Éfficacité à long terme : le talon d’Achille de la bandelette sous-urétrale chez l’homme ?

25 mars 2018

Auteurs : B. Peyronnet, V.-W. Nitti, B.-M. Brucker
Référence : Prog Urol, 2018, 4, 28, 191-192


Several male sling devices have become available over the past fifteen years [1]. Male slings have the advantage being less invasive compared to artificial urinary sphincter, but with lower efficacy rates (cure and improvement), especially in patients with severe incontinence or after radiation therapy [2]. An important limitation of available studies is the lack of data beyond 3-year follow-up [2]. In the current study by Malval et al. we do see some long-term data, though the lost to follow-up rates are high [3]. The authors did however use "intent-to-treat" analysis, an approach that should be emulated by future researchers in the field. As such they should be congratulated for their contribution.

The poor long-term outcomes (failure increased from 38% at 1 year to 78% at 5 years) reported are in line with the only series to date with a median follow-up over 36 months; McCall et al. reported a 68% failures rate of the Virtue® Quadratic sling (Coloplast, Humlebaek, Denmark) after a median follow-up of 55 months [4]. Similarly, several series have noted decreasing efficacy over time after insertion of the Advance® transobturator sling (Boston Scientific, Minnetonka, USA) [5]. With more long term data available the current role of male slings in male stress urinary incontinence treatment algorithm needs to be reassessed. This must be done in the context of the alternative therapies available, such as Adjustable Continence Therapy ACT® periurethral balloons (Uromedica, Inc., Plymouth, MN), which may compare favorably to male slings with regards to long-term follow up, and in the light of the long-term reliability of the artificial urinary sphincter (considered the gold-standard), which is well-documented in numerous series [2].

The report from Malval et al. also raises the issue of proper patient selection to optimize the outcomes of male slings. According to current EAU guidelines, male slings are advocated for mild or moderate stress urinary incontinence [6]. However, the definitions of mild to moderate incontinence remain unclear [1, 6], as the assessment on which the definition should be based (e.g. pad test, urodynamics, number of pads per day, questionnaires) as well as the thresholds have been very heterogenenous in the literature [1, 2]. The inclusion in the present series of patients with rather severe incontinence (up to 400g of urine leakage on 24hours pad test [3]) might have contributed to the decreasing efficacy observed. Hopefully standardized definitions of incontinence severity could emerge and be used in future studies. It behooves the urologic community to implement standard outcomes measures for male incontinence procedures so that different studies use the same assessments. We believe such measure should include a patient reported assessment of outcome as well as objective measures of incontinence that ultimately address rate of success (consistently defined) and predictors of success or failure.

The mechanism of action of male slings is not completely certain [1], and therefore multiple explanations could theoretically explain the progressive loss of efficacy observed in this series. As emphasized by the authors, the ageing per se could be blamed with decrease of the remnant sphincter function over time [3]. We do not see such rapid return of incontinence with the artificial urinary sphincter, which probably relies less on native sphincter function. De novo detrusor overactivity or impaired contractility with overflow incontinence as a result of long-term bladder outlet obstruction may also be hypothesized, though others have shown that the presence of detrusor overactivity does not affect sling outcomes at least in the short term [7]. Finally, Sling loosening or migration could be implicated. Studies assessing male slings long-term failures that including post procedural urodynamics and imaging-which were lacking in the present report - would be of interest as better understanding of these failures might result in modification of the techniques and/or devices that could help to prevent decreasing efficacy over time.

Recent studies suggest an increasing use of male slings over the other anti-incontinence procedures during the past few years [8]. Given the findings of the present study, pending further long-term series of the other devices available, urologists should be cautious in this growing use, as long-term efficacy might be the Achille's heel of male sling.

Disclosure of interest

Benoit Peyronnet is a consultant for Boston Scientific.

The other authors declare that they have no competing interest.

Appendix A. Supplementary data

(16 Ko)


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