 and 2018. Data on patient demographics, pre and post-operative International Consultation on Continence Questionnaire - Urinary Incontinence (Short Form) (ICIQ-UI(SF)) scores and 24 h pad usage were collected. Success was calculated as a combination of the cured rate (0-1 security pad use) and the improved rate (>50% reduction in pad usage). Data was also collected on complications, patient satisfaction as well as need for further SUI surgery.

RESULTS

A total of 91 patients underwent male sling insertion in the period specified; median follow up was 69 months. Success rates at 3 months in mild SUI, moderate SUI and severe SUI groups were 96, 86 and 80%, respectively. In the medium to long term, this drops to 65, 62 and 47%, respectively. The overall rate of artificial urinary sphincter (AUS) implantation was 15%. Common complications included groin pain (3%), infection (3%), urinary retention (10%) and de novo overactive bladder (OAB) (11%). The only factor predicting success or failure was pre-operative ICIQ-UI(SF) score.

CONCLUSIONS

AdVance™ male sling success rates deteriorate from 89% at 3 months to 61% at 5 years. The risk of complications is low and, for the most part, transient. Sling insertion remains a reasonable treatment option for male patients suffering with stress urinary incontinence (SUI).

[Incontinence surgery-quality criteria and structured follow-up]

The following article summarizes the current evidence including postoperative success rates and complications for various surgical options in the treatment of urinary incontinence. Due to different inclusion criteria and inconsistent definitions of study endpoints, the analysis of available studies is difficult. Thus, comparative studies with new devices for established treatment options should be planned. Structured processes used in certified continence centers improve the quality of care. Furthermore by documenting relevant complications, comparisons of treatment results thus become possible and provide evidence for the use of different surgical options in the treatment of urinary incontinence.

Management of voiding dysfunction associated with pelvic malignancies

Voiding dysfunction is common after surgical and radiation treatments in patients diagnosed with non-urological pelvic malignancies. Presentation might vary with lower urinary tract symptoms and/or overactive bladder, urinary retention, or incontinence. We reviewed the most recent literature with the aim of describing various types of urinary dysfunction that manifest after radical treatments for non-urological pelvic malignancies. Radical surgical or radiation treatment adversely affect other adjacent pelvic organ function, including viscera, pelvic musculature and the peripheral nervous system. This results in direct organ and indirect functional damage to the genitourinary tract. Multiple surgical and radiation modifications are available nowadays, allowing urologists to offer various treatments for better functional lower urinary tract outcomes. Diagnosing and understanding the type and severity of voiding dysfunction plays a key role in tailoring an appropriate treatment plan. The objective to better functional results relies on maintaining adequate bladder compliance and capacity while permitting volitional emptying, ideally through voiding. Management should routinely start with conservative measures, including pelvic floor muscle training with or without a combination of oral medication for urgency incontinence and clean intermittent catheterization for the management of urinary retention. Concomitant or isolated urinary incontinence can be further managed through multiple established surgical approaches. We attempted to address various treatment available for known lower urinary tract symptoms that might have been caused secondary to non-urological pelvic surgery or radiation. We discuss different diagnostic and treatment modalities individualized for patients with various entities, to help achieve optimal urinary function and improve quality of life.

Urethral Complications While Using 26F vs 28F Resectoscope Sheaths in Holmium Laser Enucleation of the Prostate: A Retrospective Observational Study

Objective: To determine the rate of the urethral stricture (US) and bladder neck contracture (BNC) between patients who undergo Holmium Laser Enucleation of Prostate (HoLEP) surgery with 26F vs 28F resectoscope sheaths (RS). Studies report rates of 2.8-4.4% and 3.6-5.4% for US and BNC, respectively. To date, there are no studies that have shown the difference between RS size and urethral complications. Methods: We retrospectively reviewed charts of patients who had HoLEP surgery between August 2015 and June 2018, by a single surgeon. Those with a prior history of US or BNC were excluded. The operative set-up for an HoLEP includes Ho:YAG laser, urethral dilation, a 26F or 28F continuous flow RS, and a tissue morcellator. Primary endpoints include postoperative US or BNC. Secondary endpoints include postoperative catheterization time, success of voiding trial, and urinary incontinence. Statistical analysis was performed by using appropriate methods. Results: Out of 502 HoLEP patients, 339 consecutive patients had surgery with a 28F RS (Group A) and 163 consecutive patients had surgery with a 26F RS (Group B). Twelve patients (A) and three patients (B) had post-op US (p = 0.41). Eight (A) and zero (B) patients had post-op BNC (p = 0.0585). Stress urinary incontinence at 6 weeks, 3-6 months, and 1 year was present in 15.9% (both A & B), 6.5% (A) vs 6.1% (B) (p = 0.88), and 3.2% (A) vs 1.8% (B) (p = 0.564), respectively. Both blood loss and change in hemoglobin were higher in the 28F group with no significant difference in rate of transfusion. Conclusions: RS size had no impact on the rate of US or BNC; however, there was lower incidence in the 26F sheath cohort for both. The 28F sheath had a larger change in hemoglobin levels and estimated blood loss, but the higher rate of transfusion was not statistically significant. There was no difference in the stress incontinence rates, length of stay, and enucleation rates.

Toxicity reduction required for MRI-guided radiotherapy to be cost-effective in the treatment of localized prostate cancer

OBJECTIVE

To determine the toxicity reduction required to justify the added costs of MRI-guided radiotherapy (MR-IGRT) over CT-based image guided radiotherapy (CT-IGRT) for the treatment of localized prostate cancer.

METHODS

The costs of delivering prostate cancer radiotherapy with MR-IGRT and CT-IGRT in conventional 39 fractions and stereotactic body radiotherapy (SBRT) 5 fractions schedules were determined using literature values and cost accounting from two institutions. Gastrointestinal and genitourinary toxicity rates associated with CT-IGRT were summarized from 20 studies. Toxicity-related costs and utilities were obtained from literature values and cost databases. Markov modeling was used to determine the savings per patient for every 1% relative reduction in acute and chronic toxicities by MR-IGRT over 15 years. The costs and quality adjusted life years (QALYs) saved with toxicity reduction were juxtaposed with the cost increase of MR-IGRT to determine toxicity reduction thresholds for cost-effectiveness. One way sensitivity analyses were performed. Standard $100,000 and $50,000 per QALY ratios were used.

RESULTS

The added cost of MR-IGRT was $1,459 per course of SBRT and $10,129 per course of conventionally fractionated radiotherapy. Relative toxicity reductions of 7 and 14% are required for SBRT to be cost-effective using $100,000 and $50,000 per QALY, respectively. Conventional radiotherapy requires relative toxicity reductions of 50 and 94% to be cost-effective.

CONCLUSION

From a healthcare perspective, MR-IGRT can reasonably be expected to be cost-effective. Hypofractionated schedules, such a five fraction SBRT, are most likely to be cost-effective as they require only slight reductions in toxicity (7-14%).

ADVANCES IN KNOWLEDGE

This is the first detailed economic assessment of MR-IGRT, and it suggests that MR-IGRT can be cost-effective for prostate cancer treatment through toxicity reduction alone.

Is pre-operative urodynamic bladder function the true predictor of outcome of male sling for post prostatectomy incontinence?

PURPOSE

To investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection.

METHODS

We performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre.

RESULTS

Successful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1-6.5) for success vs 3.6 (range 1-10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25).

CONCLUSION

Urodynamic parameters related to bladder function-detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.

Urology highlights 2017 to 2018

The final clinical session of the British Association of Urological Surgeons (BAUS) annual meeting is the Updates and Highlights session, where the most important advances in the main urological sub-specialities are summarised and presented by sub-specialist experts representing each BAUS section. The aim of the session is to disseminate knowledge on the latest research, new guidelines and changes to general and specialist clinical practice. This paper covers contemporary urological advances as presented at the Liverpool BAUS meeting in June 2018.

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.

The Impact of Frailty on Artificial Urinary Sphincter Placement and Removal Procedures

OBJECTIVE

To determine whether frailty is associated with increased odds of 30-day surgical complications among men undergoing both artificial urinary sphincter (AUS) placement and removal procedures and to determine whether frailty was associated with increased odds of having an AUS removal procedure.

METHODS

This is a retrospective cohort study of men undergoing AUS placement and removal procedures using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2006 to 2013. Frailty was quantified using the NSQIP-FI (frailty index) and was applied to logistic regression models predicting 30-day complications (overall, major, and minor) and the odds of having an AUS removal procedure (over an AUS placement procedure).

RESULTS

We identified a total of 624 and 147 men undergoing AUS placement and removal procedures, respectively. NSQIP-FI of ≥0.27, but not age, was associated with major complications (aOR 3.5, 95% confidence interval 1.2-9.9), while age ≥85 years, but not NSQIP-FI, was associated with minor complications (aOR 7.9, 95% confidence interval 1.4-45.6). Men undergoing AUS removal procedures tended to be more frail compared to men undergoing AUS placement procedures (12.9% vs 6.1% had NSQIP-FI of ≥0.27, P<.01).

CONCLUSION

Men undergoing AUS removal procedures are, on average, more frail compared to men undergoing AUS placement procedures. Frailty is associated with increased odds of major complications and with having an AUS removal procedure. These findings highlight the importance of incorporating measures of frailty, instead of age alone, into the perioperative decision-making process for adults considering these types of procedures.

Patient-reported outcomes and urodynamic findings in men with persistent lower urinary tract symptoms following robot-assisted radical prostatectomy

AIMS

To evaluate the patient-reported outcome measures (PROMs) and urodynamic findings in men seeking intervention for lower urinary tract symptoms (LUTS) after robotic-assisted radical prostatectomy (RARP) in a regional referral center for continence surgery.

METHODS

Consecutive men with post-RARP LUTS, who were referred for specialist evaluation and urodynamics between December 2012 and October 2017, were evaluated. Men were invited to complete the International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms Long Form (ICIQ-MLUTS) pre-operatively and at 6, 12 and 18 months post-RARP.

RESULTS

In total 64/860 (7.4%) men post-RARP were referred for specialist evaluation. There was a significant increase in total ICIQ-MLUTS and bother scores at 6, 12 and 18 months compared with the baseline in these men (P < 0.001 and P < 0.05, respectively). Urodynamics identified 41/64 (64%) had urodynamic stress incontinence (USI) only, 2/64 (3%) had detrusor overactivity (DO) only and 11/64 (17%) had a combination of USI and DO. Of those referred to a continence specialist 29/64 (45%) underwent a continence procedure.

CONCLUSIONS

Patients with bothersome LUTS post-RARP have higher baseline ICIQ-MLUTs scores and significant worsening of total scores at all time points compared with the baseline. Routine use of PROMs may identify patients at risk of bothersome symptoms after RARP and prompt earlier referral for further management of their LUTS. Urodynamic evaluation revealed that the most common finding was pure stress incontinence but the range of urodynamic diagnoses highlights the need to perform urodynamics before making treatment decisions for men with LUTS post-RARP.

Surgery for Male Stress Incontinence: Which Technique and When?

Several devices exist for treating postprostatectomy incontinence. In specific cases, male slings can offer good results instead of an artificial urinary sphincter. This short consultation guide aims to help in offering the right surgery to the right patient.

Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status

PURPOSE

To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort.

METHODS

658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used.

RESULTS

Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001).

CONCLUSIONS

Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

Patient reported outcome measures in male incontinence surgery

INTRODUCTION

Patient reported outcome measures (PROMs) were used to evaluate outcomes of the artificial urinary sphincter (AUS) and the AdVance™ (American Medical Systems, Minnetonka, MN, US) male sling system (AVMS) for the symptomatic management of male stress urinary incontinence.

METHODS

All male patients with stress urinary incontinence referred to our specialist clinic over a two-year period completed the ICIQ-UI SF (International Consultation on Incontinence Questionnaire on Urinary Incontinence Short Form) and the ICIQ-MLUTS LF (International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms Long Form) at consultation as well as at subsequent follow-up appointments. The Wilcoxon signed-rank test for non-parametric paired data was used for pre and postoperative comparisons. The chi-squared test was used for categorical variables.

RESULTS

Thirty-seven patients (forty surgical cases) completed a preoperative and at least one follow-up questionnaire. There was a statistically significant improvement in PROMs postoperatively, regardless of mode of surgery (p<0.01). Analysis of the ICIQ-MLUTS LF showed that patients with higher preoperative scores (>25) had greater improvement with an AUS than with the AVMS (p<0.01).

CONCLUSIONS

This prospective study shows that completion and collection of PROMs as part of routine clinical practice is achievable and useful in the assessment of male stress incontinence surgery. PROMs are important instruments to assess effectiveness of healthcare intervention and they are useful adjuncts in surgical studies.