3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 Das ET AL. 40 Office stress testing via valsalva or cough can be done to verify urine leakage and confirmSUI. TheMale Stress Incontinence Grading Scale (MSGIS) may be employed as well; Yi et al found that increased grading on the MSGIS correlated well with increased 24-hour pad weight inmenwith SUI seeking surgical intervention. 21 A 24-hour pad weight testing provides the most objective measure of daily urine leakage. 22 Pad number, in contrast, can be affected by patient age and activity level and may not accurately reflect the degree of urine lost. 23 However, formal 24-hour pad testing may be burdensome to the patient and logistically difficult to perform. The ICIQ-UI SF can additionally be correlated with both pad number and 24-padweight testing andmay be useful as a long-term tracking metric. Evaluationwith cystourethroscopy is recommended by the 2019 AUA/SUFU guidelines to rule out competing bladder/urethral pathology and to better define the patient’s anatomy. Urethral stricture disease or vesicourethral anastomotic stenosis in the post-RP setting may be identified and necessitate a staged treatment approach. Urodynamic testing may also be used if the underlying diagnosis is unclear or if the patient’s bladder function is questionable. 2 For any patient the degree of bother should be the driving force behind treatment in the absence of concerning features. The American Urological Association Symptoms Score (AUA-SS) is an additional excellent tool to assess this and is easy to administer in the office. Pre-surgical management After RP, patients should be offered PFMT as it has been shown to decrease time to continence recovery. Fernandez et al found in their meta-analysis of eight randomized trials that a regimen of three sets of 10 contractions daily led to improved short and long term continence rates compared to no therapy. 6 Critical in pre-surgical management for post-RP patients specifically is to evaluate additional UUI. The main surgical treatments for SUI do not address UUI which may lead to worsened SUI surgical outcomes if left unmanaged. If UUI is identified it should be treated in accordance with the AUA/SUFU guidelines on Diagnosis and Treatment of Non-Neurogenic Overactive Bladder inAdults. 24 This includes a stepwise approach consisting of behavioral modifications, medical therapy, and surgical intervention as indicated. Patients who have ongoing bothersome IPT with a significant component of SUI (which is typically the case) may be offered surgical treatment as early as 6 months postop. At that point it is important to decide if the patient’s continence is continuing to improve or if it has plateaued. At 12 months patients still bothered should be offered surgical intervention if no contraindications exist. 2 Surgical management Artificial urinary sphincter The artificial urinary sphincter has long been the gold standard for male SUI. The modern device consists of a pressure-regulating balloon (PRB), fluid-filled urethral cuff, and inflation pump. InAUS placement the patient is positioned in dorsal lithotomy and prepped. Flexible cystoscopy (if not done previously) is then performed to rule-out urethral stricture disease or vesicourethral anastomotic stenosis, both of which increase the risk for post-AUS failure and should ideally be treated before AUS placement. 25 After careful dissection to isolate the bulbar urethral the circumference is measured and a cuff size is selected. Men who have had prior AUS with urethral atrophy, prior urethral erosion, of pelvic radiation may require additional techniques such as double-cuff placement or transcorporal cuff placement to achieve satisfactory results. 2 Greater care should be taken in these patients especially at correct cuff sizing. After cuff placement the PRB is placed (typically into the space of Retzius) andfilledwith 23mLof sterile saline or contrast corresponding to 61-70 cmH2O. The pump is placed into a subdartos pouch completing the procedure. Excellent outcomes for the AUS have long been reported. TheAMS 800 (Boston Scientific Corporation, Marlborough, MA, USA) is widely used with the most robust literature. In a large single-center series by Linder et al in 2015, 1,083 AUS placements between 1983-2011 were analyzed. For men with any degree of initial SUI, at a median follow up of 4.1 years 59% reported 0-1 pad per day and 94% reported high- satisfaction. 26 A systematic review by Van der Aa et al combined 12AUS studies and found a general 0-1 pad per day rate of 61%-100% with “complete dryness” varying from 4%-86%. 27 Overall patients should be counseled that the effectiveness and durability of the AUS has been long tested and offers the potential for excellent results for any degree of SUI. AUS revision does sometimes become necessary due to device failure or infection. In a recent cohort of 1,154 primary AUS implants, Boswell et al reported overall device survival of 72%, 56%, and 41% at 5, 10, and 15 years postop, respectively. 28 Historically sub- cuff atrophy was thought to be the leading cause of overall device failure. However, since the introduction of the 3.5 cm cuff, atrophy leading to failuremay be less