Efficacy of Artificial Urinary Sphincter Implantation After Failed Bone-Anchored Male Sling for Postprostatectomy Incontinence

Contemporary trends in the surgical management of urinary incontinence after radical prostatectomy in the United States

PURPOSE

To identify trends, costs, and predictors in the use of different surgical procedures for post-radical prostatectomy incontinence (PPI).

MATERIALS AND METHODS

We identified 21,589 men who were diagnosed with localized prostate cancer (PCa) and treated with radical prostatectomy (RP) from 2003 to 2017. The primary outcome was the incontinence procedure performances. Optum's de-identified Clinformatics^® Data Mart Database was queried to define the cohort of interest. The average costs of the different incontinence procedures were obtained and compared. Also, demographic, and clinical predictors of incontinence surgery were evaluated by multivariable regression analysis.

RESULTS

Of the 21,589 men with localized PCa treated with RP, 740 (3.43%) underwent at least one incontinence procedure during a median of 5 years of follow-up. In total, there were 844 unique incontinence procedures. Male slings were the most common procedure (47.5%), had an intermediate cost compared to the other treatment options, and was the first-choice treatment for the majority of patients (50%). The use of an artificial urinary sphincter (AUS) was the second most common (35.3%), but also was the most expensive treatment and was first-choice-treatment for 32.3% of patients. On multivariable analysis, metabolic syndrome related disorders, adjuvant/salvage radiation therapy as well as a history of neurological comorbidities were independently associated with an increased likelihood of incontinence surgery.

CONCLUSIONS

The receipt of male slings increased and then subsequently decreased, while AUS utilization was stable, and the use of urethral bulking agents was uncommon. From a cost standpoint, AUS was the most expensive option. Finally, patient's comorbidity history and RP related factors were found to influence the choice for primary or subsequent PPI interventions.

Male post-prostatectomy incontinence MDT

The management of post-prostatectomy incontinence remains controversial with ongoing confusion as to who benefits from male sling or artificial urinary sphincter. We present a post-prostatectomy incontinence MDT format to illustrate key factors in decision-making and determination of best management in post-prostatectomy incontinence.

Artificial urinary sphincter

Although currently still the gold standard treatment for post-prostatectomy urinary incontinence, the artificial urinary sphincter (AUS) (AMS800) is an invasive procedure with associated risks factors. In this paper, we aim to outline what the scientific literature and what we personally believe are the factors that are useful and/or necessary to mitigate these risks, including both patient factors and surgeon factors. We also review special populations, including transcorporal (TC) AUS approach, AUS with inflatable penile prosthesis, AUS after male urethral sling, AUS erosion management, and AUS after orthotopic urinary diversion.

The impact of prior urethral sling on artificial urinary sphincter outcomes

INTRODUCTION

We sought to evaluate device outcomes in men who underwent primary artificial urinary sphincter (AUS) placement after failed male urethral sling (MUS).

METHODS

We performed a retrospective chart review of 990 men who underwent an AUS procedure between 2003 and 2014. Of these, 540 were primary AUS placements, including 30 (5.5%) with a history of MUS. AUS revisions and explantations were compared between men stratified by the presence of prior sling. Hazard ratios (HR) adjusting for competing risks were used to determine the association with prior sling and AUS outcomes (infection/erosion, urethral atrophy, and mechanical malfunction), while overall device failure was estimated using Kaplan-Meier and Cox-regression analysis.

RESULTS

There was no significant difference in age, body mass index, prior prostatectomy, or pelvic radiation when stratified by history of MUS. However, patients with a history of MUS were more likely to have undergone prior collagen injection (p=0.01). On univariate and multivariate analysis, prior MUS was not associated with device failure (HR 1.54; p=0.27). Three-year overall device survival did not significantly differ between those with and without prior MUS (70% vs. 85%; p=0.21). Also, there were no significant differences in the incidence of device infection/erosion, mechanical malfunction, and urethral atrophy.

CONCLUSIONS

AUS remains a viable treatment option for men with persistent or recurrent stress urinary incontinence after MUS. However, while not statistically significant, we identified a trend towards lower three-year device outcomes in patients with prior urethral sling. These findings indicate the need for longer-term studies to determine if slings pose an increased hazard.

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

Today, for the surgical treatment of postprostatectomy incontinence, several treatment options are available, e.g., adjustable and functional sling systems, artificial sphincter, bulking agents, and balloons. However, no recommendations in terms of specific diagnostic tools and differentiated treatment options for everyday life are available. Our aim is to provide some clinically relevant recommendations for the necessary diagnostic workup and different treatment options of postprostatetectomy incontinence to support clinical decisions in everyday life. Treatment selection should be based on contraindications. However, there is a broad overlap of the various surgical options.

Evaluation of salvage male transobturator sling placement following recurrent stress urinary incontinence after failed transobturator sling

OBJECTIVE

To evaluate the outcome of patients treated with a salvage AdVance male sling after a failed primary transobturator sling placement.

METHODS

Retrospective review of patients treated at our center with a primary and subsequent salvage AdVance sling. Success was defined as a dry safety pad or no pads (cured), or >50% improvement in pads used per day and patient satisfaction (improved). Early primary sling failures (<6 months) were compared with late (≥6 months) failures with regard to continence outcomes.

RESULTS

We identified 18 patients who underwent a salvage AdVance sling placement at our institution. Overall success was 72% at 6 months postoperatively and 56% at a mean follow-up of 17.5 months, including 50% and 39% of patients who were dry at those same time periods. Patients failing late after their primary sling (n = 8) enjoyed improved outcomes with salvage sling placement compared with patients who failed early (n = 10) after the primary sling. At 6 months, more patients in the late primary failure group were cured (75% vs. 30%; P = .031). These improved cure rates remained significant through final follow-up with cure rates of 63% and 20%, respectively (P = .041).

CONCLUSION

Salvage AdVance male sling is a viable treatment option after a failed primary sling procedure, especially in patients who demonstrated a prolonged efficacy period before primary sling failure.

[Therapy of persistent or recurrent stress urinary incontinence]

After synthetic sling procedures, up to 16 % of women and 45.5 % of men complain about a persistent or recurrent stress urinary incontinence (SUI). Currently, randomized studies comparing the different treatment modalities of persistent or recurrent SUI are lacking. There are data of retrospective studies investigating the efficiency of synthetic slings and the artificial urinary sphincter AMS 800® in men. Synthetic slings can be applied in patients with mild SUI and without prior radiation of the pelvic region. The AMS 800® is the treatment of choice in patients with severe SUI or previous radiation.In women with persistent and recurrent SUI, the efficiency of colposuspensions, autologous and synthetic slings as well as the AMS 800® has been investigated in retrospective studies. Due to comparable cure rates and a faster postoperative recovery, synthetic slings are now superseding colposuspensions and autologous slings. Excellent success rates after AMS 800® implantation have been described for both genders; nonetheless, postoperative complications and revisions as well as the requirement of dexterity of the patients should be taken into account. Data about the efficiency of adjustable slings, the ACT® and newer artificial urinary sphincter devices like Flow-Secure® and Zephyr® ZSI 375 in the treatment of persistent and recurrent SUI is lacking.

Stemming the tide of mild to moderate post-prostatectomy incontinence: A retrospective comparison of transobturator male slings and the artificial urinary sphincter

INTRODUCTION

The AUS remains the gold standard treatment for post-prostatectomy incontinence (PPI), although most patients with mild-moderate PPI prefer a sling without strong evidence of procedural equivalence. This study compares outcomes of 2 procedures for the treatment of mild-moderate PPI.

METHODS

A retrospective review of 124 patients (76 transobturator sling, 48 AUS) with mild-moderate PPI requiring intervention over an 8-year period. The primary outcome was continence. Secondary outcomes included global patient satisfaction, improvement, and complication rates. Mild to moderate incontinence was defined as requiring ≤5 pads/day.

RESULTS

There was no significant difference in age (66.2 vs. 68.1 years; p = 0.17) or prostate cancer characteristics for slings and AUS, respectively. AUS patients had higher Charlson comorbidity scores and were more likely to have previous radiotherapy. Median length of follow up was 24 months for slings and 42 months for AUS. There was no difference in continence rates, 88.2% vs. 87.5% (p = 0.79), rate of improvement, 94.7% vs. 95.8% (p = 1.00), or patient satisfaction, 93.4% vs. 91.7% (p = 0.73), for slings and AUS, respectively. Complication rates were equivalent (19.7% vs. 16.7%; p = 1.00), though a significantly higher proportion of complications with AUS were Clavien Grade 3 (0% vs. 75%; p = 0.006).

CONCLUSIONS

For mild to moderate PPI there is no difference in continence, satisfaction, or improvement rates, between AUS and slings. AUS complications tend to be more severe. Our study supports the use of slings as first-line treatment for mild-moderate PPI.

The virtue sling--a new quadratic sling for postprostatectomy incontinence--results of a multinational clinical trial

OBJECTIVE

To successfully perform male sling surgery, and the surgery must achieve proximal urethral relocation and/or bulbar urethral compression. The Virtue quadratic sling is a novel device that incorporates both mechanisms of action. We report the 1-year results of the Virtue sling with fixation and compare it with the results of the initial "unfixed" sling trial.

METHODS

A prospective trial was performed to assess the efficacy and safety of the Virtue sling. Objective success was predefined as >50% decrease in 24-hour pad weight and subjective success as a score of "much" or "very much" better on the Patient Global Impression of Improvement. Subgroups were analyzed by baseline incontinence: mild (<100 g), moderate (100-400 g), and severe (>400 g). After analysis of the 1-year data, a second clinical trial incorporating a novel "fixation" technique was performed, with similar outcome measures.

RESULTS

In the initial cohort, subjective and objective successes were achieved in 41.9% at 12 months. Median pad weight reduction was 51.1% at 12 months and varied with the degree of baseline leakage. In the fixation cohort, subjective and objective successes were 70.9% and 79.2%, median pad weight reduction was 88.3% at 12 months, and efficacy was similar regardless of baseline incontinence. There were no cases of prolonged retention and no severe adverse events.

CONCLUSION

The Virtue sling with fixation is a safe and efficacious treatment for postprostatectomy incontinence. Superior 12-month results compared with the unfixed device demonstrate that fixation prevents early sling loosening.

Update on management of post-prostatectomy incontinence in 2013

Surgical intervention is often required to address urinary incontinence post-prostatectomy. This summary provides an overview of surgical intervention in post-prostatectomy incontinent patients and of the evidence supporting the various surgical interventions currently in use.

Post-prostatectomy incontinence: Etiology, evaluation, and management

Urinary incontinence after prostatectomy or radiation is a devastating problem in men and remains the most feared complication following the treatment of localized prostate cancer. With an increasing number of radical prostatectomies performed globally for prostate cancer, the impact of urinary incontinence on quality of life assumes an even greater importance. With the advent of male sling procedures, more men are now seeking treatment for incontinence. Since the introduction of the artificial urinary sphincter almost four decades ago, several surgical procedures have emerged to manage post-prostatectomy incontinence, including the male sling for milder forms of incontinence. Several of the newer procedures have shown promise in the United States; many others have been developed and utilized in other parts of the world, though they have not yet gained FDA approval in the United States. The present review seeks to illuminate the etiology, evaluation, and management of post-prostatectomy incontinence. An effort has been made to provide an algorithm to clinicians for appropriate surgical management. The surgical techniques of commonly performed procedures and their outcomes are described.

Artificial urinary sphincter for post-prostatectomy incontinence: a review

The artificial urinary sphincter remains the gold standard for treatment of post-prostatectomy urinary incontinence. The AMS 800 (American Medical Systems, Minnetonka, MN, USA) is the most commonly implanted artificial urinary sphincter. Having been on the market for almost 40 years, there is an abundance of literature regarding its use, but no recent review has been published. We reviewed the current literature regarding the indications, surgical principles, outcomes and complications of artificial urinary sphincter implantation for stress urinary incontinence after prostatectomy. A PubMed search was carried out for articles on the artificial urinary sphincter from 1995 to present. The review was centered on articles related to the use of the AMS 800 for stress urinary incontinence in males after prostatectomy. Relevant articles were reviewed. The majority of patients will achieve social continence (1 pad per day) after artificial urinary sphincter implantation; however, rates of total continence (no pad usage) are significantly lower. Patient satisfaction outcomes average greater than 80% in most series. Potential complications requiring reoperation include infection (0.5-10.6%) and urethral erosion (2.9-12%). Revision surgeries are most commonly as a result of urethral atrophy, which ranges from 1.6 to 11.4%. The 5-year Kaplan-Meier freedom from reoperation ranges from 50 to 79%, while the 10-year Kaplan-Meier freedom from mechanical failure is 64%. The artificial urinary sphincter is a reliable device with good outcomes. As expected with any prosthetic device, complications including mechanical failure, infection, erosion and recurrent incontinence remain significant concerns. Despite known complications, the patient satisfaction rates after artificial urinary sphincter implantation remain high. Appropriate patient counseling and adherence to surgical principles are imperative.

Trends in the use of incontinence procedures after radical prostatectomy: a population based analysis

PURPOSE

Urinary incontinence is a frequent complication of radical prostatectomy with a detrimental impact on quality of life. We identified predictors and trends in the use of procedures for post-prostatectomy incontinence.

MATERIALS AND METHODS

Using SEER (Surveillance, Epidemiology and End Results) cancer registry data linked with Medicare claims, we identified men 66 years old or older who were treated with radical prostatectomy in 2000 to 2007. The primary outcome was performance of an incontinence procedure. Demographic and clinical predictors of incontinence surgery were evaluated by multivariable regression analysis.

RESULTS

Of 16,348 men treated with radical prostatectomy 1,057 (6%) had undergone at least 1 incontinence procedure by a median of 20 months after the procedure, including 61% who underwent the first incontinence procedure within 2 years of prostatectomy. Older age and residence in the South were associated with greater probability of an incontinence procedure. Black men and those living in nonmetropolitan areas were less likely than their peers to undergo an incontinence procedure. Of men treated with any incontinence procedure 15% underwent more than 1 type. Of those treated with bulking agents 39% also received a urethral sling or artificial urinary sphincter and 13% who received a sling also had an artificial urinary sphincter. In 34% of the men who underwent any incontinence surgery artificial urinary sphincter placement was the only procedure performed.

CONCLUSIONS

In this population based cohort of older men with prostate cancer only 6% underwent an incontinence procedure after prostatectomy. This low rate may reflect the underuse of potentially beneficial procedures.

[Treatment of stress urinary incontinence after prostate surgery: results of the artificial urinary sphincter after suburethral sling failure]

OBJECTIVE

To determine whether the presence of a previously implanted suburethral sling for post-prostatic surgery incontinence influences the outcomes of subsequent AUS implantation.

PATIENTS AND METHODS

A retrospective study comparing 15 patients who underwent AUS placement after suburethral sling failure between November 2004 and December 2009 to 15 patients who underwent AUS placement as first-line treatment during the same period. Demographic characteristics, preoperative assessment of urinary incontinence and technique of implantation of the AUS were similar in the both arms. A USP(®) continence questionnaire was sent to patients by mail. Success was defined as a subjective improvement of the incontinence in patients using less than one pad per day.

RESULTS

No perioperative incidents were noted in either arm. Mean operative time, the size of implanted cuffs, duration of catheterisation, length of hospital stay and postoperative complication rate, as well as the rate of surgical revision, were similar in both arms. The follow-up was slightly lower in the first arm (21 vs. 28.8 months, P=0.83). Stress incontinence and bladder overactivity scores of the USP(®) questionnaire, as well as success rates (73.3 vs. 80%, P=0.67), were equivalent in both arms.

CONCLUSION

The results associated with the AUS procedure were not significantly different between men who had a suburethral male sling implanted before and those who had the AUS implanted as a first-line treatment.

[Salvage therapy with artificial urinary sphincter after Advance™ male sling failure for post-prostatectomy incontinence: a first clinical experience]

OBJECTIVES

To assess the clinical outcome following artificial urinary sphincter (AUS) implantation after failure of Advance™ sub-urethral male sling for post-prostatectomy incontinence (PPI).

METHODS

A prospective evaluation was conducted about consecutive patients who received an AUS after failure of Advance™ therapy in one tertiary reference center. Evaluation included medical history, pad use and operative data (duration, cuff size, technical difficulties). Follow-up was scheduled at 1, 6, 12 months and yearly thereafter. Clinical outcome was evaluated by pad use, patient global impression of improvement (PGI-I) scale and assessment of side effects. Cure was defined as no pad usage.

RESULTS

Twelve patients were included in this evaluation. Median follow-up was 20 months (12-43). No patient was lost to follow-up. Four patients had a history of radiation therapy and all patients had mild or moderate PPI with previous failed Advance™ surgery. Median (range) operative time was 47 minutes (40-60). No technical problem occurred during AUS implantation. Hospital stay duration and catheterization duration were respectively 2 days and 24 hours in all but one case. At last follow-up, 10/12 patients (83%) were cured and fully satisfied. Two were improved, wearing only one pad per day. Postoperative complications were noted in two cases (17%) (one case of cutaneous erosion and one case of superficial iliac wound infection).

CONCLUSIONS

AUS implantation is feasible in patients who have undergone Advance™ male sling implantation. Mid-term results of this procedure are comparable to those obtained after first line AUS implantation.

Surgical practice patterns for male urinary incontinence: analysis of case logs from certifying American urologists

PURPOSE

Several options exist for the surgical correction of male stress urinary incontinence including periurethral bulking agents, artificial urinary sphincters and the recently introduced male urethral slings. We investigated contemporary trends in the use of these treatments.

MATERIALS AND METHODS

Annualized case log data for incontinence surgeries from certifying and recertifying urologists were obtained from the ABU (American Board of Urology), ranging from 2004 to 2010. Chi-square tests and logistic regression models were used to evaluate the association between surgeon characteristics (type of certification, annual volume, practice type and practice location) and the use of incontinence procedures.

RESULTS

Among the 2,036 nonpediatric case logs examined the number of incontinence treatments reported for certification has steadily increased over time from 1,936 to 3,366 treatments per year from 2004 to 2010 (p = 0.008). Nearly a fifth of urologists reported placing at least 1 sling. The proportion of endoscopic procedures decreased from 80% of all incontinence procedures in 2004 to 60% in 2010, but they remained the exclusive incontinence procedure performed by 49% of urologists. A urologist's increased use of endoscopic treatments was associated with a decreased likelihood of performing a sling procedure (OR 0.5, p <0.0005). Artificial urinary sphincter use remained stable, accounting for 12% of procedures.

CONCLUSIONS

Incontinence procedures are on the rise. Urethral slings have been widely adopted and account for the largest increase among treatment modalities. Endoscopic treatments continue to be commonly performed and may represent overuse in the face of improved techniques. Further research is required to validate these trends.

Outcomes following artificial sphincter implantation after prior unsuccessful male sling

PURPOSE

Despite the proven success and durability of the artificial urinary sphincter many patients elect an AdVance® sling as the initial treatment of male stress incontinence. We determined whether sling placement would change the outcome of an ensuing artificial urinary sphincter.

MATERIALS AND METHODS

A total of 29 patients with stress urinary incontinence after failed sling placement were treated with an AMS 800® artificial urinary sphincter between January 2006 and May 2011. A control group of 136 men with a primary artificial urinary sphincter was used for comparison. Preoperative and postoperative evaluation included demographic variables, voiding diary, 24-hour pad weight, urodynamic characteristics, operative time, estimated blood loss, complication rate, followup and cuff selection.

RESULTS

There was no statistical difference in urodynamic characteristics, operative variables or the complication rate. Pad use was reported as less than 1 pad daily in 96% of patients (28 of 29) with a secondary artificial urinary sphincter at 3-month followup. At 20.7 months 6.9% of patients (2 of 29) treated with an artificial urinary sphincter after the male sling required revision of the artificial urinary sphincter. The overall complication rate in the control group was 8.8% (12 of 136 patients) with a 2.2% infection rate (3 of 136). The overall complication rate in the artificial urinary sphincter plus male sling group was 6.9% (2 of 29 patients) with a 0% infection rate.

CONCLUSIONS

Patients who require an artificial urinary sphincter after an initial male sling seem to fare as well as those who undergo primary artificial urinary sphincter implantation.

The male sling for post-prostatectomy urinary incontinence: a review of contemporary sling designs and outcomes

OBJECTIVE

To examine the outcomes and adverse events associated with novel male sling designs described in the last decade.

METHODS

A literature review was carried out using Medline, EmBase, Cochrane Registered Trials Database and the Center for Reviews and Dissemination Database.

RESULTS

Three principal slings are described in the literature. The bone-anchored sling has success rates of 40-88%, with some series having a mean follow-up of 36-48 months. It is associated with a mesh infection rate of 2-12%, which usually requires sling explantation. The retrourethral transobturator sling has a success rate of 76-91% among three large case series with follow-ups of 12-27 months. There is a low reported explantation rate. The adjustable retropubic sling has a success rate of 72-79% with follow-ups of 26-45 months. Erosion (3-13%) and infection (3-11%) can lead to explantation.

CONCLUSIONS

Most male slings have a similar reported efficacy. Most case series define success as either dry or improved. True cure rates are lower. Mid- and long-term data are now available that indicate the male sling is a viable option for PPI. The use of male slings in severe UI, radiated patients, and non-radical prostatectomy patients is still unclear. Further study is needed to try and define criteria for the use of male slings, and to directly compare different procedures.

Management of recurrent post-prostatectomy incontinence after previous failed retrourethral male slings

OBJECTIVE

Our objective was to establish the feasibility of combining 2 minimally invasive procedures in patients with failed primary treatment (male sling) in post-prostatectomy incontinence (PPI) patients.

METHODS

From January 2007 to July 2008, 40 men with PPI were implanted with a suburethral tape (2 patients with Seratim, 3 with I-Stop and 35 with Advance). The median preoperative pad count was 4 (range 2-10). Prior to sling placement, 6 patients had undergone ProACT implantation. Of these, 4 patients required explantation due to balloon migration and 2 patients had their balloons kept in situ, with the balloons deflated.

RESULTS

Twenty-five patients were socially continent at this time. Fifteen patients (37.5%) did not improve or their improvement was not significant. These patients had a preoperative pad count between 7 and 10. Two of these patients had prostate adjustable continence therapy (ProACT) systems still in place. By gradually filling the balloons to 3 mL, both of these patients achieved complete continence, which was maintained at a mean follow-up of 8.5 months. Three patients with prior pelvic irradiation received an artificial urinary sphincter and achieved continence at mean follow-up of 8.3 months. The remaining 10 patients received a ProACT system in addition to the already implanted sling. After appropriate healing and filling of the balloons (average balloon volume 5 mL), all 10 patients reached complete continence; they were pad-free at a mean follow-up of 6 months (range 3-9).

CONCLUSIONS

The combination of ProACT and a suburethral tape was demonstrated to be a possible treatment option in recurrent or persistent PPI.

Contemporary management of postprostatectomy incontinence

CONTEXT

In recent years, despite improvement in the surgical technique, the prevalence of postprostatectomy incontinence has increased due to a rise in the number of radical prostatectomies performed annually.

OBJECTIVE

The aim of this review is to evaluate contemporary noninvasive and invasive treatment options for postprostatectomy incontinence.

EVIDENCE ACQUISITION

In August 2010, a review of the literature was performed using the Medline database.

EVIDENCE SYNTHESIS

All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included.

CONCLUSIONS

No randomised controlled trials exist to compare currently used noninvasive and invasive treatments for postprostatectomy incontinence. Pelvic floor muscle training is recommended for the initial treatment of stress urinary incontinence (SUI). Additionally, antimuscarinic therapy should be applied for urgency or urge incontinence. For decades, the artificial urinary sphincter was the reference standard for persistent SUI. Nowadays, male slings are an alternative for men with mild to moderate postprostatectomy SUI.

Are male slings for post-prostatectomy incontinence a valid option?

PURPOSE OF REVIEW

Stress incontinence in men is still a common problem after surgical treatment of prostatic disease. This article reviews the techniques and results of recently described surgical slings available to treat male stress incontinence.

RECENT FINDINGS

Medium-term follow-up (mean 3-4 years) of patients treated with bone-anchored slings has been recently published, suggesting a success rate (cured or improved) of 70-80%. Short-term follow-up (mean of 6-12 months) of transobturator retrourethral slings demonstrates a success rate of 62-83%. Novel sling designs include mechanisms to manipulate the tension postoperatively and inside-out transobturator trocar passage. Common complications associated with slings are acute urinary retention and perineal pain. Rare complications include urethral erosion and infection. Retropubic approaches are associated with a risk of bladder perforation.

SUMMARY

Male slings are a valid option for treating male stress incontinence, and do offer several advantages over the artificial urinary sphincter. However, long-term data and multicenter series are needed in order to compare directly with the artificial urinary sphincter.

Treatment options for male stress urinary incontinence

The diagnosis and management of male stress urinary incontinence (SUI) is complex. Various etiologies exist, with radical prostatectomy being the most common cause in men seeking treatment. SUI in this setting is often temporary and resolves within the first postoperative year. Therefore, it is important to understand the natural history of male SUI before initiating treatment. Generally, the initial management of SUI that persists after 12 months consists of conservative measures, such as pelvic floor muscle exercises. Several treatments are available for men whose continence does not improve after pelvic floor muscle exercises. In order of increasing complexity they are urethral bulking agents, male slings, and the artificial urinary sphincter (AUS). With over 30 years of published data suggesting excellent long-term outcomes, the AUS is considered the gold standard treatment of male SUI. Male slings have recently demonstrated efficacy for selected patients and are likely to be used more often in the future as experience with these devices grows.

Repeat retrourethral transobturator sling in the management of recurrent postprostatectomy stress urinary incontinence after failed first male sling

BACKGROUND

A failure rate between 20% and 45.5% after retrourethral transobturator sling (RTS) is reported. Recommendations for the management of persistent or recurrent postprostatectomy stress urinary incontinence (SUI) after failed male sling do not exist.

OBJECTIVE

The aim of this study was the prospective evaluation of the efficacy of repeat RTS (RRTS) in patients after failed first RTS.

DESIGN, SETTING, AND PARTICIPANTS

Between March 2007 and August 2009, 35 patients with mild to severe SUI after failed first RTS were treated with a second AdVance sling (American Medical Systems, Minnetonka, MN, USA).

MEASUREMENTS

Preoperative and postoperative evaluation included daily pad use, 1-hr pad test, postvoiding residual (PVR) urine, uroflowmetry, and quality-of-life (QoL) scores.

RESULTS AND LIMITATIONS

After 6 mo, 45.5% (15 of 33 patients) showed no pad use; 30.3% (10 of 33 patients), one dry "security" pad; 3% (1 of 33 patients), one wet pad; 6.1% (2 of 33 patients), two pads; 3% (1 of 33 patients), pad reduction ≥50%; and 12.1% (4 of 33 patients), treatment failure. After 16.6 mo, 34.5% (10 of 29 patients) showed no pad use; 37.9% (11 of 29 patients), one dry "security" pad; 3.4% (1 of 29 patients), one wet pad; 3.4% (1 of 29 patients), two pads; 10.3% (3 of 29 patients), pad reduction ≥50%; and 10.4% (3 of 29 patients), treatment failure. Daily pad use and pad weight decreased significantly. PVR and uroflowmetry results showed no significant change. QoL improved significantly. Postoperative acute urinary retention was observed in 23.6% of patients.

CONCLUSIONS

RRTS is an effective and safe treatment option for the management of SUI after failed first RTS.

Slings in iatrogenic male incontinence: Current status

OBJECTIVES

The increasing number of prostatectomies entails an increasing number of patients suffering from iatrogenic incontinence despite improved surgical techniques. The severity of this problem often requires invasive treatments such as periurethral injection of bulking agents, artificial urinary sphincter (AUS) implantation, and sub-urethral sling positioning. The artificial urethral sphincter has represented, until today, the gold standard but, in the recent years, sling systems have been investigated as minimally invasive alternative options. Today, three different sling procedures are commonly performed: bone-anchored, readjustable, and trans-obturator slings systems. The aim of this review is to critically report the current status of sling systems in the treatment of iatrogenic male incontinence.

MATERIALS AND METHODS

MEDLINE and PubMed databases were searched and all articles between 1974 and 2009 were evaluated.

RESULTS

With regard to bone-anchored, readjustable, and trans-obturator slings systems, cure rates ranged between 58.0% and 86.0%, 55.5% and 73.0%, and 40.0% and 63.0%, respectively, while major complication rates ranged between 0 and 14.5%, 10.0 and 22.2%, and 0 and 10.0%, respectively.

CONCLUSIONS

Suburethral slings are the only alternative techniques which can be favorably compared with the AUS, showing more advantages with respect to AUS implantations which are mainly represented by a quick and less invasive approach, low morbidity, and low costs. In spite of the difficulty in identifying the most effective sling procedure, overall, sling systems can be recommended for patients with persistent mild or moderate incontinence. However, the indication can also be extended to patients with severe incontinence, after appropriate counseling, allowing AUS implantation in the event of sling failure.

Artificial urinary sphincter versus male sling for post-prostatectomy incontinence--what do patients choose?

PURPOSE

Early outcomes of the male sling to correct post-prostatectomy incontinence have been promising in select patients. Long-term data are lacking to determine whether the male sling is as effective as the artificial urinary sphincter, which is the current gold standard. Because the male sling offers the significant advantage of avoiding a mechanical device but without established success, we determined the patient preference for the male sling vs the artificial urinary sphincter.

MATERIALS AND METHODS

We reviewed the charts of 133 men with post-prostatectomy incontinence who underwent the first procedure to correct incontinence. After urodynamics the surgeon recommended an artificial urinary sphincter or a male sling and patients were told the artificial urinary sphincter satisfaction rate and shorter term data on the male sling. Patients with high grade post-prostatectomy incontinence (pad weight greater than 400 gm/24 hours) were recommended to receive an artificial urinary sphincter, those with moderate post-prostatectomy incontinence (pad weight 100 to 400 gm/24 hours) were recommended to receive an artificial urinary sphincter or a male sling and those with mild post-prostatectomy incontinence (pad weight less than 100 gm/24 hours) were recommended to receive a male sling.

RESULTS

A total of 84 male sling (63%) and 49 artificial urinary sphincter (37%) procedures were performed. The surgeon recommendation was an artificial urinary sphincter in 63 men (47%) and a male sling in 46 (35%). A total of 24 men (18%) were given the option of either procedure. All patients recommended to receive a male sling chose it. When an artificial urinary sphincter was recommended, 75% of patients chose it, while 25% chose a male sling. When given a choice, 92% of patients chose a male sling and 8% chose an artificial urinary sphincter.

CONCLUSIONS

Most patients adhere to the surgeon recommendation. When men with post-prostatectomy incontinence are offered the choice of an artificial urinary sphincter vs a male sling, the opportunity to avoid using a mechanical device is preferable to undergoing a well established procedure. Men who strongly wish to avoid a mechanical device are willing to go against the surgeon recommendation for an artificial urinary sphincter.

Postprostatectomy incontinence: all about diagnosis and management

CONTEXT

The ever-increasing number of radical prostatectomies entails an increasing number of patients suffering from postprostatectomy stress incontinence despite improved surgical techniques. We provide an overview of the current diagnosis and treatment of postprostatectomy stress incontinence.

OBJECTIVE

To review previous and recent literature on this subject and to assess the current standards of diagnosis and management of postprostatectomy incontinence.

EVIDENCE ACQUISITION

The PubMed database was searched, and all articles published since 2000 were evaluated.

EVIDENCE SYNTHESIS

This review presents the current recommended diagnostic tools and available noninvasive and invasive treatment options.

CONCLUSIONS

The European Association of Urology (EAU) recommends a two-stage assessment for diagnosis of postprostatectomy incontinence. Noninvasive therapy, pelvic floor-muscle training and biofeedback, is recommended in early postoperative and mild incontinence. Pharmacological treatment with duloxetine is especially effective in combination with physiotherapy, where it synergistically improves the continence rate. For surgical treatment, the insertion of an artificial urinary sphincter, AS-800, is still the gold standard. In recent years, several minimal invasive treatment options have been introduced with different rates of success, but they have not yet surpassed the results of the artificial sphincter.