CUA 2018: The Early Canadian Experience with ATOMS for Post–Prostatectomy Incontinence

Halifax, Nova Scotia ( Urinary incontinence is a common and bothersome complication of radical prostatectomy in the treatment of prostate cancer. While many patients recover continence in the year following surgery, a significant proportion (likely approximately 5%) continue to have bothersome urinary incontinence. The artificial urinary sphincter has traditionally been considered the gold standard surgical intervention among these patients. In 2014, the ATOMS (Adjustable Trans–Obturator Male System), a self–anchoring transobturator device, featuring a non–circumferential adjustable hydraulic cushion, was first introduced to Canada. In a podium presentation today at the Canadian Urologic Association Annual Meeting, Dr. Rourke and colleagues presented a multicenter assessment of the efficacy and safety profile of the ATOMS in the Canadian context.

The authors compiled data on male patients treated with ATOMS for post–prostatectomy incontinence at eight Canadian centres. The primary outcomes were mean pad change and continence defined as requiring ≤1 pad postoperatively for patients requiring ≥2 pads preoperatively, and 0 pads for those requiring 1 pad preoperatively. Secondary outcomes included patient satisfaction, improvement (>50% change in pad use), and 90–day complications. In addition to outcome measures, the authors collected data on other patient demographics, including age, obesity (body mass index [BMI]>35), comorbidities, concurrent radiotherapy, previous incontinence surgery, previous urethral stenosis, and type of prostatectomy. Improvement in continence (mean change and absolute change in pads/day) were calculated with t–tests. Patient satisfaction, continence, and surgical complications were evaluated with descriptive statistics and Chi–square.

Among eight treating centers, the authors identified 160 patients treated with an ATOMS sling since 2014. The mean age was 70.5 years and mean follow-up was 9.5 months. Preoperatively mean pad use was 4.4 pads/day (1–10) and 36.3% of patients reported severe incontinence (>5 pads/day). Notably, 31.3% had concurrent radiotherapy, and 16.3% had failed previous incontinence surgery. Initial postoperative pad use was 1.5 pads/day (0–6) before cushion adjustment (p<0.0001) and 0.9 pads/day (0–6) following adjustments (p<0.0001); 58.3% patients underwent adjustment with a mean of 1.4 adjustments (0–7) for a total mean volume of 11.3 mL (0–31).

Overall continence rate was 80.0%, while 87.8% of patients experienced >50% improvement and 86.3% of patients were satisfied with the results of surgery. Although patients with concurrent radiotherapy did not differ by preoperative pad usage (4.6 vs. 4.1; p=0.17), they had significantly worse outcomes following insertion of the ATOM: they were less likely to be continent (62.5% vs. 87.9%; p<0.0001), less likely to experience improvement (77.1% vs. 92.6%; p=0.01), and less likely to be satisfied (69.8% vs. 93.2%; p<0.0001). Thirty–five patients (22.3%) experienced 90–day complications (any Clavien grade), mostly Clavien I (17.8%), with 4.4% (n=7) of patients experiencing Clavien III complications primarily related to the injection port.

The authors conclude, based on this multi-institutional case series, ATOMS is a safe and efficacious device for the treatment of post-prostatectomy incontinence, even in the setting of severe incontinence. Patients with concurrent radiotherapy respond to treatment but are less likely to be continent, improved, or satisfied.

While the ATOMS offers promising results, comparison to the gold standard of artificial urinary sphincter is necessary to guide treatment decision making.

Presented by: Keith Rourke, MD, University of Alberta
Co-authors: Trevor Haines, Geneviève Nadeau, Le Mai Tu, Julie Morisset, Christopher Doiron, Stephen Steele, Luc Valiquette, Dean Elterman, Conrad Maciejewski

Written by: Christopher J.D. Wallis, Urology Resident, University of Toronto, Twitter @WallisCJD at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia