A Full Bladder Is Not Needed for the Male Stress Incontinence Grading Scale.

INTRODUCTION: Our objectives were to evaluate the Male Stress Incontinence Grading Scale to stratify male patients with stress urinary incontinence for either artificial urinary sphincter or sling using a standing cough test and determine if an emptier bladder at the time of assessment carries increased risk of treatment failure. METHODS: Retrospective chart review of male patients undergoing sling and artificial urinary sphincter placement. The standing cough test score and bladder scan results were documented at initial evaluation. RESULTS: Forty patients underwent sling and 43 underwent naïve artificial sphincter placement. Median follow-up was 7.11 months. Thirty-six/forty slings had complete incontinence resolution or reduction to a safety pad vs 40/43 after sphincter (90% vs 93%, P = .62). Four sling patients (10%) had persistence or recurrence of incontinence. Cough test scores were similar between sling failure (67% grade 0, 33% grade 1) and success groups (83% grade 0, 3% grade 1, 14% grade 2). Bladder scan mean was 18.5 cc in the sling failure (SD 21.1) and 38.0 cc in the success groups (38.3), with 32% of success patients having bladder scans of 0 cc, and 63% of < 50 cc. Mean for sphincter patients was 45 cc (56.9). Ten patients with scan = 0 and 7 patients with scans < 30 cc demonstrated grade 4 incontinence. CONCLUSIONS: Cough test is a noninvasive, reliable tool to assess stress urinary incontinence severity. Our data suggest it is reliable even when bladders are nearly empty and can effectively stratify patients for sling vs artificial urinary sphincter with a high rate of success.

Guiding Clinical Decision Making for Surgical Incontinence Treatment After Prostatectomy: A Review of the Literature.

PURPOSE OF REVIEW: Stress urinary incontinence after prostatectomy is a common and debilitating side effect. Immediate post-prostatectomy management emphasizes pelvic floor muscle exercises. Per American Urologic Association guidelines, if incontinence persists for more than 12 months postoperatively, surgical interventions are the mainstay of treatment. Treatment decisions depend on a multitude of factors. The goal of this paper is to review recent literature updates regarding the diagnosis of male SUI to better guide surgical treatment decision-making. RECENT FINDINGS: Patient history is a critical component in guiding surgical decision making with severity and bother being primary factors driving treatment decisions. Recent studies indicate that a history of pelvic radiation continues to impact the overall duration and complication rate associated with artificial urinary sphincters (AUS). Cystoscopy should be done on every patient preparing to undergo surgical SUI treatment. Urodynamics and standing cough stress tests are additional diagnostic testing options; these tests may augment the diagnosis of SUI and better delineate which patients may benefit from a male sling versus AUS. Treatment of SUI after prostatectomy can improve health-related quality of life. A patient history focused on severity and degree of bother in addition to the use of ancillary office testing can help guide surgical treatment decisions to optimize patient continence goals.

Surgical Management of Male Stress Incontinence: Techniques, Indications, and Pearls for Success.

Purpose: Male stress urinary incontinence (SUI) has detrimental and long-lasting effects on patients. Management of this condition is an evolving field with multiple options for surgical treatment. We sought to review the pre-operative evaluation, intra-operative considerations, post-operative care, and future directions for treatment of male SUI. Methods: A literature review was performed using the PubMed platform to identify peer-reviewed, English-language articles published within the last 5 years pertaining to management of male stress urinary incontinence with an emphasis on devices currently on the market in the United States including the artificial urinary sphincter (AUS), male urethral slings, and the ProACTTM system. Patient selection criteria, success rates, and complications were compared between the studies. Results: Twenty articles were included in the final contemporary review. Pre-operative workup most commonly included demonstration of incontinence, PPD, and cystoscopy. Definition of success varied by study; the most common definition used was social continence (0-1 pads per day). Reported rates of success were higher for the AUS than for male urethral slings (73-93% vs 70-90%, respectively). Complications for these procedures include urinary retention, erosions, infections, and device malfunction. Newer treatment options including adjustable balloon systems and adjustable slings show promise but lack long-term follow-up. Conclusion: Patient selection remains the primary consideration for surgical decision-making for management of male SUI. The AUS continues to be the gold standard for moderate-to-severe male SUI but comes with inherent risk of need for revision. Male slings may be a superior option for appropriately selected men with mild incontinence but are inferior to the AUS for moderate and severe incontinence. Ongoing research will shed light on long-term results for newer options such as the ProACT and REMEEX systems.

Does Medicaid cover artificial urinary sphincter and male urethral sling surgery?-a state-by-state analysis.

Background: Information regarding the Medicaid coverage of artificial urinary sphincter (AUS) and male suburethral slings (MS) placement in the United States (US) is not readily available. In this manuscript, we seek to elucidate the state-by-state Medicaid coverage of these two procedures in the US. Methods: State Medicaid websites were utilized to access publicly available physician fee schedules for the calendar year 2020. Fee schedules were searched for current procedural terminology (CPT) codes. CPT codes representing insertion of tandem cuff, insertion of AUS, removal of AUS, removal and replacement AUS, sling operation for correction of male stress urinary incontinence (SUI), and removal or revision of sling for male SUI were utilized. Data were recorded by the procedure for each device, including the coverage status and physician fees. Results: Of the 50 US states analyzed, 49 publish publicly accessible physician fee schedules. All 49 of these states reported coverage for removal with and without revision of the AUS, and 48 states reported coverage for insertion of an AUS, and insertion of a tandem cuff. The median reimbursement for each AUS related procedure was $624.00 ($181.84-$10,960.90) for tandem cuff, $665.54 ($199.89-$11,949.86) for AUS insertion, $528.03 ($146.90-$1,893.12) for AUS removal, and $630.29 ($208.55-$11,586.74) for AUS revision. All 49 states reported coverage for placement of MS, and 48 states reported coverage for removal or revision of MS. The median reimbursement was $652.57 ($198.00-$5,237.35) for MS placement and $554.47 ($104.27-$2,288.93) for MS revision. Conclusions: AUS and MS procedures in the Medicaid population are covered by nearly all states. Therefore, surgical treatment of SUI may be offered to Medicaid patients in most states without reimbursement concerns.

Prior Placement of Male Urethral Slings Can Increase the Need for Revision of Artificial Urinary Sphincters.

BACKGROUND: Recurrent stress urinary incontinence (SUI) following male sling can be managed surgically with artificial urinary sphincter (AUS) insertion. Prior small, single-center retrospective studies have not demonstrated an association between having failed a sling procedure and worse AUS outcomes. The aim of this study was to compare outcomes of primary AUS placement in men who had or had not undergone a previous sling procedure. METHODS: A retrospective review of all AUS devices implanted at a single academic center during 2000-2018 was performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 19 (14.1%) patients had undergone prior sling procedures. RESULTS: There was no significant difference in demographic characteristics between patients undergoing AUS placement with or without a prior sling procedure. Average follow up time was 28.0 months. Prior sling was associated with shorter overall device survival, with an increased likelihood of requiring revision or replacement of the device (OR 4.2 (1.3-13.2), p = 0.015) as well as reoperation for any reason (OR 3.5 (1.2-9.9), p = 0.019). While not statistically significant, patients with a prior sling were more likely to note persistent incontinence at most recent follow up (68.8% vs. 42.7%, p = 0.10). CONCLUSIONS: Having undergone a prior sling procedure is associated with shorter device survival and need for revision or replacement surgery. When considering patients for sling procedures, patients should be counseled regarding the potential for worse AUS outcomes should they require additional anti-incontinence procedures following a failed sling.

Narrative review of male urethral sling for post-prostatectomy stress incontinence: sling type, patient selection, and clinical applications.

Male stress urinary incontinence (SUI) following prostate treatment is a devastating complaint for many patients. While the artificial urinary sphincter is the gold standard treatment for male SUI, the urethral sling is also popular due to ease of placement, lack of mechanical complexity, and absence of manual dexterity requirement. A literature review was performed of male urethral sling articles spanning the last zz20 years using the PubMed search engine. Clinical practice guidelines were also reviewed for comparison. Four categories of male urethral sling were evaluated: the transobturator AdVance and AdVance XP, the bone-anchored InVance, the quadratic Virtue, and the adjustable sling series. Well selected patients with mild to moderate urinary incontinence and no prior history of radiation experienced the highest success rates at long-term follow up. Patients with post-prostatectomy climacturia also reported improvement in leakage after sling. Concurrent penile prosthesis and sling techniques were reviewed, with favorable short-term outcomes demonstrated. Male urethral sling is a user-friendly surgical procedure with durable long-term outcomes in carefully selected men with mild stress urinary incontinence. Multiple sling types are available with varying degrees of efficacy and complication rates. Longer follow-up and larger cohort sizes are needed for treatment of newer indications such as climacturia as well as techniques involving dual placement of sling and penile prosthesis.

Orgasm-associated urinary incontinence (climacturia) following radical prostatectomy: a review of pathophysiology and current treatment options.

Orgasm-associated urinary incontinence, or climacturia, is a common side effect after radical prostatectomy (RP) that is gaining more attention due to the distress it causes to patients. A range of treatment options have been reported in the literature and are outlined in this review. The goal of our study is to review the pathophysiology and current management options for climacturia following RP. A PubMed search was used to review the current literature relating to the pathophysiology and the treatment of postprostatectomy climacturia. We reviewed the currently available treatment options and their success rates for climacturia. Several techniques were found to subjectively help improve the amount and bother of patients' climacturia. These include pelvic floor muscle training (PFMT), penile variable tension loop, soft silicone occlusion loop, artificial urethral sphincter, male urethral sling, and the Mini-Jupette graft. Success rates ranged from 48% to 100% depending on the modality used. For patients with erectile dysfunction and climacturia, the Mini-Jupette graft could be a valuable option. Given the lack of validated measurement tools and management options, climacturia has become a challenge for urologists. Albeit a condition that has not garnered much attention, there are several management options from conservative to invasive treatments that have shown a hopeful promise for the treatment of climacturia. These options should be discussed with patients to determine the best treatment for each individual. More clinical trials are needed to assess the efficacy and impact of the different treatment options before a definitive recommendation regarding management can be made.

AdVance male urethral sling: medium-term results in an Australian cohort.

BACKGROUND: Since 2008, the AdVance male urethral sling has emerged as a minimally invasive option for stress urinary incontinence. We aimed to evaluate the success of the AdVance sling using validated continence outcome measures. METHODS: A total of 72 patients treated with the AdVance sling completed validated questionnaires reporting on quality of life and functional outcomes. Incontinence was assessed according to pad weight, pad usage per day (PPD), International Consultation on Incontinence Questionnaire scores and Patient Global Impression of Improvement scores. RESULTS: At a median 52-month follow-up, 37 (51%) patients were pad free or used a security pad; 18 (25%) used ≥50% fewer PPDs; and the remaining 17 (24%) patients were classified as 'failed'. According to pad weights, 27 (38%) patients were dry; 32 (44%) had mild incontinence (<100 mL/day); and 13 (18%) had moderate (100-400 mL/day) or severe (>400 mL/day) incontinence. Patient satisfaction was high, with 57 (79%) very much or much better, six (8%) somewhat better and only nine (13%) unchanged or worse. There was a trend of declining continence over time, although the majority remained improved. Patients with severe preoperative incontinence performed significantly worse postoperatively (P = 0.02), as did those who had had prior pelvic radiotherapy (P = 0.02). CONCLUSIONS: The AdVance sling offers a high rate of success for the treatment of mild to moderate post-prostatectomy incontinence according to PPD; however, when using objective measures of continence, the success rates are lower. The improvement in urinary control is largely durable over the medium term; however, they may decline beyond 4 years. Reduced efficacy is seen in those with a history of radiotherapy and severe incontinence, although the majority of these men are still improved with surgery.

Comparison of complication rates related to male urethral slings and artificial urinary sphincters for urinary incontinence: national multi-institutional analysis of ACS-NSQIP database.

PURPOSE: Male stress urinary incontinence (SUI) can significantly diminish quality of life and lead to embarrassment and social withdrawal. Surgical therapies, such as male urethral slings and artificial urinary sphincters (AUS), are considered effective and safe treatments for male SUI. Our objective is to evaluate 30-day complications in patients undergoing male slings and AUS placement from a national multicenter database. METHODS: Data from the American College of Surgeons National Surgical Quality of Improvement Program for 2008-2013 were used to identify patients who underwent male slings and AUS implantation. Trained coders abstracted complication data from the patient record independent of the surgical team. We compared 30-day postoperative complications for male slings and AUS. We examined the relationship between patient factors and complication rates for each procedure type. RESULTS: Overall, 1205 incontinence surgeries in men were identified: 597 male sling placements and 608 AUS implantations. Male sling placement had a lower 30-day postoperative complication rate compared to AUS (2.8 vs. 5.1 %, p = 0.046). Compared to AUS, male sling was associated with fewer urinary tract infections (0.3 vs. 2.0 %, p = 0.020) and return trips to the operating room (1.0 vs. 3.0 %, p < 0.001). Patients with higher BMI were more likely to have a complication, while age, race and Charlson comorbidity index were not associated with higher or lower complication rates. CONCLUSIONS: Complications rates for both male sling and AUS are low. Male sling is associated with a lower rate of complications than AUS. These findings allow for better patient perioperative counseling regarding 30-day perioperative complications.

The advance transobturator male sling for post-prostatectomy incontinence: subjective and objective outcomes with 3 years follow up.

AIMS: To determine patient-perceived and clinical outcomes of the AdVance sling at 3 years follow-up in men with post-prostatectomy incontinence (PPI). METHODS: Data was prospectively collected of men with PPI treated with the AdVance male sling between February 2008 and March 2010. Twenty-four-hour pad counts and weights and patient completed validated questionnaires were obtained pre-operatively and at 3 years. The primary outcome was improvement in pad count with secondary outcomes of questionnaire scores and patient perception of success. RESULTS: At a median follow-up of 39 months (IQR: 36-44), we identified 30 men meeting inclusion criteria who had the AdVance male sling placed for mild to severe PPI. Eighteen (60%) patients were cured (no pad usage or one pad for security) and an additional 4 (13%) showed improvement (≥50% reduction in pad usage). Eight (27%) patients failed: six patients underwent seven salvage procedures including urethral bulking with collagen (n = 1), Virtue perineal sling (n = 1), and artificial urinary sphincter (n = 5). There were 16 post-operative complications: 13 Clavien I, 2 Clavien II, and 1 Clavien IIIb. CONCLUSIONS: AdVance male sling is an effective treatment option for PPI evidenced by objective improvements in 24-hr pad count and pad weight and patient perceived success via validated questionnaires.