Correlation of patient perception of pad use with objective degree of incontinence measured by pad test in men with post-prostatectomy incontinence: the SUFU Pad Test Study

Assessment of different continence definitions in the context of the randomized multicenter prospective LAP-01 trial-Does the best definition change over time?

BACKGROUND

A uniform definition of continence is urgently needed to allow the comparison of study results and to estimate patient outcomes after radical prostatectomy (RP). To identify a practical definition that includes both objective and subjective aspects in a tangible way, we assessed different continence definitions and evaluated which best reflects the patients' subjective perception of continence.

METHODS

Our analyses included 718 patients that underwent either robot-assisted radical prostatectomy (RARP) or laparoscopic radical prostatectomy (LRP) in a multicenter randomized patient-blinded trial. Continence was assessed through patient questionnaires prior to and at 3, 6 and 12 months after surgery which included the number of pads used per day, the ICIQ-SF and the question "Do you suffer from incontinence? (yes/no)" to assess subjective continence. We used Krippendorff's Alpha to calculate the agreement of different continence definitions with the subjective perception.

RESULTS

At 3 months, the "0/safety pad" definition shows the highest agreement by alpha = 0.70 (vs. 0.63 for "0 pads" and 0.37 for "0-1 pad"). At 6 and 12 months "0 pads" is the better match, with alpha values of 0.69 (vs. 0.62 and 0.31) after 6 months and 0.70 (vs. 0.65 and 0.32) after 12 months. The ICIQ-SF score shows good correlation with the subjective continence at 3 months (alpha = - 0.79), the coefficient then decreasing to - 0.69 and - 0.59 at 6 and 12 months.

CONCLUSION

The best continence definition according to the patients' perspective changes over time, "0 pads" being the superior criterion in the long-term. We recommend using the 0-pad definition for standardized continence reporting, as it is simple yet as accurate as possible given the inevitably high subjectivity of continence perception. Trial registration The LAP-01 trial was registered with the U.S. National Library of Medicine clinical trial registry (clinicaltrials.gov), NCT number: NCT03682146, and with the German Clinical Trial registry (Deutsches Register Klinischer Studien), DRKS ID number: DRKS00007138.

Artificial Urinary Sphincters for Moderate Post-Prostatectomy Incontinence: Current Research and Proposed Approach

Male urinary incontinence is a common complication after radical prostatectomy. The severity of incontinence can be assessed in various ways and helps determine the best surgical intervention to restore continence. While most patients with mild incontinence receive a sling and those with severe incontinence receive an artificial urinary sphincter (AUS), there are no clear guidelines on how to manage patients with moderate post-prostatectomy incontinence (PPI). Our discussion will focus on the current literature, which demonstrates that an AUS should be considered first-line in men with moderate PPI despite perceived concerns over complications and reintervention rates.

The Asia-Pacific AMS800 artificial urinary sphincter consensus statement

This Asia-Pacific (AP) AMS 800™ artificial urinary sphincter (AUS) consensus statement aims to provide a set of practical recommendations to assist surgeons with the AMS 800 device surgery. The AP consensus committee consisted of key opinion leaders with extensive experience with AMS 800 surgery across several AP countries. The panel reviewed and discussed relevant findings with emphasis on locoregional and specific clinical challenges relevant to the AP region. Recommendations were made in key areas namely (1) patient selection and informed consent process; (2) preoperative assessment; (3) dealing with co-existing urological disorders; (4) surgical principles and intraoperative troubleshooting; (5) postoperative care; (6) special populations; and (7) cost analysis and comparative review. The AMS 800 device should be offered to males with moderate to severe stress urinary incontinence (SUI). Full informed consent should be undertaken, and emphasis is placed on surgical contraindications and high-risk candidates. The presence of a surgical mentor or referral to experts is recommended in complex AUS candidates. Preoperative cystoscopy with or without multichannel urodynamic study is necessary and patients with pre-existing urological disorders should be treated adequately and clinically stable before surgery. Adherence to strict patient selection and safe surgical principles are critical to ensure excellent clinical outcomes and minimize complications. Given that InhibiZone-coated device is not available in many AP countries, the use of prophylactic antibiotics pre-and post-operatively are recommended. The AMS 800 device should be prepared according to the manufacturer's guidelines and remains a cost-effective treatment for male SUI. The AMS 800 device remains the surgical benchmark for male SUI but is associated with certain mechanical limitations and a unique set of complications.

A Matched-Pair Analysis after Robotic and Retropubic Radical Prostatectomy: A New Definition of Continence and the Impact of Different Surgical Techniques

Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.

Evaluation of Benefits and Harms of Surgical Treatments for Post-radical Prostatectomy Urinary Incontinence: A Systematic Review and Meta-analysis

CONTEXT

No meta-analysis has comprehensively addressed both benefits and harms, or the certainty of evidence of the implantable continence devices used in men to treat postprostatectomy urinary incontinence (PPI).

OBJECTIVE

To evaluate the benefits and harms of surgical treatments for patients suffering from PPI and assess the certainty of evidence. The primary benefit was cure (one or fewer pad per day), and the primary harm was reoperations defined by surgical procedures following implantation.

EVIDENCE ACQUISITION

We perform a search of Medline, PubMed, Embase, Cochrane Library, and gray literature. We included observational studies addressing PPI surgical interventions if they involved cohorts of ≥50 participants. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach provided the framework for certainty of evidence assessment informed by value and preference judgments provided by patients, and an advocacy group member (Canadian Cancer Society).

EVIDENCE SYNTHESIS

Of 85 observational studies involving 13 100 patients, three addressed bulking agents, 35 male synthetic slings, ten adjustable continence therapies (ACTs), and 37 artificial urinary sphincters (AUSs). Cure was 26.1% (95% confidence interval [CI]: 10.6-51.4, I2 = 92.8%, very-low-quality evidence) for bulking agents, 58.6% (95% CI: 51.3-65.5, I2 = 89.1%, low-quality evidence) for slings, 63.2% (95% CI: 57.6-68.5, I2 = 22.5%, very-low-quality evidence) for ACT, and 74.0% (95% CI:61.2-83.7, I2 = 92.1%, very-low-quality evidence) for AUS. Estimated rates of reoperation were 5.8% (95% CI: 1.9-11.6, I2 = 94.1%, moderate-quality evidence) for slings, 23.8% (95% CI: 5.9-61.0, I2 = 95.5%, low-quality evidence) for ACT, and 22.2% (95% CI: 15.2-31.3, I2 = 92.3%, high-quality evidence) for AUS.

CONCLUSIONS

Available evidence regarding the benefits of surgical interventions for PPI remains mainly uncertain while suggesting important harms. These results should guide consent procedures for PPI surgery in the context of shared decision-making, with disclosure of the uncertainty of evidence.

PATIENT SUMMARY

Despite being used worldwide, available evidence regarding the benefits of surgeries to treat postprostatectomy urinary incontinence remains mainly uncertain while suggesting important harms. This highlights the need for a more rigorous evaluation process for commercially available surgical devices.

The Effectiveness of Pelvic Floor Muscle Training in Men after Radical Prostatectomy Measured with the Insert Test

A commonly used physiotherapeutic method for the treatment of urinary incontinence (UI) after radical prostatectomy (RP) is pelvic floor muscle training (PFMT). The aim of this study was to evaluate the effectiveness of PFMT by enhanced biofeedback using the 1h pad-weighing test. The following factors were taken into consideration in the analysis of PFMT effectiveness: the relevance of the patients’ age, time from RP, BMI, mental health, functional state, and depression. A total of 60 post-RP patients who underwent 10-week PFMT were studied. They were divided into groups: A (n = 20) and B (n = 20) (random division, time from RP: 2−6 weeks) and group C (time from RP > 6 weeks). Group B had enhanced training using EMG biofeedback. UI improved in all groups: A, p = 0.0000; B, p = 0.0000; and C, p = 0.0001. After the completion of PFMT, complete control over miction was achieved by 60% of the patients in group A, 85% in group B, and 45% in group C. There was no correlation between the results of PFMT efficacy and patients’ age, BMI, time from RP, mental health, functional state, and depression. PFMT is highly effective in UI treatment. The enhancement of PFMT by EMG biofeedback seems to increase the effectiveness of the therapy.

Evaluation of the 24-h pad weight test as continence rate assessment tool after artificial urinary sphincter implantation for postprostatectomy urinary incontinence: A Swedish retrospective cohort study

AIM

Patient-reported pad-count as continence rate assessment tool after artificial urinary sphincter (AUS) implantation is common. However, lack of standardized continence definition using this method results in heterogeneous published efficacy outcomes. Data on 24-h pad weight tests (PWT) after primary AUS implantation for postprostatectomy urinary incontinence (PPUI) is scarce. Our aim was to evaluate the 24-h PWT as an efficacy assessment tool and correlate it to qualitative outcomes using validated questionnaires.

METHODS

This retrospective, single center, follow-up cohort study, evaluated 180 patients who underwent primary AUS implantation for PPUI from 2005 to 2018. Voiding diaries, 24-h PWT, validated patient satisfaction and quality of life (QoL) questionnaires were collected pre-operatively and at 3-6 months postactivation, using the institution's Electronic Medical Records.

RESULTS

The median preoperative and postoperative 24-h PWT values were 494 (interquartile range [IQR]: 304-780) and 7 (IQR: 0-25) g respectively with a significant improvement in urinary leakage of 489.5 g 99.1% (p < 0.001). Median preoperative and postoperative I-QoL results increased from 33.5 (IQR: 19.3-63.6) to 86.4 (IQR: 73.9-94.3) points, with a significant 52.9 points improvement in QoL (p < 0.001). Similarly, the median preoperative and postoperative ICIQ-SF values decreased from 20 (IQR: 17-21) to 5 (IQR: 3-9) points, showing a significant improvement of 15 points (p < 0.001). We also found a significant correlation between PWT and patient satisfaction.

CONCLUSION

The 24-h PWT provides a reliable and objective assessment of continence rates, with a strong correlation to qualitative outcomes, after primary AUS implantation for PPUI. Its use could help reduce reported outcome heterogeneity across studies.

Narrative review of male urethral sling for post-prostatectomy stress incontinence: sling type, patient selection, and clinical applications

Male stress urinary incontinence (SUI) following prostate treatment is a devastating complaint for many patients. While the artificial urinary sphincter is the gold standard treatment for male SUI, the urethral sling is also popular due to ease of placement, lack of mechanical complexity, and absence of manual dexterity requirement. A literature review was performed of male urethral sling articles spanning the last zz20 years using the PubMed search engine. Clinical practice guidelines were also reviewed for comparison. Four categories of male urethral sling were evaluated: the transobturator AdVance and AdVance XP, the bone-anchored InVance, the quadratic Virtue, and the adjustable sling series. Well selected patients with mild to moderate urinary incontinence and no prior history of radiation experienced the highest success rates at long-term follow up. Patients with post-prostatectomy climacturia also reported improvement in leakage after sling. Concurrent penile prosthesis and sling techniques were reviewed, with favorable short-term outcomes demonstrated. Male urethral sling is a user-friendly surgical procedure with durable long-term outcomes in carefully selected men with mild stress urinary incontinence. Multiple sling types are available with varying degrees of efficacy and complication rates. Longer follow-up and larger cohort sizes are needed for treatment of newer indications such as climacturia as well as techniques involving dual placement of sling and penile prosthesis.

Longer is better than shorter: The added value of the seven-day pad test in the post-radical prostatectomy urinary incontinence

AIMS

To investigate the feasibility and reliability of the seven-day pad test (7DPT), the correlation between 7DPT and 24-hour pad test (24HPT), and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire, and the different categorization by the severity of each pad test. Pad weighting tests have been recommended in the evaluation of post-radical prostatectomy urinary incontinence severity, being considered the 24HPT gold standard. Some authors consider that the longer the testing, the better assessment. We propose a self-filled pad weight, the 7DPT.

METHODS

A prospective study of incontinent male patients after radical prostatectomy. We carried out the study in two phases. All patients underwent urodynamic study. The first phase evaluated the feasibility and reliability of 7DPT. The second evaluated the correlation between 7DPT, 24HPT, and ICIQ-SF questionnaire in a larger sample.

RESULTS

First phase: 32 patients were recruited. Test-retest reliability was excellent, with good agreement between mean 7DPT and 24HPT. The number of pads and mean 7DPT showed a good correlation. Second phase: 72 patients were screened, 51 (71%) met inclusion criteria. Mean 7DPT and 24HPT showed a strong association. Mean 7DPT and 24HPT correlated moderately with ICIQ-SF score. 7DPT and 24HPT agreement with ICIQ-SF groups was slight. As 7DPT captures better days with maximum urinary leakage, up to 12 patients would have been misclassified according to 24HPT (number need to treat for 7DPT was seven).

CONCLUSIONS

7DPT is a feasible and reliable tool to evaluate post-radical prostatectomy urinary incontinence, with a strong correlation with the 24HPT and moderate with the ICIQ-SF.

What is the impact of post-radical prostatectomy urinary incontinence on everyday quality of life? Linking Pad usage and International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) for a COMBined definition (PICOMB definition)

AIMS

To identify the definition for urinary continence (UC) after radical prostatectomy (RP) which reflects best patients' perception of quality of life (QoL).

METHODS

Continence was prospectively assessed in 634 patients, 12 months after RP using the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) and the number of pads employed in a 24-hour period (pad usage). We used the one-way ANOVA technique with posthoc pairwise comparisons according to Scheffé's method (homogeneous subsets) for assessing the degree of QoL deficit related to urinary incontinence (UI).

RESULTS

The continence prevalence is 64.4%, 74.1%, 88.3%, and 35.8% using "0 pads," "1 safety pad," "1 pad," and "ICIQ score 0" definitions, respectively. Pad usage is moderately strongly associated with ICIQ 1, 2, and 3 (ρ = 0.744, 0.677, and 0.711, respectively; p < 0.001). Concordance between classical UC definitions is acceptable between "0 pads-ICIQ score 0" (K = 0.466), but poor for "1 safety pad" and "1 pad" (K = 0.326 and 0.137, respectively). Patients with "0 pad usage" have better QoL related to urine leakage than patients with "1 safety pad" or "1 pad" (1.41 vs. 2.44 and 3.11, respectively; p < 0.05). There were no significant differences found regarding QoL between patients with ICIQ score 0 and ICIQ score 2 (1.01 vs. 1.63; p = 0.63).

CONCLUSIONS

Pad usage and the ICIQ-SF's answers provide useful information. We propose a combined definition (0 pads and ICIQ score ≤2) as it is the definition with the least impact on daily QoL.

The Impact of Urinary Incontinence on Quality of Life: A Cross-Sectional Study in the Metropolitan City of Naples

Urinary incontinence is a hygienic and psychosocial problem that often brings people to restrict their social life and to experience depression. The main aim of this study was to evaluate the impact of urinary incontinence on quality of life among residents of the Metropolitan City of Naples, Italy, using a newly designed multidimensional questionnaire. The secondary objective was to find which variables affect the quality of life and symptom severity in these patients. To do so, a sample composed of twenty-eight patients was recruited in a multicentre cross-sectional study. Most of the participants had a mild impairment (60%) concerning social life and self-perception, especially those whose education was above the primary level (p = 0.036) and those who followed a pelvic floor rehabilitation program (p = 0.002). Overflow urinary incontinence was associated with a greater deterioration in the aspirational and occupational domain (p = 0.044). Symptom severity was worse in those who had comorbidities (p = 0.038), who had a high body mass index (p = 0.008) or who used diuretics (p = 0.007). In conclusion, our results suggest that there is a significant impairment of quality of life in patients who have only primary education and who follow a pelvic floor rehabilitation program.

Multicentered Assessment of Clinical Outcomes and Factors Associated With Failure of the Adjustable TransObturator Male System (ATOMS)

OBJECTIVE

To assess postoperative outcomes from the Adjustable TransObturator Male System (ATOMS) and identify factors influencing failure to achieve continence.

PATIENTS AND METHODS

A multicentered analysis was performed on all patients treated for postprostatectomy incontinence using the third-generation ATOMS at 9 Canadian tertiary referral centers. The primary outcome was continence (defined as requiring ≤1 pad postoperatively for patients requiring ≥2 pads preoperatively and 0 pads for those requiring 1 pad preoperatively). Secondary outcomes included improvement (>50% change in pad use), patient satisfaction, explantation, and postoperative complications.

RESULTS

Two hundred and eighty nine patients with a mean age of 68.9 years were analyzed. Pre-operatively mean pad per day use was 4.2 (1-12), 31.5% of patients reported severe incontinence (≥5 pads/day), 33.9% had concurrent radiotherapy and 19.4% had failed previous incontinence surgery. Overall continence rate was 73.3% (n = 212) at a mean follow-up of 19.6 months. More than eighty nine percent (89.3%) (n = 258) of patients experienced >50% improvement, 84.4% (n = 244) of patients were satisfied with the results of surgery. More than seven percent (7.9%) (n = 23) required device explantation. On multivariate Cox regression analysis, concurrent radiotherapy (hazard ratio [H.R.] 2.3, P < .001), diabetes (H.R. 2.2, P = .007) and increased pre-operative pad usage (H.R. 1.1, P = .02) were each associated with failure to achieve continence, while patient age (P = .60), obesity (P = .08), prior urethral stenosis (P = .56), and prior incontinence surgery (P = .13) were not. Radiation therapy was also associated with device explantation (H.R. 2.7, P = .02).

CONCLUSION

ATOMS is a safe and efficacious for treatment of postprostatectomy incontinence. However, patients with prior radiation, increased pre-operative pad use, or diabetes are less likely to achieve continence.

Qualitative analysis of Amazon customer reviews of penile clamps for male urinary incontinence

AIMS

Penile clamps offer an alternative to manage male urinary incontinence in patients who are unfit for surgery. Patient experience with penile clamps is poorly understood. Our study elucidates patient opinions on commercially available penile clamps and the factors that associate with favorable and unfavorable opinions.

METHODS

We collected Amazon reviews of all penile clamps marketed for male urinary incontinence from November 2011 to January 2020 and qualitatively assessed the overall sentiment towards penile clamps, key praises and key complaints. Covariates such as designated Amazon star rating were further explored for association with coding patterns.

RESULTS

Amazon reviews of penile clamps were found to be more positive (n = 425) in overall sentiment than negative (n = 294). The most frequent praise was effective incontinence control (n = 334) and the most frequent complaint was bad design or material (n = 166). The majority of reviews were for lower priced penile clamps, had higher Amazon star ratings, were written for Wiesner-produced clamps, and were written more recently (i.e., 2015-2020). Penile clamps with higher Amazon star ratings were more often coded positive and with a praise compared to lower rated penile clamps.

CONCLUSIONS

Penile clamps are seen favorably by users as an effective treatment modality for male urinary incontinence. User reviews suggest opportunities for improvement in penile clamp design. The most frequently reviewed clamp seen positively is the Wiesner Incontinence Clamp Penile Clamp whereas the most frequently reviewed clamp seen negatively is the Pacey Cuff Male Incontinence Device.

Daily Pad Usage Versus the International Consultation on Incontinence Questionnaire Short Form for Continence Assessment Following Radical Prostatectomy

Purpose

Continence assessment is an essential component of follow-up after radical prostatectomy (RP). Several methods exist to assess the severity of urinary incontinence (UI). Our study examined the relationship and degree of agreement between International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) scores and the number of pads used in a 24-hour period in the assessment of UI following RP.

Methods

Continence was prospectively assessed in 746 men from a Spanish urology clinic 12 months after RP using the ICIQ-SF and pad usage. The relationship between ICIQ-SF scores and pad usage was assessed using Spearman rank correlation coefficients. The Jonckheere-Terpstra trend test was used to determine whether the ICIQ-SF score and the component question scores increased with increasing pad usage. The Bonferroni-corrected pairwise Wilcoxon rank-sum test was used to determine which pairs of pad usage levels differed. The weighted kappa was used to evaluate the agreement between pad usage levels and ICIQ-SF questions.

Results

The continence rate was 82% using the “no pad usage” definition of continence versus 78% using the definition of an ICIQ-SF score of 0 (P<0.001). Strong positive correlations were observed between the number of pads and the ICIQ-SF total and component question scores (r_s>0.85, P<0.001). The ICIQ-SF total and component question scores increased significantly with increasing pad usage (P<0.001). The ICIQ-SF scores (P<0.018) for all pairs of pad usage levels (0, 1, 2, or 3 or more) differed significantly. The agreement between the ICIQ-SF leakage amount question and pad usage was very good (r_s=0.861, P<0.001).

Conclusions

At 12 months post-RP, 24-hour pad usage was closely correlated with ICIQ-SF, although the continence rate differed depending on the definition used. Higher levels of pad usage were associated with higher questionnaire scores, more leakage, and poor quality of life (interference with everyday life).

Pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence

BACKGROUND

Pelvic floor muscle training (PFM) training for post-prostatectomy incontinence (PPI) is an important rehabilitative approach, but the evidence base is still evolving. We developed a novel PFM training program focussed on activating fast and slow twitch muscle fibres. We hypothesized that this training, which commenced pre-operatively, would improve PFM function and reduce PPI, when compared to a control group.

METHODS

This randomized trial allocated 97 men (63 ± 7y, BMI = 25.4, Gleason 7) undergoing radical prostatectomy (RP) to either a control group (n = 47) performing low-volume rehabilitation, or an intervention group (n = 50). Both interventions commenced 5 weeks prior to surgery and continued for 12 weeks post-RP. Participants were assessed pre-operatively and at 2, 6 and 12 weeks post-RP using 24 h pad weights, International Prostate Symptom Score (IPSS), Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) and real time ultrasound (RTUS) measurements of PFM function.

RESULTS

Following RP, participants in the control group demonstrated a slower return to continence and experienced significantly more leakage (p < 0.05), measured by 24 h pad weight, compared to the intervention group, suggesting an impact of the prehabilitation protocol. PFM function measures were enhanced following RP in the intervention group. Secondary measures (IPSS, EPIC-CP and RTUS PFM function tests) demonstrated improvement across all time points, with the intervention group displaying consistently lower "bothersome" scores.

CONCLUSIONS

A pelvic floor muscle exercise program commenced prior to prostate surgery enhanced post-surgical measures of pelvic floor muscle function, reduced PPI and improved QoL outcomes related to incontinence.

TRIAL REGISTRATION

The trial was registered in the Australia New Zealand Clinical Trials Registry and allocated as ACTRN12617001400358. The trial was registered on 4/10/2017 and this was a retrospective registration.

Strong correlation between standing cough test and 24-hour pad weights in the evaluation of male stress urinary incontinence

AIMS

We sought to compare in-office physical exam findings via standing cough test (SCT) versus 24-hour pad weights among men seeking treatment for postprostatectomy stress urinary incontinence (SUI).

METHODS

A retrospective review of a single surgeon database of incontinence procedures was performed. Documentation of SUI severity (grades 0-4) was completed by SCT preoperatively utilizing the Male Stress Incontinence Grading Scale (MSIGS). All patients had pads per day (PPD) and 24-hour pad weights obtained. We determined the Spearman's correlation coefficient between these variables.

RESULTS

We identified 104 men who underwent anti-incontinence surgery (AdVance Sling or artificial urinary sphincter [AUS]). In the sling group (65 patients), nearly all (97%) had minimal incontinence with SCT (MSIGS = 0-2). In the AUS group (39 patients), most patients (69%) had an MSIGS 3 or 4 with SCT. Spearman's coefficient between quantification of SCT and pad weight for the overall group was ρ = .68 (P < .0001) demonstrating a strong positive correlation. PPD was also strongly correlated with pad weight (ρ = .55, P < .0001). As seen previously, SCT and PPD were correlated (ρ = .47, P < .0001). In a multivariable model predicting pad weight, the effect of SCT was greater than PPD (β = 83 [54-111], P < .0001 vs 45 [2169], P = .0004).

CONCLUSIONS

SCT findings strongly correlate to 24-hour pad weights in the evaluation of male SUI. The SCT shows promise as a rapid, reliable, noninvasive measure of SUI severity before anti-incontinence surgery.

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).

Long-term Success Durability of Transobturator Male Sling

OBJECTIVE

To determine the long-term outcome of transobturator sling for male stress urinary incontinence (SUI) clustered according to preoperative SUI severity, and to identify predictors of treatment success durability and failure occurrence in long-term follow-up.

METHOD

A nonconcurrent study was conducted on all transobturator male sling cases performed from August 2006 to June 2012 by a single surgeon. Preoperative SUI severity was clustered into mild (≤2 ppd), moderate (3-4 ppd) or severe (≥5 ppd). Success was defined as complete dryness with 0 pads used (cured), and a patient with ≥50% improvement, satisfied without further procedures needed. Otherwise it was considered a treatment failure. Clinical variables significantly associated with long-term treatment success were determined. Time-to-event (Kaplan-Meier) and Multiple-Cox regression analysis were performed to determine predictors of long-term treatment outcome.

RESULTS

A total of 215 patients (mild-59, moderate-94, and severe-62) with a mean follow-up of 56.4 ± 41.6 months were included. On long-term follow-up, 150 (69.8%) patients-maintained treatment success and 96 (44.7%) were dry. The long-term outcome success clustered according to SUI severity as mild, moderate, and severe was 84.7%, 72.3%, and 51.6%, respectively. Kaplan-Meier with Log-rank test and Multiple Cox-regression determined that both concomitant urge incontinence and preoperative SUI severity were independent predictors of long-term durability of treatment success and failure occurrence. Preoperative SUI severity was the only predictor of long-term cure sustainability.

CONCLUSION

The time to event analysis with an average of ∼5 years postoperative follow-up has determined that the preoperative severity and presence of concomitant urge incontinence were independent predictors for long-term outcome.

Preoperative pad usage is independently associated with failure of non-adjustable male trans-obturator slings in otherwise well-selected patients

INTRODUCTION

Our objective was to determine which clinical factors are associated with failure to achieve continence after nonadjustable trans-obturator sling in otherwise well-selected men undergoing treatment for post-prostatectomy incontinence (PPI).

METHODS

A retrospective review of AdVance/AdVance™ XP male sling procedures was performed from December 2006 to May 2017. Patients with known risk factors for sling failure, including severe incontinence (>5 pads), radiation therapy, or detrusor dysfunction, were excluded. The primary outcome was failure to achieve continence, defined as ≤1 pad per day when pad use was ≥2 preoperatively (or 0 pads if preoperative pad use was 1). Covariates included patient age, Charlson comorbidity index (CCI), diabetes, obesity (body mass index [BMI] ≥35), type of prostatectomy, and number of preoperative pads. Descriptive statistics and Cox regression analysis was performed.

RESULTS

Of 158 patients, continence was achieved in 82.3% (n=130) with a mean followup of 42.7 months. Patient-reported satisfaction was 86.7% (n=137) and the 90-day complication rate was 12% (n=19). On univariate Cox regression analysis, increasing age (p=0.02), CCI (p=0.02), and preoperative pad use (p<0.0001) were associated with sling failure, whereas obesity (p=0.95), diabetes (p=0.49), and type of prostatectomy (p=0.88) were not. On multivariate analysis, only increasing preoperative pad use remained associated with sling failure (hazard ratio [HR] 1.3; 95% confidence interval [CI] 1.1-16; p=0.008). Patients wearing >3 pads per day were more likely to experience failure (35.5% vs. 13.4%; p=0.007).

CONCLUSIONS

Increasing preoperative pad use is independently associated with an increased risk of failure after non-adjustable sling for post-prostatectomy incontinence in otherwise well-selected patients.

Adjustable transobturator male system (ATOMS®) as treatment of stress urinary incontinence secondary to transurethral resection of the prostate

OBJECTIVES

Feasibility study to evaluate efficacy and safety of Adjustable Transobturator Male System (ATOMS^®) for male stress urinary incontinence (SUI) after transurethral resection of the prostate.

MATERIALS AND METHODS

Twenty patients were implanted ATOMS^® for SUI caused by transurethral resection of the prostate with or without radiotherapy. Incontinence severity was evaluated as mild (2 pads/day), moderate (3-5 pads/day) or severe (≥6pads/day), and dryness as none or one security pad/day. Changes in pad-test and pad-count after adjustment were investigated, together with operative parameters, patient satisfaction with the procedure, and number and grade of complications (Clavien-Dindo).

RESULTS

Median age was 76.5years. Five patients received previous pelvic radiation (3 prostate, 2 rectal cancer) and 2 (10%) previous failed artificial urinary sphincter with urethral erosion and mechanical failure, respectively. Preoperative SUI was mild in 4 (20%), moderate in 7 (35%) and severe in 9 (45%). Median filling of the system was 13.5ml. Median pad-test decreased from 375±855ml baseline to 10±31.5ml and pad-count from 4±3 to 0±1.5 after adjustment (1±3fillings). Postoperative SUI distribution was mild in 2 (10%), moderate in one (5%) and severe in 2 (10%). Satisfaction rate was 80%, equal for transurethral resection of the prostate with/without previous radiotherapy. No patient had urinary retention after catheter removal. Complications presented in 3 (15%) patients, all minor. After median 38.5mo follow-up no system has been removed, 19 (95%) self-considered better than before and 11 (55%) very much better.

CONCLUSION

Based on short-term efficacy and patient satisfaction ATOMS^® can be considered a realistic alternative for SUI after transurethral resection of the prostate, even after irradiation. Absence of urethral erosion and very limited problems make this alternative especially attractive for cases with diminished dexterity, advanced age and previous failed treatments.

Patient pad count is a poor measure of urinary incontinence compared with 48-h pad test: results of a large-scale multicentre study

OBJECTIVE

To determine in a large population of community-dwelling incontinent patients the accuracy and determinants of pad count as a measure of urinary incontinence (UI), using data from a multicentre 48-h pad test study.

MATERIALS AND METHODS

Incontinent patients, who were provided with absorbent products for the period January 2012 to March 2016, volunteered to perform a 48-h home-based pad test and to fill in a diary with information on pad usage. Correlations between UI measures (48-h pad count and pad weight gain, mean pad weight gain per pad) were calculated. Logistic regression analyses were conducted to investigate patient-related and pad usage-related factors influencing pad count.

RESULTS

A total of 14 493 patients (median age 81 years) were included, with a total of 98 362 continence products used overall during the study period. The 48-h pad count showed a weak correlation with 48-h pad weight gain (R² = 0.12; 0.19 for men and 0.11 for women) and mean pad weight gain per pad (R² = -0.03). The weakest correlation was observed among patients using >6 pads/48 h (R² = 0.02). A statistically significant negative association between pad absorption capacity and pad count was observed. Patients using products with a shaped and rectangular design had 34% and 40% higher propensity to use more pads than those using briefs (P < 0.001), respectively.

CONCLUSIONS

The results of this very large observational study confirmed that pad count is a poor measure of UI severity. Pad count only measured 12% of the variability of UI volume and was affected by several patient-related and pad usage-related factors. Consequently, pad count should not be used instead of the pad test as an objective measure of UI when an accurate evaluation is required for research or clinical purposes.

Erosion rates of 3.5-cm artificial urinary sphincter cuffs are similar to larger cuffs

OBJECTIVE

To compare long-term outcomes and erosion rates of 3.5-cm artificial urinary sphincter (AUS) cuffs vs larger cuffs amongst men with stress urinary incontinence (SUI), with and without a history of pelvic radiotherapy (RT).

PATIENTS AND METHODS

We reviewed the records of all men who underwent AUS placement by a single surgeon between September 2009 and June 2017 at our tertiary urban medical centre. A uniform perineal approach was used to ensure cuff placement around the most proximal corpus spongiosum after precise spongiosal measurement. Patients were stratified by cuff size and RT status, and patient demographics and surgical outcomes were analysed. Cases of AUS revision in which a new cuff was not placed were excluded. Success was defined as patient-reported pad use of ≤1 pad/day.

RESULTS

Amongst 410 cases included in the analysis, the 3.5-cm cuff was used in 166 (40.5%), whilst 244 (59.5%) received larger cuffs (≥4.0 cm). Over a median follow-up of 50 months, there was AUS cuff erosion in 44 patients at a rate nearly identical in the 3.5-cm cuff (10.8%, 18/166) and the ≥4-cm cuff groups (10.7%, 26/244, P = 0.7). On multivariate logistic regression, clinical factors associated with AUS cuff erosion included a history of pelvic RT, prior AUS cuff erosion, prior urethroplasty, and a history of inflatable penile prosthesis (IPP) placement. Patient demographics were similar between the cuff-size groups; including age, body mass index, comorbidities, smoking history, RT history, prior AUS, and prior IPP placement. Continence rates were high amongst all AUS patients, with similar success in both groups (82% for 3.5-cm cuff, 90% for ≥4-cm cuff, P = 0.1).

CONCLUSIONS

After 8 years of experience and extended follow-up, the outcomes of the 3.5-cm AUS cuff appear to be similar to ≥4-cm cuffs for effectiveness and rates of urethral erosion. RT patients have a higher risk of cuff erosion regardless of cuff size.

Detailed analysis of patient-reported lower urinary tract symptoms and effect on quality of life after robotic radical prostatectomy

OBJECTIVE

To prospectively evaluate short- to medium-term patient-reported lower urinary tract symptoms (LUTS) and their effect on health-related quality of life (HRQoL) using validated questionnaires in a large cohort of patients following robotic-assisted radical prostatectomy (RARP) for prostate cancer.

MATERIALS AND METHODS

HRQoL and LUTS outcomes were prospectively assessed in 357 consecutive men undergoing RARP at a single center from 2012 to 2015 using the functional assessment of cancer therapy-prostate (FACT-P) and the international consultation on incontinence modular questionnaire-male LUTS (ICIQ-MLUTS). Questionnaires were administered at baseline, 6, 12, and 18 months. Data were analyzed using paired t-tests and ANOVA.

RESULTS

Questionnaire completion rates were high (over 60% of eligible men completed 18-month follow-up). Mean Total FACT-P did not significantly change after RARP: 125.95 (standard deviation [SD] = 19.82) at baseline and 125.86 (SD = 21.14) at 18-months (P = 0.55). Mean total ICIQ-MLUTS also remained unchanged: 18.69 (SD = 10.70) at baseline and 18.76 (SD = 11.33) at 18-months (P = 0.11). Mean voiding score significantly reduced from 10.34 (SD = 5.78) at baseline to 6.33 (SD = 3.99) at 6 months after RARP (P<0.001). A reciprocal significant increase in storage score was observed: 5.34 (SD = 4.26) at baseline, 9.65 (SD = 5.71) at 6 months (P<0.001). Subanalyses of ICIQ-MLUTS scores revealed increases in storage symptoms were exclusively within urinary incontinence domains and included significant increases in both urge and stress urinary incontinence scores.

CONCLUSION

Overall, patient-reported outcome measures evaluating HRQoL and LUTS do not significantly change after RARP. Detailed analysis reveals significant changes within LUTS domains do occur after surgery which could be overlooked if only total LUTS scores are reported.

Refined nomogram incorporating standing cough test improves prediction of male transobturator sling success

AIMS

To develop a decision aid in predicting sling success, incorporating the Male Stress Incontinence Grading Scale (MSIGS) into existing treatment algorithms.

METHODS

We reviewed men undergoing first-time transobturator sling for stress urinary incontinence (SUI) from 2007 to 2016 at our institution. Patient demographics, reported pads per day (PPD), and Standing Cough Test (SCT) results graded 0-4, according to MSIGS, were assessed. Treatment failure was defined as subsequent need for >1 PPD or further procedures. Parameters associated with failure were included in multivariable logistic models, compared by area under the receiver-operating characteristic curves. A nomogram was generated from the model with greatest AUC and internally validated.

RESULTS

Overall 203 men (median age 67 years, IQR 63-72) were evaluated with median follow-up of 45 months (IQR 11-75 months). A total of 185 men (91%) were status-post radical prostatectomy and 29 (14%) had pelvic radiation history. Median PPD and SCT grade were both two. Eighty men (39%) failed treatment (use of ≥1 PPD or subsequent anti-incontinence procedures) at a median of 9 months. History of radiation (P = 0.03), increasing MSIGS (P < 0.0001) and increasing preoperative PPD (P < 0.0001) were associated with failure on univariate analysis. In a multivariable model with AUC 0.81, MSIGS, and PPD remained associated (P = 0.002 and <0.0001 respectively, and radiation history P = 0.06), and was superior to models incorporating PPD and radiation alone (AUC 0.77, P = 0.02), PPD alone (AUC 0.76, P = 0.02), and a cutpoint of >2 PPD alone (AUC 0.71, P = 0.0001).

CONCLUSIONS

MSIGS adds prognostic value to PPD in assessing success of transobturator sling for treatment of SUI.

Urinary Incontinence-85: An Expanded Prostate Cancer Composite (EPIC) Score Cutoff Value for Urinary Incontinence Determined Using Long-term Functional Data by Repeated Prospective EPIC-Score Self-assessment After Radical Prostatectomy

Purpose

To determine an objective cutoff value (COV) for urinary incontinence (UI) using the Expanded Prostate Cancer Composite (EPIC) score after radical prostatectomy (RP).

Methods

From 2004–2013, all RP patients at our institution completed the EPIC urinary domain (EPIC-UD) questionnaire preoperatively and 6 weeks; 3, 6, 9, 12, and 18 months postoperatively; and yearly thereafter. The EPIC-UD is composed of several questions, 4 of which address UI qualitatively (EPIC-UI). Furthermore, patients were asked to complete a global quality of life (QoL) questionnaire regarding continence. The EPIC COV was calculated using receiver operating characteristic (ROC) analysis. Correlations between the EPIC-UI and quantitative QoL were evaluated using the Kendall-Tau test.

Results

We analyzed 239 patients with a median age of 63 years (interquartile range [IQR], 59–66 years), a median follow-up of 48 months (IQR, 30–78 months) and a median preoperative EPIC-UI score of 100 (IQR, 91.75–100). The ROC analysis for the distinction between EPIC-UI and the use of ≤1 pad/day yielded an EPIC-UI COV of >85, which we termed the UI-85, with an area under the curve of 0.857 (P<0.0001). A stronger correlation was seen between QoL scores and the UI-85 (1 year postoperatively: correlation coefficient [CC], 0.592; P<0.0001) than between QoL and not using a pad (CC, 0.512; P<0.0001).

Conclusions

The calculated COV of the EPIC-UI for continence was 85. UI is a multidimensional condition that cannot be adequately characterized by a single piece of information, such as pad usage only. Hence, the UI-85 represents a nuanced and straightforward tool for monitoring and comparing continence between different time points and cohorts in a multidimensional and objective manner.

Comparison of intrafascial and non-intrafascial radical prostatectomy for low risk localized prostate cancer

In this meta-analysis study, we compared the oncological and functional outcomes of intrafascial radical prostatectomy (IFRP) with non-intrafascial radical prostatectomy (NIFRP) in the treatment of patients with low risk localized prostate cancer (PCa). Relevant articles were identified by searching PubMed, EMBASE, Cochrane Library, Ovid, and the ISI Web of Knowledge databases. A total of 2096 patients were included from 7 eligible studies. Results of the pooled data showed that the oncological outcomes including gleason score, positive surgical margin and biochemical free survival rates were similar between the two groups. IFRP was superior to NIFRP with lower postoperative complication rates (RR 0.57, 95% CI 0.38, 0.85, p = 0.006), higher continence rates at 3 months post-operation (RR: 1.14; 95% CI, 1.04, 1.26; p = 0.006), and higher potency rates at 6 months (RR: 1.53; 95% CI, 1.07, 2.18; p = 0.02) and 12 months post-operation (RR: 1.38; 95% CI, 1.11, 1.73; p = 0.005). Additionally, there was a tendency towards higher potency rate in patients ≤65 years old compared with patients >65 years old after IFRP. Overall, these findings suggest that IFRP in young patients with low risk localized PCa had less postoperative complications, shortened time to return to continence and improved potency rate without compromising complete tumor control.

Comprehensive approach for post-prostatectomy incontinence in the era of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) has enabled steady and stable surgical procedures due to both meticulous maneuvers and magnified, clear, 3-dimensional vision. Therefore, better surgical outcomes have been expected with RARP than with other surgical modalities. However, even in the RARP era, post-prostatectomy incontinence has a relatively high incidence as a bothersome complication. To overcome post-prostatectomy incontinence, it goes without saying that meticulous surgical procedures and creative surgical procedures, i.e., "Preservation", "Reconstruction", and "Reinforcement" of the anatomical structures of the pelvis, are most important. In addition, medication and appropriate pad usage might sometimes be helpful for patients with post-prostatectomy incontinence. However, patients who have 1) BMI > 26 kg/m², 2) prostate volume > 70 mL, 3) eGFR < 60 mL/min, or a 4) Charlson comorbidity index > 2 have a tendency to develop post-prostatectomy incontinence despite undergoing the same surgical procedures. It is important for patients who have a high risk for post-prostatectomy incontinence to be given information about delayed recovery of post-prostatectomy incontinence. Thus, not only the surgical procedures, but also a comprehensive approach, as mentioned above, are important for post-prostatectomy incontinence.

Assessing variability of the 24-hour pad weight test in men with post-prostatectomy incontinence

Purpose:

Decision-making regarding surgery for post-prostatectomy incontinence (PPI) is challenging. The 24-hour pad weight test is commonly used to objectively quantify PPI. However, pad weight may vary based upon activity level. We aimed to quantify variability in pad weights based upon patient-reported activity.

Materials and Methods:

25 patients who underwent radical prostatectomy were prospectively enrolled. All patients demonstrated clinical stress urinary incontinence without clinical urgency urinary incontinence. On three consecutive alternating days, patients submitted 24-hour pad weights along with a short survey documenting activity level and number of pads used.

Results:

Pad weights collected across the three days were well correlated to the individual (ICC 0.85 (95% CI 0.74–0.93), p<0.001). The mean difference between the minimum pad weight leakage and maximum leakage per patient was 133.4g (95% CI 80.4–186.5). The mean increase in 24-hour leakage for a one-point increase in self-reported activity level was 118.0g (95% CI 74.3–161.7, p<0.001). Pad weights also varied significantly when self-reported activity levels did not differ (mean difference 51.2g (95% CI 30.3–72.1), p<0.001).

Conclusions:

24-hour pad weight leakage may vary significantly on different days of collection. This variation is more pronounced with changes in activity level. Taking into account patient activity level may enhance the predictive value of pad weight testing.

Artificial Urinary Sphincter: Report of the 2015 Consensus Conference

PURPOSE

The AMS800™ device, by far the most frequently implanted artificial urinary sphincter (AUS) worldwide, is considered to be the "gold-standard" when male incontinence surgical treatment is contemplated. Despite 40 years of experience, it is still a specialized procedure with a number of challenges. Here, we present the recommendations issued from the AUS Consensus Group, regarding indications, management, and follow-up AMS800™ implantation or revision.

MATERIALS AND METHODS

Under ICS auspices, an expert panel met on July 10, 2015 in Chicago, IL, USA in an attempt to reach a consensus on diverse issues related to the AMS800™ device. Participants were selected by the two co-chairs on the basis of their practice in a University hospital and their experience: number of implanted AUSs according to AMS (American Medical System Holdings Inc., Minnetonka, MN) records and/or major published articles. Topics listed were the result of a pre-meeting email brainstorming by all participants. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short evidence-based presentation, when possible.

RESULTS

A total of 25 urologists were invited to participate, 19 able to attend the conference. The present recommendations, based on the most recent and relevant data available in literature as well as expert opinions, successively address multiple specific and problematic issues associated with the AMS800™ trough a eight-chapter structure: pre-operative assessment, pre operative challenges, implantation technique, post-operative care, trouble-shooting, outcomes, special populations, and the future of AUSs.

CONCLUSION

These guidelines undoubtedly constitute a reference document, which will help urologists to carefully select patients and apply the most adapted management to implantation, follow-up and trouble-shooting of the AMS800™.

Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis

CONTEXT

Membranous urethral length (MUL) measured prior to radical prostatectomy (RP) has been identified as a factor that is associated with the recovery of continence following surgery.

OBJECTIVE

To undertake a systematic review and meta-analysis of all studies reporting the effect of MUL on the recovery of continence following RP.

EVIDENCE ACQUISITION

A comprehensive search of PubMed, EMBASE, and Scopus databases up to September 2015 was performed. Thirteen studies comprising one randomized controlled trial and 12 cohort studies were selected for inclusion.

EVIDENCE SYNTHESIS

Four studies (1738 patients) that reported hazard ratio results. Every extra millimeter (mm) of MUL was associated with a faster return to continence (hazard ratio: 1.05; 95% confidence interval [CI]: 1.02-1.08, p<0.001). Eleven studies (6993 patients) reported the OR (OR) for the return to continence at one or more postoperative time points. MUL had a significant positive effect on continence recovery at 3 mo (OR: 1.08, 95% CI: 1.03-1.14, p=0.004), 6 mo (OR: 1.12, 95% CI: 1.09-1.15, p<0.0001). and 12 mo (OR: 1.12, 95% CI: 1.03-1.22, p=0.006) following surgery. After adjusting for repeated measurements over time and studies with overlapping data, all OR data combined indicated that every extra millimeter of MUL was associated with significantly greater odds for return to continence (OR: 1.09, 95% CI: 1.05-1.15, p<0.001).

CONCLUSIONS

A greater preoperative MUL is significantly and positively associated with a return to continence in men following RP. Magnetic resonance imaging measurement of MUL is recommended prior to RP.

PATIENT SUMMARY

We examined the effect that the length of a section of the urethra (called the membranous urethra) had on the recovery of continence after radical prostatectomy surgery. Our results indicate that measuring the length of the membranous urethra via magnetic resonance imaging before surgery may be useful to predict a longer period of urinary incontinence after surgery, or to explain a delay in achieving continence after surgery.

The Artificial Urinary Sphincter in the Management of Incontinence

Despite the emergence of different devices in the treatment of postprostatectomy urinary incontinence, the AMS 800 (American Medical Systems, Minnetonka, MN) remains the gold standard for the treatment of stress urinary incontinence in men. We reviewed the current literature regarding the indications, surgical principles, outcomes, and complications of artificial urinary sphincter placement for stress urinary incontinence after prostatectomy. Despite all the available information, heterogeneous data, different success definitions, and the lack of high-quality prospective studies with long-term follow-up, it is difficult to compare outcomes between studies. In spite of these, the perineal implantation of a single cuff artificial urinary sphincter has withstood the test of time.

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.

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.