4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 Urethral sling Male slings provide a minimally invasive surgical alternative to AUS for SUI. They increase resistance to urinary flow by elevating the bulbar urethra. 42 They do not require manual manipulation and can be used by patients who lack the dexterity to operate an AUS. They are considered appropriate for patients withmild to moderate SUI. 2 Sling mechanisms vary including transobturator, quadratic, and bone anchored designs. 12 Patient positioning and dissection for the The AdVance/AdVance XP transobturator sling (Boston Scientific, Marlborough, MA, USA) is similar to AUS. The spongiosum is dissected ventrally to the perineal body. The mesh is attached to a passing device and passed from an outside to inside direction going through the thigh (about one fingerbreadth below adductor longus bilaterally) and obturator foramen (lateral to the pubic ramus) and out the perineal incision medial to the ipsilateral corporal body. The mesh is sutured to the spongiosum at the site of the central tendon. Under cystoscopic vision, tensioning should elevate the perineal body and proximal bulbar urethra about 3 cm-4 cm. A temporary Foley catheter is typically left postoperatively. Collado et al found the AdVance and AdVance XP to have a cure rate of 77% (defined as 0 pads used) in a cohort of 94 patients with a median follow up of just over 4 years. 43 Patients in the study had mild to moderate SUI as defined by daily pad weight < 400 g. A clinical trial for the quadratic sling by Comiter et al demonstrated a 79.2% objective success rate at 12 months (considered as > 50% reduction in pad weight). 44 A review by Doudt et al on male urethral slings showed an overall success rate of nearly 80%. 45 Their review highlighted the importance of proper patient selection including mild to moderate incontinence, absence of bladder dysfunction/DO, and absence of prior RT. Potential complications from sling placement include urinary retention, perineal pain, and hematoma with explantation rarely being necessary. 46 Adjustable balloon device The ProACT device (Uromedica, Inc., MN, USA) was FDAapproved in 2015. It consists of two balloons that are implanted on the lateral aspects of the bladder neck and provide coaptation. The balloons are filled with isotonic contrast solution and can be filled with additional fluid via subcutaneous ports in a subdartos pouch in the scrotum. The device can be adjusted every 6-8 weeks following initial implant to reach optimal symptomatic improvement in SUI. In a study by Noordhooff et al, they showed a success rate (considered zero pads or 1 pad for security) among 143 patients 41 Management of urinary incontinence following treatment of prostate disease with any degree of incontinence and no prior history of radiation of 47% at 6months and 51% at 12months. 47 Seventy-eight percent of patients had significant improvement (considered greater than 50% reduction of pad use) at 1 year. The 2019 AUA/SUFU guidelines state that the adjustable balloon device may be offered to patients with mild SUI after prostate treatment. 2 Patient factors influencing surgical treatment In a review by Ajay et al of men who failed sling surgery, outcomes were compared between revision with AUS or a second sling operation. 48 Failure rate for the repeat sling cohort was 55% compared to only 6% for those receiving AUS. Furthermore, a study comparingmen who received anAUS following failed sling placement to primary AUS patients showed a similar success rate of 96% (defined as 0-1 pads per day at 3 months) in both groups. 49 Even thoughAUS and urethral slings are considered appropriate for patients who fall into the mild to moderate category of SUI, it is important to know their history, physical capabilities, and personal preferences to guide them towards the best option that would provide thema satisfying outcome. Patientswith severe incontinence, previous RT, bladder dysfunction/DO, and those requiring revision should be offered AUS. Patients with cognitive dysfunction, poor manual dexterity, or not wanting to interact with a sphincter mechanism can be offered a sling. A balloon device should only be offered to patients with mild SUI. Post prostatectomy UUI According to the 2019AUA/SUFU guidelines, patients who experience UUI or mixed UI should initially be treated following the AUA overactive bladder guidelines. 2 The treatment algorithm includes patient education about normal/abnormal bladder function, modification of voiding habits, PFMT, and lifestyle modifications. 50,51 This can then be followed by pharmacologic treatment with either anticholinergics or beta-3 agonist medication. Third line therapies include tibial nerve stimulation (TNS), sacral neuromodulation, and botulinum toxin. Very rarely patients who are not adequately treated with the aforementioned therapies require urinary diversion or bladder augmentation. Conclusions Prostate disease is a core men’s health issue. Patients receiving RP or RT for prostate cancer or surgery for BPH have the potential of developing IPT. This