Radiotherapy is associated with reduced continence outcomes following implantation of the artificial urinary sphincter in men with post-radical prostatectomy incontinence

Complications of Prostate Cancer Treatment: Open Issues

Unfortunately, prostate cancer treatment is not free of complications [...].

The effectiveness of adjustable trans-obturator male system (ATOMS) in radiated patients is reduced: A propensity score-matched analysis

Objectives

This study aimed to compare the effectiveness and safety of the adjustable trans-obturator male system (ATOMS®) to treat post-prostatectomy incontinence (PPI) in radiated patients compared with non-radiated patients, using propensity score-matching analysis to enhance the validity of the comparison.

Patients and methods

Consecutive men with PPI treated with silicone-covered scrotal port ATOMS (A.M.I., Feldkirch, Austria) in nine different institutions between 2016 and 2022 were included. Preoperative assessment evaluated 24-h pad usage, urethroscopy and urodynamics, if indicated. Propensity score-matching analysis was based on age, length of follow-up, previous PPI treatment, previous bladder neck stricture, androgen deprivation and pad usage. The primary endpoint was dry rate, defined as no pads post-operatively with a security pad allowed. The secondary endpoints were complications, device removal and self-perceived satisfaction with the Patient Global Impression of Improvement (PGI-I) scale.

Results

Of the 710 included patients, 342 were matched, and the study groups were balanced for the baseline matched variables. The mean baseline 24-h pad was 4.8 in both groups (p = 0.48). The mean follow-up was 27.5 ± 18.6 months, which was also equivalent between groups (p = 0.36). The primary outcome was achieved in 73 (42.7%) radiated patients and in 115 (67.3%) non-radiated patients (p < 0.0001). The mean pad count at the last follow-up was 1.5 and 0.8, respectively (p < 0.0001). There was no significant difference in complications (p = 0.94), but surgical revision and device explant rates were higher (p = 0.03 and p = 0.01, respectively), and the proportion of patients highly satisfied (PGI-I = 1) was lower in the radiated group (p = 0.01). At sensitivity analysis, the study was found to be reasonably robust to hidden bias.

Conclusion

ATOMS implantation significantly outperformed in patients without adjuvant radiation over radiated patients.

Longitudinal deterioration in lower urinary tract symptoms after artificial urinary sphincter implantation in patients with a history of pelvic radiation therapy

OBJECTIVES

To evaluate longitudinal changes in lower urinary tract symptoms (LUTS) after artificial urinary sphincter (AUS) implantation in patients undergoing radiation therapy (RT) in comparison to those in non-irradiated patients.

METHODS

This retrospective study included 20 and 51 patients with and without a history of pelvic RT (RT and non-RT group, respectively) who were treated with primary AUS implantation for post-radical prostatectomy incontinence between 2010 and 2020. Longitudinal changes in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the International Prostate Symptom Score (IPSS), and the Overactive Bladder Symptom Score (OABSS) were calculated with a linear mixed model.

RESULTS

In the RT and non-RT group, 18 (90%) and 48 (94%) patients achieved social continence, defined as daily pad use ≤1 at 1 month after activation of AUS, respectively (p = .555). During the mean follow-up of 38 months, ICIQ-SF, IPSS, and OABSS significantly improved after AUS implantation in both the RT and non-RT groups. In the RT group, ICIQ-SF, IPSS, and OABSS subsequently deteriorated with a slope of 0.62/year (p = .010), 0.55/year (p = .025), and 0.30/year (p = .007), respectively. In the non-RT group, no significant longitudinal changes in subsequent IPSS and OABSS were observed, although ICIQ-SF significantly deteriorated (0.43/year, p = .006). Comparing between the groups, the slopes of IPSS and OABSS were significantly greater in the RT group than in the non-RT group (p < .001, and .015, respectively).

CONCLUSIONS

Longitudinal deterioration in LUTS that improved immediately after AUS implantation was observed in patients with a history of pelvic RT, but not in patients without a history of pelvic RT.

Results of Adjustable Trans-Obturator Male System in Patients with Prostate Cancer Treated with Prostatectomy and Radiotherapy: A Multicenter Study

(1) Background: Treatment of male stress incontinence in patients with prostate cancer treated with radical prostatectomy and adjuvant pelvic radiation is a therapeutic challenge. The efficacy and safety of the adjustable trans-obturator male system (ATOMS) in these patients is not well established, despite the general belief that outcomes are worse than in patients without radiation. (2) Methods: Retrospective multicenter study evaluating patients treated with silicone-covered scrotal port (SSP) ATOMS implant after radical prostatectomy and radiotherapy in nine different institutions between 2016 and 2022. The primary endpoint was dry patient rate, defined as pad-test ≤ 20 mL/day. The secondary endpoints were complication rate (defined using Clavien-Dindo classification), device removal and self-perceived satisfaction using the Patient Global Impression of Improvement (PGI-I) scale. Wilcoxon rank-sum test, Fisher's exact test and logistic regression were performed using stepwise method with a 0.15 entry and 0.1 stay criteria. (3) Results: 223 patients fulfilled the criteria for inclusion and 12 (5.4%) received salvage prostatectomy after radiation and 27 (12.1%) previous devices for stress incontinence. After ATOMS adjustment, 95 patients (42.6%) were dry and 36 (16.1%) had complications of any grade (grade I, n = 20; grade II, n = 11; grade III, n = 5) during the first 3 months postoperatively. At a mean of 36 ± 21 months follow-up, the device was explanted in 26 (11.7%) patients. Regarding self-perceived satisfaction with the implant, 105 of 125 patients (84%) considered themselves satisfied (PGI-I 1 to 3). In the univariate analysis, dryness was associated to younger age (p = 0.06), primary prostatectomy (p = 0.08), no previous incontinence surgery (p = 0.02), absence of overactive bladder symptoms (p = 0.04), absence of bladder neck stricture (p = 0.001), no need of surgical revision (p = 0.008) and lower baseline incontinence severity (p = 0.0003). Multivariate analysis identified absence of surgical revision (p = 0.018), absence of bladder neck stricture (p = 0.05), primary prostatectomy (p = 0.07) and lower baseline incontinence severity (p < 0.0001) were independent predictors of dryness. A logistic regression model was proposed and internally validated. (4) Conclusions: ATOMS is an efficacious and safe alternative to treat male incontinence after radical prostatectomy and adjuvant radiotherapy. Factors predictive of dryness are identified in this complex scenario to allow for better patient selection.

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.

Impact of Radiation Therapy on Outcomes of Artificial Urinary Sphincter: A Systematic Review and Meta-Analysis

Background

To compare incontinence rates and complications in patients receiving artificial urinary sphincter (AUS) with or without radiotherapy (RT).

Methods

PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched for studies comparing outcomes of AUS between patients with and without RT. Search limits were from 1st January 2002 to 15th September 2021.

Results

Eighteen studies were included. Meta-analysis revealed statistically significant reduced odds of the absence of incontinence in the RT group (OR: 0.35 95% CI: 0.21, 0.59 I2 = 51% p &lt; 0.0001) as compared to the no-RT group. We also noted statistically significant increased risk of revision surgery in the RT group (OR: 1.74 95% CI: 1.16, 2.60 I2 = 73% p = 0.07). There was increased risk of infections (OR: 2.51 95% CI: 1.00, 6.29 I2 = 46% p = 0.05) and erosions (OR: 2.00 95% CI: 1.15, 3.45 I2 = 21% p = 0.01) in the RT group, but the difference was significant only for erosions. Meta-analysis revealed a statistically significant increased risk of explantation in patients with RT (OR: 3.00 95% CI: 1.16, 7.75 I2 = 68% p = 0.02) but there was no difference in the risk of urethral atrophy (OR: 1.18 95% CI: 0.47, 2.94 I2 = 46% p = 0.72) and mechanical failure (OR: 0.90 95% CI: 0.25, 3.27 I2 = 54% p = 0.87) between the two groups.

Conclusions

Our meta-analysis of recent studies indicates that RT significantly reduces the odds of achieving complete continence after AUS placement. History of RT does not increase the risk urethral atrophy or mechanical failure in patients with AUS. However, the risk of revision surgery, erosions and explantations is significantly increased in patients with RT with a non-significant but increased tendency of infections.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: NCT02612389.

Longitudinal changes in patient-reported outcomes after artificial urinary sphincter implantation

OBJECTIVE

To evaluate the time course of lower urinary tract symptoms (LUTS) after artificial urinary sphincter (AUS) implantation based on individual longitudinal changes of patient-reported outcomes.

METHODS

This retrospective study included 66 male patients with severe urinary incontinence who were treated with primary AUS implantation between 2009 and 2019. International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and International Prostate Symptom Score (IPSS) questionnaires were used to evaluate continence status and LUTS preoperatively, 1, 3, and 12 months after activation, and then annually. The annual changes in scores were calculated with a linear mixed model.

RESULTS

Of the 66 patients, 63 (95%) achieved complete or social continence (number of pads used ≤1/d) at 1 month after activation. Mean preoperative ICIQ-SF, IPSS, and IPSS-quality of life (QOL) score were 18.9, 14.9, and 5.4, respectively; the corresponding scores at 1 month after activation were 4.5, 9.0, and 1.7 (all P < .001), respectively. During the mean follow-up period of 36 months, the annual changes in the scores from 1 month after activation were 0.51 (P = .002), -0.30 (P = .184), and 0.19 (P < .001), respectively. As for individual IPSS items, while incomplete emptying, frequency, urgency, and weak stream improved significantly 1 month after activation, no significant changes from 1 month after activation were observed except for longitudinal deterioration of incomplete emptying score (0.08/y, P = .029).

CONCLUSION

Continence status and QOL score markedly improved by AUS implantation immediately, but deteriorated over time. Improved LUTS were maintained without a worsening trend, however.

Evaluation of benefits and harms of surgical treatments for post-radical prostatectomy urinary incontinence: a systematic review and meta-analysis protocol

Background: Post-radical prostatectomy urinary incontinence (PPI) is a frequent and feared complication that can affect approximately 25% of patients. Between 1 and 10% of patients suffering from PPI will require surgery. The effectiveness of the available surgical interventions has only been compared in a few randomized controlled trials and the available reviews have important limitations regarding both benefits and harms that make them insufficient to inform decision-making. The aim of the study is to provide systematic summaries of benefits and harms of contemporary surgical treatment options for PPI through systematic review and meta-analysis using GRADE methodology and reporting in accord with the PRISMA-P statement. Methods: Studies pertaining to bulking agents, male synthetic slings, compressive balloon systems (ProACT) or artificial urinary sphincters (AUS) used for the treatment of patients suffering from PPI will be included. A systematic search will be conducted using the OVID and PubMED platforms in MEDLINE, Embase and Cochrane databases, and reference lists of relevant reviews and guidelines. Trained independent reviewers will conduct study selection and data extraction. Outcomes will include the number of pads used per day, the 24-h pad weight test, the Patient Global Impression of Improvement (PGI-I) and the Incontinence Quality of Life (IQOL) as possible benefits and the reoperations, the Clavien-Dindo complications and the other reported adverse events as the harms. When possible, pooled analyses will be completed. Risk of bias will be assessed using the CLARITY tools and a new tool for the before-and-after studies without a control group. Finally, study heterogeneity will be assessed, publication bias will be evaluated with funnel plots and quality of evidence rated for each outcome. Discussion: Our study will address patient-important outcomes and will be useful in clinical decision-making as well as identifying key elements for future research. Study registration: PROSPERO: CRD42018073923 05/12/2018.