Postprostatectomy incontinence: Pathophysiology and management (original) (raw)
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Urology, 2007
OBJECTIVES To evaluate the feasibility and efficacy of artificial urinary sphincter placement after failed bone-anchored male sling for postprostatectomy stress urinary incontinence. METHODS Eleven patients with postprostatectomy stress urinary incontinence who failed bone-anchored male sling underwent artificial urinary sphincter placement. All patients were evaluated before and after artificial urinary sphincter placement with a history and physical examination, pad score, and the incontinence section of the University of California, Los Angeles (UCLA)/ RAND prostate cancer index (total score possible ϭ 26). Urodynamic evaluation was performed before sphincter placement. RESULTS The average age in our study population was 70 years (range, 51 to 80 years). The mean follow-up after artificial urinary sphincter placement was 14.2 months (range, 3 to 20 months). Incontinence was defined as mild (1 to 2 pads), moderate (3 to 5 pads), or severe (more then 5 pads). After sling placement, cure was defined as no pad use, failure as same pad usage, and improvement as fewer pads used. The severity of incontinence before artificial urinary sphincter placement was mild, moderate, and severe in 3, 1, and 7 patients, respectively. After artificial urinary sphincter placement the severity of incontinence was cured, mild, and moderate in 8, 2, and 0, respectively. One patient required artificial urinary sphincter removal because of infection. Mean UCLA/RAND scores increased from 10.8 to 19.7. Patient satisfaction after artificial urinary sphincter placement was 74.5%. No intraoperative complications or urethral injuries occurred. CONCLUSIONS Artificial urinary sphincter placement after failed bone-anchored male sling is technically feasible and does not affect the short-term efficacy of the artificial sphincter. UROLOGY 70:
World Journal of Urology, 2018
Purpose To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. Methods 658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann-Whitney U test were used. Results Patients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients' perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001). Conclusions Patients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.
Clinical Overview of the AdVance® Male Sling in Postprostatectomy Incontinence
European Urology Supplements, 2011
Context: Postprostatectomy stress incontinence can be treated with a number of nonsurgical and surgical methods. Urethral slings represent one of the less invasive surgical options, and a more recent addition to this class of devices is the nonobstructive transobturator sling, the AdVance 1 male sling. We provide a review of the clinical outcomes with this sling. Objective: To evaluate the literature on published clinical studies on the AdVance 1 sling in treating postprostatectomy incontinence. Evidence acquisition: We searched the PubMed database and evaluated all clinical studies on the AdVance 1 sling published from 2008 to 2010 involving a minimum of 35 patients. Evidence synthesis: The use of the AdVance 1 sling in postprostatectomy incontinence results in success rates of 54.6-90.6% up to 1 yr. Lower success rates are linked to poor patient selection, early part of the learning curve for the technique, and debatable definitions of success. The technique is durable, and success rates of 67.7-77% have been reported at 2 yr. One-hour and 24-h pad weight tests also reflect the efficacy of the technique, with significant reductions reported. The AdVance 1 sling is associated with significant improvements in patients' quality of life and satisfaction. Common adverse events include mild dysuria, perineal and scrotal pain, and urinary retention, all of which resolved completely in a short period of time. Conclusions: The AdVance 1 transobturator nonobstructive sling is an effective and safe treatment of postprostatectomy incontinence. Durable results have been reported in large patient series.
European Urology, 2009
Background: Although surgical techniques for radical prostatectomy (RP) have been refined significantly, a significant number of patients still suffer from persisting postprostatectomy stress urinary incontinence (SUI). In recent years, various minimally invasive sling systems have been investigated as treatment options for such incontinence. Objective: The aim of the study was the prospective evaluation of the efficacy of the retrourethral transobturator sling for the functional treatment of male SUI after RP. Design, setting, and participants: The study documents a single-centre prospective evaluation of the outcome of 124 patients with mild to severe SUI following RP in whom an AdVance sling was implanted between February 2006 and September 2008. Measurements: All patients were comprehensively evaluated preoperatively and after 6 mo and 1 yr regarding daily pad use, 1-h and 24-h pad tests, residual urine, uroflowmetry, Incontinence Quality of Life Scale (I-QOL) score, and Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) score. Data were collected prospectively. Results and limitations: After 6 mo, a cure rate (no pads or one dry security pad) of 55.8%, an improved rate (one to two pads or pad reduction 50%) of 27.4%, and a failure rate of 16.8% were observed. After 1 yr, the cure rate was 51.4%, the improved rate was 25.7%, and the failure rate was 22.9%. Daily pad use and pad weight decreased significantly postoperatively. No significant changes were seen in residual urine and flow rate. Quality-of-life scores improved significantly. Postoperative acute urinary retention was seen in 12.9% of patients. One patient had a local wound infection that was cured with antibiotics. One patient had the sling removed due to misplacement. Conclusions: The retrourethral transobturator sling is an effective and attractive treatment option for male SUI resulting from RP after 1 yr of implantation.
Male Slings for Postprostatectomy Incontinence: A Systematic Review and Meta-analysis
European Urology Focus, 2019
Context: Male slings are recommended by the European Association of Urology guideline for the treatment of mild to moderate postprostatectomy incontinence. However, none of them has been proved to be superior to the others, and there are no defined guidelines to preference of a given sling model. Objective: To evaluate and compare the efficacy and safety of the different types of male slings in the treatment of postprostatectomy incontinence. Evidence acquisition: This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. A systematic literature search in the databases of PubMed, Embase, and Cochrane using the keywords "incontinence," "prostatectomy," and "male sling/system" was conducted in June 2018. Studies in English with at least 15 patients and a minimum follow-up of 12 mo were included. As the primary endpoint, we assessed the cure rate of the different sling types. As secondary endpoints, we assessed the improvement rate, subjective cure rate, overall complication rate, explantation rate, risk factors for failure, and effect on patients' quality of life. Evidence synthesis: The literature search identified 833 articles. A total of 64 studies with 72 patient cohorts were eligible for inclusion. Fixed slings were implanted in 55 (76.4%) of the patient cohorts. The objective cure rate varies between 8.3% and 87% (pooled estimate 0.50, 95% confidence interval [CI] 0.45-0.56, I 2 = 82%). Subjective cure was achieved in 33-94.4%. Adjustable slings showed objective cure rates between 17% and 92% (pooled estimate 0.61, 95% CI 0.51-0.71, I 2 = 88%). The subjective cure rate varies between 28% and 100%. In both types of slings, pain was the most common complication, but chronic painful conditions were really rare (1.3% in fixed slings and 1.5% in adjustable slings). The most common complication after pain was urinary retention in fixed slings, and infection and consequential explantation in adjustable slings. Conclusions: Both fixed and adjustable slings are beneficial for the treatment of postprostatectomy incontinence. Although adjustable slings might lead to higher objective cure rates, they might be associated with higher complication and explantation rates. However, at present, due to significant heterogeneity of the data, this cannot be said with certainty. More randomized controlled trials with long-term follow-up and the same definition for continence are needed.
Bju International, 2010
Study Type – Therapy (outcomes research) Level of Evidence 2cStudy Type – Therapy (outcomes research) Level of Evidence 2cOBJECTIVETo present a prospective long-term evaluation of the bone-anchored male sling (InVanceTM, American Medical Systems, Minnetonka, MN, USA) for patients with moderate to severe stress urinary incontinence (SUI) after prostate surgeryTo present a prospective long-term evaluation of the bone-anchored male sling (InVanceTM, American Medical Systems, Minnetonka, MN, USA) for patients with moderate to severe stress urinary incontinence (SUI) after prostate surgeryPATIENTS AND METHODSForty-five patients had a male sling implanted for SUI after prostate surgery. The evaluation before and after surgery included a complete history and physical examination, various questionnaires (American Urological Association Symptom Score, University of California Los Angeles/RAND prostate index), cysto-urethroscopy, International Continence Society (ICS) 1-h pad test and a urodynamic study. The follow-up assessments were at 2, 6 and 12 months after surgery, and yearly thereafter. The success rate was defined as the percentage of patients ‘dry’ and ‘improved’.Forty-five patients had a male sling implanted for SUI after prostate surgery. The evaluation before and after surgery included a complete history and physical examination, various questionnaires (American Urological Association Symptom Score, University of California Los Angeles/RAND prostate index), cysto-urethroscopy, International Continence Society (ICS) 1-h pad test and a urodynamic study. The follow-up assessments were at 2, 6 and 12 months after surgery, and yearly thereafter. The success rate was defined as the percentage of patients ‘dry’ and ‘improved’.RESULTSThe median (range) follow-up was 36 (2–64) months. Twelve patients (27%) had previous adjuvant radiotherapy. Eighteen patients (40%) had moderate SUI (two or three pads/day) and 27 (60%) had severe SUI (more than three pads/day). All preoperative ICS 1-h pad tests were positive. The success rate was 76%; 16 patients were dry (36%), 18 were improved (one or two pads/day, 40%) and in 11 the sling was a failure (24%); 76% of ICS 1-h pad tests were negative after surgery. The postoperative urodynamic study showed no signs of bladder outlet obstruction. In all, 72% of patients were satisfied/very satisfied with the surgery and 86% considered themselves cured/almost cured. The success rate was not affected by the presence of previous radiotherapy or the severity of SUI. Ten patients had perineal numbness, but in all it resolved within 1–3 months. There was one mesh infection which required its removal. There was no urethral erosion.The median (range) follow-up was 36 (2–64) months. Twelve patients (27%) had previous adjuvant radiotherapy. Eighteen patients (40%) had moderate SUI (two or three pads/day) and 27 (60%) had severe SUI (more than three pads/day). All preoperative ICS 1-h pad tests were positive. The success rate was 76%; 16 patients were dry (36%), 18 were improved (one or two pads/day, 40%) and in 11 the sling was a failure (24%); 76% of ICS 1-h pad tests were negative after surgery. The postoperative urodynamic study showed no signs of bladder outlet obstruction. In all, 72% of patients were satisfied/very satisfied with the surgery and 86% considered themselves cured/almost cured. The success rate was not affected by the presence of previous radiotherapy or the severity of SUI. Ten patients had perineal numbness, but in all it resolved within 1–3 months. There was one mesh infection which required its removal. There was no urethral erosion.CONCLUSIONCompared to previous studies, the InVance male sling had a good success rate for moderate and severe SUI, with a median follow-up of 36 months. The results did not differ for moderate or severe SUI or with the presence of previous radiotherapy.Compared to previous studies, the InVance male sling had a good success rate for moderate and severe SUI, with a median follow-up of 36 months. The results did not differ for moderate or severe SUI or with the presence of previous radiotherapy.
European Urology, 2009
Background: Transobturator male slings have been proposed to manage stress urinary incontinence (SUI) after prostatic surgery, but data are still lacking. Objective: To determine the safety and prospectively evaluate the clinical outcome after management of SUI after prostatic surgery by placement of a transobturator male sling. Design, setting, and participants: We conducted a prospective evaluation on 102 patients treated in a single center between 2007 and 2009 for mild to moderate SUI following prostatic surgery. Interventions: Placement of a suburethral transobturator sling and clinical followup. Measurements: Patients were evaluated by medical history, preoperative urodynamics, maximum flow rate measurement, 24-h pad test, and daily pad use. During follow-up, data on patients' pad use, complications, and answers to the Patient Global Impression of Improvement (PGI-I) questionnaire were collected. Cure was defined as no pad usage or one pad for security reasons and improvement as reduction of pads !50%. Median follow-up was 13 mo (range: 6-26). Results and limitations: Most patients (95%) presented post-radical prostatectomy incontinence (PRPI). Hospital stay was 2 d in 97 cases, and all patients were catheterized for 24 h except two (48 h). Of 102 patients, 64 were cured, 18 were improved, and 20 were not improved. According to the PGI-I questionnaire, 85%, 11%, and 4% of patients described a respectively better, unchanged, and worse urinary tract condition, respectively. Previous radiation was associated with higher rate of failure (p = 0.039). Neither severe complication nor postoperative urinary obstruction was noted during follow-up. Conclusions: Placement of a transobturator sling is a safe and effective procedure, giving durable results after >1 yr of follow-up. Further evaluation and high-quality controlled, randomized studies are needed to assess long-term efficacy and precise indications of this procedure for post-prostatic-surgery SUI management.