Dr. Zillioux discusses cognitive and manual dexterity disorders after AUS placement

Jacqueline Zillioux, MD

In this interview, Jacqueline Zillioux, MD, discusses the Journal of Urology study “Prevalence of Cognitive and Manual Dexterity Disorders Among Men Following Artificial Urinary Sphincter Placement.” Zillioux is an assistant professor of urology at the University of Virginia in Charlottesville.

Please describe the background for this study.

This study was looking at the incidence of cognitive impairment and/or manual dexterity disorder diagnoses in men who underwent an artificial urinary sphincter after treatment for prostate cancer. Artificial urinary sphincters are the well-accepted gold standard for severe or persistent bothersome stress incontinence after prostate cancer treatment. And our guidelines acknowledge that patients need a certain level of cognitive and manual dexterity function to safely utilize these devices. The patient has to activate them appropriately every time he goes to void, otherwise [he] risks issues such as device erosion, infections, renal issues. And although the guidelines say that you should be assessing for that upfront, this patient population who's getting implanted is an older population; the average age is around 70 years old. That's the same population that's at risk of developing new cognitive or dexterity issues. And yet, we have hardly any data on that, until now, thankfully. And so our institution actually did a cross sectional telephone-based study where we looked at patients who had had an implant in the past and called the patients, did a telephone MoCA exam of cognitive screening tests in patients who answered. We found a 25% incidence of cognitive impairment just based on this telephone test and in our patient population. Those patients were more likely to report not using the device correctly.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

[This] was a retrospective cohort study of the SEER Medicare and Medicare files, which is a registry that's maintained nationally of patients with cancer diagnoses. We looked at men that had a diagnosis of prostate cancer between the years 2000 and 2015 and had subsequently undergone an artificial sphincter implantation. We looked broadly at cognitive impairment diagnoses and also manual dexterity diagnoses based on CPT codes and looked at the incidence of those over time and also looked at complication rates. We found 1930 patients that met our inclusion criteria. We surprisingly had to exclude patients that had baseline cognitive or manual dexterity impairment. What was surprising was that we had to exclude 322 of these patients. Those are patients that normally per our guideline would not be a candidate for an implant, potentially. And of the 1900 or so patients that were included, we found that over time, when you are controlling for possible competing risk of death because of age, that there was an estimated 44% incidence of cognitive impairment diagnosis at 15 years and 17% for manual dexterity diagnosis at 15 years. But when we looked at the complication rates based off of presence of any of those diagnoses, adjusted modeling showed that only cognitive impairment with or without manual dexterity was associated with an increased risk of any complication with a hazard ratio of about 1.5, but manual dexterity diagnoses alone were not. We also did a sub analysis looking at just those complications that were more serious, so patients that needed to have a device revision, for example, or had Fournier's or urethra erosion and we did not find a significant difference based on the presence of those diagnoses for that, but did find it for just overall.

What sorts of questions arise from this study?

This study is a first look at how common are these diagnoses in this patient population? But what it can't answer is, what is the appropriate baseline screening test that we do, and how should we follow these patients after implant? We know now that these diagnoses are likely common. And we know that, just based on common sense, we probably should be looking for these issues and patients on follow-up and ensure longitudinal follow-up. We don't know what interval makes sense. The median time to having one of these diagnoses show up in the patient's chart based off of this study was about 4 to 5 years, depending on which diagnosis you're looking at. That's well within the range of the patient normally potentially needing some sort of revision or replacement. And so, at the very least, they should be checked at the time of considering whether or not to do a device replacement or revision. What cognitive thresholds do you really need based off of objective screening tools? How closely should we follow these patients? Is it annually? Is it every other year? Is it just like the bare minimum, before you do anything else to them? Those are some outstanding questions.

What is the take-home message for the practicing urologist?

I think the take-home message is that cognitive impairment and manual dexterity issues are common in these patients, and we should not only be assessing for these at baseline but also ensuring that the patients have routine and longitudinal follow-up and that some sort of assessment is done at these follow up visits. It might be as simple as saying, "Show me how to cycle this device," which I think a lot of people are doing anyways. But it can also be doing a hand strength test or doing a timed get-up-and-go for frailty test. There are different cognitive screening tests. But the take-home is that we should be paying attention to these on follow-up.