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

© The Canadian Journal of Urology TM : International Supplement, August 2020 41 Male urinary incontinence after prostate disease treatment common. Bergeson et al reviewed 177 AUS revisions between 2007-2019 of which only 8% were resultant from urethral atrophy. Notably there was only 1 case of atrophy leading to failure with a 3.5 cm cuff. In this series PRB failurewas themost frequent cause of device failure (34%) followedbymechanical cuff failure (17%). 29 Fortunately, long term satisfaction with AUS is excellent even after revision surgery. Viers et al reviewed a cohort of 467 primaryAUS implants and 122 revision implants. Eight-five percent of men in his cohort had undergone RP and 26% had prior radiation therapy. At over 10 years follow up, satisfaction remained up to 75% with no difference between the primary and revision groups. 30 Patients should always be counseled on the possibility of device failure and need for revision surgery during preop office consultation. Male urethral sling Male urethral slings are becomingmore popular for use in male SUI. First developed in the 1960s and 1970s, multiple changes in design and materials over time have decreased complication rates and increasedpatient satisfaction. Physiologically male slings function by compression or repositioning of the urethra to increase outflow resistance. 31 However this process must be done without creating frank urinary obstruction. Several general designs have been developed including the bone-anchored male sling (BAMS), transobturator sling, adjustable sling, and the quadratic sling. 32 One of themost studiedmodernurethral slings is the transobturatorAdVancemodel sling (Boston Scientific, Minnetonka, MN, USA). Collado et al evaluated long term outcomes of the AdVance sling and AdVance XP sling for men with mild-to-moderate SUI (defined as 24-hour pad weight < 400 mL). 33 Inclusion criteria for this study also included a positive “repositioning test” whereby coaptation of the rhabdosphincter was assessed and confirmed during active contraction. The overall cure rate (defined as no pad use) among a total of 94 patients was 77% at a median follow up of 49 months. Small bladder capacity and DO were found to be predictive of surgical failure. A review by Doudt et al in 2018 identified a similar success rate among three studies of the AdVance or AdVance XP slings at between 74%-93%. 34 Recent studies of other sling types have shown similar results. 34 With regard to adverse events, in 2018 Ye et al performed a review of outcomes and complications in seven studies using the AdVance sling. 35 They identified an acute urinary retention rate of 0.6%-15%, perineal pain rate of 0.8%-50%, and hematoma rate of 0.7%-3.2%. Explanation was uncommon and occurred in up to 1.6% during a period of 27 month follow up. Overall the complications after male urethral sling are reversible and should not be deterrent from pursuing sling if it is otherwise appropriate. AUS versus male urethral sling Men who present with bothersome mild-to-moderate SUI are generally faced with a decision between pursuing AUS or male urethral sling. Both options are considered appropriate based on the 2019 AUA/ SUFU guidelines, however several patient-specific factors must be taken into consideration. 2 Raup et al found that cognitive dysfunction and decreased manual dexterity predicted overall AUS failure independent of age. 36 Menwith such issuesmay ultimately enjoy better quality of lifewithmale urethral sling. Bladder dynamics must be considered as well as prior studies have shown that DO increasesß the risk for worse outcomes after sling placement. 33 This is of particular importance given the risk of DO after radical prostatectomy (2%-63%) and after radiation therapy for prostate cancer (up to 85%). 10 The 2019 AUA/SFU guidelines recommend that AUS was the preferred option in the setting of pelvic RT given the lack of robust data for sling in this group. 2 Advances in sling technology may change this recommendation in the future. Special consideration should be given to men seeking treatment for SUI after previously having an incontinence procedure. Ajay et al retrospectively reviewed 61menwho failedmale urethral sling therapy and compared outcomes between revision with AUS vs revision with repeat sling. 37 Secondary treatment failure occurred in only 6%of those undergoing revision with AUS compared to 55% for repeat sling. Similarly, Lentz et al analyzed 29 men who underwent AUS placement after failing sling therapy and compared them to a control group of men undergoing primary AUS placement. 38 Men who received AUS after sling experienced similar results to primary AUS with 96% using 0-1 pads per day at 3 months. Overall, in the context of revision surgery after either AUS or male urethral sling, men should be counseled that secondary AUS placement is the preferred option and can have similar results to primary AUS. The decision betweenAUS and male urethral sling must therefore be highly individualized. Poor manual dexterity/cognition and aversion to mechanical implants should direct towards male urethral sling. In contrast, a history of prior RT, the presence of DO, the need for revision surgery, or severe SUI (24-hour pad weight > 400 mL) should direct toward AUS.