[Diagnosis and surgical treatment of postprostatectomy stress incontinence: recommendation of the working group Urologische Funktionsdiagnostik und Urologie der Frau]

The impact of perioperative complications on favorable outcomes after artificial urinary sphincter implantation for post-prostatectomy incontinence

Objective

To investigate the effect of perioperative complications involving artificial urinary sphincter (AUS) implantation on rates of explantation and continence as well as health-related quality of life (HRQOL).

Materials and methods

Inclusion criteria encompassed non-neurogenic, moderate-to-severe stress urinary incontinence (SUI) post radical prostatectomy and primary implantation of an AUS performed by a high-volume surgeon (>100 previous implantations). Reporting complications followed the validated Clavien-Dindo scale and Martin criteria. HRQOL was assessed by the validated IQOL score, continence by the validated ICIQ-SF score. Statistical analysis included Chi (2) test, Mann-Whitney-U test, and multivariate regression models (p <0.05).

Results

105 patients from 5 centers met the inclusion criteria. After a median follow-up of 38 months, explantation rates were 27.6% with a continence rate of 48.4%. In the age-adjusted multivariate analysis, perioperative urinary tract infection was confirmed as an independent predictor of postoperative explantation rates [OR 24.28, 95% CI 2.81-209.77, p=0.004). Salvage implantation (OR 0.114, 95% CI 0.02-0.67, p=0.016) and non-prostatectomy related incontinence (OR 0.104, 95% CI 0.02-0.74, p=0.023) were independent predictors for worse continence outcomes. Low visual analogue scale scores (OR 9.999, 95% CI 1,42-70.25, p=0.021) and ICIQ-SF scores, respectively (OR 0.674, 95% CI 0.51-0.88, p=0.004) were independent predictors for increased HRQOL outcomes. Perioperative complications did not significantly impact on continence and HRQOL outcomes.

Conclusion

Findings show postoperative infections adversely affect device survival after AUS implantation. However, if explantation can be avoided, the comparative long-term functional results and HRQOL outcomes are similar between patients with or without perioperative complications.

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Zusammenfassung. Die funktionelle Urologie befasst sich mit der Diagnostik und Therapie von Störungen der Harnblasen- und Beckenbodenfunktion und der Harninkontinenz. Die urodynamische Funktionsdiagnostik als zentrale diagnostische Methode ermöglicht durch die Messung einfacher physiologischer Parameter eine direkte Beurteilung der Funktion des unteren Harntraktes. Die Urodynamik dient dazu, klinische Symptome quantitativ zu reproduzieren, die Änderung physiologischer Parameter während der Messung in einen pathophysiologischen Zusammenhang zu stellen, eine Diagnose abzuleiten, eine Behandlung einzuleiten und im Verlauf deren Erfolg zu kontrollieren. Facetten der funktionellen Urologie sind die Neurourologie, die Urologie der Frau, die funktionelle Kinderurologie, die psychosomatische Urologie und die Behandlung der Harninkontinenz bei Frauen und Männern jeglichen Alters.

Long-term Outcome of the Retrourethral Transobturator Male Sling After Transurethral Resection of the Prostate

Purpose

To evaluate long-term outcomes of AdVance and AdVanceXP male slings in patients with persistent stress urinary incontinence (SUI) after transurethral resection of the prostate (TURP).

Methods

A total of 18 consecutive patients received AdVance (n=14) or AdVanceXP (n=4) male sling implantation between 2007 and 2013. Continence was determined by pad use, 24-hour pad testing and validated questionnaires (International Consultation on Incontinence Questionnaire Short Form, ICIQ-SF). Quality of life was evaluated by International Quality of Life (IQoL) score. Patient satisfaction was measured with patient’s global impression of improvement score. Cure was defined as 0–5 g in the 24-hour pad test. Statistical analysis included Fisher exact and Wilcoxon test (P<0.05).

Results

Follow-up was available for 15 patients who underwent further analysis. After a median follow-up of 70 months (range, 18–83 months), mean daily pad usage was 1.8±2.1 pads (P=0.015 vs. baseline level). Mean IQoL score was 66.4±31.6 (P=0.050 vs. baseline level), and mean ICIQ-SF score was 9.5±6.6 (P=0.077 vs. baseline level). Based on 24-hour pad testing, mean daily urine loss was 31.2±64.5 g (median, 0 g; range, 0–209 g). Cure rate was 46.7%, and cure-and-improved rate was 60.0%. Assessing predictive features for success, better results were found in patients who needed up to 4 pads preoperatively (P=0.041) as well as for patients ≤71 years at the time of implantation (P=0.041).

Conclusions

The findings indicate that AdVance and AdVanceXP implantation can be performed effectively and safely in men suffering from SUI after TURP. However, long-term success rates seem to be lower compared to SUI after radical prostatectomy and patients should be counseled accordingly.

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.

Reconstructive surgery for male stress urinary incontinence: Experiences using the ATOMS(®) system at a single center

OBJECTIVE

To propose possible success-driven solutions for problem and complication rates encountered with the ATOMS(®) sling system, based on first-hand experience; and to provide possible actual alternative scenarios for the treatment of male stress urinary incontinence (SUI).

PATIENTS AND METHODS

During the defined period (between 4/2010 and 04/2014), 36 patients received ATOMS(®) system implants at our clinic. We collected pre- and post-operative evaluation data using the International Consultation on Incontinence Questionnaire Short Form (ICIQ SF). As an expansion of the questionnaire, we added questions about post-operative perineal pain, the general satisfaction with the results of the intervention and willingness to recommend the operation to a best friend.

RESULTS

Our data shows a relatively high explantation rate, but a surprisingly high patient satisfaction rate. Explantation was required mainly due to late onset infections or other symptomatic factors. Compared to other studies early onset infections were rare.

CONCLUSION

A non-invasive, uncomplicated adjustable system to alleviate male stress urinary incontinence remains a challenge. Although there are various systems available for the treatment of male stress urinary incontinence, it seems that despite the advantages of the ATOMS(®) system, an artificial sphincter system may pose more advantages based on our experience, understanding and knowledge of its well-documented long-term solutions and problems.