Long-term outcomes and patient satisfaction after artificial urinary sphincter implantation

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.

Impact of Artificial Urinary Sphincter Placement on Quality of Life: A Validated Outcome Assessment

INTRODUCTION

Artificial Urinary Sphincter (AUS) placement is the preferred treatment for moderate to severe incontinence following prostate cancer treatment. While device related outcomes related to device survival are well reported, literature on quality-of-life outcomes, including the use of validated measures is limited.

METHODS

We queried a prospectively maintained database of male patients undergoing primary AUS implantation from 2015 to 2023 at our institution. All patients completed a preoperative Michigan Incontinence Symptom Index (M-ISI) and Patient Global Impression of Improvement (PGI-I). Postoperative quality of life data was obtained by mailed correspondence. Surveys obtained following AUS reoperation/revision were excluded. Pairwise comparisons were performed between preoperative functional status and the Postoperative responses. Logistic regression analysis was performed to identify preoperative variables associated with a favorable PGI-I score defined as "very much better or much better," or a decrease in pad usage from > 1 pad per day to ≤ 1 pad per day.

RESULTS

During the study timeframe, 383 patients underwent primary AUS placement, of which 163 patients (42%) completed a postoperative survey and were included in the study. Median age was 69.0 (IQR: 64-74) and 54.6% of patients had a history of pelvic radiation. The median time from surgery to the postoperative survey was 2.2 years (IQR: 0.9, 4.3). Compared to baseline, following AUS placement there was a significant improvement in the total M-ISI score (10 [6, 16) vs 26 [22, 30]; p < 0.0001) (Minimally Important Difference = 4). This included improvements in the SUI subscore [4 (IQR 2, 6) vs 10 (IQR: 9, 12); p < 0.0001] and bother score [1 (IQR: 0, 3) vs 6 (IQR: 5, 7); p < 0.001)]. Pad usage significantly decreased following device placement (p < 0.0001). The vast majority of patients (90.7%) would "definitely or probably recommend to a friend/family member." On univariable analysis, active smoking (ref. never) was associated with adverse pad use outcomes (OR: 0.1, 95% CI: 0-0.8; p = 0.03) and older age was associated with adverse PGI-I outcome (OR: 0.93, 95% CI: 0.87-0.99; p = 0.02).

CONCLUSIONS

Following AUS implantation, most patients have significant improvement in validated quality of life outcomes and low pad usage. These findings persist despite multiple preoperative comorbidities and should be considered when counseling patients before AUS placement.

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.

Prevalence and risk factors for overactive bladder symptoms in patients with artificial urinary sphincter

To demonstrate the prevalence and risk factors for overactive bladder symptoms associated with artificial urinary sphincter implantation, we investigated the patients who underwent primary artificial urinary sphincter implantation with severe urinary stress incontinence. Forty-eight patients who completely answered the questionnaires of the overactive bladder symptom score before surgery were included. Patient characteristics, urinary status at pre and 1, 3, 6, and 12 months post-device activation, and predictive factors for overactive bladder symptoms were examined. Sixty percent of the patients had preoperative overactive bladder symptoms. Until 12 months after device activation, 35-40% of all patients had overactive bladder symptoms. The rate of persistent and de novo postoperative overactive bladder symptoms was 44.8% and 26.3%, respectively. Daily pad use was not different between patients w/wo overactive bladder symptoms. The only risk factor for postoperative overactive bladder symptoms was a max cystometoric capacity < 200 mL measured by a preoperative urodynamic study. Attention must be given to both persistent and de novo overactive bladder symptoms associated with artificial urinary sphincter implantation for patients with stress incontinence. Counsel should equally be provided for preoperative overactive bladder symptoms, especially in cases with a cystometric capacity < 200 mL.

Primary implantation of an artificial urinary sphincter using the perineal and penoscrotal approaches: Functional results and assessment of reoperative procedures

INTRODUCTION

Artificial urinary sphincter (AUS) is the standard treatment for severe stress urinary incontinence in men. While the perineal access is considered the gold standard, some authors have proposed penoscrotal AUS in order to facilitate the procedure. The main objective of our study was to evaluate the duration of survival without revision surgery (SSRC) according to the surgical approach for primary implantation.

MATERIAL AND METHODS

Data from 1179 patients implanted in France between 1991 and 2020 with an AMS 800 AUS were retrospectively analyzed. A total of 762 men were implanted perineally (VP) and 417 penoscrotally (VPS).

RESULTS

Median follow-up was 20 vs. 25months respectively. The groups were equivalent overall, apart from the use of anticoagulants (11% VP vs. 6.3% VPS P=0.014). In our population, 54% patients were considered as "dry" in the case of VPS vs. 42% for VP. There was no significant difference in terms of survival time without reoperation, revision, replacement or explantation. In univariate and multivariate analysis, age over 70years was predictive of more reinterventions, whereas the use of a 4.5cm cuff was protective, with hazard ratios of 1.42 (P=0.001) and 0.78 (P=0.04), respectively.

CONCLUSION

The penoscrotal approach does not appear to be associated with more complications, has good functional results and no significant difference in reoperation-free survival. A prospective multicenter non-inferiority study could be of interest to confirm our findings.

LEVEL OF EVIDENCE: 4

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.

Latest Evidence on Post-Prostatectomy Urinary Incontinence

A radical prostatectomy is frequently used as the first-line treatment for men with prostate cancer. Persistent urinary incontinence after surgery is one of the most severe adverse events. We report the results of a comprehensive literature search focused on post-prostatectomy urinary incontinence (PPI), performed by a panel of experts on non-neurogenic lower urinary tract symptoms. The data on the prevalence and timing of PPI are very heterogeneous. The etiology of PPI can be multifactorial and mainly dependent on patient characteristics, lower urinary tract function or surgical issues. The medical history with a physical examination, the use of validated questionnaires with a voiding diary and pad tests are determinants in identifying the contributing factors and choosing the right treatment. Lifestyle intervention and urinary containment are the most frequently used strategies for the conservative management of PPI, while antimuscarinics, beta-3 agonists and duloxetine (off-label) are drugs indicated to manage PPI with a concomitant overactive bladder. Surgical therapies for the management of post-prostatectomy SUI include non-adjustable trans-obturator slings in men with mild-to-moderate incontinence and an artificial urinary sphincter in men with moderate-to-severe incontinence.

Single center experience and long-term outcomes of implantable devices ACT and Pro-ACT (Uromedica, Irvin, CA, USA) - Adjustable continence Therapy for treatment of stress urinary incontinence

PURPOSE

In this study, we aimed at evaluating the long-term adjustable peri-urethral balloons (PUB) durability in both male and female with neurogenic or non-neurogenic stress urinary incontinence.

MATERIAL AND METHODS

Each consecutive patient who underwent surgery for PUB placement before 2008 was included in this study. A PUB was proposed for patients with refractory to perineal reeducation stress urinary incontinence (SUI) caused by intrinsic sphincter deficiency. There were no exclusion criteria. Demographic, clinical and perioperative data were collected retrospectively from our clinical follow-up notes.

RESULTS

A total of 177 patients were included in the study. Median [IQR] follow-up was 5 years [1.8-11.2]. The 3 main causes of SUI were radical prostatectomy (n=82, 46.3%), idiopathic intrinsic sphincter deficiency (n=55, 31.1%) and neurogenic sphincter deficiency (n=32, 18.1%). Complete continence (no pad necessary) was achieved for 109 patients (61.6%). At the end of the follow-up, the PUB global survival rate was 47.5% (Fig. 1). Median [IQR] PUB survival without removal was 57.8 months [42.3-81.7]. PUB survival without failure rate was 68.4% accounting for a median [IQR] survival duration of 116.9 months [86.2-176.9] CONCLUSION: In this study, we evidenced acceptable long-term efficiency and survival of PUB in the management of SUI in both neurogenic and non-neurogenic population. Given those results it could be a good alternative to AUS on unfit or unwilling population.

LEVEL OF EVIDENCE: 5

Outcomes of artificial urinary sphincter implantation in patients with diabetes mellitus: A subgroup analysis

OBJECTIVES

To estimate the surgical and quality-of-life outcomes of artificial urinary sphincter implantation in patients with diabetes mellitus (DM). Subanalyses were performed using the same population as that in our previous multicenter, prospective, observational study.

METHODS

A total of 135 male patients who underwent primary artificial urinary sphincter implantation were divided into two groups: those with and without DM. The revision-free rates, that is, the percentage of patients who did not require revision surgery, were compared between patients with and without DM. The number of urinary pads required per day, International Consultation on Incontinence Questionnaire-Short Form, and King's Health Questionnaire were used to compare the continence status and quality of life (QOL) between the two groups preoperatively and at 1, 3, and 12 months after surgery.

RESULTS

Revision-free rates were significantly lower in the DM group (83.9%, 77.4%, and 67.8% at 1, 2, and 3 years after implantation, respectively) than in the non-DM group (95.5%, 92.5%, and 85.5% at 1, 2, and 3 years after implantation, respectively). Both continence status and QOL, assessed by questionnaires, markedly improved after surgery in patients with and without DM.

CONCLUSIONS

Despite differences in the durability of the artificial urinary sphincters, patients with DM can obtain as much benefit from artificial urinary sphincter implantation regarding continence and quality-of-life improvement as patients without DM. Therefore, DM was not considered a comorbidity that contraindicated artificial urinary sphincter implantation. Additional large-scale studies are required to verify our findings.