Long‐term efficacy of the bone‐anchored male sling for moderate and severe stress urinary incontinence

Study Type – Therapy (outcomes research)
Level of Evidence 2c

OBJECTIVE

To present a prospective long‐term evaluation of the bone‐anchored male sling (InVance^TM, American Medical Systems, Minnetonka, MN, USA) for patients with moderate to severe stress urinary incontinence (SUI) after prostate surgery

PATIENTS AND METHODS

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’.

RESULTS

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.

CONCLUSION

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.     

Artificial urinary sphincter for post‐prostatectomy incontinence: A review

The artificial urinary sphincter remains the gold standard for treatment of post‐prostatectomy urinary incontinence. The AMS 800 (American Medical Systems, Minnetonka, MN, USA) is the most commonly implanted artificial urinary sphincter. Having been on the market for almost 40 years, there is an abundance of literature regarding its use, but no recent review has been published. We reviewed the current literature regarding the indications, surgical principles, outcomes and complications of artificial urinary sphincter implantation for stress urinary incontinence after prostatectomy. A PubMed search was carried out for articles on the artificial urinary sphincter from 1995 to present. The review was centered on articles related to the use of the AMS 800 for stress urinary incontinence in males after prostatectomy. Relevant articles were reviewed. The majority of patients will achieve social continence (1 pad per day) after artificial urinary sphincter implantation; however, rates of total continence (no pad usage) are significantly lower. Patient satisfaction outcomes average greater than 80% in most series. Potential complications requiring reoperation include infection (0.5–10.6%) and urethral erosion (2.9–12%). Revision surgeries are most commonly as a result of urethral atrophy, which ranges from 1.6 to 11.4%. The 5‐year Kaplan–Meier freedom from reoperation ranges from 50 to 79%, while the 10‐year Kaplan–Meier freedom from mechanical failure is 64%. The artificial urinary sphincter is a reliable device with good outcomes. As expected with any prosthetic device, complications including mechanical failure, infection, erosion and recurrent incontinence remain significant concerns. Despite known complications, the patient satisfaction rates after artificial urinary sphincter implantation remain high. Appropriate patient counseling and adherence to surgical principles are imperative.     

The 7‐year outcome of the tension‐free vaginal tape procedure for treating female stress urinary incontinence

OBJECTIVE

To evaluate the long‐term results and predictive risk factors for efficacy after the tension‐free vaginal tape (TVT) procedure for treating female stress urinary incontinence (SUI).

PATIENTS AND METHODS

Inall, 306 women (mean age 50.7 years, sd 8.7) who had a TVT procedure for SUI were selected and followed ≥7 years (mean 92.3 months, range 84–110) after surgery. We analysed the long‐term results, the variables predictive of cure rates, and patient satisfaction.

RESULTS

The overall 7‐year cure rate was 84.6%, with a satisfaction rate of 69.3%. The cure rates were lower in patients with high‐grade SUI (50% in grade III, 82.8% in grade II and 90.7% in grade I; P < 0.001). On multivariate analysis, there were no independent risk factors related to cure rate, and urgency was the only factor independently associated with patient satisfaction (P = 0.008; odds ratio 2.47). Seventy‐one patients (23.2%) had complications at the 1‐month follow‐up after surgery, but only eight (2.6%) had complications at the 7‐year follow‐up, including mesh exposure in six and de novo urgency in two.

CONCLUSION

The absence of long‐term adverse events associated with the TVT procedure, and high subjective and objective 7‐year success rates with no independent predictive factors affecting the long‐term cure rate, make the TVT procedure a recommendable surgical treatment for female SUI.     

Long‐term follow‐up after anterior sphincter repair: influence of age on functional outcome

Aim Anterior sphincter repair has been advocated for women with anterior sphincter defects and faecal incontinence. There have been a number of reports of deterioration in functional outcome from anal sphincter repair over the long‐term and of inferior outcomes in older patients. This study set out to examine these issues in a specialist tertiary referral unit. Method Patients having a sphincter repair were identified from a prospectively collected database. The information within the database was expanded by the use of a postal questionnaire and structured review of the case notes. The questionnaire incorporated commonly used validated scoring systems as well as subjective questions. Results One hundred and thirteen patients were identified, of whom 66 (58%) responded. Of these patients, four had incomplete medical notes, leaving 62 (55%) with both returned questionnaires and complete medical notes. Forty‐eight (72%) patients reported subjective initial improvement in their symptoms, though only 37 (56%) believed themselves improved at long‐term follow‐up (median 8.8 years; range 1.1–13.6 years). Incontinence and quality of life scores mirrored these patients’ subjective responses. The median age of those patients reporting a subjective improvement at long‐term follow‐up was 38, compared with 56 in those who thought they were not improved (P < 0.001). Conclusions Outcome from anal sphincter repair deteriorates with time. Subjective outcome is worse in older patients who additionally tend to have worse incontinence scores and quality of life measures.