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

Factors Influencing Postoperative Overactive Bladder after Adjustable Trans-Obturator Male System Implantation for Male Stress Incontinence following Prostatectomy

We aimed to determine the risk factors for postoperative overactive bladder (OAB) in patients treated with an adjustable trans-obturator male system (ATOMS) for stress incontinence after radical treatment of prostate cancer. A prospective study was performed on 56 patients implanted with an ATOMS for PPI. Clinical and urodynamic information was recorded before and after ATOMS implantation. We built a multivariate model to find out the clinical and urodynamic factors that independently influenced postoperative OAB and the prognostic factors that influenced the efficacy of medical treatment of OAB. We found that the clinical risk factors were the preoperative intensity of urinary incontinence (number of daily pads used and amount of urinary leakage), International Consultation on Incontinence Questionnaire (ICIQ) score, postoperative number of ATOMS adjustments, final cushion volume, and incontinence cure. The urodynamic data associated with OAB were cystometric bladder capacity, voided volume, volume at initial involuntary contraction (IC), maximum flow rate, bladder contractility index (BCI), and urethral resistance (URA). The prognostic factors for the efficacy of oral treatment of OAB were the volume at the first IC (direct relationship) and the maximum abdominal voiding pressure (inverse relationship). The multivariate model showed that the independent clinical risk factors were the daily pad count before the implantation and the ICIQ score at baseline and after treatment. The independent urodynamic data were the volume at the first IC (inverse relationship) and the URA value (direct relationship). Both predictive factors of treatment efficacy were found to be independent. Detrusor overactivity plays an important role in postoperative OAB, although other urodynamic and clinical factors such as the degree of urethral resistance and abdominal strength may influence this condition.

Guiding Clinical Decision Making for Surgical Incontinence Treatment After Prostatectomy: A Review of the Literature

PURPOSE OF REVIEW

Stress urinary incontinence after prostatectomy is a common and debilitating side effect. Immediate post-prostatectomy management emphasizes pelvic floor muscle exercises. Per American Urologic Association guidelines, if incontinence persists for more than 12 months postoperatively, surgical interventions are the mainstay of treatment. Treatment decisions depend on a multitude of factors. The goal of this paper is to review recent literature updates regarding the diagnosis of male SUI to better guide surgical treatment decision-making.

RECENT FINDINGS

Patient history is a critical component in guiding surgical decision making with severity and bother being primary factors driving treatment decisions. Recent studies indicate that a history of pelvic radiation continues to impact the overall duration and complication rate associated with artificial urinary sphincters (AUS). Cystoscopy should be done on every patient preparing to undergo surgical SUI treatment. Urodynamics and standing cough stress tests are additional diagnostic testing options; these tests may augment the diagnosis of SUI and better delineate which patients may benefit from a male sling versus AUS. Treatment of SUI after prostatectomy can improve health-related quality of life. A patient history focused on severity and degree of bother in addition to the use of ancillary office testing can help guide surgical treatment decisions to optimize patient continence goals.

Bladder Capacity in Women With Overactive Bladder Syndrome: A Cross-sectional Study

OBJECTIVE

To evaluate bladder capacity in women with idiopathic overactive bladder syndrome (OAB) through bladder diary, cystomanometry, and uroflowmetry and assess the concordance of the different measures of bladder capacity. A secondary objective is to describe the relationship between bladder capacity and urinary frequency in OAB patients.

METHODS

An observational cross-sectional multicentric study was conducted, including female patients diagnosed with idiopathic OAB. All participants underwent a urodynamic study and completed a 3-day bladder diary (3dBD). Different parameters were used to calculate bladder capacity: maximum cystometric capacity (MCC) assessed at the end of filling cystometry, voided volume (VV) during the uroflowmetry, maximum voided volume (VVmax), and average voided volume (VVmed), both assessed through the 3dBD. Reproducibility analysis was performed to assess the agreement among the different bladder capacity measures. Intraclass correlation coefficient (ICC) and weighted Kappa index were used. Bladder capacity parameters were also assessed in relation to urinary frequency.

RESULTS

Bladder capacity measures were diminished in this population, except for VVmax. Poor correlation was found between the different bladder capacity variables (ICC and weighted Kappa index <0.4). Twenty-four-hour frequency and average VV present a weak negative linear relationship (Pearson coefficient -0.344).

CONCLUSION

MCC and average VV are reduced in OAB patients. MCC does not correlate well with functional bladder volumes determined by voiding diary in the OAB population.

Modified female mid-urethral sling for the treatment of incontinence after prostate treatment: One-center experience

BACKGROUND

The male sling has emerged as a minimally invasive option for incontinence after prostate treatment (IPT) in recent years, but it has not yet been introduced into China. This study retrospectively evaluated the clinical outcomes of the modified female mid-urethral sling in the treatment of IPT and explored potential preoperative factors to better predict surgical outcomes.

METHODS

From May 2014 to January 2021, a total of 70 patients with IPT who underwent transobturator male sling procedure using the modified female mid-urethral sling were retrospectively reviewed. All surgeries were performed by a single surgeon. Functional outcomes were evaluated by daily pad usage, and the severity of incontinence was classified as mild (≤2 pads), moderate (3-4 pads), or severe (≥5 pads). Success was defined as no pad usage or 1 pad for safety (cure), or a reduction in daily pad use by >50% (improved). Patients were followed up at 3, 6 months, and yearly thereafter.

RESULTS

At a final follow-up of 6-80 months, 35 (50.0%) patients were cured, 12 (17.1%) were improved, and 23 (32.9%) were still incontinent. There was a slight trend of declining continence over time, and the majority of patients remained improved. During follow-up, 25 patients had perineal or scrotal pain, five patients had voiding difficulty and two had de novo urgency, one developed infection and underwent sling explantation. Early urinary retention was the only significant factor linked to better surgical outcomes.

CONCLUSION

The modified female mid-urethral sling represents a viable option for the treatment of IPT. Improved efficacy is seen in patients with a history of early postoperative urinary retention.

Prevalence of chronic pain following suburethral mesh sling implantation for post-prostatectomy incontinence

PURPOSE

To evaluate postoperative pain and complications following AdVance™/AdVance™ XP male sling implantation.

MATERIALS AND METHODS

A multi-center retrospective medical notes review of patients implanted for bothersome post-prostatectomy incontinence was conducted. All patients were telephoned to provide further information on pain or further complications related to their surgery. Statistical evaluation utilized logistical regression analysis. Additionally, a literature review was conducted reviewing pain outcomes following AdVance™/AdVance™ XP implantation.

RESULTS

One-hundred and twenty-seven men were reviewed over an 8-year period. The mean age was 70 years, with mean follow up 52 months. Of those with mild stress urinary incontinence, 45 (79%) had a successful outcome compared to 42 (72%) in the moderate group. Twenty-nine (23%) men reported postoperative pain, with a mean maximal pain score of 6 (range: 0-10). The majority of pain resolved within 4 weeks (19/29 men). A further seven patients resolved by 3 months. Only three men (2.3%) had chronic pain greater than 3 months, which all resolved by 1 year. Men less than 65 years were more likely to suffer pain (p = 0.009). Acute urinary retention occurred in 23 (18%) men and correlated significantly with postoperative pain (p = 0.04). Overactive bladder symptoms, severity of incontinence or radiotherapy were not correlated with postoperative pain. In our cohort, there were no extrusions, divisions, or explantations.

CONCLUSION

Approximately a quarter of men experience pain in the early postoperative period. However, the severity and rates of chronic pain (>3 months) are low (2.3%) but all settle within a year.