Date Published: May 8, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Landon Trost, Daniel S. Elliott.
Introduction and Objective. Iatrogenic male stress urinary incontinence (SUI) affects a percentage of men undergoing urologic procedures with a significant impact on quality of life. The treatment of male SUI has evolved significantly with multiple current options for treatment available. The current paper discusses preoperative evaluation of male SUI, available surgical options with reported outcomes, and postoperative complication management. Methods. A pubMed review of available literature was performed and summarized on articles reporting outcomes of placement of the artificial urinary sphincter (AUS) or male slings including the bone anchored sling (BAS), retrourethral transobturator sling (RTS), adjustable retropubic sling (ARS), and quadratic sling. Results. Reported rates of success (variably defined) for BAS, RTS, ARS, and AUS are 36–67%, 9–79%, 13–100%, and 59–91% respectively. Complications reported include infection, erosion, retention, explantation, and transient pain. Male slings are more commonly performed in cases of low-to-moderate SUI with decreasing success with higher degrees of preoperative incontinence. Conclusions. An increasing number of options continue to be developed for the management of male SUI. While the AUS remains the gold-standard therapy for SUI, male sling placement is a proven viable alternative therapy for low-to-moderate SUI.
Urinary incontinence is estimated to affect 12–17% of US males, with increasing prevalence associated with aging [1, 2]. Stress urinary incontinence (SUI) as a subtype has been defined by the International Continence Society as the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing . Although any surgical or radiotherapeutic manipulation of the external urinary sphincter may result in SUI, radical prostatectomy (RP), transurethral resection of the prostate (TURP), and radiation therapy are most commonly associated with RP accounting for the majority of iatrogenic etiologies. The true prevalence of SUI following RP is unknown with widely varying estimates reported from 2 to 43%, which is likely reflective of differing surgical techniques, methodology, definitions, and followup performed, among others [4–9]. External beam radiation therapy and TURP are less commonly associated with SUI, with reported outcomes ranging from 1 to 16% and 1 to 3%, respectively [10–12]. Given that prostate cancer is the most commonly diagnosed malignancy in US males, the true scope and impact of iatrogenic male SUI on quality of life (QOL) is likely significant.
Males presenting with stress urinary incontinence should undergo a complete history and physical examination to include reviewing the underlying etiology and duration of the incontinence, current and prior urinary symptoms, history of genitourinary pathology (ex, nephrolithiasis, urothelial carcinoma), urinary tract infections, the degree and subjective bother of incontinence, and a review of prior procedures including radiation. Additional quantitative measures which may be employed include obtaining pad weights and standardized QOL questionnaires [14–16]. Patients should further undergo a genitourinary examination and be assessed as to their physical and mental capacity to function a potential AUS device.
Although numerous treatment options for male SUI exist, including penile clamps, transurethral bulking agents, or catheters (condom or indwelling), the most commonly utilized surgical therapies performed include placement of a male sling or AUS.
Multiple series are currently available reporting outcomes of the various male sling techniques and AUS implantation. However, given the nature of the studies performed and methodology for reporting, outcomes should be interpreted with caution. There is currently no accepted standard method for reporting pre- and postoperative degrees of incontinence or any consistent method for defining success with treatment. The majority of studies have poorly or undefined inclusion/exclusion criteria with significant heterogeneity of the patient population including inconsistent inclusion of patients with varied etiologies for SUI or prior radiation therapy. These factors, among others, limit the ability to draw comparisons between studies and techniques.
Complications resulting from either male sling or AUS implantation may be categorized as occurring intraoperative, early postop (<90 days) or late postop (>90 days). Intraoperative complications may include urethral injury occurring at the time of urethral dissection or passage of a trocar for male sling placement. If a small injury is recognized, placement of the AUS/male sling may continue at a separate site to prevent subsequent erosions. A large urethral injury should be repaired primarily with the procedure aborted and a catheter placed. Bladder injuries occurring during trocar passage may be managed with repassing of the trocar and subsequent catheterization for a period of several days postoperatively. Given the relative incidence of bladder injury with retropubic sling placements, patients undergoing these procedures should undergo intraoperative cystoscopy to rule out bladder perforation.
The decision as to which procedure to perform in males presenting with stress urinary incontinence is based on several factors. Most commonly, male slings are offered in cases of lower-volume incontinence (1–3 pads/day), or in the setting of complicating patient factors including inability to function the AUS pump. Placement of an AUS may be performed with any degree of SUI and may be employed in the setting of prior male sling failures.
The treatment of male SUI has evolved significantly over the past 40 years, with numerous improvements made to the AUS and multiple variations of the male sling developed in a relatively short period of time. And given the prevalence of prostate cancer with need for ongoing treatments, there will likely remain a significant need for treatment of iatrogenic SUI for the foreseeable future. It is anticipated that there will be ongoing improvements to the AUS to increase device longevity, reduce infectivity, and to better cater to patients with limited manual/mental capability. It is similarly expected that new variations and improvements to the existing male slings will continue to be developed, with further studies performed providing additional and longer-term followup on previously installed slings.
Iatrogenic male stress urinary incontinence remains a significant problem impacting a large number of patients with resultant impairment of quality of life. Patients presenting with SUI should undergo a thorough history and physical examination with additional studies obtained as indicated. Several therapies are currently available for the treatment of low-to-moderate volume incontinence including the AUS and several variations of male slings (BAS, RTS, ARS, and quadratic sling). Patients with large-volume incontinence are best managed with AUS when found to be an appropriate surgical candidate. Complications of sling/AUS placement include temporary retention, perineal pain, infections, erosions, de novo urinary symptoms, and device malfunction. Patients desiring surgical management of SUI should be counseled as to expected outcomes as well as potential complications.