EURURO Vol. 72 No. 2

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[5]
Nikhil K. Gupta, Kevin T. McVary *
Southern Illinois University School of Medicine, Springfield, IL, USA
*Corresponding author. Urology Department, Southern Illinois Univer-
sity School of Medicine, St. John’s Pavilion, 301 North 8th Street,
Springfield, IL 62794-9665, USA.
E-mail address: (K.T. McVary).
# 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Mid-term Outcomes After AdvanceXP Male Sling
Implantation
Kretschmer A, Grabbert M, Sommer A, et al
BJU Int 2016;118:458–63
Experts’ summary:
In this article the authors report their experience in 41 male
incontinent patients with the AdvanceXP male sling. The
success of the procedure (cured) was defined as use of 0 or
1 safety pads and <8 g in a 24-h pad test. Improvement was
defined as a >50% reduction in daily pad use and pad weight
after 24 h. The inclusion criteria included daily pad use of up to
8 pads (defined as mild to moderate incontinence).
After mean follow-up of almost 3 yr, 46% of the patients
could be classified as cured and 29% as improved on the
basis of pad use and a 24-h pad test. The authors found a
significant decrease in mean pad use per day and in
International Consultation on Incontinence Questionnaire
score, and a significant increase in Incontinence Quality of
Life score. The authors did not observe differences in
efficacy between 1 yr and 3 yr after implantation. Similarly,
no significant differences were observed with regard to pad
use or 24-h pad test between patients with and without
radiation treatment or between mild and moderate
incontinence. Three patients (7%) required transection of
one sling arm within the first year because of de novo
urgency and an increase in postvoid residual urine volume.
However, no complications were observed after the first
year of follow-up.
Experts’ comments:
An artificial urinary sphincter (AUS) is considered the gold
standard treatment for moderate to severe stress urinary incon-
tinence (SUI) in men [1]. There is a growing trend for the use of
male slings since commercial introduction of the first transob-
turator sling because of the ease of the operation, lower financial
cost, and the lack of a need to operate a device to void. The main
mechanism of action of this sling relies on proximal urethra
relocation. Most authors recommend evaluation of sphincter
function via the ‘‘repositioning test’’ [2,3].In this test, cystosco-
pically visible sphincter closure occurs on perineal elevation in
men with sufficient residual sphincter function.
Success rates in prospective series range from 54% to
80%, with cure rates generally around 50% similar to the
results reported by the authors. Acute urinary retention
(3–23%) and perineal pain (0–20%) are the main complica-
tions described in the literature [1,3].
The main question is how to decide when an AUS or male
sling is best for male SUI. Sling placement is associated with
a lower 30-d complication rate compared to AUS, but higher
body mass index is associated with a greater likelihood of
developing 30-d postoperative complications for both sling
and AUS procedures . Successful outcomes with either
device require careful patient selection, with special
attention to current status regarding prostate cancer,
adjuvant radiation therapy, history of anastomotic/bladder
neck contracture or urethral stricture, degree and character
of urinary leakage (mixed symptoms), prior incontinence
surgery, manual dexterity, and cognition [5].
Although male slings have traditionally been reserved
for mild SUI, some clinicians report success with slings
when treating moderate to severe SUI [6]. However, it has
been demonstrated that incontinence severity is a predictor
of successful outcome. Collado et al [2] demonstrated that
for each 1-g increase in the 24-h pad test, the cure rate
decreased by 0.4%, such that success rates were >83% for
pad weights of <400 g/d and only 40% for >400 g/d.
A history of pelvic irradiation is an independent
predictor of explantation for both sling and AUS procedures,
and a prior urethral stricture and pelvic irradiation are
independent predictors of urethral erosion in AUS [7]. Despite
this, the authors did not find any differences between
patients with and without radiation treatment. In the
literature, the rate of sling success is lower in patients with
prior radiotherapy because radiation limits urethral mobility
and hinders the ability of the sling to achieve adequate
proximal urethral relocation. For this reason, AUS remains the
treatment of choice in patients with prior radiotherapy
The index male sling case is a man without prior
radiation, with less than 200 g of daily urine loss, and
adequate mobility of the proximal urethra as demonstrated
by a positive repositioning test [5].
AUS is regarded as the most effective long term-surgical
option with high satisfaction rates, even without total
continence [5].
Conflicts of interest: The authors have nothing to disclose.
References
[1]
[2]
[3]
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