Management of post-prostatectomy incontinence Growing evidence about anti-incontinence device implantation Growing evidence The level of evidence regarding the use of antiincontinence device implantation in men has been historically poor, based on mostly retrospective cohort studies performed at the end of the last century. [9] Artificial sphincter has always been considered as the gold standard based on these old data and gigantic clinical experience by urologists worldwide. In the last 20 years, more stringent requirements have been set Jean-Nicolas.Cornu@ up for introducing new implantable devices, in line chu-rouen.fr with stronger market regulations, diffusion of evidence-based medicine, and strengthening of A specific context guidelines processes. For these reasons, newly Stress urinary incontinence (SUI) after prostatic released minimally invasive options (mostly male surgery (post-prostatectomy incontinence (PPI)) is slings and Pro-ACT™) have been studied through a daily challenge for urologists. Most cases of PPI more rigorous clinical protocols, including prospective are transient, as many patients fully regain their design, comparative trials, and clearer efficacy continence after one year. [1] Persistent symptoms endpoints. However, up to 2020, only level 2 evidence after 12 months may require specific management, has been published, with the field lacking a depending on symptoms severity, associated bother, large-scale randomised controlled trial to increase the and global clinical picture. While PPI is mostly a degree of evidence. [10] consequence of radical prostatectomy (around 10% of cases), SUI can also happen after benign prostatic MASTER trial obstruction relief surgery. [2] Despite several The MASTER trial is a multicentre, randomised possible explanations, the pathophysiology of PPI controlled trial (RCT) evaluating the efficacy of is rather seen as a confluence of several factors and transobturator male sling compared to standard remains poorly elucidated. The main hypothesis is a AMS800™ device for PPI management (after radical deficiency of the striated sphincter. prostatectomy or benign prostatic obstruction surgery). [11] In this non-inferiority trial, 380 men Patients seeking care for persistent PPI are in a very with PPI were randomised in 27 UK recruiting centres. specific situation. First, their symptoms are iatrogenic The main outcome criterion was incontinence (by definition). Gathering details about index prostatic symptoms 12 months after randomisation, and surgery, and taking a complete medical history non-inferiority was proven. However, the rather strict (including co-morbidities, pelvic radiation history, definition of incontinence (‘any self-reported and oncologic outcomes) is the first step of adequate symptom of incontinence at 12 months’) led to and personalised management. [3] The second step is somewhat surprising results, with 87% incontinent to assess the symptoms as precisely as possible, as men in the male sling group versus 84.2% in the SUI can be isolated or associated with other lower artificial sphincter group. Secondary analysis has urinary tract symptoms, such as overactive bladder or shown that men with > 250 g leakage at baseline did voiding difficulties. Severity of incontinence is a better after an AUS, especially regarding satisfaction. crucial point. Today there is no consensus about the Few severe adverse events were reported (6 after definition of mild, moderate or severe SUI, but the sling and 11 after AUS implantation). most widely used tool is 24-hr pad test, with a cut-off around 250 ml. [4] Unsolved issues Although it brings major information, and level 1 Beyond clinical evaluation, additional work-up may evidence supporting the use of transobturator male be proposed. Endoscopy can rule out urethral stenosis slings as well as the use of AUS, some issues remain or anastomotic stricture, or concomitant bladder unsolved. disease. Urodynamic studies are useful to assess any associated detrusor dysfunction, especially in case of First, the efficacy of transobturator male sling in the mixed incontinence. long term remains largely unknown. In case of failure, a subsequent AUS implantation can however be Principle of clinical management proposed. Furthermore, all slings are not equal, and Patients with PPI usually use collecting devices such mixing all transobturator tapes in the same trial could as pads, and less frequently penile sheaths or penile appear as confusing. A number of cohort studies have clamps. While the two latter are possible palliative shown that the complication rate after adjustable options and can offer some advantages over standard slings appears higher than after the retrourethral pads [5], they require specific information, male sling. [12] However, no head-to-head explanation and prescription. The first contact with comparison is available. the patient is the best occasion to deliver adequate information of availability of these products. Second, patient selection is an important issue. While the MASTER trial identifies a trend towards a The next discussion is about treatment options. While superiority of AUS in more severe cases, results do the solution may be surgical in most cases (see not reach statistical significance. However, this is in below), possible medical options include bladder line with previous reports suggesting that severe training, physiotherapy and duloxetine. [1] Bladder incontinence > 250 grams per day, pelvic radiation training and dietary measures (e.g. adequate fluid history, prior anti-incontinence surgery and previous intake) can always be an option since they are not urethral surgery are important factors to consider for harmful, but their efficacy remains elusive. patient selection for a male sling. [13] Physiotherapy, including pelvic floor muscle training, has been widely proposed but very often patients Third, patient preference is a really important issue. already do this within the early post-operative period. Since non-inferiority is established between AUS and The role of electrical stimulation and biofeedback slings, patients would rather opt for the less invasive remains unclear. Among drugs, duloxetine has been option, as previous papers have already shown. The studied for PPI management with encouraging results role of the surgeon is to provide complete, but in smaller studies to date. [6] The optimum independent, expert and adequate counselling in this dosage remains unknown. The patient has to be field. warned about off-label use in this indication, and about potential adverse events specific to this drug. New level of evidence Drug treatment (mainly antimuscarinics and Recent advances in the field of PPI have set a new beta-3-adrenergics) can be options for treating an level of evidence, possibly impacting the guidelines associated storage component of symptoms. [7] and recommendations. More than before even, transobturator slings and artificial sphincter are the In case of failure of conservative measures, surgical leading surgical options among the surgical treatment is required. Many surgical options are today armamentarium (see figure 1). Patient selection is the available since the introduction of the AMS800™ major challenge when choosing the way to treat PPI. artificial urinary sphincter marketed in 1972 and in its current shape since the early 80’s (see figure). [8] References Alternatives are peri-urethral injections, male slings 1. Rahnama'i MS, Marcelissen T, Geavlete B, Tutolo M, Hüsch (either autologous, synthetic bone-anchored (not T. Current Management of Post-radical Prostatectomy anymore used), synthetic fixed placed by Urinary Incontinence. Front Surg. 2021 Apr 9;8:647656 transobturator route (popular today), or adjustable, 2. Sabbagh P, Dupuis H, Cornu JN. State of the art on stress peri-urethral balloons (Pro-ACT™ device), and incontinence management after benign prostatic innovative sphincters. [9] obstruction surgery. Curr Opin Urol. 2021 Sep 1;31(5):473Prof. Jean-Nicolas Cornu Dept of Urology Charles Nicolle University Hospital Rouen (FR)
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478 3. Clark CB, Kucherov V, Klonieck E, Shenot PJ, Das AK. Management of urinary incontinence following treatment
Fig. 1: Surgical therapeutic approach for post-prostatectomy incontinence management
of prostate disease. Can J Urol. 2021 Aug;28(S2):38-43 4. Constable L, Cotterill N, Cooper D, et al. Male synthetic sling versus artificial urinary sphincter trial for men with urodynamic stress incontinence after prostate surgery (MASTER): study protocol for a randomised controlled trial. Trials. 2018 Feb 21;19(1):131 5. Macaulay M, Broadbridge J, Gage H, et al. A trial of devices for urinary incontinence after treatment for prostate cancer. BJU Int. 2015 Sep;116(3):432-42 6. Kotecha P, Sahai A, Malde S. Use of Duloxetine for Postprostatectomy Stress Urinary Incontinence: A Systematic Review. Eur Urol Focus. 2021 May;7(3):618-628 7. Andersson KE. The use of pharmacotherapy for male patients with urgency and stress incontinence. Curr Opin Urol. 2014 Nov;24(6):571-7 8. Van der Aa F, Drake MJ, Kasyan GR, Petrolekas A, Cornu JN; Young Academic Urologists Functional Urology Group. 9. The artificial urinary sphincter after a quarter of a century: a critical systematic review of its use in male non-
neurogenic incontinence. Eur Urol. 2013 Apr;63(4):681-9 10. Choinière R, Violette PD, Morin M, et al. Evaluation of Benefits and Harms of Surgical Treatments for Post-radical Prostatectomy Urinary Incontinence: A Systematic Review and Meta-analysis. Eur Urol Focus. 2021 Sep 22:S24054569(21)00236-4 11. Abrams P, Constable LD, Cooper D, et al. Outcomes of a Noninferiority Randomised Controlled Trial of Surgery for Men with Urodynamic Stress Incontinence After Prostate Surgery (MASTER). Eur Urol. 2021 Jun;79(6):812-823 12. Bole R, Hebert KJ, Gottlich HC, Bearrick E, Kohler TS, Viers BR. Narrative review of male urethral sling for postprostatectomy stress incontinence: sling type, patient selection, and clinical applications. Transl Androl Urol. 2021 Jun;10(6):2682-2694 13. Grabbert M, Bauer RM, Hüsch T, et al. Patient Selection in Surgical Centers of Expertise in the Treatment of Patients with Moderate to Severe Male Urinary Stress Incontinence. Urol Int. 2020;104(11-12):902-907
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