Selecting the best candidate for a male incontinence device or another: dream or nightmare?

Abstract

After initial encouraging results, the published outcomes of retrobulbar slings to treat postprostatectomy incontinence can be considered suboptimal for moderate-to-severe incontinence, especially in patients with high body mass index and previous radiotherapy (1). However, the artificial urinary sphincter (AUS) is not the single alternative for these patients as different options of adjustable systems remain. The adjustable transobturator male system (ATOMS) has shown interesting results and can be an option even in radiated patients (2, 3). Other adjustable systems, such as male readjustment mechanical external system (male-REEMEX), adjustable sling Argus and adjustable continence therapy (ProACT) have different modes of action, variable results and also different security profile. Systematic reviews and meta-analysis allow indirect comparison of these systems, and the definition of their risk of failure, surgical revision and device explant (4-6). However, in the absence of randomized comparative studies the definition of the best patient profile for each device is not easy. The aforementioned devices can be used to treat moderate-to-severe-incontinence in patients retaining certain sphincteric function. Then, the AUS is not the only resource to consider in a patient with stress incontinence other than mild. Besides, when natural history of the aging male, prone to manual dexterity and cognitive deterioration, is taken into account and the patient beyond the sphincter is fully considered (7) these options are very attractive, especially from the patients' point of view (8). The standing cough test was proposed as a rapid and office-based surrogate for the evaluation of male postprostatectomy incontinence (9, 10). The male stress incontinence grading system (MSIGS) is a modified standardized application of the standing cough test was proposed to stratify patients according to leakage severity and to guide surgical planification. It quantifies standing cough test using a 0 to 4 scale based on the observed leakage pattern noted during four strong coughs in the standing position (11). It is true that the MSIGS correlates well to patient reported pad count (number of pads per day used) (11, 12), but a correlation with 24-h pad test has never been proved. Also, several limitations need being addressed. First of all, it is admitted that the patient has not voided at least 1 hour before the examination, but neither bladder filling needed for the assessment nor the intraabdominal pressure are standardized. Also, interobserver consistency of the test has never been evaluated and the MSIGS should be evaluated prospectively and not according to what is taken in clinical records. Anyway, it is beyond discussion that the MSIGS can be of value to predict a negative result after male transobturator sling success and thus can be incorporated to refine predicted nomogram based on several independent variables that include (in order of decreasing weight) history of radiation, pad-count and MSIGS (12).

Update on Adjustable Trans-Obturator Male System (ATOMS) for Male Incontinence after Prostate Cancer Surgery

“…Fixed sling tends to be used in patients with limited urine loss, and radiotherapy is generally considered a contraindication for this incontinence surgery [ 39 ]. Adjustable slings were developed to cover a wider range of incontinence because intraoperative (i.e., Argus system) or postoperative (i.e., ATOMS, ProACT or the male REEMEX system) adjustment may correct mild-to-moderate PPI, and even severe incontinence in selected cases [ 50 ].…”

Clinical and Urodynamic results of the Argus T® sling in moderate and severe male stress urinary incontinence after radical prostatectomy – a 5 year prospective study.

“…In the last two decades, there has been a resurgence of interest in the use of slings as a therapeutic option for male UI, as it is a relatively simple surgery and has the ability to modulate urethral compression (11,12). However, there are no studies in the literature that objectively demonstrate the presence and effects of an eventual urethral obstruction after sling implantation (1,2,13), with few studies having long-term follow-up (14)(15)(16)(17).…”