Effectiveness of surgical management with an adjustable sling versus an artificial urinary sphincter in patients with severe urinary postprostatectomy incontinence: a systematic review and network meta-analysis

Background: The purpose of this study was to determine the effectiveness of an adjustable sling compared with an artificial urinary sphincter (AUS) in patients with severe urinary incontinence (SUI) postprostatectomy (PP). Methods: This review was carried out following the Cochrane Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. We searched Medline, Embase, LILACS, and CENTRAL databases. Studies with patients older than 18 years of age with SUI PP who underwent sling or AUS intervention and had been monitored for longer than 12 months were included. Results: Seven studies were included, yielding a sample size of 420. Pads were reportedly dry or improved in 70% of the sling group compared with 74% in the AUS group. The Incontinence Impact Questionnaire, Short Form (IIQ-7) was the most frequently used scale and showed improvement, with a score of 82.8% in the AUS group compared with 86.1% in the sling group. When comparing interventions with nonintervention, relative risks (RRs) of 35.37 (95% confidence interval [CI]: 7.17–174.35) and 45.14 (95% CI: 11.09–183.70) were found for the adjustable sling and AUS, respectively, which were statistically significant. No significant differences were found when AUS versus adjustable sling were compared, with an RR of 0.78 (95% CI: 0.09–6.56). We found a low risk of bias in most studies. Conclusions: Both interventions can reduce incontinence and improve the quality of life of patients with SUI PP. The published literature is substantially limited as no randomized clinical trials are available, no consensus has been reached regarding the definition of severity of incontinence, and considerable heterogeneity exists across the outcome variables measured.

Preoperative pad usage is independently associated with failure of non-adjustable male trans-obturator slings in otherwise well-selected patients

Introduction: Our objective was to determine which clinical factors are associated with failure to achieve continence after nonadjustable trans-obturator sling in otherwise well-selected men undergoing treatment for post-prostatectomy incontinence (PPI). Methods: A retrospective review of AdVance/AdVanceTM XP male sling procedures was performed from December 2006 to May 2017. Patients with known risk factors for sling failure, including severe incontinence (>5 pads), radiation therapy, or detrusor dysfunction, were excluded. The primary outcome was failure to achieve continence, defined as ≤1 pad per day when pad use was ≥2 preoperatively (or 0 pads if preoperative pad use was 1). Covariates included patient age, Charlson comorbidity index (CCI), diabetes, obesity (body mass index [BMI] ≥35), type of prostatectomy, and number of preoperative pads. Descriptive statistics and Cox regression analysis was performed. Results: Of 158 patients, continence was achieved in 82.3% (n=130) with a mean followup of 42.7 months. Patient-reported satisfaction was 86.7% (n=137) and the 90-day complication rate was 12% (n=19). On univariate Cox regression analysis, increasing age (p=0.02), CCI (p=0.02), and preoperative pad use (p<0.0001) were associated with sling failure, whereas obesity (p=0.95), diabetes (p=0.49), and type of prostatectomy (p=0.88) were not. On multivariate analysis, only increasing preoperative pad use remained associated with sling failure (hazard ratio [HR] 1.3; 95% confidence interval [CI] 1.1–16; p=0.008). Patients wearing >3 pads per day were more likely to experience failure (35.5% vs. 13.4%; p=0.007). Conclusions: Increasing preoperative pad use is independently associated with an increased risk of failure after non-adjustable sling for post-prostatectomy incontinence in otherwise well-selected patients.