A comparison of artificial urinary sphincter outcomes after primary implantation and first revision surgery

Objective:The artificial urinary sphincter(AUS)is the gold standard for severe male stress urinary incontinence,though evaluations of specific predictors for device outcomes are sparse.We sought to compare outcomes between primary and revision AUS surgery for non-infectious failures.Methods:We identified 2045 consecutive AUS surgeries at Mayo Clinic(Rochester,MN,USA)from 1983 to 2013.Of these,1079 were primary AUS implantations and 281 were initial revision surgeries,which comprised our study group.Device survival rates,including overall and specific rates for device infection/erosion,urethral atrophy and mechanical failure,were compared between primary AUS placements versus revision surgeries.Patient follow-up was obtained through office examination,written correspondence,or telephone correspondence.Results:During the study period,1079(79.3%)patients had a primary AUS placement and 281(20.7%)patients underwent a first revision surgery for mechanical failure or urethral atrophy.Patients undergoing revision surgery were found to have adverse 1-and 5-year AUS device survival on Kaplan-Meier analysis,90%vs.85% and 74%vs.61%,respectively(p<0.001).Specifically,revision surgery was associated with a significantly increased cumulative incidence of explantation for device infection/urethral erosion(4.2%vs.7.5%at 1 year;p=0.02),with similar rates of repeat surgery for mechanical failure(p=0.43)and urethral atrophy(p=0.77).Conclusions:Our findings suggest a significantly higher rate of overall device failure following revision AUS surgery,which is likely secondary to an increased rate of infection/urethral erosion events.

Simultaneous penile prosthesis and male sling/artificia urinary sphincter

Erectile dysfunction （ED） and stress urinary incontinence （SUI） from urethral sphincteric deficiency is not an uncommon problem. The commonest etiology is intervention for localized prostate cancer and/or radical cystoprostatectomy for muscle invasive bladder cancer. Despite advances in surgical technology with robotic assisted laparoscopic prostatectomy and nerve sparing techniques, the rates of ED and SUI remain relatively unchanged. They both impact greatly on quality of life domains and have been associated with poor performance outcomes. Both the artificial urinary sphincter and penile prosthesis are gold standard treatments with proven efficacy, satisfaction and durability for end-stage SUI and ED respectively. Simultaneous prosthesis implantation for concurrent conditions has been well described, mostly in small retrospective series. The uptake of combination surgery has been slow due in part to technical demands of the surgery and to an extent, a heightened anxiety over potential complications. This paper aims to discuss the technical aspect of concurrent surgery for both disease entity and the current published outcomes of the various surgical techniques with this approach.

Delayed healing is common in in-situ urethroplasty patients after artificial sphincter cuff erosion

Introduction:Urethral erosion is a known complication of artificial urinary sphincter(AUS)surgery.We performed an in-situ urethroplasty(ISU)to reduce the healing time and time to reimplantation of the AUS.We sought to assess urethral integrity one month after ISU and to identify factors associated with delayed healing in our high-volume tertiary referral center experience. Methods:A retrospective review of our AUS database from 2009 to 2023 was conducted to identify all ISU cases.Patients were stratified as healed or non-healed based on the absence of extravasation on voiding cystourethrogram(VCUG)obtained 4 weeks postoperatively.Background characteristics were evaluated including age,body mass index,diabetes,hypogonadism and smoking history.Operative variables included degree of erosion,location of defect,and the number of stitches required for repair. Results:Among 98 patients undergoing an ISU,61 underwent VCUG at one month.Of these,34.4%(21/61)had evidence of delayed healing on VCUG requiring prolonged catheterization.Although a higher average number of repair sutures were used in ISU,this was not significant(p=0.381).The most common complication in both groups was urinary tract infection(UTI).Non-healed patients had a higher rate of UTI,without significant predilection towards fistula,stricture or diverticulum.No other patient or operative characteristic was significantly different between groups. Conclusion:Despite an aggressive approach to management via ISU,many patients still require prolonged catheterization after AUS erosion to ensure complete healing of the defect.

Combination therapy for male erectile dysfunction and urinary incontinence

Urinary incontinence （UI） and erectile dysfunction （ED） are both very prevalent conditions. Insertion of an artificial urinary sphincter （AUS） and penile prosthesis （PP） is an effective and proven method of treatment for both conditions. With advancing age, as well as with increasing populations of patients radically treated for prostate cancer, the occurrence of both conditions found in the same patient is increasing. The purpose of this article was to analyze the available evidence for simultaneous surgical management of male ED and UI using prosthetic devices. The existing literature pertaining to dual implantation of AUS and PP was reviewed. The concomitant insertion of the PP with the male perineal sling was also considered. Concurrent ED and UI are increasingly seen in the post radical prostatectomy population, who are often younger and less willing to suffer with these conditions. Insertion of an AUS and PP, either simultaneously or as a two-stage procedure, appears to be a safe, efficacious and long-lasting method of treatment. The improvements in design of both the AUS and PP as well as the development of the single transverse scrotal incision have made simultaneous insertion of these prostheses possible. Dual implantation of the PP and male sling looks promising in a selected population. In conclusion, the insertion of the AUS and PP for the treatment of concurrent UI and ED is safe and effective. Simultaneous insertion of these prostheses in the same patient offers potential advantages in operative and recovery time and is associated with high patient satisfaction. Combination therapy should therefore be included in the arsenal of treatment of these conditions.

Qualitative analysis of online discussion boards for male urinary incontinence after prostate treatment

Introduction:Though urinary incontinence(UI)after prostate treatment often contributes to emotional distress and significantly impacts quality of life,many patients do not discuss this condition with their physicians.We analyzed the patient perspective by examining online support group posts to gain insight into specific challenges associated with different UI management methods. Methods:We examined discussion board threads from multiple patient-focused forums on experiences of UI due to prostate treatment(threads from January 2016 to January 2022).Principles of grounded theory in thematic analysis were used to analyze the threads. Results:Three hundred and eighteen posts from 84 unique users were analyzed.Among users,47(56%)reported UI following radical prostatectomy(RP),5(6%)secondary to radiation therapy(RT),12(14%)after a combination of RP and RT,and 20(24%)were ambiguous.UI management methods included pads/diapers/liners,condom catheters/external clamps,Kegels/pelvic floor physiotherapy,and surgical treatment(artificial urinary sphincter or sling placement).We identified challenges common to all management methods:"requires trial and error,""physical discomfort,"and"difficult to be in public."Factors influencing management choices included the ability to"feel normal"and the development of a management routine. Conclusion:The current study identifies opportunities for improved expectation-setting and education regarding post-procedural UI and its management.These findings can serve as a guide for providers to counsel patients on the advantages and disadvantages of UI management devices.

Management of end-stage erectile dysfunction and stress urinary incontinence after radical prostatectomy by simultaneous dual implantation using a single trans-scrotal incision： surgical technique and outcomes

Stress urinary incontinence （SUI） and end-stage erectile dysfunction （ED） after radical prostatectomy （RP） can decrease a patient＇s quality of life （QoL）. We describe a surgical technique involving scrotal incision for simultaneous dual implantation of an artificial urinary sphincter （AUS） and an inflatable penile prosthesis （IPP）. Patients with moderate to severe SUI （〉3 pads per day） and end-stage ED following RP were selected for dual implantation. An upper transverse scrotal incision was made, followed by bulbar urethra dissection and AUS cuff placement. Through the same incision, the corpora cavernosa was exposed, and an IPP positioned. Followed by extraperitoneal reservoirs placement and pumps introduced in the scrotum. Short-term, intra- and post-operative complications; continence status and erectile function; and patient satisfaction and QoL were recorded. A total of 32 patients underwent dual implantation. Early AUS-related complications were： AUS reservoir migration and urethral erosion. One case of distal corporal extrusion occurred. No prosthetic infection was reported. Over 96% of patients were socially the continent （≤1 pad per day） and 〉95% had sufficient erections for intercourse. Limitations of the study were the small number of patients, the lack of the control group using a perineal approach for AUS placement and only a 12 months follow-up. IPP and AUS dual implantation using a single scrotal incision technique is a safe and effective option in patients with SUI and ED after RP. Further studies on larger numbers of patients are warranted.