Artificial urinary sphincter for post-prostatectomy incontinence: Impact of prior collagen injection on cost and clinical outcome

Purpose: We retrospectively reviewed our experience with the artificial uri nary sphincter in men with post-prostatectomy incontinence to determine the impact of prior collagen injection therapy on surgical outcome and overall cost of treatment. Materials and Methods: The records and preoperative urodynamic studies of 3 0 men with post-prostatectomy incontinence who underwent artificial urinary sphincter placement were reviewed. Of these patients 23 (76.6%) had underg one prior collagen injection (collagen group) and 7 had not (noncollagen gr oup). Preoperative and postoperative severity of incontinence was assessed with the American Urological Association quality of life index (scale 0 to 6) and number of pads used daily. Using a Valsalva leak point pressure of l ess than 60 cm. water as a predictor of failure with collagen injection, we calculated the potential savings had these patients foregone collagen inje ction and chosen artificial urinary sphincter primarily. Results: Of the 30 patients 24 (80%) were incontinent following radical ret ropubic prostatectomy and 6 (20%) after transurethral resection. Intrinsic sphincter deficiency was the sole etiology of incontinence in most patients (83.3%) and 5 (16.7%) had concomitant detrusor instability. Six patients a lternated the use of pads with the use of clamps or a condom catheter to ai d in controlling leakage. Mean number of collagen treatment sessions for th e injection group was 2.9 (range 1 to 7). There was a significant differenc e in mean time from prostatectomy to artificial urinary sphincter between t he noncollagen (25.3 months) and collagen (35.8 months) groups (p = 0.04). There were no other statistically significant differences between the group s, including mean age (66.2 years, range 45 to 83), mean followup (26.2 mon ths), mean preoperative pads daily (5.8 +/- 3.4), median preoperative quali ty of life index (6, range 3 to 6), median preoperative American Urological Association symptom score (13, range 3 to 35) and mean preoperative Valsal va leak point pressure (42.7 +/- 21.4 cm. water). For all patients in the s tudy the mean postoperative pads daily was 0.8, mean quality of life index 1 and surgical complication rate 13.3%. There were no statistically signifi cant differences between the collagen and noncollagen groups in any of thes e parameters. Among the collagen group 17 patients (73.9%) had a Valsalva l eak point pressure less than 60 cm. water. Considering the mean additional period of incontinence (time between prostatectomy and artificial urinary s phincter) to be 12.9 months and the additional treatment costs (including p ads daily and mean number of collagen syringes per patient), the direct cos ts of treatment for the collagen group were 85.6% higher than those for pat ients who chose artificial urinary sphincter primarily. Conclusions: Prior collagen therapy did not adversely influence the surgica l complication rate or compromise effectiveness of the artificial urinary s phincter. However, patients with Valsalva leak paint pressure less than 60 cm. water have lower rates of success with collagen injection therapy and c ould benefit from a more successful, timely and cost-effective treatment of incontinence by choosing the artificial urinary sphincter as primary thera py.