Urology

Aug. 21, 2021

Artificial urinary sphincter (AUS) placement represents the gold standard for surgical treatment in male stress urinary incontinence. While relatively uncommon, stress incontinence can occur in men after treatment for prostate cancer. Men who require treatment for prostate cancer may receive radical prostatectomy, radiation therapy or a combination thereof.

Historically, there has been considerable and appropriate concern about the potential success and complications of AUS placement in men with a history of radiation for prostate cancer. However, men who have had prostatectomy and adjuvant or salvage radiation may be those most affected by stress incontinence, which may impact quality of life significantly.

"Previous studies have demonstrated variable results regarding the success and complications of primary AUS placement for men with stress incontinence and a history of pelvic radiation. Some studies have demonstrated inferior outcomes for AUS placement in men with a history of radiation, while others have shown no significant difference," says Daniel S. Elliott, M.D., a urologist at Mayo Clinic in Rochester, Minnesota. "Men with stress incontinence after treatment for prostate cancer often have trialed conservative therapies, including pelvic floor muscle exercises. These patients, and we as their providers, are highly motivated to do something to improve their incontinence and quality of life. Understandably there has been concern about complications in revising AUS devices in men with a history of radiation. We have worried about device erosion or infection."

Dr. Elliott and fellow researchers' study of the impact of prior external beam radiation therapy on device outcomes following AUS revision surgery was published in Translational Andrology and Urology in 2020.

Methodology

The research team performed a retrospective chart review of patients who received AUS revision surgery. Men with a history of external beam radiotherapy to the pelvis were considered to have a history of radiation. These men were compared with those who received revision surgery without a history of radiation. Patient and surgical characteristics were recorded and compared. Primary outcomes were device erosion, device infection or both; urethral atrophy; and device malfunction and failure.

Results

The institutional database included 527 patients who received AUS revision surgery between 1983 and 2016. Of these men, 173 (33%) had prior pelvic radiation. Median follow-up was 2.4 years (interquartile range 0.3 to 7.0 years).

Ultimately, 121 patients required a subsequent revision surgery. Indications cited for surgery included infection or erosion, device malfunction, urethral atrophy, and device failure.

In univariate analysis, there was no significant difference in five-year overall AUS device survival for patients with and those without a history of radiation (51% vs. 64%, p = 0.07). Likewise, there were no major differences in other important surgical outcomes:

• Infection, p = 0.10
• Device malfunction, p = 0.18
• Urethral atrophy, p = 0.57

After assessment in multivariable analysis (including age, body mass index and hypertension), radiation was not associated with worse overall device survival (HR 1.5, 95% CI 0.9-2.4, p = 0.1).

The following variables were associated with adverse outcomes:

• Age was associated with increased risk of device infection and erosion (HR 1.04, 95% CI 1.002 to 1.1, p = 0.04).
• Diabetes was associated with increased risk of device malfunction (HR 2.4, 95% CI 1.1 to 5.4, p = 0.03).

Conclusions

In a large cohort of men receiving AUS revision surgery, the authors found no definite evidence to support a significantly increased risk of adverse outcomes for patients with a history of radiation compared with patients without a history of radiation.

Notes Dr. Elliott, "We find these results to be extremely encouraging. There has been historical reservation about performing AUS revision surgery in men with a history of radiation treatment. These data suggest that, perhaps especially in the setting of a transcorporeal cuff placement, men can receive AUS revision surgery in a relatively safe way. Of course, this outcome is a great boon for our patients who rely on an AUS for a better quality of life."

For more information

Manka MG, et al. The impact of prior external beam radiation therapy on device outcomes following artificial urinary sphincter revision surgery. Translational Andrology and Urology. 2020;9:67.