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Article of the week: A national study of artificial urinary sphincter and male sling implantation after radical prostatectomy in England

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to this post, there is an editorial written by a prominent member of the urological community. Please use the comment buttons below to join the conversation.

If you only have time to read one article this week, we recommend this one. 

A national study of artificial urinary sphincter and male sling implantation after radical prostatectomy in England

Amandeep Dosanjh*†, Simon Baldwin*, Jemma Mytton*†, Dominic King†, Nigel Trudgill†, Mohammed Belal‡ and Prashant Patel†

*Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK , †Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK and ‡Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Abstract

Objectives

To consider the provision of post‐radical prostatectomy (RP) continence surgery in England.

Materials and Methods

Patients with an Office of Population Census and Surveys Classification of Interventions and Procedures, version 4 code for an artificial urinary sphincter (AUS) or male sling between 1 January 2010 and 31 March 2018 were searched for within the Hospital Episode Statistics (HES) dataset. Those without previous RP were excluded. Multivariable logistic regressions for repeat AUS and sling procedures were built in stata. Further descriptive analysis of provision of procedures was performed.

Fig.3. Funnel plot displaying the standardized redo/removal rate for centres implanting artificial urinary sphincter, coloured by provider volume tertile. The inner control lines are set at 2 sd from the mean and outer at 3.

Results

A total of 1414 patients had received index AUS, 10.3% of whom had undergone prior radiotherapy; their median follow‐up was 3.55 years. The sling cohort contained 816 patients; 6.7% of these had received prior radiotherapy and the median follow‐up was 3.23 years. Whilst the number of AUS devices implanted had increased each year, male slings peaked in 2014/2015. AUS redo/removal was performed in 11.2% of patients. Patients in low‐volume centres were more likely to require redo/removal (odds ratio [OR] 2.23 95% confidence interval [CI] 1.02–4.86; P = 0.045). A total of 12.0% patients with a sling progressed to AUS implantation and 1.3% had a second sling. Patients with previous radiotherapy were more likely to require a second operation (OR 2.03 95% CI 1.01–4.06; P = 0.046). Emergency re‐admissions within 30 days of index operation were 3.9% and 3.6% fewer in high‐volume centres, for AUS and slings respectively. The median time to initial continence surgery from RP was 2.8 years. Increased time from RP conferred no reduced risk of redo surgery for either procedure.

Conclusion

There is a volume effect for outcomes of AUS procedures, suggesting that they should only be performed in high‐volume centres. Given the known impact of incontinence on quality of life, patients should be referred sooner for post‐prostatectomy continence surgery.

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Editorial: A contemporary view on the use of slings and artificial urinary sphincters for the treatment of post‐prostatectomy incontinence in England

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Post‐prostatectomy urinary incontinence (UI) is a well‐recognised consequence of radical prostatectomy carried out as treatment for organ‐confined prostate cancer. This interesting article [1] reviews the in-practice surgical management of post‐prostatectomy UI in England over an 8‐year period, using the Hospital Episodes Statistics (HES) database.

In total, 1414 patients had an artificial urinary sphincter (AUS) implanted, with a median follow‐up of 3.55 years. In contrast, 816 patients were treated with a male sling, with a median follow‐up of 3.23 years. Post‐prostatectomy AUS implantation was performed in 49 centres and male sling surgery in 48 centres. It is not clear whether the same centres were involved in implanting both devices; it is however of note that for AUS implantation, 34.7% of the centres performed fewer than six post‐prostatectomy AUS implantations over the 8‐year period and 18.4% performed >50 in the same period. Both re‐do and removal surgery of AUS had some association with low‐volume providers; 7.7% of patients received a second AUS and 0.8% had undergone the procedures three or more times. A total of 12.5% of patients had an AUS re‐do or removal; 0.6% of these were within 6 weeks of the index procedure. Prior sling surgery did not predict an increased likelihood of re‐do or removal. Similarly, 33.3% of centres performed less than six post‐prostatectomy sling surgeries over the 8‐year period and only 4.3% performed >50 procedures. There was no association of centre volume with the likelihood of sling revision.

With reference to the potential impact of radiotherapy (RT), in two centres there was a 19.3% incidence of patients with prior RT compared to 9.4% for the other provider groups. Prior RT was associated with a two‐fold increase risk of sling revision. The authors conclude that previous RT did not confer a higher risk of re‐do or removal of AUS.

As with any real‐life practice study, there are potential limitations to interpretation of the data.

  • The two surgical approaches have often been used for different levels of UI, where clearly the more severe forms of UI have tended to be considered as an indication for the AUS.
  • It is not possible to identify the severity of the preoperative UI.
  • There is no standard code for the removal of a male sling, which limits the ability to comment accurately on this. Nevertheless, as a proxy, a failed sling procedure would usually be an indication for using an AUS rather than another sling.

The most important take home message from this article is the importance of undergoing post‐prostatectomy UI surgery in a high‐volume centre. A prospective database should be established to document the indications for, as well as outcomes, following both AUS and sling surgery in real‐life clinical practice. Certainly, this is likely to become mandatory under European Commission law and it would be of importance for this to be likewise implemented in the UK in the future.

by Christopher Chapple

Reference

  1. Dosanjh A, Baldwin S, Mytton J et al. A national study of artificial urinary sphincter and male sling implantation after radical prostatectomy in England. BJU Int 2020; 125: 467‐ 75.
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