Surgery for postprostatectomy incontinence: which procedure for which patient?

Recent Advances in Diagnosing and Treating Post-Prostatectomy Urinary Incontinence

Radical prostatectomy and radiotherapy are common first-line treatments for clinically localized prostate cancer. Despite advances in surgical technology and multidisciplinary management, post-prostatectomy urinary incontinence (PPI) remains a common clinical complication. The incidence and duration of PPI are highly heterogeneous, varying considerably between individuals. Post-prostatectomy urinary incontinence may result from a combination of factors, including patient characteristics, lower urinary tract function, and surgical procedures. Physicians often rely on detailed medical history, physical examinations, voiding diaries, pad tests, and questionnaires-based symptoms to identify critical factors and select appropriate treatment options. Post-prostatectomy urinary incontinence treatment can be divided into conservative treatment and surgical interventions, depending on the severity and type of incontinence. Pelvic floor muscle training and lifestyle interventions are commonly conservative strategies. When conservative treatment fails, surgery is frequently recommended, and the artificial urethral sphincter remains the "gold standard" surgical intervention for PPI. This review focuses on the diagnosis and treatment of PPI, based on the most recent clinical research and recommendations of guidelines, including epidemiology and risk factors, diagnostic methods, and treatment strategies, aimed at presenting a comprehensive overview of the latest advances in this field and assisting doctors in providing personalized treatment options for patients with PPI.

[Use of implants to treat male urinary incontinence]

Treatments for benign and malignant pathologies of the prostate can compromise urine control. Urinary incontinence (UI) affects the quality of life of patients and limits their ability to carry out usual activities. The degree of impact of UI is variable and the associated discomforts make patients seek treatment for it. At the center of the management of urinary incontinence in men are surgical interventions that seek to replace the affected sphincter function through implants. The artificial urinary sphincter since its development in the 1970s has been considered the standard of treatment for UI in men. More recently artificial sphincter and slings have been shown to be effective in a selected group of incontinent men. The goals of surgical treatment of incontinence include the preservation of bladder function, the ability to improve the strength of the urinary sphincter, and to reduce or eliminate urine leakage, and thereby improve the quality of life. The aim of the article is to present various implants for the correction of male urinary incontinence.

Regenerated Cell Therapy for Stress Urinary Incontinence: A Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of regenerated cell therapy for stress urinary incontinence (UI) in humans.

METHODS

We searched articles from PubMed, Embase, and the Cochrane Library database published before February 24, 2020. Of 396 records identified, 23 articles on human clinical research met our criteria, including a total of 890 patients. Stata/SE12.0 software was used to analyze cure, efficiency (cure rate plus improvement rate), and complication rates.

RESULTS

No significant differences in cure rates and effective rates were observed for any cell type in males. However, in females, the myocytes with fibroblasts subgroup (82%) and nucleated cells with platelets subgroup (89%) exhibited significantly higher cure rates compared with the other two subgroups (25% and 36%). Pooled effective rates of myocytes and fibroblasts (92%) and nucleated cells with platelets (97%) were also higher compared with the other two subgroups (72% and 60%). Pooled complication rates were 23% and 26% in males and females, respectively, and there were some differences among subgroups. Although some studies reported postoperative complications, no serious complications were reported and most recovered within 1-2 weeks.

CONCLUSIONS

Limited studies have indicated the safety and effectiveness of regenerated cells for treating stress UI in the follow-up period, which may be an ideal method to treat stress UI in the future. Moreover, nucleated cells with platelets and myocytes with fibroblasts were markedly effective, but whether cell injection therapies elicit superior effects need further confirmation.

Is pre-operative urodynamic bladder function the true predictor of outcome of male sling for post prostatectomy incontinence?

PURPOSE

To investigate pre-operative urodynamic parameters in male sling patients to ascertain whether this might better predict surgical outcomes and facilitate patient selection.

METHODS

We performed a retrospective, case notes and video-urodynamics, review of men who underwent AdVanceXP male sling in three London hospitals between 2012 and 2019. Urodynamics were performed in all centres, while retrograde leak point pressure (RLPP) was performed in one centre.

RESULTS

Successful outcome was seen in 99/130 (76%) of men who required one pad or less per day. The dry rate was 51%. Pad usage was linked to worse surgical outcomes, mean 2.6 (range 1-6.5) for success vs 3.6 (range 1-10) although the ranges were wide (p = 0.002). 24 h pad weight also reached statistical significance (p = 0.05), with a mean of 181 g for success group versus 475 g for the non-successful group. The incidence of DO in the non-successful group was significantly higher than in successful group (55% versus 29%, p = 0.0009). Bladder capacity less than 250 ml was also associated with worse outcomes (p = 0.003). Reduced compliance was not correlated with outcomes (31% for success groups vs 45% for non-successful group, p = 0.15). Preoperative RLPP was performed in 60/130 patients but did not independently reach statistical significance (p = 0.25).

CONCLUSION

Urodynamic parameters related to bladder function-detrusor overactivity and reduced maximum cystometric capacity predict male sling outcomes and may help in patient selection for male sling (or sphincter) surgery; whereas urodynamic parameters of sphincter incompetency (RLPP) were not predictive. Further larger scale studies are required to confirm these findings.

Is the adjustable transobturator system ATOMS® useful for the treatment of male urinary incontinence in low to medium volume urological centers?

INTRODUCTION

Urinary incontinence (UI) is a complication of radical prostatectomy (RP) and transurethral resection of the prostate (TURP). The gold-standard treatment is the artificial urinary sphincter, however, new treatments have been investigated.

OBJECTIVE

To examine the outcome of an adjustable transobturator male system (ATOMS^®) in men with UI after prostatic surgery in a low to medium volume continence center.

MATERIALS AND METHODS

Twenty-five men with UI were implanted with ATOMS^® system between 2012 and 2014. The most common indication was UI after RP (92%), followed by UI after TURP (8%). Eleven patients (44%) had received adjuvant external beam radiotherapy (RT). Patients were considered to be 'dry' if they stopped wearing pads or needed just one protective pad per day; and improved if the daily number of pads used decreased by at least half. The Incontinence Quality of Life questionnaire (ICIQ-SF) was used, adding a verbal question about the satisfaction of the patient considering the outcome.

RESULTS

After a mean follow-up of 21.56 months, 64% were dry and 8% revealed a significant improvement. The success of the procedure was negatively correlated with the severity of the previous UI and with previous treatment with RT. Concerning patients satisfaction, 84% of the patients would repeat the procedure.

CONCLUSION

ATOMS^® offers good rates of cure and improvement of UI after prostatic surgery with a reasonable rate of minor complications. The results of this study, performed in a low to medium volume continence center, are comparable to the results achieved in high volume continence centers.

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.

Telephone - delivered quality of life after 365 male stress urinary incontinence (SUI) operations

Objectives:

To assess patient satisfaction and quality of life and factors that may be related to these outcomes.

Materials and Methods:

Between 2000 and 2008 a retrospective chart review and telephone survey of all surgeries for male SUI was performed. Average age at times of operation was 69.4 ± 7.4 (median 69). As part of the survey 270 of 365 patients were available (response rate: 74%). The average follow up time (from operation to telephone survey) was 34.8 ± 22.8 months (median 32).

Results:

Pad use per day improved significantly after operation from 6.23±5.3 to 1.61±2.92 pads/day (p=0.001). 74.7% (n=198) declared to be continent with one safety pad and 87.7% (n=236) confirmed the postoperative improvement of incontinence. 189 (70.5%) patients were “very satisfied” and “satisfied”. In 81% (n=218) the expectation in operation could be met, therefore 84.3% (n=226) would undergo it again and 90.3% (n=243) would recommend it to others. Lower age (rs=0.211), few postoperative pads per day (rs=0.58), high reduction of pads (rs=-0.35) and physical activity level (rs=0.2) correlate significantly with better satisfaction.

Conclusions:

Eighty-seven pint seven percent (87.7%) of our incontinence operations (n=236) lead to an improvement, which is independent from the number of prior incontinence operations and preoperative pad count. The postoperative quality of life remains constant over the observed follow up time. Certain subgroups of patients (younger age, high physical activity level, large reduction of pads) demonstrated superior satisfaction rates.

Artificial urinary sphincters for male stress urinary incontinence: current perspectives

The artificial urinary sphincter (AUS), which has evolved over many years, has become a safe and reliable treatment for stress urinary incontinence and is currently the gold standard. After 4 decades of existence, there is substantial experience with the AUS. Today AUS is most commonly placed for postprostatectomy stress urinary incontinence. Only a small proportion of urologists routinely place AUS. In a survey in 2005, only 4% of urologists were considered high-volume AUS implanters, performing >20 per year. Globally, ~11,500 AUSs are placed annually. Over 400 articles have been published regarding the outcomes of AUS, with a wide variance in success rates ranging from 61% to 100%. Generally speaking, the AUS has good long-term outcomes, with social continence rates of ~79% and high patient satisfaction usually between 80% and 90%. Despite good outcomes, a substantial proportion of patients, generally ~25%, will require revision surgery, with the rate of revision increasing with time. Complications requiring revision include infection, urethral atrophy, erosion, and mechanical failure. Most infections are gram-positive skin flora. Urethral atrophy and erosion lie on a spectrum resulting from the same problem, constant urethral compression. However, these two complications are managed differently. Mechanical failure is usually a late complication occurring on average later than infection, atrophy, or erosions. Various techniques may be used during revisions, including cuff relocation, downsizing, transcorporal cuff placement, or tandem cuff placement. Patient satisfaction does not appear to be affected by the need for revision as long as continence is restored. Additionally, AUS following prior sling surgery has comparable outcomes to primary AUS placement. Several new inventions are on the horizon, although none have been approved for use in the US at this point.

The artificial urinary sphincter and male sling for postprostatectomy incontinence: Which patient should get which procedure?

Surgery is the most efficacious treatment for postprostatectomy incontinence. The ideal surgical approach depends on a variety of patient factors including history of prior incontinence surgery or radiation treatment, bladder contractility, severity of leakage, and patient expectations. Most patients choose to avoid a mechanical device, opting for the male sling over the artificial urinary sphincter. The modern male sling has continued to evolve with respect to device design and surgical technique. Various types of slings address sphincteric incompetence via different mechanisms of action. The recommended surgery, however, must be individualized to the patient based on degree of incontinence, detrusor contractility, and urethral compliance. A thorough urodynamic evaluation is indicated for the majority of patients, and the recommendation for an artificial urinary sphincter, a transobturator sling, or a quadratic sling will depend on urodynamic findings and the patient's particular preference. As advancements in this field evolve, and our understanding of the pathophysiology of incontinence and mechanisms of various devices improves, we expect to see continued evolution in device design.

Foley or Fix: A Comparative Analysis of Reparative Procedures at the Time of Explantation of Artificial Urinary Sphincter for Cuff Erosion

OBJECTIVE

To examine artificial urinary sphincter (AUS) cuff erosion intraoperative management methods: Foley catheter placement, abbreviated urethroplasty (AU), or mobilization with primary urethral anastomosis (PA). We reviewed these options to compare postoperative complications and probability of AUS reimplantation.

MATERIALS AND METHODS

Medical records of patients treated for AUS cuff erosion from 2005 to 2015 were retrospectively reviewed. We divided patients into 3 groups based on intraoperative management of the urethra: Foley only, AU, or PA. Patient characteristics, operative times, outcomes, complications, and reimplantation factors were recorded and analyzed.

RESULTS

Seventy-five patients with a median age of 77 years (72-83) were treated for AUS cuff erosion. Fifty-two underwent Foley placement, 8 AU, and 15 PA. Mean follow-up was 13 months (0-106). Severe erosions were more common in the PA group than Foley or AU (100% vs 37%, 100% vs 38%, P <.001, P <.001, respectively). Severe erosions treated with Foley were more likely to develop strictures than mild erosions (38% vs 5%, P = .009). Tandem cuff patients treated with Foley were more likely to develop diverticuli than single cuff patients (33% vs 4%, P = .016). There was no difference in probability of reimplantation between PA and Foley or AU (63% vs 69%, 63% vs 33%, P = .748, P = .438, respectively).

CONCLUSIONS

Foley catheter placement alone may represent suboptimal management for severe or tandem cuff erosions due to increased risk of urethral complications. Urethral defect management should be determined at the time of explantation by individual patient characteristics and surgeon experience.