Comparing Argus sling and artificial urinary sphincter in patients with moderate post-prostatectomy incontinence

Artificial Urinary Sphincter Is Better Than Slings for Moderate Male Stress Urinary Incontinence With Acceptable Complication Rate: A Systematic Review and Meta-Analysis

Background

This meta-analysis aimed to compare the efficacy of artificial urinary sphincter (AUS) and slings for the treatment of moderate male stress urinary incontinence (SUI) based on existing data.

Methods

The study was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We searched the widely acknowledged database including PubMed, Embase (Ovid version), Medline (Ovid version), and Cochrane Central Register of Controlled Trials (till February 2021). Male patients with moderate SUI who underwent AUS or slings procedure over 18 years old and had been monitored with a mean follow-up time of at least 12 months were included. The primary outcome was success rate defined as daily pad use with 0–1 pad/d postoperatively. Articles with congruent outcomes were suitable for inclusion. The secondary outcome included complication rate of infection, erosion, acute urinary retention, and surgical revision.

Results

Five studies with a total of 509 patients (295 for slings and 214 for AUS) were recruited. The success rate was higher in AUS with an odds ratio (OR) = 0.57 (95% CI: 0.36–0.90). As for the overall complication rate, no significant difference was discovered between slings and AUS groups (OR = 1.06, 95% CI: 0.58–1.92, P = 0.86).

Conclusion

To conclude, AUS was better than slings for moderate male SUI treatment according to daily pad use with an acceptable complication rate. The slings also had clinical value and were options when aging male patients were AUS naive and refused inserted mechanical devices. High-quality pieces of evidence are needed to confirm the efficacy of AUS and slings in moderate male SUI.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=271203, identifier: CRD42021271203.

Complications after male adjustable suburethral sling implantation

Introduction

Argus suburethral sling implantation is a minimally invasive operation with the possibility to adjust the tension of the sling at any time after the procedure, which provides good treatment results for male stress urinary incontinence (SUI).

Aim

To determine the predictive factors, the incidence, severity and timing of the onset of complications after Argus sling implantation for males with post-operative SUI.

Material and methods

A total of 41 patients who underwent Argus sling implantation due to post-operative SUI were included. Median follow-up was 12 months. All complications were captured and graded according to severity and classified by timing of onset. Logistic regression analysis was performed to identify predictors of the most common side effects.

Results

Overall 22 (54%) of 41 males have experienced 31 complications. Three (7%) patients have experienced only intra-operative, 16 (39%) patients only post-operative and 3 (7%) patients both intra-operative and post-operative complications. The most common intra-operative complications were bladder perforation (12%) and external iliac vein injury (5%), while post-operative complications were acute urinary retention (29%), infection (10%) and perineal pain (7%). Previous radiotherapy has significantly increased the risk of intra-operative complications, while a non-significant tendency was observed for younger age, previous androgen deprivation therapy and grade 3 SUI. In terms of severity, most post-operative complications were classified as grade 3 according to the modified Clavien-Dindo system.

Conclusions

Argus sling implantation provides a tolerable complication rate, where acute urinary retention was the most common side effect. Previous radiotherapy significantly increases the risk of serious intra-operative complications.

Parameters of 2-Dimensional Perineal Ultrasonography Before and After Male Sling Procedure for Urinary Incontinence After Radical Prostatectomy

OBJECTIVE

To compare ultrasonographic patterns of 2-dimensional perineal ultrasonography in men in the preoperative and postoperative periods after transobturator sling deployment for the treatment of urinary incontinence after radical prostatectomy. Radiotherapy and radical prostatectomy are the primary treatments for localized prostate cancer. Studies comparing anatomic changes in men before and after radical prostatectomy based on perineal ultrasonography are scarce in the literature.

METHODS

Thirty-one patients from 2 centers were selected for examination and surgery. They were allocated into mild and/or moderate and severe incontinence groups who underwent the transobturator sling procedure between August 2014 and August 2018. Perineal ultrasonography was performed in the preoperative period for 21 of these patients and 3-6 months postoperatively after the transobturator sling procedure for 30 patients. Hypermobility of the proximal urethra and voluntary contraction of the pelvic floor were evaluated during the Valsalva maneuver, perineal contraction and at rest.

RESULTS

Clinical improvements of >50% were significantly more frequent in the mild and/or moderate vs severe incontinence group after male sling surgery (P = .035). Patients who demonstrated clinical improvement >50% showed a significantly greater displacement of the posterior portion of the bladder neck during contraction than those with clinical improvement <50% (P = .024).

CONCLUSION

The most important finding of this study was the significant difference in the posterior displacement of the bladder neck during contraction in patients who showed an improvement >50% compared with those with an improvement <50%. These data support the use of perineal ultrasonography in evaluating and selecting patients for the male sling procedure.

Adjustable sling for the treatment of post-prostatectomy urinary incontinence: systematic review and meta-analysis

Urinary incontinence after prostatectomy has a significant negative impact on the quality of life of the patient. The surgical treatment includes several models of male slings, such as adjustable slings. The objective of this study was to evaluate the effectiveness and safety of adjustable sling in the treatment of post-prostatectomy urinary incontinence. This is a systematic review of literature. The following electronic databases were searched until January 2018: PubMed®, Embase, CENTRAL and LILACS. The keywords used in the search strategies were: "prostatectomy" [Mesh], "urinary incontinence" [Mesh] and "suburethral slings" [Mesh]. Randomized clinical trials and observational studies, with or without Control Group, and follow-up of more than 12 months were included. Only one randomized study with high risk of bias was included and it concluded the effectiveness equivalence between adjustable and non-adjustable slings. All other studies were cases series with patients of varying levels of incontinence intensity and history of pelvic radiation therapy and previous surgeries. The meta-analysis for 0 pad in 24 hours demonstrated an effectiveness of 53%. For the 0 to 1 pad test in 24 hours, the meta-analysis resulted in an effectiveness of 69%. Risk factors for surgery failure include prior radiation, severity of post-prostatectomy urinary incontinence, and previous surgeries. The meta-analysis of the extrusion rate was 9.8% and the most commonly reported adverse effects were pain and local infection. Evidence of low quality indicates that adjustable slings are effective for treating post-prostatectomy urinary incontinence, with frequency of adverse events similar to the surgical option considered gold standard (the artificial urinary sphincter implant).

Implantation of the argus sling in a hard-to-treat patient group with urinary stress incontinence

INTRODUCTION

Awareness of prostate cancer is growing in the Western population, and an increasing number of patients are being referred to prostate surgery. This is a significant contributor to male stress urinary incontinence (SUI). Implantation of an artificial sphincter (AUS) is considered the gold standard treatment of SUI. This study investigates the role of minimally invasive treatment with the Argus sling in a heterogenic hard-to-treat patient group.

METHOD

The study was a retrospective follow-up study with patients as their own controls. Forty-one patients were enrolled and treated with the Argus sling. Patients enrolled had persisting SUI after prostate surgery for more than 12 months, despite conservative treatment. The pre-operative daily usage of pads and the 24 hours urinary leakage were compared to the post-operative findings. The primary goal was to achieve complete continence or a reduction of more than 50% in pad usage or urinary leakage.

RESULTS

In total, 71% of the 41 patients enrolled met our primary objective. Complete continence was obtained in 56%, and a reduction of 50% or more was obtained in an additional 15%.

CONCLUSION

This study has reproduced continence rates seen in previous studies, but in the hard-to-treat patients with urgency or formerly failed surgery, the continence rate was found to be inferior. The AUS has produced similar results and must still be considered the gold standard treatment of SUI, but the Argus sling is an alternative for patients who want a passive system or for patients not suitable for AUS.

SURGICAL MANAGEMENT OF POST-PROSTATECTOMY INCONTINENCE

Post-prostatectomy incontinence (PPI) is a common and significant issue that can affect the quality of life in men who are undergoing treatment for prostate cancer. While some patients opt for conservative management of their incontinence, many elect to undergo surgical treatment as a result of the significant impact to quality of life. The most commonly employed surgical techniques to address PPI are placement of a male sling or artificial urinary sphincter (AUS). Currently, the AUS continues to serve as the gold standard for management, with robust data concerning longitudinal outcomes available. However, in recent years, the various methods to place the male sling have emerged as viable, less complex alternatives that avoid the need for pump manipulation. In the present review, we discuss these main surgical treatment modalities for PPI, and focus on the selection criteria that may influence appropriate operative stratification of PPI patients. Indeed, an individualised, comprehensive assessment of baseline urinary function, age, radiation, prior surgeries, functional status, and other comorbidities must be considered in the context of shared decision-making between the treatment provider and the patient in determining the optimal approach to managing PPI.

Evaluation and Management of Postprostatectomy Incontinence: A Systematic Review of Current Literature

CONTEXT

Radical prostatectomy is the most common reason for male stress urinary incontinence. There is still uncertainty about its diagnostic and therapeutic management.

OBJECTIVE

To evaluate current evidence regarding the diagnosis and therapy of postprostatectomy incontinence (PPI).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in October 2015 using the Medline database.

EVIDENCE SYNTHESIS

Diagnosis and conservative treatment of PPI are currently mostly based on expert opinions. Pelvic floor muscle training is the noninvasive treatment of choice of PPI. For invasive management of moderate to severe PPI, the artificial urinary sphincter is still the treatment of choice, but an increasing number of adjustable and nonadjustable, noncompressive as well as compressive devices are used more frequently. However, no randomized controlled trial has yet investigated the outcome of one specific surgical treatment or compared the outcome of different surgical treatment options.

CONCLUSIONS

The level of evidence addressing the surgical management of PPI is still unsatisfactory. Further research is urgently needed.

PATIENT SUMMARY

Incontinence after the removal of the prostate (postprostatectomy incontinence) is the most common cause of male stress urinary incontinence. First-line therapy is physiotherapy and lifestyle changes. If no satisfactory improvement is obtained, various surgical treatment options are available. The most commonly used is the artificial urinary sphincter, but other treatment options like male slings are also available.