Comparison of standardized pre- and postoperative functional pelvic cine-MRI in patients with a bulbourethral composite suspension due to post-prostatectomy incontinence

[Urodynamic evaluation of patients cured of their post-radical prostatectomy stress urinary incontinence following transobturator male sling implantation]

INTRODUCTION

The mechanism(s) responsible(s) for continence recovery after male sling implantation for post-radical prostatectomy incontinence are imperfectly known. The goal of this study was to evaluate urodynamic parameters before and after male sling insertion, only in patients cured of their stress urinary incontinence.

PATIENTS AND METHODS

In total, 10 continent patients after transobturator male sling, with no history of urethral stenosis or pelvic radiation, were randomly selected from a database for urodynamic studies. Urodynamic parameters included urethral pressure profiles (UPP), with measurements of maximal urethral closure pressure (MUCP) and functional urethral length (FUL), and were compared with preoperative urodynamic data. Paired sampled were compared with the use of the Wilcoxon signed-rank test (StatPlus®).

RESULTS

Urodynamic studies were performed after a median time of 9months (min 4 - max 34) following sling implantation. Postoperatively, a rise of 11cm H₂O in median MUCP (P=0.09) and an increase of 14mm in median FUL (P=0.13) were observed. None of the urodynamic changes was statistically significant.

CONCLUSIONS

Following sling implantation, modifications in UPPs were observed, with increases in MUCP and FUL but these increments were not statistically significant. Limitations to our study include biases inherent to the interpretation and reproducibility of urethral profilometry, the sample size, and the variable delay between sling implantation and postoperative urodynamic studies.

LEVEL OF EVIDENCE

4.

Magnetic resonance imaging as an assessment tool following intervention with an AdVance XP suburethral sling for postprostatectomy urinary incontinence

AIMS

The aim of this study was to compare magnetic resonance imaging (MRI) parameters in patients with mild incontinence after radical prostatectomy, who had undergone treatment with a suburethral sling. The objective was to compare patients who had been successfully treated with unsuccessful patients.

METHODS

This observational cohort study at a single institution evaluated consecutive patients treated with an AdVance XP sling. MRI was performed using a 1.5 Tesla system. Preoperative urodynamic assessment and flexible cystoscopy were performed. The qualitative analysis was based on sling indentation (complete vs incomplete). The quantitative analysis comprised the following three parameters: the sling-pubis distance, the thickness of the proximal urethral bulb, and the sling backward distance (SBD), defined as the distance between the prolongation of a line through the major axis of the pubis (the line-segment joining the vertices of the pubis) and the sling indentation. The primary outcome was pad count at 3 months; cure as zero pads. A logistic univariate regression model was employed to assess the potential predictors of successful outcomes. An adjusted multivariate logistic regression model using the significant univariate factors was developed.

RESULTS

Of the 83 patients enrolled, the univariate analysis revealed a relationship between failure and adverse urodynamics and between success and sling indentation, thickness of the proximal bulb and SBD. Only the association with SBD persisted in the multivariate analysis.

CONCLUSIONS

MRI revealed a strong relationship between proper positioning of the sling (small SBD) and continence outcome. These data have important implications for a second surgery following initial sling failure.

Recent research on the role of urodynamic study in the diagnosis and treatment of male lower urinary tract symptoms and urinary incontinence

Although evidence shows that urodynamic study may not improve outcomes, it can be used to evaluate men with lower urinary tract symptoms (LUTSs) which have not been adequately delineated and treated. In young men with LUTS not responding to treatment based on clinical examination, or elderly men with LUTS and incontinence, a complete urodynamic evaluation is mandatory to understand the pathophysiology underlying LUTS, such as bladder outlet obstruction (BOO), detrusor overactivity, and detrusor underactivity. Preoperative urodynamic study-proven BOO is a predictor of a successful surgical outcome. An urodynamic study should be performed when patients with LUTS are planning to undergo surgical treatment for benign prostatic obstruction.

A pragmatic approach to the characterization and effective treatment of male patients with postprostatectomy incontinence

PURPOSE OF REVIEW

To highlight the recent developments in the past 12 months in the field of postprostatectomy incontinence.

RECENT FINDINGS

The evaluation of postprostatectomy incontinence is mainly based on clinical details and symptoms assessment. The situation in which urodynamics will change the management and influence clinical decision-making is still unknown. MRI may play a role in the future for postprostatectomy incontinence assessment. Artificial urinary sphincter is the most widely used treatment, and the literature is full of technical reports to improve the management of challenging cases and minimize the risk of complications. Advance male sling has been the subject of multiple reports that support its safety and efficacy. Many other innovative devices have been presented but not adequately tested.

SUMMARY

Evaluation of postprostatectomy incontinence is based on clinical data, involving symptoms assessment, quality of life, and incontinence severity. Endoscopy is requested, and urodynamic study indications are debated. The treatment is mainly focused on surgical options, of which artificial urinary sphincter and transobturator male slings are the two leaders. The field is critically lacking of comparative studies.