A transobturator adjustable system for male incontinence: 30-month follow-up of a multicenter study

Clinical and Urodynamic results of the Argus T® sling in moderate and severe male stress urinary incontinence after radical prostatectomy - a 5 year prospective study

PURPOSE

Sling as a therapeutic option for male stress urinary incontinence (SUI) has been reviewed in the last two decades, as it is a relatively simpliest surgery compared to artificial urinary sphincter and has the ability to modulate urethral compression. This study aims to evaluate the efficacy, rate of complications, quality of life and the effects on bladder emptying of the Argus T® compressive and ajustable sling in moderate and severe male SUI treatment.

MATERIALS AND METHODS

Men eligible for stress urinary incontinence treatment after radical prostatectomy were recruited and prospectively evaluated, from March 2010 to November 2016. It was selected outpatient men with moderate and severe SUI, after 12 months of radical prostatectomy, who have failed conservative treatment. All patients had a complete clinical and urodynamic pre and post treatment evaluation, by means of clinical history, physical examination, urine culture, 1-hour pad test and ICIq-SF questionnaire. The UDS was performed after 12, 18 and 24 months postoperatively.

RESULTS

Thirty-seven men underwent sling surgery, 19 patients (51.4%) with moderate and 18 (48.6%) with severe SUI. The minimum follow-up time was 5 years. Overall, we had a success rate of 56.7% at 60 months follow-up. After surgery, we did not observe significant changes in the urodynamic parameters evaluated during the follow-up. No patient had urodynamic bladder outlet obstruction (BOO) after sling implantation. Readjustment of the Argus T® sling was performed in 16 (41%) of the patients and 51% of the patients reported some adverse event.

CONCLUSION

We demonstrate a long-term efficacy and safety of Sling Argus T® as an alternative to moderate and severe male SUI treatment. Furthermore, in our study bulbar urethra compression does not lead to bladder outlet obstruction.

Artificial Urinary Sphincter for Postradical Prostatectomy Urinary Incontinence - Is It the Best Option?

Male stress urinary incontinence (SUI) can undoubtedly reduce quality of life and promote personal distress and psychosocial alienation. The frequency of postprostatectomy urinary incontinence (PPI) counts on the characterization of urinary incontinence and the periods of patient follow-up. Operational therapeutics, for instance, urethral male slings and artificial urinary sphincters, are well-chosen as adequate and secure surgeries for male SUI in men with continual PPI when conservative treatment is ineffective. Over the former 2 decades, surgery has progressed regarding both operative approach and sling architecture. However, there are no guidelines about when surgery should be carried out and which is the most appropriate surgical option. In this review, we summarize recent advances in implantable devices for PPI and also discuss traditional surgical care. When we are planning the male PPI surgery, careful preoperative work-up should be performed and surgical method should be chosen according to the severity of the disease. Male sling is preferred in mild and moderate symptomatic patients with normal detrusor pressure and it is recommended to select traditional artificial urinary sphincter device in those with severe symptoms. It is expected that effective devices without adverse events will be developed with technical advances in near future.

Effectiveness of surgical management with an adjustable sling versus an artificial urinary sphincter in patients with severe urinary postprostatectomy incontinence: a systematic review and network meta-analysis

Background:

The purpose of this study was to determine the effectiveness of an adjustable sling compared with an artificial urinary sphincter (AUS) in patients with severe urinary incontinence (SUI) postprostatectomy (PP).

Methods:

This review was carried out following the Cochrane Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. We searched Medline, Embase, LILACS, and CENTRAL databases. Studies with patients older than 18 years of age with SUI PP who underwent sling or AUS intervention and had been monitored for longer than 12 months were included.

Results:

Seven studies were included, yielding a sample size of 420. Pads were reportedly dry or improved in 70% of the sling group compared with 74% in the AUS group. The Incontinence Impact Questionnaire, Short Form (IIQ-7) was the most frequently used scale and showed improvement, with a score of 82.8% in the AUS group compared with 86.1% in the sling group. When comparing interventions with nonintervention, relative risks (RRs) of 35.37 (95% confidence interval [CI]: 7.17–174.35) and 45.14 (95% CI: 11.09–183.70) were found for the adjustable sling and AUS, respectively, which were statistically significant. No significant differences were found when AUS versus adjustable sling were compared, with an RR of 0.78 (95% CI: 0.09–6.56). We found a low risk of bias in most studies.

Conclusions:

Both interventions can reduce incontinence and improve the quality of life of patients with SUI PP. The published literature is substantially limited as no randomized clinical trials are available, no consensus has been reached regarding the definition of severity of incontinence, and considerable heterogeneity exists across the outcome variables measured.

Sling Surgery for Male Urinary Incontinence Including Post Prostatectomy Incontinence: A Challenge to the Urologist

The management of postprostatectomy urinary incontinence (PPI) is still challenging for urologists. In recent decades, various kinds of male sling system have been developed and introduced; however, they have not yet shown as good a result as that of artificial urinary sphincter (AUS). However, a male sling is still in an important position because patients have a high demand for sling implantation, and it can allow the avoidance of the use of mechanical devices like AUS. Recently, the male sling has been widely used in mild-to-moderate PPI patients; however, there are no studies that compare individual devices. Thus, it is hard to directly compare the success rate of operation, and it is impossible to judge which sling system is more excellent. It is expected that many sling options will be available in addition to AUS in the near future with the technological development of various male slings and the accumulation of long-term surgical outcomes. In that in patients with PPI, sling implantation is an option that must be explained rather than an option that need not be explained to them, this review would share the latest outcomes and complications.

Adjustable sling for the treatment of post-prostatectomy urinary incontinence: systematic review and meta-analysis

Urinary incontinence after prostatectomy has a significant negative impact on the quality of life of the patient. The surgical treatment includes several models of male slings, such as adjustable slings. The objective of this study was to evaluate the effectiveness and safety of adjustable sling in the treatment of post-prostatectomy urinary incontinence. This is a systematic review of literature. The following electronic databases were searched until January 2018: PubMed®, Embase, CENTRAL and LILACS. The keywords used in the search strategies were: "prostatectomy" [Mesh], "urinary incontinence" [Mesh] and "suburethral slings" [Mesh]. Randomized clinical trials and observational studies, with or without Control Group, and follow-up of more than 12 months were included. Only one randomized study with high risk of bias was included and it concluded the effectiveness equivalence between adjustable and non-adjustable slings. All other studies were cases series with patients of varying levels of incontinence intensity and history of pelvic radiation therapy and previous surgeries. The meta-analysis for 0 pad in 24 hours demonstrated an effectiveness of 53%. For the 0 to 1 pad test in 24 hours, the meta-analysis resulted in an effectiveness of 69%. Risk factors for surgery failure include prior radiation, severity of post-prostatectomy urinary incontinence, and previous surgeries. The meta-analysis of the extrusion rate was 9.8% and the most commonly reported adverse effects were pain and local infection. Evidence of low quality indicates that adjustable slings are effective for treating post-prostatectomy urinary incontinence, with frequency of adverse events similar to the surgical option considered gold standard (the artificial urinary sphincter implant).

[Differentiated surgical treatment of male stress urinary incontinence-between intention and reality?]

The differentiated surgical treatment of male urinary incontinence is a very interesting and sometimes also emotional topic, in which evidence is increasingly maturing. Nowadays, the most common surgical procedures are fixed sling and adjustable incontinence systems as well as the artificial urinary sphincter. The evidence for the procedures varies and there is currently a lack of prospective, comparative studies. The challenging question is: Which operation is the best for which patient? The following article is intended to give an overview of the surgical options and a constructive attempt to differentiate the indication.

Implantable Systems for Stress Urinary Incontinence

Stress urinary incontinence (SUI), the involuntary urine leakage due to failure of the urethral closure mechanism, is a global health challenge with substantial human suffering and socioeconomic costs. Approximately 167 million male and female patients are predicted to suffer from SUI in 2018, worldwide. A wide range of surgical interventions are available for the treatment of SUI. Severe cases, however, usually require the implantation of artificial urinary sphincter devices. This review comparatively presents and analyzes the working principles, as well as the challenges, associated with the current implantable SUI systems in clinical use. These include slings, urethral bulking agents, artificial urinary sphincters, and adjustable continence devices. It further reports on recent research progress and state-of-the-art in the field of SUI implants, including an original approach proposed by the authors with a pressure feedback sensory mechanism. The new emerging field of artificial muscle devices, including electroactive polymers, provides a promising innovative solution for replacing the weakened urethral sphincter in SUI patients.

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.

The role of male slings in post prostatectomy incontinence: ICI-RS 2015

AIMS

Post prostatectomy stress urinary incontinence can significantly impact on quality of life and is bothersome for patients. The artificial urinary sphincter is still considered the gold standard surgical treatment. Male slings are an alternative surgical option and several designs are currently available. This review will focus on efficacy, adverse events, and mechanism of action of male slings. The context of this review was a proposal at the ICI-RS meeting 2015. Following synthesis of the evidence we address the question: does it matter how male slings work?

METHODS

The proposal lecture was reviewed and a comprehensive review of the literature undertaken utilising the PubMed database.

RESULTS

Male slings can be broadly divided into adjustable retropubic and suburethral transobturator slings. Male slings are efficacious and can improve quality of life. Adjustable retropubic slings appear to be compressive but studies suggest efficacy can be achieved without voiding dysfunction. Transobturator slings work by urethral compression and/or re-locating the urethral bulb. There is a recognized failure rate in all sling types and most studies suggest radiotherapy as a risk factor for failure. Adjustable slings have the ability to be altered to optimize continence or to prevent retention of urine. However, there appears to be a higher explantation rate in some of these systems.

CONCLUSIONS

It is important to understand how male slings work and by doing so we are more reliably able to choose the appropriate sling, predict outcomes, and as a result counsel patients. Suggestions for future research are proposed.

Single-centre experience in using the adjustable transobturator male system in treatment of stress urinary incontinence in patients after radical prostatectomy

Context:

Urinary incontinence is the most threatening complication after radical prostatectomy. This disorder has an important impact on the quality of life of patients and its treatment is a challenge for urologists as well.

Objective:

The objective of this article is to report our experience with the adjustable transobturator male system (ATOMS, AMI, Austria) for the treatment of post-prostatectomy incontinence.

Material and methods:

A total of 35 men with post-prostatectomy incontinence were treated. Before and after device implantation, the number of pads used per day was counted, and a one-hour pad test, uroflowmetry and postmicturition residual volume were assessed. Prior to surgery, anastomosis stricture was either ruled out or treated. To evaluate the success rate, ‘cured’ was defined as no pad use or one safety pad, ‘improved’ was defined as one or two pads or reduction of pad usage by more than 50%, respectively. All data about efficacy and safety were collected from all 35 patients.

Results:

After a median (range) follow-up of 21.2 (3–63) months, the success rate was 32 out of 35 patients (91.5%) with 22 patients (62.9%) ‘cured’ and 10 patients (28.6%) ‘improved’. Recovery of continence was achieved in seven patients (20.0%). The remaining patients (80%) needed an adjustment. The mean (range) number of adjustments to reach desired results (continence, improvement or patient satisfaction) was 4.3 (1–15). The most common adverse event was transient perineal pain, which was reported in 14 (40%) patients and disappeared within two weeks. Temporary urine retention appeared in one patient (2.9%). There were three cases (8.6%) of wound infection at the site of a port leading to explantation of the port in two patients (5.7%) and the removal of the system in one patient (2.9%).

Conclusion:

Treatment of post-prostatectomy incontinence with the self-anchoring ATOMS is safe and effective.

Five-year experience with the adjustable transobturator male system for the treatment of male stress urinary incontinence: a single-center evaluation

BACKGROUND

We report on our 5-year experience with the adjustable transobturator male system (ATOMS^®, A.M.I., Feldkirch, Austria).

METHODS

Between 10-2009 and 10-2014, 54 patients received an ATOMS. The mean follow-up of this retrospective observational trial was 27.5 ± 18.4 (2.3-59) months. Within each follow-up, the following were evaluated: micturition protocol, 24-h pad count, uroflowmetry and residual volume. Statistical analysis was performed with SigmaPlot^® 11.0, p < 0.05 considered as significant.

RESULTS

Stress urinary incontinence (SUI) I°, II° and III° was seen in 1 (1.9 %), 16 (29.6 %) and 37 patients (68.5 %), respectively. In summary, 48.1 % of the patients became "dry" (0-"safty pad"/day), while 29.6 % achieved at least an "improvement" of about more than 50 % (1-2 pads/day), which corresponds to an overall success rate of 77.7 %. The mean number of pads/day decreased from 7.7 to 1.6. Regarding the initial degree of SUI, patients with mild or moderate incontinence had a significantly better outcome (p = 0.002, 95 % CI 0.9066 to 2.760). Postoperative complications were scaled according to the Clavien classification, in which we have seen 4 grade I-, 1 grade IIIa- and 9 grade IIIb-complications (overall 25.9 %). The evaluation of quality of life by ICIQ-SF showed a significant improvement (p = 0.0001, 95 % CI -14.56 to -11.75).

CONCLUSION

The treatment of male SUI using the ATOMS incontinence system achieved the best results in patients with mild and moderate incontinence. For severe incontinent patients, the system represents an efficient alternative.

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.

Current interventional management of male stress urinary incontinence following urological procedures

Introduction

Despite improvements in surgical techniques and implementation of minimally invasive procedures, male stress urinary incontinence affects a substantial number of patients after prostatic surgery. In response to increasing demand of optimal treatment modality, new alternatives to artificial urinary sphincter have recently been introduced. This review summarises the therapeutic surgical options with their outcomes in management of postprostatectomy stress incontinence.

Material and methods

We performed a literature review by searching the PubMed, Web of Science and Embase databases for articles published from January 2000 until April 2015 based on clinical relevance.

Results

Artificial urinary sphincter is currently considered the “gold standard” treatment of male stress urinary incontinence. Although the new devices in this group have recently been investigated, the AMS 800 remains the only widely used implant. Male slings and adjustable continence devices, achieve the social continence rates up to 60%. Periurethral injections of bulking agents, have limited efficacy of male stress incontinence. Argus sling and ProACT are both associated with substantial explantation rates. Stem cell therapy is a promising option but still requires additional testing.

Conclusions

The development of new alternatives to artificial urinary sphincter is constantly progressing. Although recently introduced minimally invasive treatment options have not yet surpassed the outcomes of the artificial urinary sphincter they should continue to be evaluated and compared against the gold standard.