At the 2024 Annual Urology Advocacy Summit in Washington, DC, the Sexual Medicine Society of North America held a session focused on the health and psychological benefits of urological prosthetics in prostate cancer survivors. Dr Hossein Sadeghi-Nejad moderated the session, commencing with a poignant quote by Dr Litwin and colleagues, stressing the need to enhance not only survival but also the quality of life for men with localized prostate cancer. Highlighting the paper from their own group, and specifically looking at the SEER database between 2006 and 2011, it was demonstrated that of 13,812 patients diagnosed with erectile dysfunction in a cohort of more than 30,000 radical prostatectomy and radiation therapy patients, only 3.6% of the radical prostatectomy group and 1.4% of the radiation group underwent penile prosthesis surgery as treatment for erectile dysfunction, illustrating likely underutilization of this treatment modality.¹ Problems with posttreatment incontinence were introduced to the audience by means of a 2024 publication in JAMA on the functional outcomes after localized prostate cancer treatment in which the authors had shown that at 10-year follow-up, 14% of radical prostatectomy patients had moderate/big problems with urinary leakage.²

Dr Daniela Wittmann focused her presentation on the enormous psychological benefits of urological prosthetics for cancer survivors. There are close to 6 million urological cancer survivors in the US, most of whom live in prostate cancer survivorship as a result of earlier diagnosis and improved outcomes.^3-5 Long-term treatment-related side effects thus become the significant factors that affect the quality of the cancer survivors’ lives. For many prostate cancer and bladder cancer patients, posttreatment urinary incontinence can lead to distress, loss of confidence, and potential social withdrawal. The embarrassment about public leakage, odor, and a need to change bulky pads contributes to the distress.^6,7 On another front, despite the well-documented high prevalence of erectile dysfunction, research has shown that both clinicians and patients avoid sexual health discussions, partly because nonspecialist clinicians may have insufficient knowledge and because patients as well as their partners are often unsure about how to address their needs and discuss the problem.^8,9 For patients with persistent urinary incontinence and erectile dysfunction, the availability of urological prostheses, such as the artificial urinary sphincter and an inflatable penile implant, brings psychological relief and regained confidence in managing their own bodies. Urinary control results in the patients’ ability to reemerge into their social activities. Inflatable penile prostheses ensure patients’ ability to reengage in sexual interactions with their partners or begin to engage with new partners with confidence. It is important for clinicians and patients to explore insurance coverage, as it can be variable across states and across insurance companies.¹⁰

Dr Tobias Köhler gave a presentation entitled “AUA Guidelines & Surgical Outcomes of Artificial Urinary Sphincter (AUS) and Inflatable Penile Prostheses (IPPs).” Approximately 25,000 IPPs (about 1% of those eligible) are placed in the US per year and about 11,500 AUSs (about 8% of those eligible) are placed annually worldwide. This is in contrast to about 300,000 breast implants, 600,000 hips, and 1.2 million knees placed in the US per year. AUA guidelines for IPPs have evolved away from a previously routine stepwise approach—ie, from lifestyle change to pills to vacuum erection device to injections to penile implant surgery—to a patient-based discussion focused on any approach, including IPP surgery, as a primary choice that may be optimal for a given patient.¹¹ Dr Kohler further highlighted high IPP patient and partner satisfaction rates of 75% to 97% and 83% respectively, as well as low failure rates of 5% to 10% at 5 years, 15% at 10 years, and 30% to 50% beyond 15 years. Infections occur 1% to 2% of the time, injury to adjacent structures occurs 1/500 to 1/1000. Dissatisfaction most often occurs around penile length concerns and improper expectations of what a hydraulic device can accomplish.

Dr Kohler also specifically addressed posttreatment incontinence, reminding the audience that AUA guidelines lists the AUS as a first-line option for severe incontinence stemming from prostatectomy or radiation.¹² With satisfaction rates typically exceeding 90%, total dryness is reported in about 29% of patients. Although continence decreases with time secondary to AUS malfunction, secondary operations have similar satisfaction outcomes based on degree of continence. AUS failure occurs in about one-quarter of patients at 5 years and one-half of patients at 10 years. AUS Infection and erosion rates are 1% to 5% and 1% to 10%.

Allostatic load refers to combined physiologic stress from environmental factors and trauma. Perception of stress is influenced by one’s experiences, genetics, and behavior. Allostatic load has been shown to increase all-cause mortality by 22% and cardiovascular disease mortality by 31%.¹³ Incontinence results in substantial decreases in quality of life and substantial regret. Similarly, erectile dysfunction after prostatectomy results in substantial depression and regret. Treatment of either incontinence or erectile dysfunction with implants results in significant improvement in depression and quality of life. Dr Kohler concluded that by reduction of allostatic load, the use of AUS and IPP can improve not only quality of life but perhaps quantity of life.

To illustrate the profound impact that urologists can have on patients’ lives and happiness, a patient of Dr Ira Sharlip’s and his wife traveled from Red Bluff, California, to the AUA Advocacy meeting in Washington, DC, to explain how implantation of an artificial urinary sphincter had dramatically changed his life. The patient, Buck Jones, and his wife, Janilee Jones, own and run a walnut farm in northern California. They also serve as mentors and community leaders in a local church. Buck had become totally incontinent of urine after radiation therapy for prostate cancer that had infiltrated his anterior rectal wall. He and Janilee explained in very articulate and very emotional terms that the incontinence destroyed Buck’s sense of masculinity, his self-confidence, his sense of being a good husband and father, and the meaning of his life. His description of the psychological impact of the incontinence brought tears to the eyes of many in the audience.

About 3 months before the wedding of one of their daughters (who, incidentally, was the product of a vasectomy reversal), Buck and Janilee asked Dr Sharlip if there was anything that could be done to reduce his incontinence in time for the wedding. He was considering not attending the wedding because he felt it was inappropriate for a father to attend a wedding when his clothes might accidentally reveal his incontinence. Dr Sharlip implanted an artificial urinary sphincter 8 weeks prior to the wedding and activated the sphincter 2 weeks prior to the wedding. Buck experienced a 95% reduction in incontinence immediately after activation of the sphincter. He and Janilee explained to the audience that the device made the wedding a joyful family event thanks to advances in urological health care. Buck explained that his entire personality, deep depression, physical stamina, joie de vivre, and happiness for his daughter and his family were immediately changed positively when he went “from wet to dry.” His description of the elimination of depression, restoration of joy, and his deep sense of gratitude to urological science and surgery were the most powerful and most deeply felt emotions that many in the audience had ever experienced in a scientific setting.