Chapitre C-2 E - Chirurgie prothétique de l’incontinence urinaire d’effort par insuffisance sphinctérienne neurologique

Management of stress urinary incontinence in female patients with spinal cord injury by autologous fascial sling: time for a revival?

STUDY DESIGN

This study is a retrospective chart analysis.

OBJECTIVES

Surgical treatment of stress urinary incontinence (SUI) in women with neurogenic lower urinary tract dysfunction (NLUTD) is a challenge, as minimally invasive procedures do not seem to be effective, whereas synthetic implants are associated with substantial risks. Thus, we evaluated the results of an autologous sling procedure in this group of patients SETTING: This study was performed at a spinal cord injury rehabilitation center in Switzerland.

METHODS

In this retrospective analysis, we evaluated the objective, subjective, and urodynamic results in women undergoing autologous sling insertion for SUI due to NLUTD at our institution.

RESULTS

The data of 17 women who underwent fascial sling surgery were analyzed. After a median follow-up of 40 months, 8 women (47%) were continent, and another 8 patients (47%) significantly improved (1 pad/day). Median video-urodynamic parameters remained unchanged after sling insertion, but two women developed de novo detrusor overactivity. Postoperative complications occurred in 6 of the 17 patients (35.3%), which required surgical interventions in 2 women (12%) (urethral erosion by the sling and complete occlusion of the urethra after removal of the catheter), which could be resolved without loss of continence.

CONCLUSION

In our case series, autologous fascial slings were effective in the treatment of SUI in women with NLUTD. As they are more effective than minimally invasive procedures, are associated with fewer complications than AUS, and seem to omit possible severe long-term consequences of synthetic slings, they are an excellent treatment option in this group of patients. Urodynamic controls are recommended, as de novo detrusor overactivity may occur after sling insertion.

Outcomes of robot-assisted urinary sphincter implantation for male neurogenic urinary incontinence

OBJECTIVES

To report the functional outcomes of robot-assisted laparoscopic artificial urinary sphincter implantation (R-AUS) in men with neurogenic stress urinary incontinence (SUI).

PATIENTS AND METHODS

A monocentric retrospective study included all consecutive adult male neuro-urological patients who underwent R-AUS for SUI between January 2011 and August 2018. The AUS was implanted via a transperitoneal robot-assisted laparoscopic approach. Intraoperative and early postoperative complications were reported (Clavien-Dindo classification). Continence was defined as no pad usage. Revision and explantation rates were also evaluated.

RESULTS

Overall, 19 men with a median (interquartile range [IQR]) age of 45 (37-54) years were included. No conversion to laparotomy was needed. Three minor (Clavien-Dindo Grade I-II) early postoperative complications occurring in three (15.8%) patients were reported. The median (IQR) follow-up was 58 (36-70) months. At the end of the follow-up, the continence rate was 89.5%. The AUS revision and explantation rates were 5.3% and 0%, respectively.

CONCLUSION

A R-AUS is a safe and efficient procedure for AUS implantation in adult male neuro-urological patients, referring to the challenging open technique.

Neurogenic bladder - concepts and treatment recommendations

Introduction:

Bladder and urinary sphincter malfunctioning that results from some change in the central and/or peripheral nervous system is defined as neurogenic bladder. The urinary tract symptoms that can be related to its filling, emptying, or both have a significant impact on the quality of life of individuals. The present review was based on the document prepared for the public health system in Brazil as a treatment guidelines proposal.

Material and Methods:

Survey questions were structured as per PICO (Population, Intervention, Control, and Outcome). Search strategies were defined and performed in the MEDLINE/Pubmed, Embase, Epistemonikos and Google Scholar databases. The selection of articles followed the evidence hierarchy concept; evidence body was identified, and the quantitative study data were extracted. The quality of evidence and grade of recommendation were qualitatively assessed according to GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

Results:

A total of 2.707 articles were identified, with 49 of them being selected to compose the basis for this review. Neurogenic bladder treatments were classified according to their focus on filling or emptying symptoms and sub- classified in pharmacological and surgical treatments.

Conclusion:

Treatment guidelines are important tools for the public health system to promote the best practice when treating neurogenic bladder patients.

[Male neurogenic stress urinary incontinence treated by artificial urinary sphincter AMS 800™ (Boston Scientific, Boston, USA): Very long-term results (>25 years)]

OBJECTIVE

The aim of the study was to report the very long-term functional outcomes of artificial urinary sphincter (AUS) in male neurological patients.

MATERIAL AND METHODS

Male neurological patients diagnosed with stress urinary incontinence due to sphincter deficiency and undergoing AUS (AMS 800^®) implantation between 1985 and 1992 were enrolled. Continence, defined by no pad/condom usage, explantation and revision rates were reported.

RESULTS

Fourteen patients with a median age of 27.3 years (IQR: 27.3-40.8) were included: four had a spinal cord injury and ten a spina bifida. Prior continence surgery was reported by 6 patients (42.9 %). Artificial urinary sphincter was implanted in a peribulbar (n=4) or periprostatic position (n=10). Median follow-up was 18.3 years (IQR: 10.1-20.3). At last follow-up, all patients were alive. Three native devices were still in place, eight were revised (four of them were secondarily explanted) and three were explanted due to erosion or infection. The 5-, 10-, 15-, 20-year explantation-free survival rates were respectively 85.7, 62.3, 52.0, 39.0 %. The 5-, 10-, 15-, 20-year revision-free survival rates were respectively 78.6, 42.9, 28.6, 7.1 %. At last follow-up, 50 % patients were continent.

CONCLUSION

In the very long run, AUS provided a 50 % continence rate in male neurological patients but the revision rates were important.

LEVEL OF EVIDENCE

4.

[Functional results and complications of artificial urinary sphincter AMS 800: About 84 cases]

PURPOSE

To verify the effectiveness and safetiness of artificial urinary sphincter (SUA) AMS 800™ in the management of urinary incontinence by sphincter incompetence.

PATIENTS AND METHODS

Retrospective study of patients who received SUA by the same operator between 1992 and 2006. Fifty-seven men and 27 women whose average age was 61 years (22-82) suffered from incontinence by sphincter incompetence: after radical prostatectomy (46%), primary stress or mixed incontinence (21.4%), transurethral resection of prostate (9.5%), injury and neurological malformations (9.5%), pelvic or urethral trauma (7.1%), rectal surgery (3.6%), adenomectomy (2.4%). Functional assessment was made by telephone based on a 23-item questionnaire (Appendix 2).

RESULTS

The mean follow-up was 52.6 months (5.3-187.1): 64% had their original SUA, 50 re-interventions were necessary for 30 patients with 13.1% mechanical complications, 6.6% urethral atrophy, and 13.9% infectious complications, 2.5% failures and 9% definitive explant. The half-time survival without revision was 8.3 years. Sixty-seven percent of patients were contacted for the functional assessment: 77% success rate (≤1 protection), 85% of patients improved, 87% satisfied or very satisfied and 94% would go again through the same operation.

CONCLUSION

The artificial urinary sphincter AMS 800™ remains still the reference in the management of urinary incontinence by sphincter incompetence in improving the quality of life of patients implanted at the cost of a significant revision rate and frequent residual leaks.