Functional: Surgery for Male SUI

See 2019 AUA Incontinence after Prostate Therapy Guideline Notes

Pathogenesis of Male SUI

• Stress urinary incontinence (SUI) develops only in men with concomitant internal and external sphincter impairment
  • Causes of internal sphincter incompetence:
    • Pelvic surgery
    • Bladder neck injury
    • Specific sympathetic neuropathic dysfunction
    • Embryologic disruption
  • Causes of external sphincter incompetence:
    1. Radical prostatectomy (most common cause)
    2. TURP
       • Incontinence after TURP may reflect persistent bladder overactivity but rarely results from damage to the external sphincter during resection
       • In a large Veterans Study, the rate of de novo UI after TURP was no different from that in the watchful waiting group
    3. Pelvic fracture urethral injuries
    4. Myelopathy (traumatic and acquired)
    5. Congenital disorders such as spinal dysraphism, sacral agenesis, and the exstrophy/epispadias complex

Diagnosis and Evaluation

• Mandatory (2):
  1. History and Physical exam
  2. Labs: urinalysis

History and Physical Exam

• History
  • Characterize incontinence (type and severity of UI)
    • Differentiation between stress and urge UI is important and can be aided by the voiding diary and pad test
  • Previous surgical procedures
  • Symptoms of neurologic disease
• Physical exam
  • Abdomen, back, genitalia, perineum, rectum, and neurologic system
    • Inguinal hernias should be identified, and, if contralateral pressure-regulating balloon (PRB) placement is not possible, concomitant repair is advisable.
  • Scrotal examination may detect pathologic processes that can influence pump placement such as hydrocele, hernias, and scrotal masses.
  • Previous surgical incisions should be noted when planning AUS pressure-reservoir balloon placement

Labs

• Urinalysis +/- culture are required before surgical correction of male UI

Other

• Complex cases of sphincteric UI also will require cystoscopy and pressure-flow urodynamics to evaluate potential bladder neck stenosis and bladder storage function, respectively
• Cystoscopy
  • If there is any suspicion of bladder neck stenosis after radical prostatectomy or TURP, which is rare, endoscopic evaluation should be considered before surgical correction of UI beecause unrecognized urethral pathologic processes can significantly complicate all surgical approaches
• Urodynamics
  • Campbell's (CW12 p.2997): Assessment of bladder capacity, compliance, and contractility is required before considering surgical correction of UI (different than AUA Incontinence after Prosate Therapy guidelines)
    • Careful history and voiding diary may be sufficient to assess the adequacy of bladder function
    • Non-invasive studies with uroflowmetry and PVR, when normal, serve to confirm bladder capacity, completeness of bladder emptying, and the absence of bladder neck stenosis.
    • When more comprehensive evaluation is required, however, pressure-flow urodynamics permits an accurate determination of bladder function and incontinence type and severity. Intrinsic sphincteric dysfunction will be identified in almost all cases.
    • In 2012, the American Urological Association (AUA) released guidelines on the use of urodynamics in the clinical evaluation of the patient with voiding dysfunction.
      • Specific recommendations for the patient with SUI include at minimum that: surgeons considering invasive therapy in patients with SUI should assess the PVR.
      • Furthermore, clinicians may perform multichannel urodynamics in patients with both symptoms and physical findings of stress incontinence who are considering invasive, potentially morbid or irreversible treatments, which include placement of the male sling or AUS.
  • Detrusor hypocontractility may indicate the need for AUS instead of sling if adequate detrusor function does not exist to overcome the fixed resistance of a compressive sling
  • Reduced bladder compliance is concerning because prolonged storage at high pressures may lead to deteriorating renal function.

Management

Options

• Conservative:
  • Pelvic floor muscle training
• Non-surgical:
  • Pharmacological
    • Duloxetine, a serotonin norepinephrine reuptake inhibitor, can be tried
  • Penile clamp such as Dribble-Stop
  • Containment products such as a condom catheter, urethral, or suprapubic catheter or incontinence pads.

• Surgical
  1. Transurethral bulking agent
  2. Bulbar urethral sling
  3. ProACT balloon
  4. Artificial Urinary Sphincter (AUS)
  5. Bladder neck closure with diversion

Conservative

• Males with SUI should initially be treated with pelvic floor muscle training for at least 3 months
• After radical prostatectomy, it is recommended that no surgical treatment be considered until at least 6-12 months subsequently as some patients will continue to improve.
  • Progressive improvement in urinary control has been reported to occur for as long as 2 years after surgery

Surgical

• Factors to consider include the severity of UI and associated bother; patient characteristics, including BMI, prior surgical procedures, adjuvant radiation therapy, bladder function, and cystoscopic findings; manual dexterity and cognitive function; efficacy of the various implants; long-term risk for complications and reoperation; and patient preference
• Contraindications
  • Absolute:
    • Bladder disorders that compromise renal function, such as:
      1. Diminished bladder compliance
      2. Vesicoureteral reflux at low intravesical pressure
    • ***AUA 2019 IPT Guidelines do not describe these as contraindications; the guidelines mention that with poor compliance should be followed closely, and do not explicitly mention VUR***
  • Relative
    1. Urinary tract abnormalities that require future transurethral management, such as
       • Bladder cancer
       • Refractory vesicourethral anastomotic strictures
    • In such cases, an AUS or sling procedure could impair transurethral access and repeated instrumentation may put the devices at risk for infection or erosion.
  • Detrusor overactivity, if present, is not a contraindication to the treatment for sphincteric incontinence but requires realistic counseling regarding the likelihood of successful outcome
• Options (5):
  1. Bulking agents
     • Limited role after prostatectomy given the severity of incontinence and post-surgical scarring in the vesicourethral region
     • A trial of bulking agent may be appropriate in men with neurogenic SUI
  2. Bulbar urethral slings
     • Viable treatment options for mild-to-moderate incontinence
       • Mild-to-moderate incontinence defined as a 24-hour pad weight < 150 g for mild UI and < 400 g for moderate UI
     • Alternatives for those who refuse AUS from fear of infection, erosion, or mechanical failure, as well as those with limited physical or cognitive capacity
     • Contraindications (3):
       1. Radiation
       2. Urethral erosion
       3. Severe gravitational UI
     • Types (3)
       1. InVance (AMS): mesh placed outside the bulbospongiosus muscle and anchored to the pubic rami
          • No longer available in the US
          • Mechanism of continence thought to be from compression of urethra
       2. AdVance (AMS): transobturator fixation of mesh
          • Mechanism of continence thought to be from enhanced rhabdosphincter function without significant compression; designed to reposition and lengthen the membranous urethra
          • See Figure
       3. Virtue (Coloplast): combined prepubic and transobturator sling
          • Four-armed mesh device (quadratic fixation) that provides a long segment of urethral compression against the urogenital diaphragm and a separate elevation component because of the prepubic and transobturator arms, respectively
          • Limited data on efficacy and durability
     • After urethral disruption due to pelvic fracture, neither the InVance or the AdVance slings are likely to reliably provide effective elevation, elongation, or compression because of distortion of the bony pelvic anatomy and high likelihood of rhabdosphincter damage
     • Determining the appropriate tension of the sling is the most critical portion of the operation
     • Complications
       • Perineal pain, urinary retention, infection, anchoring complications from bone anchors, and rare cases of erosion.
  3. ProACT Balloons
  4. AUS (AMS 800)
     • Gold standard for the treatment of UI in males
     • Advantages:
       • Long-term durability
         • Revision rates:
           • 2 years: 16%
           • 5 years: 28%
       • Effective across the spectrum of moderate and severe degrees of urinary loss
     • Consists of a fluid-filled cuff placed around the bladder neck or bulbar urethra, which provides a 2-cm zone of circumferential compression.
       • The degree of compression is determined by the compliance of the pressure-regulating balloon (PRB), with the pressure selected based on patient tissue characteristics and location of the cuff.
         • The standard PRB for bulbar AUS is 61-70 cm H2O and balances the need for occlusion with the risk for erosion. Lower pressures provide reduced continence rates but may be advisable if risk for erosion is considered excessive.
     • Insert figure
     • Insert figure
     • Bulbar urethral placement of an AUS will not allow appropriate instrumentation and transurethral resection in patients with recurrent bladder tumors; in these patients, a male sling is preferred
       • A male sling will allow passage of a 24-Fr resectoscope
     • Contraindications (in addition to general CI for surgical correction of male UI above) (4):
       1. Poor manual dexterity
       2. Cognitive disability
       3. Poor urethral tissue integrity
       4. Active infection at surgical site
  5. Bladder neck closure or diversion
     • May be required if inadequate tissue integrity at the bladder neck or urethra to accommodate a sling or AUS
  6. The trade-off between risk and efficacy must be considered, with AUS recommended for more severe UI. For mild UI, bulbar sling procedures become viable alternatives, whereas AUS may represent therapeutic overkill. The bone-anchored and transobturator slings primarily should be used in cases with mild-to-moderate incontinence

Technique of implantation

• AUS
  • Steps described in Campbell’s page 2174
  • Cuff is most commonly placed around bulbar urethra via a perineal incision. The aim is to place the cuff as proximal on the bulbar urethra as possible, proximal to the convergence of the corporeal bodies
  • Summary of Steps:
    • After incision of the skin, Colles fascia, and bulbospongiosus muscle, the Buck fascia is incised as it reflects off the bulbar urethra onto the diverging corporeal bodies.
    • A 2-cm wide tunnel is created under direct vision using sharp dissection, dorsal to the Buck fascia over the roof of the urethra.
    • A right-angle clamp is then passed through this tunnel.
    • The circumference of the urethra is measured around the corpus spongiosum to guide selection of cuff size, most commonly 4 or 4.5 cm.
    • The tubing from the AUS cuff is passed through the overlying bulbospongiosus muscle into the deep perineal space beneath the Colles fascia.
    • The placement of the pressure-regulating balloon may be achieved through a scrotal, perineal, or abdominal incision, depending on prior surgical incisions, body habitus, and surgeon preference.
      • Contraindications to the scrotal/perineal approach:
        1. Mesh hernia repairs
        2. Radical cystectomy and other extensive abdominal surgery
        • In such cases, the abdominal approach reduces the risk for bladder or intestinal injury
    • The pump assembly is placed into the anterior scrotum from the inguinal, scrotal, or perineal incision.
    • After completing the connections, the device is cycled several times through the activation and deactivation states.
    • Adequate coaptation of the urethra is verified via urethroscopy. The closed cuff should cause slight blanching of the urethral tissue, indicating adequate urethral coaptation, filling, and connection of the device.
  • Bladder neck AUS
    • Remains an optional, although more invasive, method of cuff placement in men with sphincteric UI in whom the prostate is without external surgical or traumatic disruption.
      • Thus, for cases of myelomeningocele and other neuropathic disorders, it should be considered as an alternative to bulbar AUS.
      • Contraindicated after radical prostatectomy
    • Advantages include lower likelihood of erosion and cuff atrophy
    • Requires higher PRB pressures to ensure coaptation
  • Postoperative deactivation of the cuff for 4-6 weeks is essential for proper healing without erosion.

AUS Complications

Intraoperative urethral injury

• Urethral injury during any implant surgery places the patient at risk for device infection due to the presence of colonizing bacteria in the urethra.
• The risk of devastating device infection outweighs any benefit and thus the procedure should be aborted. The defect should be repaired and a catheter inserted for 7 days

Urinary retention

• Rare
• Rule out inadvertent cuff activation
• In the immediate postoperative period, should be managed by with a small (10 or 12 Fr) catheter for 24-48 hours. Cuff deactivation must be confirmed before catheterization.
  • Instructions to deactivate AUS (pdf) (video)
• If the patient fails a voiding trial at 48 hours, suprapubic cystostomy drainage is recommended to reduce the risk for urethral erosion
• Retention persisting beyond several weeks implies undersizing of the cuff; in such cases, reoperation and cuff replacement may be required. Correlation with preoperative urodynamic findings is advised in such cases.
• Late-onset urinary retention mandates endoscopic and urodynamic evaluation to rule out:
  • Proximal urethral obstruction
  • Erosion
  • Detrusor failure

Device infection

• The rate of infection with initial AUS surgery is 1-3%
• Skin pathogens (staphylococcus epidermidis (most common) and staphylococcus aureus) are the most commonly cultured organisms
• Diagnosis and Evaluation
  • Initial presentation of an early postoperative AUS infection is usually scrotal pain, although can be erythema, edema, and frank purulence
• Management
  • Almost always require explantation
    • Implant infections are not amenable to antibiotic therapy
    • Traditional management includes device removal followed by a waiting period of several months with delayed reimplantation.
    • Immediate salvage of infected, noneroded AUS can be accomplished with complete device removal, antiseptic irrigation, and immediate reimplantation
      • Contraindications to salvage include sepsis, ketoacidosis, necrotizing infection, immunosuppression, and the finding of gross purulent material at the time of explantation

Urethral erosion

• Occurs in up to 5% of AUS implantations
  • Introduction of narrow back modification of AUS has reduced the risk of erosion
• Risk factors:
  • Campbell’s: radiation therapy, prior erosions with the need for removal of the device, prolonged catheterization and instrumentation, hypertension and other comorbidities
    • No increased risk of erosion with prior transobturator sling
  • SASP 2016: radiation therapy, prior erosions or infection in a previous AUS, a prior urethroplasty, multiple endoscopic treatments for bladder neck contracture or urethral stricture, or prior urethral stent placement. There is also a much lower but still significant increased risk of erosion with a prolonged postoperative catheterization interval (> 48 hours), or use of either a 3.5 cm or transcorporal cuff compared to a standard 4 cm cuff.
    • No increased risk of erosion with increasing age, proximal or distal bulbar urethral placement of the AUS, or prior radical prostatectomy
• Management
  • Immediate removal of all the components of the AUS is imperative because they are assumed to be infected.
  • The urethral injury is managed with urethral catheter drainage and/or suprapubic cystostomy
  • Reimplantation is considered only after a delay of 3-6 months and urethral healing is confirmed by urethrography

Urethral atrophy

• Results from the chronic compression of the spongy tissue under the occlusive cuff
• Most common cause of gradual return of incontinence and revision of the AUS
• Management
  • Options:
    • Cuff downsizing
    • Movement of the cuff to a more proximal or distal location where the urethra may be thicker
    • Placement of a second cuff in tandem

Urethral stricture

• The safest approach for an initial stricture would be laser incision through a smaller caliber endoscope such as a ureteroscope.
  • Although exploration of the AUS cuff with uncoupling of the cuff will allow safe endoscopic management of strictures and tumors with resectoscopes, this should be reserved for cases not amenable to simple laser incision with small caliber and scopes.
  • Antegrade incision is feasible but offers less control than the retrograde approach.
  • Open surgical reconstruction should be reserved for refractory cases.

Mechanical failure

• 7-10-year device life for the AUS
• Management
  • In the absence of infection or erosion, replacement of an isolated malfunctioning component may be feasible if the revision occurs within 3 years of implantation.
    • However, a slow leak from the PRB may be difficult to diagnose intraoperatively, and, if in doubt, total device replacement is prudent.
  • Devices older than 3 years old should be replaced in entirety.

Persistent incontinence

• Causes
  1. Inadvertent deactivation
  2. Insufficient urethral compression (oversizing of cuff)
  3. Cuff erosion
  4. Bladder storage failure
  5. Mechanical failure with fluid loss
  6. Plugged delay-fill resistor
  7. Kinked tubing
• Timing
  • After AUS insertion,
    • A slow onset of incontinence suggests atrophy
    • The sudden recurrence of incontinence indicates
      • Mechanical failure
      • Fluid leak
      • Erosion of the device
• Inadvertent deactivation
  • Active cycling of the device excludes inadvertent deactivation.
    • If the pump is deactivated with inadequate fluid to cycle, passive filling can be achieved by squeezing the pump on its lateral edges or by pushing on the pump with a cotton-tipped applicator opposite the deactivation button.
• Mechanical failure with fluid loss
  • Plain radiography (for contrast-filled systems) or ultrasonography (for saline-filled systems) of the pressure-reservoir balloon during cycling can help differentiate fluid loss from cuff atrophy.
    • If the pressure-reservoir balloon size changes with cycling and refills passively, mechanical failure is less likely and thus suggests cuff atrophy
• Cuff erosion
  • Cystoscopy, in addition to excluding erosion, can be used to visualize the cuff during cycling and give insight into the likelihood of atrophy.
• Bladder storage failure
  • Urodynamics should be performed when bladder storage failure is suspected
    • The best indicators for patients who may develop overactive bladder after treatment of their outlet for sphincteric incontinence include (2):
      1. Bladder capacity < 200 mL on urodynamics or diary
      2. Presence of symptomatic overactive bladder before surgical treatment for the incontinence
    • Patients with prior radiation therapy may develop urgency and frequency at a later time, but this is not a significant risk factor before proceeding with outlet procedures such as male slings or AUS.
    • Leak-point pressure and prior procedures do not indicate a risk for development of overactive bladder.
• Revision surgery for non-mechanical causes may require (3):
  1. Tandem cuff
  2. Modified cuff placement using 3.5-cm cuff
  3. Transcorporeal placement
  • When the cause of persistent UI is incomplete urethral occlusion, the addition of a second tandem cuff around the bulbar urethra can yield satisfactory continence.
    • Connection to the existing device requires division of the existing cuff tubing and use of a metal Y connector. An additional 3 mL of fluid must be added to the system.
  • However, in a relatively young patient, the cuff should be downsized rather than placing a second cuff to avoid using additional locations on the bulbar urethra, which will be necessary for future device replacements over time.

Long-term results of AUS and slings

• On average 76% of AUS patients were dry (0-1 pad per day)
• Success rates for revision surgery compare favorably with initial surgery, although infection and erosion rates are higher
• Poorer prognosis for patients having undergone prior adjuvant radiotherapy

Questions

1. What are the contraindications to surgery for male SUI? Specifically, AUS? Sling?
2. What are some differences between the InVance and AdVance sling?
3. What is the typical pressure in the pressure regulating balloon?
4. What are contraindications to scrotal/perineal pump placement?
5. Describe the management of urinary retention following insertion of AUS
6. What is the most common pathogen involved in AUS infections?
7. What are risk factors for AUS erostion?
8. List causes of persistent incontinence following insertion of AUS
9. What is the most common cause of AUS revision surgery

Answers

1. What are the contraindications to surgery for male SUI? Specifically, AUS? Sling?
2. What are some differences between the InVance and AdVance sling?
3. What is the typical pressure in the pressure regulating balloon?
4. What are contraindications to scrotal/perineal pump placement?
5. Describe the management of urinary retention following insertion of AUS
6. What is the most common pathogen involved in AUS infections?
7. What are risk factors for AUS erostion?
8. List causes of persistent incontinence following insertion of AUS
   1. Inadvertent deactivation
   2. Insufficient urethral compression (oversizing of cuff)
   3. Cuff erosion
   4. Bladder storage failure
   5. Mechanical failure with fluid loss
   6. Plugged delay-fill resistor
   7. Kinked tubing
9. What is the most common cause of AUS revision surgery
   • Urethral atrophy

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 91