Safety and efficacy of male urethral slings for management of persistent stress urinary incontinence after holmium laser enucleation of the prostate

Abstract

Holmium laser enucleation of the prostate gland (HoLEP) is an alternative to the traditional transurethral resection of the prostate, especially for large-volume prostates. One complication is urinary incontinence, which is usually stress urinary incontinence (SUI). Little data exist on surgical interventions for SUI after HoLEP. This retrospective case series examined the safety and possible efficacy of a midurethral sling (MUS) following HoLEP. Between January 2016 and February 2019, 610 HoLEPs were performed at our institution. Three (0.5%) had persistent, overly bothersome symptoms of SUI. All three underwent MUS placement with a transobturator AdVance^® male sling after failed pelvic floor rehabilitation. The degree of SUI was evaluated by pad use pre-HoLEP, post-HoLEP, and post-MUS placement. Surgical times for HoLEP and MUS were evaluated. No patients were using pads for incontinence before HoLEP. The average pad use was 7 post-HoLEP and 0.3 post-MUS. The average morcellated prostate was 48 g, and surgical time was 68 min (52 for enucleation and 15 for morcellation). No complications were reported with MUS placement intraoperatively or postoperatively. MUS for persistent and bothersome SUI after HoLEP shows promise as a safe and effective surgical option.

Holmium laser enucleation of the prostate (HoLEP) has become an increasingly popular alternative to the more traditional transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia, ¹ especially with larger-volume prostate sizes. While it has a steeper learning curve, ² long-term comparisons have shown HoLEP outcomes to be at least equivalent to those of TURP. ³ One of the most common complications following HoLEP is urinary incontinence. A large number of patients, up to 43%, have some degree of urinary incontinence 1 month after surgery, with the majority, 86%, having pure stress urinary incontinence. ⁴ Persistent incontinence is typically mild and has been shown to affect between 0.5% and 10% of the patients who undergo HoLEP. ^{4 , 5} Incontinence, especially stress urinary incontinence, after HoLEP has been associated with several risk factors, including larger-volume prostates, longer operating times, operative blood loss, diabetes mellitus, removal of larger volumes of the transition zone of the prostate, and larger enucleation ratios. ^6–8 There is little information on surgical intervention for urinary incontinence following HoLEP. In this study, we present a case series of three patients who had persistent postoperative stress urinary incontinence following HoLEP with failed pelvic floor rehabilitation who underwent treatment with placement of a male midurethral sling (MUS).

METHODS

A retrospective chart analysis in a prospectively maintained database was performed on patients who underwent HoLEP for obstructive lower urinary tract symptoms between January 1, 2016, and February 10, 2019. A total of 610 HoLEPs were performed. Three patients (0.49%) developed persistent, bothersome urinary incontinence and eventually underwent placement of a MUS. No patients had undergone placement of an artificial urethral sphincter (AUS).

In these patients, we characterized the type of urinary incontinence post-HoLEP and the presence of any risk factors such as age, body mass index, comorbidities, length of HoLEP operation, amount of prostate morcellated at the time of HoLEP, and any noted perioperative or postoperative complications. HoLEP was done using the two lobes technique, with the median lobe enucleated with one of the lateral lobes, and morcellation was done using the Wolf^® Piranha Morcellator. We also examined the safety and efficacy of placing a MUS for urinary incontinence. Specifically, we looked at pad use before and after the MUS. Any perioperative and postoperative complications associated with MUS placement were reviewed.

At our facility, the MUS was a transobturator AdVance^® male sling. We used a midline perineal approach and dissected the bulbo-spongiosus muscle off of the bulbar urethra. Dissection was carried both anteriorly and posteriorly to allow for necessary mobilization. A transobturator needle was then used to slide under the superior media aspect of the pubic symphysis to place the mesh in an appropriate position. A cystoscopy was performed to ensure that the urethra and bladder were not injured and to show coaptation of the membranous urethra, and a 14 French Foley catheter was used to ensure that this was not done to excess.

RESULTS

The pertinent characteristics of the three patients and the associated surgical interventions are summarized in Table 1. A total of 3 patients, out of 610, were found to have stress incontinence requiring MUS after HoLEP (0.49%). The average age at the time of initial HoLEP was 74 years (range 67–82), with an average body mass index of 27.8 kg/m² (Table 1). All three patients were able to hold urine midstream before surgery. All three patients had a transobturator AdVance male sling placed.

Table 1.

Patient and surgical findings in three cases using male urethral slings for management of persistent stress urinary incontinence after HoLEP

	Case 1	Case 2	Case 3	Average
Age (years) at time of HoLEP	82	74	67	74.3
Body mass index (kg/m2)	24.6	28.5	30.4	27.83
Reason for HoLEP	Obs LUTS	Obs LUTS	Obs LUTS
Preoperative PSA	3.2	1.3	5.5	3.3
Prostate malignancy	No	No	No
Prostatic urethra length (cm)	5.0	5.5	5.0	5.2
HoLEP operative time (min)	78	59	66	67.7
Enucleation time (min)	65	44	48	52.3
Morcellation time (min)	13	15	18	15.3
Prostate morcellated (g)	45.1	52.8	47.3	48.4
Bladder stones during HoLEP	Yes	No	No
Time from HoLEP to MUS (mo)	13.8	12.9	6.8	11.2
MUS operative time (min)	64	56	76	65.3
Pre-HoLEP incontinence	No	Mild, mixed (no pads)	No
Type of post-HoLEP incontinence	Primarily stress	Mixed	Mixed
Pre-HoLEP pad use (per day)	0	0	0	0
Post-HoLEP pad use (per day)	10	6	5	7
Post-MUS pad use (per day)	1	0	0	0.33

HoLEP indicates holmium laser enucleation of the prostate; MUS, midurethral sling; Obs LUTS, obstructive lower urinary tract symptoms; PSA, prostate-specific antigen.

The patients underwent HoLEP for obstructive lower urinary tract symptoms. The average total operating time for HoLEP was 67.7 min (average of 52.3 min of enucleation and 15.3 min of morcellation), with an average of 48.4 g of prostate tissue morcellated (Table 1). One of the three patients reported mild, mixed incontinence/dribbling before having HoLEP surgery. Each had persistent, bothersome urinary incontinence despite conservative management, which included pelvic floor physical therapy for at least 6 months. The average time from HoLEP to MUS was 11.2 months. All three patients had significant improvement in their urinary incontinence after MUS, using one pad or less per day (Table 1).

DISCUSSION

Urinary incontinence is a well-known complication of HoLEP, particularly in the immediate postoperative setting, although some studies report overall urinary incontinence rates as low as 1%. ^{4 , 5} A large majority of urinary incontinence is described as purely stress urinary incontinence, ⁴ although in our presented cases, all three patients reported mixed urinary incontinence, with only one having predominantly stress-related symptoms.

Persistent urinary incontinence has been associated with several risk factors, including but not limited to larger-volume prostates (including larger resection of the transition zone), longer operating times, increased blood loss, and diabetes mellitus. ^6–8 However, due to the small sample size in this study, it is difficult to determine specific risk factors that these patients had in comparison with the general HoLEP population.

The artificial urethral sphincter is still considered the gold standard for treatment of stress urinary incontinence, particularly after radical prostatectomy. ^{9 , 10} However, MUS placement is less invasive and has a lower overall complication rate, including rate of explantation, compared to AUS. ¹¹ However, “cure” rates or improvements in urinary incontinence have ranged widely based on study and type of MUS (40%–91%). ¹² To date, our three patients have not had any complications associated with MUS placement. Two patients have been completely dry, and one uses only one pad per day.

Placement of a MUS instead of an AUS may be preferable in sicker patients with more comorbidities given its noninvasive nature. All three of our patients had extensive cardiac histories, including coronary artery disease, history of myocardial infarction, coronary artery bypass grafting with multiple coronary stents, atrial fibrillation, and need for anticoagulation. All patients were able to hold urine midstream before surgery. After extensive counseling, each patient elected to have a transobturator advance male sling system placed.

Much of the literature surrounding the use of MUS and even AUS is in the setting of stress urinary incontinence following radical prostatectomy. Mechanisms of urinary incontinence following a HoLEP/TURP can also differ from that caused during a radical prostatectomy. Persistent stress urinary incontinence after HoLEP/TURP is thought to be associated with injury/stress to the proximal part of the sphincter distal to verumontanum, particularly with longer operative time, ¹³ while persistent stress urinary incontinence after radical prostatectomy can be multifactorial, including but not limited to intrinsic sphincter deficiency and bladder denervation. ¹⁴ As such, it can be argued that it is difficult to extrapolate the effectiveness of MUS in the postprostatectomy setting to post-TURP or post-HoLEP.

Little data have been published with regards to the use of MUS for post-TURP stress urinary incontinence. A previous meta-analysis revealed 23 patients in a total of 6 studies. There was large variation in the improvement of incontinence. An average of 78% of patients were dry, had >50% improvement in incontinence, or reported improvement in incontinence after placement of MUS. ¹³ A small prospective cohort study of 8 patients demonstrated that 4 patients were completely dry after a year and 2 had pad improvement of >50%. ¹³ All of these studies, similar to our own retrospective analysis, involved small numbers of patients, and additional studies are needed to draw more significant conclusions. To our knowledge, no study has examined the efficacy and safety of an MUS (or AUS) in patients with urinary incontinence following a HoLEP.

In conclusion, based on our study, only a small percentage of patients, 0.49% (3 of 610), maintained persistent urinary incontinence following HoLEP that was bothersome enough to proceed with placement of a MUS. All three patients had minimal to no urinary incontinence after the second procedure, and no complications have occurred. MUS for urinary incontinence after HoLEP shows promise to be a safe and effective option.