Fixed or Adjustable Sling in the Treatment of Male Stress Urinary Incontinence

Results From a Large Cohort Study

Tanja Hüsch; Alexander Kretschmer; Alice Obaje; Ruth Kirschner-Hermanns; Ralf Anding; Tobias Pottek; Achim Rose; Roberto Olianas; Alexander Friedl; Roland Homberg; Jesco Pfitzenmaier; Rudi Abdunnur; Fabian Queissert; Carsten M. Naumann; Josef Schweiger; Carola Wotzka; Joanne Nyarangi-Dix; Torben Hofmann; Kurt Ulm; Wilhelm Hübner; Ricarda M. Bauer; Axel Haferkamp

Disclosures

Transl Androl Urol. 2020;9(3):1099-1107. 

In This Article

Results

A total of 294 (62.6%) patients received a fixed and 176 (37.4%) an adjustable MS. In the fixed MS group, 109 (37.1%) and 185 (62.9%) patients had an AdVance or AdvanceXP (Boston Scientific, Marlborough, Massachusetts, US) respectively. In the adjustable MS group, 127 (72.2%) patients presented with an Argus classic or Argus-T (Promedon, Cordoba, Argentina) and 49 (27.8%) with an ATOMS (AMI, Feldkirch, Austria). The baseline characteristics are presented in Table 1. Prior surgeries for SUI included other MS, bulking agents, ProAct (Uromedica, Plymouth, US) or artificial urinary sphincters.

The mean operation time (P=0.036; 75.9 vs. 70.3 minutes) was significantly longer for adjustable slings. Furthermore, significantly more intraoperative complications occurred in adjustable slings (P<0.001, 0.3% vs. 10.2%). In subgroup analysis of adjustable MS, intraoperative complications occurred only in Argus classic (P<0.001) which included 17 perforations of the urinary bladder and one prolonged operation time due to scarred tissue. Regarding fixed sling, only one prolonged operation time because of scarred tissue was reported. Postoperative complication rates according Clavien Dindo classification[13] are demonstrated in Table 2.

Infection occurred only in adjustable slings (P=0.009). In subgroup analysis of adjustable MS, no differences between Argus or ATOMS regarding infection rates could be identified (P=0.579). In three patients, Argus had to be removed completely and one patient with the ATOMS presented with infection of the port which had to be temporarily removed. Moreover, significantly more patients with an adjustable sling reported postoperative pain (P<0.001). In subgroup analysis of adjustable slings, more patients with Argus-T reported pain in comparison to Argus classic or ATOMS (P<0.001, 43.8% vs. 5.3% vs. 4.1% respectively).

Explantation occurred in 5 (1.7%) and 7 (4.0%) patients with fixed or adjustable MS group respectively (P=0.130). Argus-T had to be removed in two patients due to persistent SUI and pain and in one patient due to washer-dislocation which impeded further adjustment of the sling. Argus classic was removed in one patient due to urethral erosion and in two patients due to infection. another. Unilateral transection of the sling had to be performed in four patients with a fixed sling due to hypercontinence with recurrent acute urinary retentions. One fixed sling had to be removed due to dislocation of the sling.

Follow-up

Follow-up was available in 126 (42.9%) patients with fixed and 78 (44.3%) with adjustable MS. The mean follow-up time was 41.4±13.5 months for fixed and 36.9±13.3 months for adjustable slings (P=0.421). Change of the continence device or additional secondary fixed MS due to persistent or recurrent incontinence occurred in 17 (5.8%) patients with fixed and 16 (9.1%) patients with adjustable MS. In fixed slings, nine patients received an additional fixed sling (Advance, AdvanceXP), three patients an adjustable MS (Remeex, Argus, Phorbas), five patients an artificial urinary sphincter and one patient underwent cystectomy with incontinent diversion because of recurrent urethral strictures. In adjustable slings, 11 patients received an artificial urinary sphincter and five patients a distinct adjustable MS (ATOMS, Argus).

Regarding functional outcome, no differences in ICIQ-SF, I-QoL (Figure 1) or PGI-I could be identified between adjustable and fixed slings (Table 3). There was no significant difference concerning the recommendation of the operation to a friend (P=0.523) or the willingness to repeat the surgery (P=0.797).

Figure 1.

Comparison of the Incontinence Quality of Life Score and Subscales between fixed and adjustable slings.

The mean pain rates were significantly higher in adjustable slings according the VRS of pain (Table 3). The mean difference in pain according VRS were 0.8, 0.5, 0.3 and 0.5 points regarding perineal (Figure 2), genital, symphyseal and inguinal pain respectively. In subgroup analysis, no significant differences could be identified between the devices.

Figure 2.

Perineal pain according the verbal rating scale of pain.

Furthermore, no correlation between PGI-I and grade of incontinence (P=0.460), prior urethral stricture (P=0.450) or a history of pelvic irradiation (P=0.427) could be identified in the adjustable MS group. In the fixed MS group, worse PGI correlated significantly with a history of urethral stricture disease (P=0.002). There was no correlation between a history of pelvic irradiation (P=0.589) or grad of incontinence at baseline (P=0.509).

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