Refined Nomogram Incorporating Standing Cough Test Improves Prediction of Adjustable Trans-Obturator Male System (ATOMS) Success to Treat Post-Prostatectomy Male Stress Incontinence

Abstract

(1) Background: The adjustable transobturator male system (ATOMS) device serves to treat post-prostatectomy incontinence, as it enhances residual urinary sphincteric function by dorsal compression of the bulbar urethra. We investigated the clinical parameters affecting continence recovery using this device and developed a decision aid to predict success. (2) Methods: We reviewed consecutive men treated with first-time ATOMS for post-prostatectomy incontinence from 2014 to 2021 at our institution. Patient demographics, reported pads per day (PPD), 24-h pad-test and Standing Cough Test (SCT), results’ grades 1–4, according to Male Stress Incontinence Grading Scale (MSIGS), and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire were assessed. Treatment success was defined as no pads or a single PPD with ≤20-mL 24-h pad-test. Logistic regression was performed using a stepwise model (entry 0.15 and stay criterium 0.1) to evaluate independent variables’ determinant of dryness. Receiver-operating characteristic (ROC) curves for predictive variables were evaluated and their area under curve (AUC) was compared. A nomogram was generated and internally validated to predict probability of treatment success. (3) Results: Overall, 149 men (median age 70 years, IQR 7) were evaluated with a median follow-up of 45 months (IQR 26). Twelve patients (8%) had previous devices for incontinence, and 21 (14.1%) had pelvic radiation. Thirty-five men (23.5%) did not achieve continence after ATOMS adjustment (use of no or one security PPD with ≤20-mL 24-h pad-test). In univariate analysis, Charlson comorbidity index (p = 0.0412), previous urethroplasty (p = 0.0187), baseline PPD (p < 0.0001), 24-h pad-test (p < 0.0001), MSIGS (p < 0.0001), and ICIQ-SF questionnaire score (p < 0.0001) predicted ATOMS failure. In a multivariable model, 24-h pad-test (p = 0.0031), MSIGS (p = 0.0244), and radiotherapy (p = 0.0216) were independent variables, with AUC 0.8221. The association of MSIGS and 24-h pad-test was the superior combination (AUC 0.8236). A nomogram to predict the probability of ATOMS failure using the independent variables identified was proposed. (4) Conclusions: Several variables were identified as predictive of success for ATOMS using clinical history, physical examination (MSIGS), and factors that evaluate urine loss severity (PPD, 24-h pad-test, and ICIQ-SF questionnaire). MSIGS adds prognostic value to 24-h pad-test in assessing success of ATOMS device to treat post-prostatectomy incontinence. A nomogram was proposed to calculate the risk of ATOMS failure, which could be of interest to personalize the decision to use this device or not in the individual patient.

A narrative review of the role of the Male Stress Incontinence Grading Scale in the surgical management of male stress urinary incontinence

“…MSIGS has also been shown to correlate strongly with the 24-hour pad weight, which has a high predictive value for sling outcomes (18-21) (Table 1) (1,22). While there is currently no standardized cutoff for incontinence procedure selection based on the 24-hour pad weight test, Kumar et al found that slings have significantly lower efficacy for patients with pad weight ≥400 g which correlates closely to MSIGS score of three (1,15,22,23).…”

“…; Feldkirch, Austria) with an accuracy of 82.21%. Moreover, the ATOMS trial found MSIGS combined with a pad test (mean 24-hour pad weight over 3-day period) was superior to pad test alone as a predictor of success (AUC 82.36 vs. 77.43) (22). Abramowitz et al failed to find a correlation between MSIGS and success rates (defined by 1 or less PPD at last follow-up) for the Virtue male quadratic sling (Coloplast, Humlebaek, Denmark), however this study deviated from our published protocol as the SCT was performed immediately following cystoscopic bladder filling (29).…”

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

“…The adjustable trans-obturator male system (ATOMS) exerts as a sling that reinforces the urethral sphincter by compression of the bulbar urethra without the need for manipulation by the patient. However, to exert its role ATOMS requires some residual sphincteric function [ 12 ].…”

“…This device allows the bulbar urethra to be compressed only on one side and not circumferentially like the AUS. Ventral urethral compression can be increased after surgery by percutaneous injection of sterile saline solution into the port without intervention [ 11 , 12 ]. A prospective comparative study between the ATOMS and the AUS confirmed equivalent efficacy and patient satisfaction results, with a lower revision rate and higher durability for ATOMS [ 10 ].…”

ATOMS (Adjustable Trans-Obturator Male System) in Patients with Post-Prostatectomy Incontinence and Previously Treated Urethral Stricture or Bladder Neck Contracture

“…Other options such as retro-urethral fixed bulbar slings are preferred for the first-line treatment of mild-to-moderate incontinence after radical prostatectomy in the absence of radiation, and the artificial urinary sphincter (AUS) is probably the best option for severe SUI without residual sphincteric function [ 2 ]. However, choosing the best treatment option for a particular patient can be a difficult task [ 3 ].…”