Male sling offers alternative to AUS after RP

May 15, 2005

Istanbul, Turkey--For men with mild to moderate incontinence following radical prostatectomy, the minimally invasive perineal bone-anchored male sling (BAMS) may offer an interesting treatment alternative to the gold standard treatment, artificial urinary sphincter (AUS), according to a new study that compared the efficacy and functional durability of both treatment modalities.

Intermediate-term results demonstrated a higher success rate in terms of cured/improved rates in the male sling group (85%) versus the AUS group (75%).

The retrospective investigation involved chart reviews of 56 men suffering from mild to moderate post-radical prostatectomy incontinence secondary to sphincteric insufficiency. Twenty-seven of the patients underwent the bone-anchored sling procedure using the InVance (American Medical Systems, Minnetonka, MN), and 29 underwent placement of an artificial sphincter (American Medical Systems).

Data were presented at the European Association of Urology annual congress.

Preoperative VLPP, Qmax, PVR values, and presence of detrusor overactivity were not statistically different between the groups. The postoperative UCLA/RAND scores in BAMS patients also showed no statistically significant difference from that of the patients in the AUS group (Mann-Whitney Utest, 11.8±5.3 vs. 12.1±4.4, respectively), Dr. Singla reported. The mean patient age in both groups was 69.9±8.5 years (range 50 to 85 years), and mean follow-up time was just over 22 months in both groups.

A direct comparison of the two methods revealed that, of the 11 unsuccessful surgeries, four were sling operations (36%) and seven were artificial sphincter surgeries (64%). (The data for only 28 of 29 AUS patients were available for statistical evaluation.)

Twenty-three bone-anchored sling and 21 artificial sphincter patients had successful surgeries. Of the 19 patients who experienced improvements in continence, six (32%) had sling placements and 13 (68%) received an artificial sphincter. Of the cases completely cured of incontinence (25 patients), 17 (68%) were sling patients and nine (32%) were AUS patients.

Different for severe incontinence The investigators noted no major complications such as urethral erosion, infection, or mechanical problems that would have required re-operation within the intermediate period of follow-up (22 months). They suggested that performing BAMS surgery may therefore offer a viable and perhaps better alternative to AUS surgery.

An audience member attending the presentation expressed concern about cases of severe incontinence, as this comparison did not explore the success rates in such cases. Dr. Singla maintained that in severe cases (more than three pads/day), the male sling is inferior to an artificial sphincter (50% vs. 65% in this data). He explained that currently established surgical options included transurethral injection of bulking agents, sling procedures, and AUS, only the last of which has shown good results in severe incontinence. In prior published male sling studies, the sling failed to show good results in severe incontinence, Dr. Singla said.

As a next step, Dr. Singla plans to investigate the placement of a minimally invasive adjustable continence therapy device (ProACT [Uromedica, Plymouth, MN]), which is under investigation in the United States. The device puts extrinsic compression on the membranous urethra in cases of severe post-prostatectomy incontinence. A longer follow-up time alone would ultimately establish whether the technique represents a viable long-term alternative to AUS, he noted.

Dr. Singla is a paid consultant for American Medical Systems.