Urodynamics for postprostatectomy incontinence: when are they helpful and how do we use them?

Influence of Prostate Volume on the Incidence of Complications and Urinary Incontinence Following Thulium Fiber Laser Enucleation of the Prostate: Results from Multicenter, Real-world Experience of 2732 patients

Background

The use of the new thulium fiber laser in enucleation of the prostate (ThuFLEP) has been introduced recently.

Objective

To evaluate complications and urinary incontinence (UI) after ThuFLEP in small and large prostate volume (PV).

Design setting and participants

We retrospectively reviewed patients who underwent ThuFLEP in six centers (from January 2020 to January 2023). The exclusion criteria were concomitant lower urinary tract surgery, previous prostate/urethral surgery, prostate cancer, and pelvic radiotherapy.

Outcome measurements and statistical analysis

Patients were divided into two groups: group 1: PV ≤80 ml; group 2: PV >80 ml. Univariable and multivariable logistic regression analyses were performed to evaluate the independent predictors of overall UI.

Results and limitations

There were 1458 patients in group 1 and 1274 in group 2. There was no significant difference in age. The median PV was 60 (61-72) ml in group 1 and 100 (90-122) ml in group 2. En bloc enucleation was employed more in group 1, while the early apical release technique was used more in group 2. The rate of prolonged irrigation for hematuria, urinary tract infection, and acute urinary retention did not differ significantly. Blood transfusion rate was significantly higher in group 2 (0.5% vs 2.0%, p = 0.001). There was no significant difference in the overall UI rate (12.3% in group 1 vs 14.7% in group 2, p = 0.08). A multivariable regression analysis showed that preoperative postvoiding urine residual (odds ratio 1.004, 95% confidence interval 1.002-1.007, p < 0.01) was the only factor significantly associated with higher odds of UI. A limitation of this study was its retrospective nature.

Conclusions

Complications and UI rates following ThuFLEP were similar in patients with a PV up to or larger than 80 ml except for the blood transfusion rate that was higher in the latter.

Patient summary

In this study, we looked at outcomes after thulium fiber laser in enucleation of the prostate stratified by PV. We found that blood transfusion was higher in men with PV >80 ml, but urinary incontinence was similar.

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.

Clinical and Urodynamic Determinants of Earlier Time to Failure for the Artificial Urinary Sphincter

OBJECTIVE

To determine clinical, surgical and urodynamic attributes associated with earlier AUS reintervention. The artificial urinary sphincter (AUS) is the gold standard treatment for postprostatectomy stress urinary incontinence. Factors impacting long-term device survival have not been investigated.

MATERIALS AND METHODS

We identified men with post-prostatectomy incontinence who underwent AUS reintervention from 2011 to 2021 at a single center. Urodynamic study, pad weights and voiding diaries are routinely assessed prior to AUS placement. Relationships between clinical, urodynamic and surgical variables and AUS reintervention were assessed using cox regression. Multiple imputation of chained equations was used to handle missing data elements, with truncated linear regression for continuous variables and logistic regression for binary variables.

RESULTS

A total of 524 records were reviewed and 92 met inclusion. Median time to AUS reintervention was 5.7 years (2.3, 9.4). Indications were mechanical failure (38; 41.3%), sub-cuff atrophy (37; 40.2%), erosion/infection (11; 11.9%) and other (6; 6.5%). On univariable testing, earlier intervention was associated with pad weight (P < .01), nocturnal voids (P = .01), bladder capacity (P = .01), bladder volume at strong sensation (P = .03), detrusor overactivity (P < .01) and maximum voiding pressure (P = .02). On multivariable analysis, earlier surgical intervention was associated with detrusor overactivity (HR 1.95, P < .01 CI 1.22-3.1) and pad weight (HR 1.0006, P = .02, CI 1.000-1.001).

CONCLUSIONS

Detrusor overactivity is associated with significantly shorter time to AUS failure. This information may allow for more individualized counseling.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 2 - Male and neurogical population

Recent studies in literature, have raised some doubts on the routine use of urodynamic testing. Many physicians and articles recommend a selective use of this tool, considering carefully risks and benefits. These recommendations are intended to guide clinicians in the right selection of the male and neurological patients to submit to a urodynamic evaluation. This is the second part of a previous article regarding the urodynamic recommendations in the female population. We reviewed the literature, regarding the use of UDS in male and neurological population with lower urinary tract symptoms (LUTS). Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and urogynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in male and neurological population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with LUTS, and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

Basics of videourodynamics for adult patients with lower urinary tract dysfunction

AIMS

Videourodynamics is the addition of imaging to invasive urodynamics and one of the methods to ensure objective diagnosis in persons with signs or symptoms of lower urinary tract dysfunction. This manuscript has the aim to outline the basics of the practice of videourodynamics and to elementary explain interpretation of the results.

METHODS

Literature sources and expert opinion were arranged to provide the reader with an introductory overview of current knowledge.

RESULTS

Videourodynamics was-like most diagnostics in health care-introduced on the basis of plausibility and expert conviction but has stood the test of time. Videourodynamics has, especially in patients with congenital or acquired neurogenic dysfunction of the lower urinary tract, undisputedly although not precisely quantifiable, added to (lower urinary tract) health care quality.

CONCLUSION

The manuscript summarizes the basic elements of indication, practice, and interpretation of videourodynamics.

Efficacy of the VIRTUE male quadratic sling in the treatment of stress urinary incontinence: A retrospective study

AIM

To assess the efficacy and the impact on the quality of life (QoL) of patients suffering stress urinary incontinence (SUI) treated with VIRTUE © sling.

MATERIAL AND METHOD

Retrospective monocenteric study where patients treated with VIRTUE © sling were included between January 2016 and May 2018. The severity of the incontinence was judged based on the number of protection used per day (PPD) and/or on the 24hours pad test into mild, moderate and severe: ≥2 protections and/or <100ml/24h, 3-4 protections and/or 101-200ml/24h, >4 protections and/or>200ml/24h respectively. The criteria of success was achieved when the patient is dry or ameliorated. The ICIQ- UI sf questionnaire was used as a measure of QoL.

RESULTS

Thirty-five patients were included in this study with mean follow up time of 11 months (range: 3-26). Twenty-nine patients had a radical prostatectomy, 3 had endoscopic treatment for benign prostatic hyperplasia, 9 patient had radiotherapy of which one had a complementary focal treatment (HIFU), and two patients had spinal cord injury. The success rate was 83%. The score ICIQ-UI sf showed a statistical difference between the pre and post-operative periods in both success and failure groups (P<0.001). History of radiotherapy, low bladder compliance, and severe incontinence were associated with negative result. Pain was the most recorded post-operative complication and no>grade 2 Clavien Dindo complications were encountered.

CONCLUSION

The VIRTUE © sling seems to be an effective, safe tool treating SUI at short term.

LEVEL OF EVIDENCE

3.

Use of an occlusive penile clamp during filling cystometry in men with symptoms of stress urinary incontinence

OBJECTIVE

In severe post-prostatectomy stress urinary incontinence (SUI), urodynamics may not identify crucial parameters because of inadequate bladder filling. This study evaluated cystometry and pressure flow studies (PFS) in men in whom severe SUI during attempted filling necessitated application of a penile clamp to allow filling to reach cystometric capacity. Men who had undergone prior radical prostatectomy were identified from a database of patients attending for video urodynamic testing between 2012 and 2017. Symptom scores, bladder diary and free flow rate tests were retrieved. Measurements of the subgroup of men for whom a Thomson-Walker compression clamp was used to enable full urodynamic evaluation were evaluated. 166 patients were identified. In 30 patients (18%), severe SUI led to incomplete filling cystometry. Following application of the penile compression clamp, further filling was achieved in each case. Applying the clamp did not alter vesical filling or impede pressure recording. These men had a lower maximum urethral closure pressure (31.6 vs. 46.5 cm H₂ O; P < 0.001), volume at strong desire to void (132 vs. 242 mL; P = 0.003) and cystometric capacity (226 mL with clamp applied vs. 310 mL; P < 0.001) than the overall post-prostatectomy incontinence population. Flow rates during PFS were comparable, but detrusor pressure at maximum flow was lower in the clamp group (11 vs. 22 cm H₂ O; P = 0.009). A penile clamp applied at the time when leakage becomes excessive during filling cystometry avoids premature test termination in men with severe incontinence.

Functional follow-up after Advance® and Advance XP® male sling surgery: assessment of predictive factors

PURPOSE

To evaluate the efficacy of the Advance^® and AdvanceXP^® slings in men with stress urinary incontinence (SUI) post-radical prostatectomy and to identify predictive factors for outcome.

METHODS

Included were male patients with SUI following radical prostatectomy who had a positive "repositioning test", 24 h-pad weight (PW) test < 400 g and who were continent at night and at rest. Urgency was defined as a sudden compelling desire to pass urine, which was difficult to defer. The cure rate was defined as no pad use.

RESULTS

From February 2008 to October 2014, 24 AdVance^® and 70 AdVance XP^® were implanted. The median (range) follow-up was 49 (12-102) months. The overall cure rate was 77%. The preoperative 24 h PW was significantly related to the continence outcome (p = 0.044). A total of 12 patients (13%) presented with postoperative AUR, which was significantly related to abnormal voiding detrusor activity (p = 0.036). Twenty-two patients (23%) had postoperative urgency (16% "de novo"), which was significantly related to preoperative urgency (p = 0.003). During follow-up, a degree of deterioration of continence was observed in five patients who were classed as cured initially. To date, no reports of urethral sling erosion have been made.

CONCLUSIONS

The AdVance^® and AdVanceXP^® slings are safe and effective in relieving SUI following post-radical prostatectomy. There were no differences between the two slings in terms of efficacy, urgency or postoperative AUR. There was a moderate rate of "de novo "urgency and low rate of loss of continence during follow-up.

Evaluation of urodynamic parameters after sling surgery in men with post-prostatectomy urinary incontinence

Objective:

To evaluate urodynamic alterations after sub-urethral sling surgery (SSU) in patients with post-prostatectomy urinary incontinence (PPUI).

Materials and Methods:

We evaluated data of 22 patients submitted to radical prosta- tectomy (RP) or transurethral resection of prostate (TURP) that presented post-surgical urinary incontinence and were treated with SSU implant in a pilot study previously performed in our institution.

Methods:

Those patients with PPUI were evaluated by urodynamic exam (UD) before and after surgery, and the parameters were compared, including uroflow, cystometry and micturition study. Exclusion criteria included patients without pre-operatory urodynamic study, those with urethral stenosis, those not healed of prostate cancer, pa- tients without clinical conditions to be submitted to urodynamic study and those with severe neurological diseases or that refused to sign the consent form. Results were analyzed statistically by Fisher, Wilcoxon or Mann-Whitney tests.

Results:

During free uroflow, none parameters showed any statistical significant differ- ences. During cystometry, there were also no statistical differences and the same was observed at pressure versus flow study; the exception was at maximal flow detrusor pressure (PdetQmax), that was lower at post-operatory (p=0.028). In relation to the presence of urinary dysfunctions associated to PPUI, we observed a significant reduc- tion of detrusor overactivity (p=0.035) in relation to pre-operatory period.

Conclusion:

SSU surgery significantly reduced detrusor overactivity and PdetQMax; however, there were no alterations of other evaluated urodynamic parameters.

Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence-a review

Bladder dysfunction is a relatively common urodynamic finding post radical prostatectomy (RP). It can be the sole cause of post prostatectomy incontinence (PPI) or may be found in association with stress urinary incontinence (SUI). The aim of this review is to provide a comprehensive review of the diagnosis and different treatments of post RP bladder dysfunction. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, PPI, detrusor overactivity (DO), detrusor underactivity (DU), impaired compliance, anticholinergic, onabotulinumtoxinA (Botox^®) and sacral neuromodulation (SNM). Definitions, general overview and management options were extracted from the relevant medical literature. DO, DU and impaired compliance are common and may occur alone or in combination with SUI. In some patients the conditions exist pre RP, in others they arise due to denervation and surgical changes. DO can be treated with anticholinergics, Botox^® and SNM. DO may need to be treated before SUI surgery. DU may be a contraindication to male sling surgery as some patients may go into urinary retention. Severely impaired bladder compliance may be a contraindication to SUI surgery as the upper tracts may be at risk. Each individual dysfunction may affect the outcome of PPI treatments and clinicians should be alert to managing bladder dysfunction in PPI patients.

When should video be added to conventional urodynamics in adults and is it justified by the evidence? ICI-RS 2014

AIMS

To debate and evaluate the evidence base regarding the added value of video to urodynamics in adults and to define research questions.

METHODS

In the ICI-RS Meeting 2014 a Think Tank analyzed the current guidelines recommending video urodynamics (VUD) and performed a literature search to determine the level of evidence for the additional value of the imaging with urodynamic assessment of both neurogenic and non-neurogenic lower urinary tract dysfunction.

RESULTS

Current guidelines do not specify the added value of imaging to urodynamics. Recommendations are based on single center series and expert opinion. Standard imaging protocols are not available and evidence regarding the balance between number and timing of pictures, patient positioning, and exposure time on the one hand and diagnosis on the other hand is lacking. On the basis of expert consensus VUD is relevant in the follow-up of patients with spinal dysraphism. Evidence for the value of VUD in non-neurogenic lower urinary tract dysfunction is sparse. There is some evidence that VUD is not necessary in uncomplicated female SUI, but expert opinion suggests it might improve the evaluation of patients with recurrent SUI.

CONCLUSIONS

There is only low level evidence for the addition of video to urodynamics. The ICI-RS Think Tank encourages better reporting of results of imaging and systematic reporting of X-ray doses. Specific research hypotheses regarding the added value of imaging are recommended. The panel suggests the development of standards for technically optimal VUD that is practically achievable with machines that are on the market.

The Value of Urodynamic Study for Diagnosing the Causes of Lower Urinary Tract Symptoms in Male Patients: A Study From Iran

Background

Most disorders of the lower urinary tract are functional, so diagnoses are typically based on urodynamic findings. Treatment is likely to fail if the pathology is not correctly diagnosed.

Objectives

There are various diagnostic tests for lower urinary tract symptoms (LUTS). In this study, we evaluated the value of urodynamic testing to diagnose the causes of lower urinary symptoms in male patients.

Patients and Methods

Urodynamic tests were performed in 407 patients referred to the urology clinic in Baqiyatallah in 2014 with complaints of LUTS, and the diagnosis was based on the findings of the tests.

Results

The mean age of patients in this study was 50.88 years, and most patients were in their third decade (20 - 30 years of age). Urinary frequency (28.8%), enuresis (22.22%), and incontinence (16.12%) were the most common complaints. The most prevalent disorder was bladder sensation disorder.

Conclusions

Patients made various complaints, and several pathologies were diagnosed, which emphasizes the importance of using urodynamic tests for subsequent medical approaches as a non-invasive, accessible, and inexpensive tool.

Urodynamic assessment of bladder and urethral function among men with lower urinary tract symptoms after radical prostatectomy: A comparison between men with and without urinary incontinence

Purpose

We compared bladder and urethral functions following radical prostatectomy (RP) between men with and without urinary incontinence (UI), using a large-scale database from SNU-experts-of-urodynamics-leading (SEOUL) Study Group.

Materials and Methods

Since July 2004, we have prospectively collected data on urodynamics from 303 patients with lower urinary tract symptoms (LUTS) following RP at three affiliated hospitals of SEOUL Study Group. After excluding 35 patients with neurogenic abnormality, pelvic irradiation after surgery, or a history of surgery on the lower urinary tract, 268 men were evaluated. We compared the urodynamic findings between men who had LUTS with UI (postprostatectomy incontinence [PPI] group) and those who had LUTS without UI (non-PPI group).

Results

The mean age at an urodynamic study was 68.2 years. Overall, a reduced bladder compliance (≤20 mL/cmH₂O) was shown in 27.2% of patients; and 31.3% patients had idiopathic detrusor overactivity. The patients in the PPI group were older (p=0.001) at an urodynamic study and had a lower maximum urethral closure pressure (MUCP) (p<0.001), as compared with those in the non-PPI group. Bladder capacity and detrusor pressure during voiding were also significantly lower in the PPI group. In the logistic regression, only MUCP and maximum cystometric capacity were identified as the related factor with the presence of PPI.

Conclusions

In our study, significant number of patients with LUTS following RP showed a reduced bladder compliance and detrusor overactivity. PPI is associated with both impairment of the urethral closuring mechanism and bladder storage dysfunction.