Surgical treatment of post-prostatectomy stress urinary incontinence in adult men: Report from the 6th International Consultation on Incontinence

British Association of Urological Surgeons (BAUS) consensus document on post-prostatectomy incontinence-stress urinary incontinence

OBJECTIVES

To report the British Association of Urological Surgeons (BAUS) consensus document on the assessment and management of post-prostatectomy incontinence-stress urinary incontinence (PPI-SUI).

METHODS

We conducted a contemporary literature search to identify the current evidence base. A guideline development group was formed by the Female, Neurological and Urodynamic Urology (FNUU) Section of BAUS to formulate and review the recommendations. Where a lack of evidence was identified, expert opinion of the FNUU Executive Committee and a modified Delphi approach was utilised.

RESULTS

This consensus addresses several knowledge gaps in the current literature on PPI-SUI, in addition to tackling areas not addressed by the current international guidelines, e.g., prostate cancer survivorship. Of the initial draft, the modified Delphi consensus methodology was applied to 65 statements split into seven broad categories: terminology, assessment, conservative management, surgical treatment, perioperative care, complication management, and follow-up after PPI-SUI surgery. This is applicable to general and specialist Urologists worldwide. After three rounds, consensus was achieved with 63/65 statements.

CONCLUSIONS

We provide a modified Delphi consensus on the assessment and management of PPI-SUI to help guide and standardise the assessment and management pathway of these patients.

Mesenchymal stromal cell exosomes for drug delivery of prostate cancer treatments: a review

Interest in prostate cancer as a research topic has gradually increased. As a result, a series of innovative treatment strategies have emerged with an in-depth understanding of the disease. Owing to their unique biological characteristics, mesenchymal stromal cell exosomes (MSC-Exos) have garnered significant attention for their potential to deliver targeted drugs and enable precise prostate cancer treatment. Herein, prostate cancer treatment with MSC-Exos drug-delivery systems is reviewed. This review provides a comprehensive introduction to the advantages of these systems, current research trends and progress, as well as an analysis of current challenges and future research directions. Moreover, this review lays a solid foundation for the continued development and application of MSC-Exos.

Usefulness of Mesh Reinforcement in Pubic Fixation Urethral Sling Surgery for Urinary Incontinence After Radical Prostatectomy

OBJECTIVES

In our institution, a unique sling technique is performed for urinary incontinence after radical prostatectomy. However, in cases of severe urinary incontinence or in the medium to long term, the therapeutic effect may be insufficient. Therefore, a urethral sling technique that provides stronger compression of the bulbar urethra was developed, and its effectiveness was compared with the conventional technique.

METHODS

Seventeen cases of conventional sling surgery and 16 cases of improved sling surgery were included. The number of pads used per day, safety pad rate, and International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) were evaluated before and after surgery, and a retrospective comparison was made between the two groups. Furthermore, patients were divided into those who used ≤ 4 pads per day before surgery and those who used ≥ 5 pads per day, and the difference between the two groups was examined. We also examined changes over time between groups.

RESULTS

Compared with the conventional group, the improved group showed significant improvement in the number of pads per day, safety pad rate, and ICIQ-SF 18 months after surgery. In the group with ≤ 4 preoperative pads, the improved group showed significant improvement in all safety pad rates except at 1 and 12 months after surgery. There were no significant differences in all items between the two groups when the number of preoperative pads was ≥ 5.

CONCLUSIONS

The improved urethral sling technique appeared to contribute to improving moderate urinary incontinence by adding a simple procedure, especially for patients using ≤ 4 pads per day.

Treatment strategies for revision surgery of artificial urinary sphincter: A review

Artificial urinary sphincters (AUS) are an effective treatment for male stress urinary incontinence (SUI). However, infection, erosion, mechanical failure, atrophy, and balloon deterioration cause device malfunction in approximately half of patients by 10 years after implantation. Many patients desire to regain urinary continence and require revision surgery (RS), including device removal and simultaneous or delayed implantation. Patients for whom RS is considered should be examined physically and by interview for signs of infection. Urethral erosion should be assessed using cystoscopy. If there is infection or erosion, all devices should be removed first, and a new device should be implanted several months later. During the RS, after strong adhesion around the urethra, transcorporal cuff implantation is a safe choice. Device removal and simultaneous implantation can be performed in the absence of infection or erosion. If a long time has passed since device implantation, the entire device should be replaced due to device aging and deterioration; however, if the time is short, only the defective component need be replaced. Intraoperative assessment of urethral health is necessary for device removal and implantation. If the urethra is healthy, a new cuff can be placed in the same position as the old cuff was removed from; however, if the urethra is unhealthy, the cuff can be implanted in a more proximal/distal position, or a transcorporal cuff implant may be chosen. This article reviews the literature on diagnostic and treatment strategies for recurrent SUI in male patients with AUS and proposes a flowchart for AUS revision.

Impact of Intraoperative Prognostic Factors on Urinary Continence Recovery Following Open and Laparoscopic Radical Prostatectomy

Background and Objectives: Radical prostatectomy (RP) stands as the predominant instigator of postoperative stress urinary incontinence. Techniques such as the preservation of the neurovascular bundles, bladder neck preservation, and ensuring longer postoperative urethral length have shown positive impacts on continence. The posterior reconstruction is another method that aids in early continence recovery. Anterior suspension as simulator of puboprostatic ligaments is another factor. Materials and Methods: This study was conducted in the Clinic of Urology, University Clinical Center of Serbia, between December 2014 and January 2020, employing a prospective, non-randomized comparative design. Data were meticulously gathered from 192 consecutive patients. The process of regaining continence was monitored at intervals of 1, 3, 6, 12, and 24 months after surgery. The main criterion for assessing the level of urinary continence was the number of pads used daily. Results: The distribution of overall continence rates in the BNP vs. no-BNP group at 3, 6 and 12 months was 86% vs. 60% (p < 0.0001), 89% vs. 67% (p < 0.0001), 93% vs. 83% (p = 0.022). Continence rates in non-posterior reconstruction group (10%, 22%, 34%, and 54% at 1, 3, 6, and 12 months) were statistically significantly lower (p < 0.0001). The patients who underwent urethral suspension exhibited significantly higher rates of overall continence at 1 mo (73% vs. 29%, p < 0.0001), 3 mo (85% vs. 53%, p < 0.001), 6 mo (89% vs. 62%, p < 0.0001), 12 mo (95% vs. 76%, p < 0.0001), and 24 mo (93% vs. 81%, p = 0.007). Patients who underwent urethral suspension had a four-fold greater likelihood of regaining continence (p = 0.015). Conclusions: Patients who underwent urethral suspension or BNP or posterior reconstruction had higher continence rates. Only the urethral suspension was found to be a significant prognostic factor of continence recovery.

Outcome of post-prostatectomy stress urinary incontinence surgery in men with preoperative idiopathic detrusor overactivity

Background

Urodynamic evidence of storage dysfunction such as detrusor overactivity (DO) and/or poor compliance are present in up to 30-40% of patients after Radical Prostatectomy (RP). However, the current optimal management of men with DO on preoperative urodynamics prior to male stress urinary incontinence (SUI) surgery is not known.

Methods

We performed a systematic search of the literature including articles on patients undergoing SUI surgery after prostatectomy with preoperative DO between January 2003 and May 2023 to ensure contemporaneous data was obtained.

Results

We identified 11 eligible publications with a total of 792 patients. On Urodynamics, 29% (n = 229) patients had DO prior to SUI surgery. Overall 69% patients had a successful outcome after SUI surgery while 26% (132/499) failed while 34% (32/95) patients who had proven DO preoperatively failed SUI surgery. The difference was not statistically significant. Considering the sub-group analysis, the failure rate with preoperative DO was significantly higher in the sling group (43%) than in the AUS group (18%). The review was limited by the outcome heterogeneity, variability in study inclusion criteria, reporting and analysis and the quality of the available studies.

Conclusions

Within the limitations of the data, this review did not show a statistically significant higher failure rate of male incontinence surgery in patients with DO. Hence, patients with DO on preoperative urodynamics who are eligible for male SUI surgery should not be denied surgery but should be counselled appropriately of the risks and potential need for subsequent treatment, to manage expectations.

Artificial urinary sphincter: recent developments and the way forward

PURPOSE OF REVIEW

The AMS 800 has dominated the treatment of postprostatectomy urinary incontinence (PPUI) due to intrinsic sphincter deficiency (ISD) for five decades. A narrative review from June 2022 to June 2024 was conducted using 'artificial urinary sphincter' (AUS) MeSH terms in Embase. We extracted information on innovative AUS, randomized controlled trials (RCTs) or prospective studies, and systematic reviews. We evaluated the latest guidelines and consensus and analyzed current trends to discuss options for advancing AUS practices.

RECENT FINDINGS

Of 465 papers identified, 320 were excluded (irrelevant, duplicates, non-AUS devices, non-English, veterinary), and 145 were reviewed, with 24 selected: seven on novel AUS in development, 7 with higher-level evidence (1 RCT, 1 prospective, 4 systematic reviews, 1 nonsystematic review), and 9 retrospective relevant studies [pressure regulating balloon (PRB), revision strategies, radiotherapy history, manual dexterity/cognition, transscrotal vs. transperineal approach]. The final paper summarized current guidelines from Asia & Pacific on AUS.

SUMMARY

In the past 2 years, six novel AUS have emerged, two female RCTs are ongoing, the SATURN study published its 1-year outcomes, and four systematic reviews on female AUS were conducted. These findings enhance evidence levels and position novel AUS to challenge the Gold Standard.

[Structural health care reality in the surgical treatment of male stress incontinence in Germany]

BACKGROUND

Stress urinary incontinence in men is predominantly iatrogenic after radical prostatectomy or transurethral interventions. Current studies show that there is a deficit in the availability of surgical therapy not only in Germany. The aim of this study is to investigate in more detail the structural health care situation of surgical treatment of male stress incontinence in Germany.

MATERIALS AND METHODS

The evaluation of the surgical therapy of male stress incontinence in Germany is based on the OPS (Operationen- und Prozedurenschlüssel-German procedural classification) codes from hospital quality reports from 2011-2019.

RESULTS

From 2012-2019, the number of male incontinence surgeries declined from 2191 to 1445. The number of departments performing incontinence surgeries decreased from 275 to 244. In the multivariate analysis, a high number (≥ 50) of radical prostatectomies/year (RPE/year) is an independent predictor of a high-volume centre (≥ 10 procedures/year; odds ratio [OR] 6.4 [2.3-17.6]; p < 0.001). The most significant decrease was in sling surgery (from 1091 to 410; p < 0.001). Here, the number of cases decreased especially in departments that implanted a high number of slings (≥ 10 slings/year; -69%; -62.4 ± 15.5 surgeries/year; p = 0.007). In addition, the number of departments implanting slings decreased over the investigated time period (from 34 to 10; p < 0.001). This particularly affected departments that also had a low number of RPE/year (from 9 to 0; -100%).

CONCLUSION

The situation of surgical treatment of male stress urinary incontinence in Germany shows a clear decline in sling implantation, especially in small departments. On the one hand, this reflects the increasingly differentiated indications for sling implantation. On the other hand, it raises the suspicion that a gap in care has developed, as the decline was not compensated for by other surgical therapies.

Post-prostatectomy incontinence: a guideline of guidelines

AIM

To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI).

MATERIALS AND METHODS

The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018).

RESULTS

In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well.

CONCLUSION

This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

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.

Characterizing patient experiences with repeat artificial urinary sphincter revisions through quantitative surveys and qualitative patient interviews

Background

Artificial urinary sphincter (AUS) placement remains the gold-standard treatment for post-prostatectomy urinary incontinence (PPUI), despite their need for periodic surgical revision.

Objective

To understand the experiences of patients who undergo repeat AUS revisions.

Design

Mixed design including quantitative surveys and qualitative interviews for thematic analysis.

Methods

Men with ⩾2 revisions were collected from a single-institution, retrospective database of AUS patients. Participants were interviewed about their prostatectomy, incontinence, AUS placement, and revisions. A survey was administered utilizing validated tools (e.g., Decision Regret Scale (DRS), Incontinence Impact Questionnaire-7) for quantitative analysis. Interview transcripts were used for qualitative thematic analysis.

Results

Of 26 respondents, 20 completed the interview. Twenty-three men completed the survey. The mean DRS score for prostatectomy was 24 (standard deviation (SD) = 27), indicating low regret. Median Incontinence Impact Questionnaire score was 54 (SD = 27), with 70% of participants describing their PPUI as "severe." Participants experienced a significant decrease in daily pad usage with AUS placement (5.5 pre-AUS vs 1.4 post-AUS, p < 0.0001). Qualitative analysis revealed themes involving prostatectomy urgency, physician-patient relationships, expectation setting, and quality of follow-up. Most participants (96%) were satisfied with their initial AUS placement and endorsed a positive relationship with their urologist. However, 22% of participants were unaware of device limitations, including the need for revision. Some participants (26%) were uncertain of the status of their AUS, while some participants (35%) desired improved follow-up.

Conclusions

Initial improvement and positive experiences with urologists motivate patients to undergo AUS repeat revision. Urologists should emphasize the limitations of the AUS before placement and follow up with patients to evaluate their needs for future care.

Impact of Stress Urinary Incontinence After Radical Prostatectomy on Time to Intervention, Quality of Life and Work Status

OBJECTIVE

To characterize the incidence of stress urinary incontinence (SUI) after radical prostatectomy (RP), its treatment, and impact on quality of life (QoL) and work status 1year after RP.

MATERIALS AND METHODS

Prostate cancer patients treated by RP (1998-2016) were selected from CaPSURE. SUI was defined as any pads per day (ppd) 1 year after RP. SUI procedures were tracked by CPT codes (sling and artificial sphincter). Patients reported work status (full-time, part-time, unpaid), UCLA PCa Index urinary function (UF) and bother (UB) and SF36 Index physical function (PF). Associations of incontinence with UF, UB, and PF and work status changes were assessed (ANOVA). Lifetable estimates and Cox proportional hazards regression evaluated risk of undergoing SUI procedures.

RESULTS

664/2989 (22%) men treated with RP reported SUI at 1 year. More men with SUI had ≥GG2, intermediate to high-risk disease and non-nerve-sparing surgery (all P < .01). Cumulative incidence of SUI procedures was 1.4% at 10years after RP. Age (HR 2.68 per 10years, 95% CI 1.41-5.08) and number of ppd at 1 year (HR 3.20, 95% CI 2.27-4.50) were associated with undergoing SUI procedures. UF declined at 1year after RP, while UB and PF remained stable. UF, UB, and PF were inversely associated with number of ppd (all P < .01). Change in work status was not associated with incontinence or QoL scores.

CONCLUSION

Incontinence affected QoL without impacting work status, suggesting that men with SUI after RP may continue working and go under-treated despite impact on QoL.

The added value of devices to pelvic floor muscle training in radical post-prostatectomy stress urinary incontinence: A systematic review with metanalysis

PURPOSE

To investigate the role of pelvic floor devices (e.g., biofeedback, electrical stimulation, magnetic stimulation, or their combination) as adjunctive treatments in pelvic floor muscle training (PFMT) in stress urinary incontinence (SUI) after radical prostatectomy.

MATERIALS AND METHODS

A systematic review with meta-analysis. We searched for randomised controlled trials (RCTs) and prospective non-randomised studies investigating the effectiveness of pelvic floor devices as an adjunctive treatment for SUI symptoms assessed with weight pad-test or standardised questionnaires. To assess the risk of bias (RoB) and overall certainty of evidence, the RoB 2.0 or the ROBINS-I, and the GRADE approach were used.

RESULTS

Eleven RCTs met our eligibility criteria. One was at a 'low' RoB, one had 'some concerns', while nine were at a 'high' RoB. Two meta-analyses were conducted to analyse the pooled results of six RCTs included. Specifically, two RCTs reported at week 4 with a 1h pad test a mean difference of 0.64 (95% CI = [-13.09, 14.36]), and four RCTs reported at week 12 with a 24h pad test a mean difference of -47.75 (95% CI = [-104.18, 8.69]). The heterogeneity was high in both analyses (I2 = 80.0%; I2 = 80.6%). The overall level of certainty was very low.

CONCLUSIONS

In line with our results, we cannot conclude whether pelvic floor devices add any value as adjunctive treatment in the management of SUI after radical prostatectomy. Future studies require more comprehensive and standardised approaches to understand whether these devices are effective.

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.

Robot-assisted radical prostatectomy: Advancements in surgical technique and perioperative care

We reviewed the evolving strategies, practice patterns, and recent advancements aimed at improving the perioperative and surgical outcomes in patients undergoing robot-assisted radical prostatectomy for the management of localized prostate cancer.

Therapeutic Efficacy and Mid-Term Durability of Urethral Sphincter Platelet-Rich Plasma Injections to Treat Postprostatectomy Stress Urinary Incontinence

Platelet-rich plasma (PRP) is used for tissue repair and regeneration. Herein, we investigated the therapeutic efficacy and mid-term durability of injections of PRP into the urethral sphincter for the management of postprostatectomy incontinence (PPI). Thirty-nine patients with PPI that were refractory to conservative treatments were prospectively enrolled. They received repeated PRP urethral sphincter injections monthly for a total of four months. The primary endpoint was the Global Response Assessment (GRA) score after treatment. The secondary endpoints included changes in the stress urinary incontinence (SUI) visual analog scale (VAS) from baseline to the end of follow-up and urodynamic parameters from baseline to 3 months. The mean follow-up period after the entire treatment course was 21.0 ± 11.3 (range: 1.6−36.3) months. After PRP injections, the median GRA score with quartiles was 2.0 (1.0, 2.0). The SUI VAS and abdominal leak point pressure significantly improved from 6.9 ± 1.8 to 4.4 ± 2.3, p < 0.001, and from 74.8 ± 37.0 to 115.5 ± 57.9 cmH2O, p = 0.004, respectively, after the fourth PRP urethral sphincter injection. Following PRP urethral sphincter injections, the severity of SUI significantly reduced, indicating efficacy and mid-term durability as a novel treatment for PPI.

The role of preoperative prostatic shape in the recovery of urinary continence after robotic radical prostatectomy: a single cohort analysis

BACKGROUND

To explore the role of preoperative MRI prostate shape in urinary incontinence after robot-assisted radical prostatectomy (RARP).

METHODS

Patients were stratified into four groups based on the mpMRI prostatic apex shape: Group A (prostatic apex overlapping the membranous urethra anteriorly and posteriorly), Group B and C (overlap of the prostatic apex of the anterior or posterior membranous urethra, respectively) and Group D (no overlap). Preoperative variables and intraoperative data were compared. Continence recovery was defined as no pad/day or 1 safety pad/day by an outpatient evaluation performed at 1, 3, 6, and 12 months after RARP.

RESULTS

One hundred patients underwent RARP were classified as belonging to Group A (n = 30), Group B (n = 16), Group C (n = 14), and Group D (n = 40). Group D showed a significantly more favorable urinary continence recovery after RARP respect to all the other shapes presenting any forms of overlapping (HR = 1.9, 95% CI 1.2-3.1, p = 0.007). The estimated HR remained substantially unchanged after adjusting by age, body mass index, CCI, prostate volume, and bladder neck sparing (HR = 1.9, 95% CI 1.1-3.2, p = 0.016). The continence recovery median time was 9 months for Group A + B + C (95% CI 5-11) and 4 months for Group D (95% CI 2-6) (p = 0.023).

CONCLUSION

Shape D showed a better continence recovery when compared to other shapes presenting any kind of overlapping of the prostatic apex over the membranous urethra.

Evaluation of the effect of levator ani muscle contraction on post-prostatectomy urinary incontinence using cine MRI

AIM

Post-prostatectomy urinary incontinence (PPI) is the greatest concern for urologists after radical prostatectomy (RP). It is thought that PPI is composed of multiple factors including static and dynamic components. The purpose of this study is to show visually levator ani muscle (LAM) contraction during pelvic floor muscle contraction and to evaluate the dynamic differences in its contraction between men with and without PPI.

METHODS

This study was a case-control study of the urinary continent or incontinent men. It investigated whether LAM contraction was involved in urinary leakage based on examination of LAM contraction by cine magnetic resonance imaging.

RESULTS

The LAM contracted from the coccyx to the pubis in the same manner before and after surgery. The degree of contraction of the LAM in post-prostatectomy groups was smaller than that in the healthy adult group. The contraction distances of each part of the pelvic floor were decreased by 50%-70% in the incontinence group compared to those in the continence group. The bladder neck moved 2.5-fold further in the continence group and the direction of movement was more vertical than in the incontinence group. Urethral compression was attenuated by about 40% in the incontinence group compared to that in the continence group.

CONCLUSIONS

RP can cause damage to the LAM. LAM contraction is reduced after RP compared with that in healthy adult men. In men with PPI, the reduced muscle contraction might not compress the urethra sufficiently when abdominal pressure is raised. Pelvic floor muscle training might provide a meaningful method for the recovery of LAM contraction in patients with PPI.

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.

Análisis bibliométrico de la incontinencia urinaria masculina. Una mirada de los últimos 20 años

Introducción y Objetivo En las últimas décadas, la incidencia y prevalencia de la incontinencia urinaria han venido en aumento. Existen numerosas publicaciones sobre este tema, se han introducido nuevos dispositivos, y se han modificado las líneas de manejo de esta patología. El objetivo de este estudio es realizar un análisis bibliométrico de las publicaciones sobre incontinencia urinaria masculina en las revistas indexadas.

Métodos Se realizó un análisis bibliométrico descriptivo de corte retrospectivo de la literatura médica disponible en la base de datos Web of Science (WOS) en relación con incontinencia urinaria masculina entre 2002 y 2020. Por medio de la WOS, se obtuvieron las variables a analizar, y se elaboraron tablas y gráficas en el programa Microsoft Office Excel 2017.

Resultados Encontramos un total de 498 publicaciones en 88 revistas. Hubo un crecimiento exponencial de las publicaciones a partir de 2006. Las 3 revistas con mayor porcentaje de publicaciones fueron: J Urol, con 25,2% (125), Neurol Urodyn, con 16,5% (82), European Urology Journal, con 11,1% (55); sólo 5 de las 20 revistas con más publicaciones tuvieron un factor de impacto ≥ 3. El país que tuvo mayor porcentaje fue Estados Unidos con 21,2% (105), seguido por países europeos. En América Latina, el país con mayor número de publicaciones fue Brasil, con 2,6% (13). No se encontraron estudios colombianos con esta búsqueda específica.

Conclusión Este es el primer estudio bibliométrico sobre incontinencia urinaria masculina. Con el tiempo, han aumentado las publicaciones acerca de este tema, y la mayoría está concentrada en revistas de Estados Unidos y Europa. No es predominante la publicación en revistas de alto factor de impacto, y es muy baja la cantidad de publicaciones que aporta Colombia y los demás países latinoamericanos.

Prior Placement of Male Urethral Slings Can Increase the Need for Revision of Artificial Urinary Sphincters

Background: Recurrent stress urinary incontinence (SUI) following male sling can be managed surgically with artificial urinary sphincter (AUS) insertion. Prior small, single-center retrospective studies have not demonstrated an association between having failed a sling procedure and worse AUS outcomes. The aim of this study was to compare outcomes of primary AUS placement in men who had or had not undergone a previous sling procedure. Methods: A retrospective review of all AUS devices implanted at a single academic center during 2000–2018 was performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 19 (14.1%) patients had undergone prior sling procedures. Results: There was no significant difference in demographic characteristics between patients undergoing AUS placement with or without a prior sling procedure. Average follow up time was 28.0 months. Prior sling was associated with shorter overall device survival, with an increased likelihood of requiring revision or replacement of the device (OR 4.2 (1.3–13.2), p = 0.015) as well as reoperation for any reason (OR 3.5 (1.2–9.9), p = 0.019). While not statistically significant, patients with a prior sling were more likely to note persistent incontinence at most recent follow up (68.8% vs. 42.7%, p = 0.10). Conclusions: Having undergone a prior sling procedure is associated with shorter device survival and need for revision or replacement surgery. When considering patients for sling procedures, patients should be counseled regarding the potential for worse AUS outcomes should they require additional anti-incontinence procedures following a failed sling.

[Künstliche Harnsphincter zur Behandlung von Stress-Harninkontinenz - eine oft nicht ausgelastete Behandlungsoption in Deutschland]

ABSTRAKT

Harninkontinenz ist in Deutschland weit verbreitet und betrifft Millionen von Frauen und Männern. Vor allem Männer, die postoperativ dauerhaft inkontinent sind, werden hierzulande trotz der ausreichenden Verfügbarkeit chirurgischer Optionen unterbehandelt. Der künstliche Schließmuskel wird seit Jahrzehnten erfolgreich zur Behandlung angeborener und erworbener Stress-Harninkontinenz bei Männern und Frauen sowie neurogener Harninkontinenz eingesetzt und wird in Form neuer Modelle weiterentwickelt. Aufgrund der guten Ergebnisse, Es gilt jetzt als Standardtherapie für Männer mit anhaltender, mittelschwerer bis schwerer Harninkontinenz. Die operationstechnische Technik ist anspruchsvoll, kann aber erlernt werden. Die meisten Komplikationen können in erfahrenen Händen deutlich reduziert werden. Patientenzufriedenheit mit künstlichen Harnsphinctern (AUS) ist hoch und korreliert mit der Kontinenzrate und nicht mit der relativ hohen Revisionsrate, weshalb diese Behandlungsoption in Deutschland zunehmend mehr Patienten mit mittelschwerer bis schwerer Harninkontinenz angeboten werden sollte. Urologen in der allgemeinen Praxis spielen in diesem Zusammenhang eine zentrale Rolle.

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.

Adverse Events Associated With Synthetic Male Slings: An Analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience Database

PURPOSE

We sought to describe and analyze the adverse events associated with synthetic male slings reported to the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

We queried the MAUDE database for all entries including the terms "Male Sling," "InVance," "Virtue," or "Advance" from January 1st, 2009 to December 31st, 2018. We collected and analyzed information about the event type, date received, report source, source type, and manufacturer. We reviewed and categorized the event description text for each medical device report (MDR).

RESULTS

A total of 497 adverse events related to the male sling were identified. The adverse events were classified as injury (95.4%), malfunction (4.2%), and other (0.4%). There were no deaths described. The slings involved were the Advance or Advance XP sling (69.8%), InVance (15.5%), Virtue Quadratic (12.3%), or unknown (2.4%). The 4 most common adverse events described were urinary incontinence (46.7%), sling erosion (9.1%), mechanical malfunction (8.2%), and pain/numbness (8.2%). There was no increase in the number of reports in the years following the FDA warnings for urogynecologic mesh.

CONCLUSION

There was an overall modest number of MDRs related to male slings and the majority of them were reported by the manufacturer. The reporting of adverse events for male slings does not seem to be affected by the controversy and scrutiny towards transvaginal mesh and midurethral slings. Further clinical studies and more objective and detailed databases are needed to investigate the safety of these synthetic slings.

Artificial Urinary Sphincter Complications: Risk Factors, Workup, and Clinical Approach

PURPOSE OF REVIEW

To review risk factors for AUS complications and present a systematic approach to their diagnosis and management.

RECENT FINDINGS

Established risk factors for AUS complications include catheterization, channel TURP, pelvic radiation, urethroplasty, anticoagulation, cardiovascular disease, diabetes mellitus, frailty index, hypertension, low albumin, and low testosterone. We present our algorithm for diagnosis and management of AUS complications. Despite being the gold standard of treatment for men with SUI, major and minor complications can occur at any point after AUS insertion. Careful consideration of the urologic, medical, and operative risk factors for each patient can help prevent complications. A systematic approach to early and late complications facilitates their identification and effective management. The evaluating urologist must have a thorough understanding of potential AUS complications in order to restore quality of life in men with bothersome SUI.

A novel management for postprostatectomy urinary incontinence: platelet-rich plasma urethral sphincter injection

Platelet-rich plasma (PRP) is the most innovative blood-derived product used in regenerative medicine. We aimed to investigate the therapeutic efficacy of PRP urethral sphincter injection for the management of postprostatectomy incontinence (PPI). In total, 28 PPI patients with a mean age of 71.8 ± 8.9 years were prospectively enrolled. They received four PRP urethral sphincter injections each month. The clinical outcomes were assessed 3 months after the fourth injection as posttreatment Global Response Assessment (GRA) score, the newly designed visual analogue scale of stress urinary incontinence (VAS of SUI), and in urodynamic parameters. After injections, the posttreatment median GRA with quartiles was 2.0 (1.0, 2.0). Overall, six (21.4%) patients achieved complete continence and pad-free status, 20 (71.4%) achieved successful outcome (GRA score ≥ 2), and 26 (92.9%) showed clinical improvement (GRA score ≥ 1). The VAS of SUI significantly improved from 6.5 (5.0, 8.0) to 3.5 (2.0–5.8) (p < 0.001) as well as abdominal leak point pressure, from 57.5 (50.0, 115.0) to 126.0 (68.3, 150.0), (p = 0.004). After repeated PRP urethral sphincter injections, the SUI severity reduced significantly with high success rates. There was no major adverse event, except three patients with mild hematuria and micturition pain. In conclusion, PRP urethral sphincter injection is safe and effective as a novel management of PPI.

Standing cough test stratification of moderate male stress urinary incontinence

PURPOSE

Patient-reported history of pads per day (PPD) is widely recognized as a fundamental element of decision-making for anti-incontinence procedures. We hypothesize that SUI severity is often underestimated among men with moderate SUI. We sought to compare patient history of incontinence severity versus objective in-office physical examination findings.

MATERIALS AND METHODS

We retrospectively reviewed our single-surgeon male SUI surgical database from 2007-2019. We excluded patients with incomplete preoperative or postoperative data and those who reported either mild or severe SUI, thus having more straightforward surgical counseling. For men reported to have moderate SUI, we determined the frequency of upgrading SUI severity by recording the results of an in-office standing cough test (SCT) using the Male Stress Incontinence Grading Scale (MSIGS). The correlation of MSIGS with sling success rate was calculated. Failure was defined as >1 PPD usage or need for additional incontinence procedure.

RESULTS

Among 233 patients with reported moderate SUI (2-3 PPD), 89 (38%) had MSIGS 3-4 on SCT, indicating severe SUI. Among patients with 2-3 PPD preoperatively, sling success rates were significantly higher for patients with MSIGS 0-2 (76/116, 64%) compared to MSIGS 3-4 (6/18, 33%) (p <0.01).

CONCLUSIONS

Many men with self-reported history of moderate SUI actually present severe SUI observed on SCT. The SCT is a useful tool to stratify moderate SUI patients to more accurately predict sling success.

[Health care reality of urological endoprosthetics in Germany from 2006 to 2016]

Hintergrund

Die Behandlung von Harninkontinenz und erektiler Dysfunktion verbessert die Lebensqualität vieler Patienten. Insbesondere die Endoprothetik mit Sphinkter- und Penisprothesen erzielt hierbei sehr gute Ergebnisse, wenn konservative Therapieoptionen ausgeschöpft sind. Ziel dieser Studie ist eine Darstellung der Entwicklung und aktuellen Versorgungslage der Sphinkter- und Penisprothesenimplantation in Deutschland.

Material und Methoden

Wir führten eine Analyse der Diagnosis-Related-Groups-Abrechnungsdaten in Deutschland im Zeitraum von 2006 bis 2016 durch. Die Versorgungslage im Jahr 2016 beschrieben wir auf Basis der Qualitätsberichtsdaten der deutschen Krankenhäuser.

Ergebnisse

Von 2006 bis 2012 stieg die Zahl der implantierten Sphinkterprothesen in Deutschland von 739 auf 1112 (p < 0,001) und die Zahl der implantierenden Kliniken von 129 auf 206 (p < 0,001). Von 2012 bis 2016 fielen die Fallzahlen auf 980 und die Zahl der Kliniken auf 198. Im Jahr 2016 implantierten 168 (88 %) urologische Kliniken 1–9 Sphinkterprothesen und 23 (12 %) Kliniken ≥ 10 Sphinkterprothesen. Die 10 Top-Kliniken (≥20 Sphinkter) implantierten 34 % (283/839) aller Sphinkter. Von 2006 bis 2013 stieg die Zahl der implantierten Penisprothesen kontinuierlich von 263 auf 503 (p < 0,001) sowie die Zahl der implantierenden Kliniken von 71 auf 107 (p < 0,001). Von 2013 bis 2016 stagnierte die Fallzahl (p = 0,9) und die Zahl der implantierenden Kliniken (p = 0,5). Der Anteil implantierter Penisprothesen im Rahmen von Geschlechtsumwandlungen stieg von 17 % im Jahr 2006 auf 25 % im Jahr 2016 (p = 0,03). Im Jahr 2016 implantierten 83 (85 %) urologische Kliniken 1–6 Penisprothesen und 14 (15 %) Kliniken ≥ 7 Prothesen. Die 7 Top-Kliniken (≥20 Prothesen/Jahr) implantierten 232/448 (52 %) der Prothesen.

Diskussion

Der Versorgungsstand der urologischen Endoprothetik in Deutschland zeigt eine deutliche Zentrenbildung, aber auch eine große Zahl von Kliniken mit geringer Fallzahl. Seit 2012/2013 zeigt sich eine Stagnation der Fallzahlen von Penis- und Sphinkterprothesenimplantationen, die in Zusammenschau mit den Prostatektomiefallzahlen eine Unterversorgung vermuten lässt.

Zusatzmaterial online

Die Online-Version dieses Artikels (10.1007/s00120-021-01444-5) enthält weitere Tabellen zu Fallzahlen von Sphinkterprothesen und Penisprothesenimplantationen. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Robot-assisted artificial urinary sphincter implantation

PURPOSE OF REVIEW

The aim of the present manuscript was to provide an overview on the current state of robotic artificial urinary sphincter (AUS) implantation in male and female patients.

RECENT FINDINGS

Over the past few years, several series have been reported, with promising outcomes for the most part. This has contributed to expand the use of bladder neck AUS, especially in female patients, which was, until then, hampered by its perioperative morbidity.

SUMMARY

Robotic AUS has been developed to overcome the technical challenge of bladder neck implantation in female patients and in specific male subgroups, especially self-catheterizing neurological patients. All the series of robotic AUS implantation published in the past few years reported much lower rates of cuff erosion and AUS explantation than the historical open cohorts suggesting that the robotic approach might become the standard for female AUS implantation. This less morbid approach along with technological improvement of the AUS device may contribute to make it a more popular option in the treatment of female stress urinary incontinence due to intrinsic sphincter deficiency. There are much less data available on robotic bladder neck AUS implantation in male patients.

[Survival analysis of adjustable continence therapy device (ACT®/proACT®): a new message for patients]

INTRODUCTION

The main purpose was to assess the failure free survival of adjustable continence therapy ACT®/proACT® after continence was obtained and to seek factors influencing it.

MATERIAL AND METHODS

Retrospective, single-center survival study of peri-urethral balloons implanted between 2007 and 2014. Efficacy was defined by the wearing of 0 or 1 safety pad per day. The primary end point was time to failure estimated from a survival curve (Kaplan-Meier). Factors that could influence failure free survival were: sex, age, radiotherapy, diabetes, number of pad before surgery, number of balloon inflation, early complications, mixed urinary incontinence and previous ACT®/proACT® placement. They were analyzed in a COX regression.

RESULTS

Of the 82 peri-urethral balloons placed, 41 were effective in 36 patients. The failure free survival was 50 % at 60 months. Radiotherapy, diabetes and previous peri-urethral balloon placement appeared to significantly decrease survival (P=0.031;P=0.025;P=0.029, respectively). Fifteen peri-urethral balloons were still effective at the last follow-up, one was lost to follow-up and 25 required re-intervention for loss of efficacy. The main cause of efficacy loss was system leakage. Fifty-two percent of peri-urethral balloons that became ineffective were replaced by new peri-urethral balloons and 28% by an artificial urinary sphincter.

CONCLUSION

Patients who became continent with adjustable continence therapy (ACT®/proACT®) had a 50 % new surgery probability at 5 years for a loss of efficacy. Radiotherapy seems to be the main risk factor of the efficacy loss.

LEVEL OF EVIDENCE

IV.

How to Prevent and Manage Post-Prostatectomy Incontinence: A Review

PURPOSE

To provide an overview of the currently available evidence relating to the prevention and management strategies of urinary incontinence (UI) after radical prostatectomy (RP).

MATERIALS AND METHODS

A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning post-RP UI. The search strategy included these words: urinary continence; urinary continence recovery; urinary incontinence; radical prostatectomy; and prostate cancer.

RESULTS

Post-RP UI still represents a challenging issue for both urologic patients and clinicians. A complete preoperative assessment of the risk factors associated with post-RP UI aids both in counseling those patients with a higher estimated likelihood of postoperative UI and in identifying those who would probably benefit from preventive strategies in the preoperative and in the intraoperative settings. Over the last decades different surgical strategies based on either the "preservation" or the "reconstruction" of the anatomical elements responsible for urinary continence (UC) led to an overall improvement of postoperative functional outcomes. Finally, several therapeutic strategies should be evaluated for the postoperative UI management. Artificial urinary sphincter implantation represents the gold standard for treatment, notwithstanding its wide adoption is limited due to high costs and significant risk of surgical revision. In this context, male sling positioning seems the most promising strategy, in particular in mild and moderate post-RP UI.

CONCLUSIONS

To enhance the likelihood of obtaining an optimal UC recovery after RP, it is here strongly suggested to intervene throughout the overall clinical management process thus including the pre-, intra- and postoperative settings.

Deep learning using preoperative magnetic resonance imaging information to predict early recovery of urinary continence after robot-assisted radical prostatectomy

OBJECTIVES

To investigate whether a deep learning model from magnetic resonance imaging information is an accurate method to predict the risk of urinary incontinence after robot-assisted radical prostatectomy.

METHODS

This study included 400 patients with prostate cancer who underwent robot-assisted radical prostatectomy. Patients using 0 or 1 pad/day within 3 months after robot-assisted radical prostatectomy were categorized into the "good" group, whereas the other patients were categorized into the "bad" group. Magnetic resonance imaging DICOM data, and preoperative and intraoperative covariates were assessed. To evaluate the deep learning models from the testing dataset, their sensitivity, specificity and area under the receiver operating characteristic curve were analyzed. Gradient-weighted class activation mapping was used to visualize the regions of deep learning interest.

RESULTS

The combination of deep learning and naive Bayes algorithm using axial magnetic resonance imaging in addition to clinicopathological parameters had the highest performance, with an area under the receiver operating characteristic curve of 77.5% for predicting early recovery from post-prostatectomy urinary incontinence, whereas machine learning using clinicopathological parameters only achieved low performance, with an area under the receiver operating characteristic curve of 62.2%. The gradient-weighted class activation mapping methods showed that deep learning focused on pelvic skeletal muscles in patients in the good group, and on the perirectal and hip joint regions in patients in the bad group.

CONCLUSIONS

Our results suggest that deep learning using magnetic resonance imaging is useful for predicting the severity of urinary incontinence after robot-assisted radical prostatectomy. Deep learning algorithms might help in the choice of treatment strategy, especially for prostate cancer patients who wish to avoid prolonged urinary incontinence after robot-assisted radical prostatectomy.

How can we prevent postprostatectomy urinary incontinence by patient selection, and by preoperative, peroperative, and postoperative measures? International Consultation on Incontinence-Research Society 2018

AIMS

To review current prevention strategies for urinary incontinence among patients undergoing radical prostatectomy (RP).

METHODS

This is a consensus report of the proceedings of a research proposal from the annual International Consultation on Incontinence-Research Society (ICI-RS), 14 to 16 June 2018 (Bristol, UK): "How can we prevent postprostatectomy incontinence by patient selection, and by preoperative, peroperative, and postoperative measures?"

RESULTS

Several baseline parameters were proposed as predicting factors for postprostatectomy urinary incontinence (PPUI), including age, tumor stage, prostate volume, preoperative lower urinary tract symptoms, maximum urethral closure pressure, and previous transurethral resection of the prostate. More recently, magnetic resonance imaging has been used to measure the membranous urethral length and sphincter volume. Peroperative techniques include preservative and reconstructive approaches. Bladder neck preservation improved early (6 months), as well as long-term (>12 months) continence rates. Several prospective studies have reported earlier return of continence following preservation of puboprostatic ligaments, although no long-term data are available. Preservation of the urethral length yielded controversial outcomes. Concerning postoperative strategies, it is probably optimal to remove the catheter in a window between 4 and 7 days if clinically appropriate; however, more research in this regard is still required. Postoperative PFME (preoperative pelvic floor muscle exercise) appears to speed up the recovery of continence after RP.

CONCLUSIONS

Conservative strategies to prevent PPUI include proper patient selection and PFME. Peroperative techniques have largely shown benefit in the short term. Postoperative complications and timing of trial without catheter can influence continence status. Future research initiatives must assess peroperative and postoperative measures, with longer-term follow-up.

A new male sling for minimal to moderate incontinence and climacturia

Erectile dysfunction (ED) and stress urinary incontinence (SUI) are known bothersome sequelae to radical prostatectomy. In recent years, additional attention has been placed on another less commonly described and reported side effect to this surgery, climacturia. While various noninvasive and surgical interventions have been described for the management of climacturia, until recently, none has provided reliable and meaningful results. In the past few years, the Mini-Jupette sling has gained popularity as an adjunct to inflatable penile prosthesis placement in patients with concomitant ED and climacturia. Recent data have also suggested its feasibility in patients with mild SUI. While the original technique described by Pr. Andrianne has shown long-term, reproducible, and safe results, innovative modifications such as the use of autologous rectus fascia, the Male Urethral Mini-Sling and the Mayo Clinic modified Mini-Jupette sling have also been suggested, proof of widespread interest amongst clinicians toward achieving the optimum surgical technique.

Impact of Preoperative Magnetic Resonance Imaging Anatomic Features on Urinary Continence Recovery after Laparoscopic Radical Prostatectomy

PURPOSE

To evaluate the impact of preoperative magnetic resonance imaging anatomic features on urinary continence recovery after laparoscopic radical prostatectomy (LRP).

METHODS

We retrospectively analyzed 150 consecutive prostate cancer patients who underwent LRP between July 2015 and June 2018 in our institution. Patients reporting freedom from using safety pad (0 pads/day) were defined as urinary continent. We evaluated the association of urinary continence recovery after LRP and the perioperative variables, including age, prostatic volume (PV), intravesical prostatic protrusion length (IPPL), membranous urethral length (MUL), and neurovascular bundle (NVB) sparing status. Kaplan-Meier and log-rank tests were used to compare urinary continence rates between groups. Univariate and multivariate Cox proportional hazards regression analyses were used to identify independent predictors for urinary continence recovery.

RESULTS

60.6% (91/150), 83.3% (125/150), and 96.0% (144/150) of the patients experienced urinary continence recovery at 3, 6, and 12 months, respectively. There was significant difference in PV, IPPL, MUL, and NVB sparing between groups stratified by urinary continence status at 3, 6, and 12 months. Kaplan-Meier curves of urinary continence rates showed significant differences between groups stratified by PV (<50 mL vs. ≥50 mL, p < 0.001), IPPL (<5 mm vs. ≥5 mm, p < 0.001), MUL (≥15 mm vs. <15 mm, p < 0.001), and NVB sparing status (yes vs. no, p = 0.003), respectively. On univariate analysis, PV, IPPL, MUL, and NVB sparing were significantly associated with urinary continence recovery (all, p < 0.05). On multivariate analysis, only IPPL (HR = 0.94, p = 0.003) and MUL (HR = 1.10, p < 0.001) were independent predictors for urinary continence recovery.

CONCLUSION

Patients with larger IPPL and shorter MUL have higher chances of delayed recovery of urinary continence after LRP. IPPL and MUL were reliable morphometric parameters for predicting urinary continence.

Fundamentals of prosthetic urology

The field of prosthetic urology demonstrates the striking impact that simple devices can have on quality of life. Penile prosthesis and artificial urinary sphincter implantation are the cornerstone procedures on which this specialty focuses. Modern research largely concentrates on decreasing the rates of complication and infection, as the current devices offer superior rates of satisfaction when revision is not necessary. These techniques are also able to salvage sexual function and continence in more difficult patient populations including female-to-male transgender individuals, those with ischemic priapism, and those with erectile dysfunction and incontinence secondary to prostatectomy. This review summarizes modern techniques, outcomes, and complications in the field of prosthetic urology.

Strong correlation between standing cough test and 24-hour pad weights in the evaluation of male stress urinary incontinence

AIMS

We sought to compare in-office physical exam findings via standing cough test (SCT) versus 24-hour pad weights among men seeking treatment for postprostatectomy stress urinary incontinence (SUI).

METHODS

A retrospective review of a single surgeon database of incontinence procedures was performed. Documentation of SUI severity (grades 0-4) was completed by SCT preoperatively utilizing the Male Stress Incontinence Grading Scale (MSIGS). All patients had pads per day (PPD) and 24-hour pad weights obtained. We determined the Spearman's correlation coefficient between these variables.

RESULTS

We identified 104 men who underwent anti-incontinence surgery (AdVance Sling or artificial urinary sphincter [AUS]). In the sling group (65 patients), nearly all (97%) had minimal incontinence with SCT (MSIGS = 0-2). In the AUS group (39 patients), most patients (69%) had an MSIGS 3 or 4 with SCT. Spearman's coefficient between quantification of SCT and pad weight for the overall group was ρ = .68 (P < .0001) demonstrating a strong positive correlation. PPD was also strongly correlated with pad weight (ρ = .55, P < .0001). As seen previously, SCT and PPD were correlated (ρ = .47, P < .0001). In a multivariable model predicting pad weight, the effect of SCT was greater than PPD (β = 83 [54-111], P < .0001 vs 45 [2169], P = .0004).

CONCLUSIONS

SCT findings strongly correlate to 24-hour pad weights in the evaluation of male SUI. The SCT shows promise as a rapid, reliable, noninvasive measure of SUI severity before anti-incontinence surgery.