Hypothesis / aims of study
Post-prostatectomy urinary incontinence (PPUI) is a serious complication after prostate cancer treatment, significantly affecting patients’ quality of life. According to large population studies, up to 5% of patients will undergo surgical treatment of incontinence after radical prostatectomy (1,2). Male slings are increasingly used over the past decade due to a good balance between surgical complexity, costs, and outcomes. Our aim is to evaluate surgical and patient-reported outcomes of a fixed transobturator retrourethral male sling in patients with at least 24 months of follow-up.
Study design, materials and methods
After Institutional Review Board approval, we conducted a retrospective observational study of men undergoing AdVanceTM XP male sling system (Boston Scientific) for PPUI between August 2013 and February 2019. Preoperative evaluation includes physical examination, 24 hours pad count and weight, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), urethrocystoscopy, filling cystometry and pressure-flow study. Surgical variables recorded were operative time and hospital stay. Functional outcomes were postoperative daily pad count and ICIQ-SF questionnaire. Data regarding patient-reported outcomes and satisfaction were obtained through a phone interview with three questions: quality of life before and after surgery (being 0 “the worst imaginable health state” and 100 “the best imaginable health state”), satisfaction with the procedure (from 0 “extremely dissatisfy” to 10 “extremely satisfy”), and if they would recommend the procedure to a friend or relative. Adverse events were also recorded.
Results
During the study period, 36 patients underwent an AdvanceTM XP sling implantation for PPUI. Preoperative continence status: pad test ranged between 20 and 700 g (M=234.5; SD=175.54), and daily pads use between 1 and 6 (M=3.08 pads; SD=1.29)
Mean operative time was 63,9 minutes with no intraoperative complications. Mean hospital stay changed from 1.44 days in the first 18 patients to 0.56 days in the following cases. At a mean follow up of 44.9 months (92-26 months), 74.3% of patients gained “social continence” (0-1 pads/day), with 28.6% being “cured” defined as no pads use and ICIQ-SF = 0. (Figure 1).
Statistically significant reductions in daily pads use and ICIQ-SF (t(21)=5.73; p<.001) were obtained (Figure 2). Patient-perceived quality of life significantly changed (t(26)=-7.18; p<.001) from a mean of 36.66 (SD=14.94) preoperatively to a mean of 76.11 (SD=21.14) after AdvanceTM XP implant on a 0-100 scale. Satisfaction with the procedure, on a 0-10 scale, was high (M=7.5; SD=2.3) and 78,8% would recommend the procedure to a friend or relative.
Twelve postoperative complications were recorded, being eight Clavien 1 (4 perineal hematomas, 1 transient retention, 1 voiding LUTS, 1 inguinal pain and 1 lumbar pain) and four Clavien 2 (3 superficial wound infections and 1 urinary tract infection). No patient required further intervention due to complications.
Interpretation of results
Our data show that the transobturator retrourethral male sling is a safe and effective procedure in men with PPUI. There is also a tendency to perform it as an outpatient surgery in many cases, which reduces costs, postoperative pain, and infections (3). Most men (nearly 75%) are “socially continent” after the procedure, and complications can be conservatively or pharmacologically managed in most cases. Patient’s perception of health improves with the procedure and the satisfaction is high.