40 - Should irradiated patients with postprostatectomy incontinence be excluded from fixed sling implantation? A case series and meta-analytic study

Introduction and aim of the study: Not clear consensus exists on whether previous pelvic radiotherapy is a contraindication for male sling placement in patients with postprostatectomy urinary incontinence (PPI), because of poor functional outcomes.We aimed to perform a retrospective assessment of the prognostic value of the radiotherapy on multiple functional outcomes in our male sling series and estimate the overall effect size of this risk factor based on the best available literature on the topic.Materials and methods: Consecutive patients with PPI that from Jan. 2013 to Dec. 2020 underwent a fixed, repositioning transobturator sling placement with 12-months minimum follow-up were included.Multiple 12-months continence outcomes were regressed on the index risk factor (radiotherapy) and potential confounders, by univariable and multivariable logistic regression analyses.A systematic literature search and a random-effect meta-analysis were undertaken, including studies reporting adjusted effect measures, to obtain the best pooled estimate of the effect of radiotherapy on sling outcome. Results:The study included 80 patients (mean age 68.5 ± 5.6 years), of which 19 (23.8%) had previous radiotherapy.Overall 12-months subjective (much-very much improved at PGI-I) and objective (24 h pad test ≤5 g) success, and social continence (≥50% improvement in pad count and ≤2 pads per day) were 76.3%, 61.3% and 80%, respectively.The same figures in irradiated versus nonirradiated cases were 57.9%, 47.4% and 57.9% versus 81.9%, 65.6% and 86.8%, respectively (p<0.05 for all comparisons).In our multivariate model, adjusting for age, BMI, comorbidity, incontinence severity and surgical experience, radiotherapy resulted to be an independent predictor of all continence outcomes.The result for social continence (beta 1.3; SE 0.43) was pooled with those extracted from the other six eligible observational studies (overall, 952 patients of which 154 irradiated), yielding an overall odds ratio of 2.69 (95%CI: 1.69-4.28;I2 =49%; Cochrane Q p=0.07;Z test p<0.001).Interpretation of results: Our findings add more evidence on the prognostic value of previous pelvic irradiation in the setting of PPI patients treated with fixed sling implantation.Although the finding must be considered with caution due to methodological heterogeneity among included studies, the likelihood of postoperative failure among irradiated patients is more than double compared to nonirradiated ones.Conclusions: During the informed consent process, irradiated patients must be made aware about their higher risk of failure after sling surgery, weighing benefits and harms of this treatment in comparison with other options.