Special series on the surgical management of stress urinary incontinence in men

This special series focuses on efforts that are being made to improve the lives of men suffering from stress urinary incontinence (SUI), a condition which severely impacts quality of life (QOL). Male SUI is common among older men, affecting 10–14% of those over the age of 65 and one in six men over the age of 85, with rates of long-term incontinence after prostatectomy as high as 30% (1-3). Despite this, there are many gaps in the existing literature. The topics discussed in this dedicated series are fresh and relevant, ranging from novel methods to quantify degree of SUI, to better understanding the decisions involved in seeking surgery treatment, to recommendations on how to approach SUI in transgender patients.

Since the first implantation of the artificial urinary sphincter (AUS) in 1972, several iterations of the AUS and new devices have followed, while many others have failed to make it to market. The advent of new devices on the horizon brings competition and innovation in this field (4). One challenge with comparing success of SUI treatments are the varied measures of incontinence and inconsistent outcome definitions utilized (5). In this series, Langford et al. present the standing cough test as a practical, objective evaluation which can be easily incorporated into practice and may help to standardize future treatment studies (6).

The lived experience of SUI patients and the challenges with decision-making are both emerging topics. The needs and expectations of SUI patients need to be better understood to improve patients’ expectations and QOL. Jones et al. present the complex relationship between frailty and incontinence, while Shaw et al. introduce the importance of shared decision-making and the need for decision tools to aid this complex decision (7,8). Prebay et al. present updated surgical outcomes of AUS surgery, reporting higher complication and revision rates than previously reported, which may be important for patients and providers to consider (9).

Practice patterns for SUI treatment are changing. Long-held practice patterns are beginning to be evaluated, including the routine use of peri-operative antibiotics, the utility of the 3.5 cm cuff, and a transition to outpatient surgery (10). Alternative sling procedures (i.e., mini-Jupette) have been introduced with medium-term outcomes which may improve treatment for men with isolated climacturia (11). How to manage complications is also being examined, with Shumaker et al. presenting a case series on the delayed or conservative management of AUS cuff erosion in the absence of infection, suggesting that perhaps not all erosions need to be immediately explanted, with some patients appearing to not have any immediate issues (12). Furthermore, Leong et al. show that fungal organisms can be identified in the biofilm of AUS devices, similar to the penile implant literature (13,14). Although this finding may help to direct peri-operative antimicrobial use, the clinical significance has not been established.

Several areas within the body of SUI research need development, including the management of the fragile and high-risk urethra, as discussed by Baaklini et al. and Lin et al. in this series (15,16). Many questions remain, such as the utility of testosterone replacement in hypogonadal men undergoing SUI surgery, the benefit of urethral wrapping in preventing device erosion, and the potential effects of high- and low-pressure regulating balloons on long-term erosion.

As can be appreciated in this special series, researchers are exploring innovative avenues for both SUI treatment and research, which are progressions from the historical studies limited to surgical outcomes. It is also exciting to see completely new areas arising, such as new techniques and research for the management of incontinence following gender-affirming surgery (17). We hope that the included studies will educate readers and help to advance our understanding and management of SUI to ultimately improve care for patients impacted by incontinence.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Andrology and Urology for the series “Surgical Management of Stress Urinary Incontinence in Men”. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2023-01/coif). The series “Surgical Management of Stress Urinary Incontinence in Men” was commissioned by the editorial office without any funding or sponsorship. PHC served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Translational Andrology and Urology from April 2019 to November 2023. PHC received research support from and consult for both Boston Scientific and Coloplast. LAH served as the unpaid Guest Editor of the series, and she reports that she has spoken and consulted on behalf of Boston Scientific. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. UCLA, RAND, NIDDK, editors. Urologic Diseases in America. UCLA, 2018. Available online: https://www.uclahealth.org/sites/default/files/documents/UDA_2012_Compendium.pdf
2. Ficarra V, Novara G, Rosen RC, et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012;62:405-17. [Crossref] [PubMed]
3. Milam DF, Franke JJ. Prevention and treatment of incontinence after radical prostatectomy. Semin Urol Oncol 1995;13:224-37. [PubMed]
4. Prebay ZJ, Foss HE, Wang KR, et al. A narrative review on surgical treatment options for male stress urinary incontinence. Transl Androl Urol 2023;12:829-31. [Crossref]
5. Kovacic J, Dhar A, Shepherd A, et al. A narrative review: evaluation and surgical management of persistent and recurrent urinary incontinence after previous surgical treatment. Transl Androl Urol 2023;12:887-97. [Crossref]
6. Langford BT, Johnson BE, Morey A. A narrative review of the role of the Male Stress Incontinence Grading Scale in the surgical management of male stress urinary incontinence. Transl Androl Urol 2023;12:926-31. [Crossref]
7. Shaw NM, Nik-Ahd F, Jones C, et al. Patient decision-making for surgical treatment of post-prostatectomy stress urinary incontinence: a mixed-methods exploratory pilot study. Transl Androl Urol 2023;12:849-58. [Crossref]
8. Jones CP, Shaw NM, Mena J, et al. The relationship between frailty, incontinence severity, and treatment decisions for men with post-prostatectomy stress urinary incontinence: a mixed methods analysis. Transl Androl Urol 2023;12:840-58. [Crossref]
9. Prebay ZJ, Ebbott D, Foss H, et al. A global, propensity-score matched analysis of patients receiving artificial urinary sphincters and the risk of complications, infections, and re-interventions. Transl Androl Urol 2023;12:832-9. [Crossref]
10. Desai TJ, Rozanski AT. Changes and debates in male stress urinary incontinence surgery practice patterns: a contemporary review. Transl Androl Urol 2023;12:918-25. [Crossref]
11. Hammad MAM, Barham DW, Osmonov D, et al. Longterm assessment of the safety and effectivity of the mini-jupette sling: 5-year follow-up of the original series. Transl Androl Urol 2023;12:859-65.
12. Shumaker LA, Compher TR, Selph JP. Delayed management of artificial urinary sphincter cuff erosion. Transl Androl Urol 2023;12:944-8. [Crossref]
13. Leong JY, Ancira J, Bulafka J, et al. Characterizing the biofilm of artificial urinary sphincters (AUS). Transl Androl Urol 2023;12:866-73. [Crossref]
14. Gross MS, Reinstatler L, Henry GD, et al. Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses. J Sex Med 2019;16:1100-5. [Crossref] [PubMed]
15. Baaklini GT, Hofer MD. Are androgens important in the setting of stress urinary incontinence? Transl Androl Urol 2023;12:949-51. [Crossref]
16. Lin JS, Skokan AJ, Wessells H, et al. Management of male stress urinary incontinence in high-risk patients: a narrative review. Transl Androl Urol 2023;12:898-917. [Crossref]
17. Fascelli M, Sajadi KP, Dugi DD, et al. Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy. Transl Androl Urol 2023;12:932-43. [Crossref]

Paul H. Chung

Lindsay A. Hampson