Artificial Urinary Sphincter Cuff Placement Research Articles

Management of male stress urinary incontinence in high-risk patients: a narrative review.

The artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence (SUI). However, highly complex patients such as those with bulbar urethral compromise, bladder pathology, and lower urinary complications pose a particular challenge for the surgeon. In this article, we will address critical risk factors and synthesize existent data across relevant disease states to support surgeons in successful management of SUI in high-risk patients. A comprehensive review of current literature was performed utilizing the search term "artificial urinary sphincter" in conjunction with any of the following additional terms: "radiation", "urethral stricture", "posterior urethral stenosis", "vesicourethral anastomotic stenosis", "bladder neck contracture", "pelvic fracture urethral injury", "penile revascularization", "inflatable penile prosthesis", and "erosion". Guidance is provided based upon expert opinion where existing literature was sparse or nonexistent. Several known patient risk factors are associated with AUS failure and can ultimately lead to device explantation. Each risk factor requires careful consideration and investigation, or intervention as appropriate, prior to device placement. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients. Several surgical strategies to decrease device complications can be considered: optimization of testosterone, avoidance of 3.5 cm AUS cuff, transcorporal AUS cuff placement, relocation of AUS cuff site, use of lower pressure-regulating balloon, penile revascularization, and intermittent nocturnal deactivation. A number of patient risk factors are associated with AUS failure and can ultimately lead to device explantation. We present an algorithm for management of high-risk patients. Optimization of urethral health, confirmation of anatomic and functional stability of the lower urinary tract, and thorough patient counseling are a necessity for these high-risk patients.

Transalbugineal Artificial Urinary Sphincter: A Refined Implantation Technique to Improve Surgical Outcomes.

The artificial urinary sphincter (AUS) implantation is an effective treatment of post-prostatectomy urinary incontinence (PPI). Still, it may result in troublesome complications such as intraoperative urethral lesion and postoperative erosion. Based on the multilayered structure of the tunica albuginea of the corpora cavernosa, we evaluated an alternative transalbugineal surgical technique of AUS cuff placement with the aim to decrease perioperative morbidity while preserving the integrity of the corpora cavernosa. A retrospective study was conducted in a tertiary referral center from September 2012 to October 2021, including 47 consecutive patients undergoing AUS (AMS800®) transalbugineal implantation. At a median (IQR) follow-up of 60 (24-84) months, no intraoperative urethral injury and only one noniatrogenic erosion occurred. The actuarial 12 mo and 5 yr overall erosion-free rates were 95.74% (95% CI: 84.04-98.92) and 91.76% (95% CI: 75.23-97.43), respectively. In preoperatively potent patients, the IIEF-5 score remained unchanged. The social continence (0-1 pads per day) rate was 82.98% (CI 95%: 68.83-91.10) at 12 mos and 76.81% (CI 95%: 60.56-87.04) at 5 yrs follow-up. Our technically refined approach to AUS implantation may help to avoid intraoperative urethral lesions and lower the risk of subsequent erosion without compromising sexual function in potent patients. Prospective and adequately powered studies are necessary to achieve more compelling evidence.

Indications and Outcomes for Intermittent Catheterization following Bulbar AUS Cuff Placement

ObjectiveTo evaluate the functional and surgical impact of CIC protocols in men with a bulbar AUS in place. Stress urinary incontinence (SUI) and poor bladder emptying are both sequelae of prostate cancer treatment, though there is sparse data to guide concomitant management. The safety of intermittent catheterization (CIC) in men with an artificial urinary sphincter (AUS) at the bulbar urethra remains unclear. MethodsWe performed a retrospective review of all bulbar urethral AUS procedures at our institution. Inclusion criteria were patients with a history of prostate cancer treatment, AUS placement for SUI, and a history of CIC before and/or after AUS placement. All eligible cases were retrospectively reviewed. Surgical and continence outcomes were analyzed. ResultsA total of 57 patients were identified with a history of CIC and AUS placement under the care of two surgeons. Eighteen continued to perform CIC or first initiated CIC after AUS placement and 39 discontinued CIC prior to AUS placement. The incidence of erosion was no different amongst patients who continued or discontinued CIC after AUS placement (17.9% vs 22.2%, P = .79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, P = .41). Both groups experienced improvement in urinary incontinence after placement of an AUS. ConclusionBulbar AUS placement in the setting of continuous intermittent catheterization can be considered in patients who are not surgical candidates for definitive treatment of their outlet obstruction.

118 Evaluation of Long Term Complication Rates of Primary Transcorporal Artificial Urinary Sphincter Cuff Placement

Transcorporal artificial urinary sphincter (AUS) cuff placement has been suggested as an option to reduce the risk of urethral erosion in patients with fragile urethras and to potentially reduce the rate of erosions/atrophy in the primary implant patient. Ourprevious published data demonstrated > 50% urethral erosions occur within two years of implantation. Therefore, we sought to evaluate if transcorporal (TC) AUS implantation in the primary, non-fragile urethra implant patient would reduce complication rates compared to primary non-transcorporal (nTC) AUS implant patients with a minimum of 2 years follow-up.

Re: Dorsolateral Fibromuscular Tissue Preservation during Artificial Urinary Sphincter Cuff Placement is Associated with Low Infection and Erosion Rates.

Re: Dorsolateral Fibromuscular Tissue Preservation during Artificial Urinary Sphincter Cuff Placement is Associated with Low Infection and Erosion Rates.

Dorsolateral fibromuscular tissue preservation during artificial urinary sphincter cuff placement is associated with low infection and erosion rates.

To present a modified technique in artificial urinary sphincter (AUS) placement that is associated with low rates of erosion and infection in a high-risk population. After Institutional Review Board approval, we identified patients who underwent primary AUS placement using the modified technique between January 2007 and November 2015. Our modification consists of preserving the dorsolateral fibromuscular tissue surrounding the bulbar urethra and horizontally transecting the ventral bulbospongiosus muscle during urethral cuff placement. Preoperative variables such as radiotherapy (RT) and bladder neck contractures were recorded. Effectiveness and complications including infections, erosions, and re-operations were recorded at follow-up. The new technique was used on 208 patients: 40% had a history of RT, including 15% who had had a salvage radical prostatectomy; 26% had had previous bladder neck contractures. No patients developed infection. Overall, erosion occurred in six (2.9%) patients and spontaneous erosions occurred in two (0.9%) during the study period. In all, 21 patients underwent re-operation for device failure. The probability of re-operation for 'any' reason was 7% (95% confidence interval [CI] 4-12%) at 1 year. The 1-year social continence rate was 74% (95% CI 67-81%). Preservation of dorsolateral fibromuscular tissue during AUS placement is an effective means to achieve a low risk of erosions. Our modified technique is safe with low infection and erosion rates, whilst maintaining good functional outcomes despite a high-risk population.

PD29-03 MODIFIED TRANSCORPORAL CUFF PLACEMENT IN COMPLEX ARTIFICIAL URINARY SPHINCTER IMPLANTS

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II1 Apr 2017PD29-03 MODIFIED TRANSCORPORAL CUFF PLACEMENT IN COMPLEX ARTIFICIAL URINARY SPHINCTER IMPLANTS André Cavalcanti, Carlos Felipe Restreppo, Henrique Florindo, Roberto Medeiros, Túlio Rojas, and Neildo Chaves André CavalcantiAndré Cavalcanti More articles by this author , Carlos Felipe RestreppoCarlos Felipe Restreppo More articles by this author , Henrique FlorindoHenrique Florindo More articles by this author , Roberto MedeirosRoberto Medeiros More articles by this author , Túlio RojasTúlio Rojas More articles by this author , and Neildo ChavesNeildo Chaves More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1355AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The transcorporal (TC) artificial urinary sphincter (AUS) cuff placement was first described in 2002 for cases requiring revision for erosion and urethral atrophy. A distal cuff location is often required in patients undergoing artificial urinary sphincter re-implantation after previous erosion or in those requiring revision because of urethral atrophy at the original cuff site. Dissecting the urethra at a more distal site increases the risk of urethral injury and erosion, and often the urethral circumference is so small. A distal cuff placement using TC dissection that leaves corporal tunica albuginea on the dorsal surface of the urethra, allowing for its safer mobilization and adding to its bulk. We present a technical modification on the TC AUS cuff placement based on the use of local tunica albuginea flaps. METHODS The charts of 11 patients submitted to a modified TC cuff placement during a period of 7 years were analysed. The age of the patients ranged from 53 to 81 years (mean of 69 years). The initial approach to the distal urethral and corporal bodies is similar to the classic TC approach. The two bilateral vertical incisions, on each side of the urethra, was modified for a creation of two bilateral tunica albuginea flaps with a rectangular shape. Those flaps are mobilized medially to cover the lateral and ventral portions of the urethra. As on the classic TC approach the corporal septum was opened to create a space to the cuff placement. The tunica albuginea gap created by the flaps mobilization was closed with grafts or treated with glues. A 5.0 cuff was used in 2 cases, a 5.5 cuff in 6 cases and a 6.0 cuff in 3 cases. The modified TC cuff placement was used in 5/11 patients with a history of urethroplasty (4/5 irradiated patients), in 2/11 patients with a history of radiotherapy to treat prostate cancer, in 4/11 patients with a history of previous erosion/infection AUS implants ( 1 or 2 surgeries). RESULTS After a mean follow up of 27,3 months, the rate of implant explantation was 27% (2 associated to cuff erosion and 1 to infection without erosion). 7/11 (63,6%) were using 1 pad or less. A temporary retention was observed in 5/11 patients (45,5%). In 5/11 patients (45,5%) a staged implant was performed. In 3 patients, the cuff was placed on the first procedure and the PRB balloon/cuff on the second procedure. In 2 patients we used a silicone tape was implanted on the first procedure and the AUS implanted on a second procedure. CONCLUSIONS The modified TC AUS cuff placement is an safe and viable technique and could be used as part of the technical armamentarium to deal with complex AUS implants. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e572-e573 Advertisement Copyright & Permissions© 2017MetricsAuthor Information André Cavalcanti More articles by this author Carlos Felipe Restreppo More articles by this author Henrique Florindo More articles by this author Roberto Medeiros More articles by this author Túlio Rojas More articles by this author Neildo Chaves More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Transcorporal artificial urinary sphincter in radiated and non - radiated compromised urethra. Assessment with a minimum 2 year follow-up

ABSTRACTPurpose to assess the efficacy of transcorporal artificial urinary sphincter (AUS) implantation on continence for male stress urinary incontinence in cases of prior surgical treatment or/and radiation failure, and as a first option in radiation patients.Materials and Methods From March 2007 to August 2012, 37 male patients were treated with transcorporal AUS AMS™ 800. Twelve patients had primary placement of transcorporal cuff, a surgical option due to a previous history of radiation and 25 patients had secondary procedure after failure of AUS or urinary incontinence surgery. Functional urinary outcomes were assessed by daily pad use, 24-hour Pad-test and ICIQ-SF questionnaire. Quality of life and satisfaction were assessed based on I-QoL and PGI-I questionnaires.Results After a median of 32 months, the continence rate (0 to 1 pad) was 69.7%. Median pad test was 17.5g (0-159), mean ICIQ-SF score was 7.3/21 (±5.4) and mean I-QoL score was 93.9/110. A total of 88% of the patients reported satisfaction with the AUS. The 5-year actuarial revision-free for AUS total device was 51%. Patients for primary implant for radiation were not more likely to experience revision than non-radiation patients. Preservation of erections was reported in half of the potent patients.Conclusions Transcorporal AUS cuff placement is a useful alternative procedure option for severe male UI treatment, especially in patients with a compromised urethra after prior surgery or radiation. A high continence rate was reported and implantation as first option in radiation patients should be considered.

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.

3.5 cm Artificial Urinary Sphincter Cuff Erosion Occurs Predominantly in Irradiated Patients

We analyzed our initial 100-case experience with the 3.5 cm artificial urinary sphincter cuff to identify risk factors for cuff erosion. We reviewed the records of a single surgeon, consecutive series of patients treated with 3.5 cm artificial urinary sphincter cuff placement from September 2009 to August 2013. Each patient underwent single perineal cuff placement via standardized technique. Preoperative characteristics, technical considerations and postoperative outcomes were analyzed and compared to those in a cohort of patients in whom a larger (4.0 cm or greater) artificial urinary sphincter cuff was placed during the same period. We identified clinical factors associated with an increased risk of 3.5 cm artificial urinary sphincter cuff erosion. Of the 176 men who met study inclusion criteria during the 4-year period 100 (57%) received the 3.5 cm artificial urinary sphincter cuff and 76 (43%) received a larger cuff (4.0 cm or greater). The continence rate (83% vs 80%, p = 0.65) and mean followup (32 vs 25 months, p = 0.14) were similar in the 2 groups. Erosion developed in 16 of the 176 patients (9%) during the study period, of whom 13 had the 3.5 cm cuff. Of the 100 patients with the 3.5 cm cuff 52 (52%) had a history of radiation, including 11 (21%) with erosion. Cuff erosion developed only rarely in nonirradiated men (2 of 48 or 4%, p = 0.01). A history of radiation was the only significant risk factor associated with 3.5 cm cuff erosion (OR 6.2, 95% CI 1.3-29.5). Men with a history of radiation who underwent placement of a 3.5 cm artificial urinary sphincter cuff experienced an increased (21%) risk of cuff erosion.

Transcorporal artificial urinary sphincter implantation as a salvage surgical procedure for challenging cases of male stress urinary incontinence: surgical technique and functional outcomes in a contemporary series

To describe the surgical technique of transcorporal artificial urinary sphincter (AUS) implantation. To assess the efficacy of the AUS on continence and erectile function. A prospective evaluation was conducted between December 2007 and October 2012 at a tertiary referral centre of all male patients treated by transcorporal AUS (AMS800™, AmericanMedicalSystems, Minnetonka, MN, USA) implantation for stress urinary incontinence (SUI) recurrence, after failure of previous anti-incontinence surgery. Functional urinary outcomes were assessed according to daily pad use, the Urinary Symptom Profile questionnaire, and International Consultation on Incontinence Questionnaire - Short-Form. Erectile function was evaluated using the five-item International Index of Erectile Function (IIEF-5) questionnaire and patient satisfaction was assessed by Patient Global Impression of Improvement questionnaire. Data were collected by telephone interview. A total of 23 patients were included. Their mean (sd; range) age was 70 (7; 60-85) years. Of these, 18 patients had urethral atrophy and/or erosion after placement of AUS (11 patients), male sling (four patients) or both (three patients), and five patients had severe urethral atrophy after pelvic radiation therapy. The implantation of the AUS with transcorporal cuff placement was successful in all patients, with no peri-operative complications. Follow-up data over 1 year were available for 17 patients. After a median (sd; range) follow-up of 20 (15; 2-59) months, eight patients were perfectly dry (no pad use and no symptoms), five achieved social continence (less than one pad/day), and four still had SUI (required two or more pads/day). Among six patients who had good preoperative erectile function and were sexually active, four had no decrease in their IIEF-5 score. Transcorporal AUS cuff placement is a useful alternative for challenging cases of male SUI after failure of previous surgical treatment, urethral atrophy or erosion. Erectile function can be maintained despite dissection of the corporal body.

Long-Term Device Outcomes of Artificial Urinary Sphincter Reimplantation Following Prior Explantation for Erosion or Infection

We evaluated clinical outcomes in patients treated with artificial urinary sphincter reimplantation after artificial urinary sphincter explantation for erosion or infection. We identified 704 consecutive artificial urinary sphincter implantation procedures performed at our institution from 1998 to 2012, including 497 (71%) as primary implantation and 138 (20%) as revision surgery for device malfunction. A total of 69 patients (10%) had undergone at least 1 prior artificial urinary sphincter explantation secondary to urethral erosion and/or device infection, of whom 36 (52%) were treated with 2 to 5 prior reimplantation procedures. Patient followup was performed through office examination, or written or telephone correspondence. Patients treated with artificial urinary sphincter reimplantation had a median age of 78 years (IQR 72, 80) and a median followup of 34 months (IQR 5, 61). Artificial urinary sphincter reimplantation was done a median of 9 months (IQR 6, 13) after explantation. Patients treated with reimplantation after erosion or infection were more likely to require repeat explantation than those with primary implantation (13 of 69 or 19% vs 32 of 497 or 6.4%, p = 0.002). However, when evaluating repeat procedures, the 5-year device survival rate after reimplantation due to erosion or infection vs primary implantation was 68% vs 76% (p = 0.38). Our findings suggest that artificial urinary sphincter reimplantation after explantation for urethral erosion and/or device infection is associated with an increased rate of recurrent erosion/infection requiring repeat explantation. However, in appropriately selected and counseled patients clinically acceptable long-term device use can be achieved.

Combined Inflatable Penile Prosthesis-Artificial Urinary Sphincter Implantation: No Increased Risk of Adverse Events Compared to Single or Staged Device Implantation

Little data exist on the outcome of combined inflatable penile prosthesis and artificial urinary sphincter insertion for erectile dysfunction and stress urinary incontinence. We assessed patient outcomes for combined vs single device implantation at a single institution. We retrospectively reviewed the records of all patients who underwent inflatable penile prosthesis and artificial urinary sphincter insertion at our hospital from January 2000 to December 2011. A total of 55 combined procedures were performed compared to the single insertion of 336 inflatable penile prostheses and 279 artificial urinary sphincters. The surgical approach consisted of penoscrotal incisions for inflatable penile prostheses and transperineal incisions for artificial urinary sphincter cuff placement with a secondary lower abdominal incision for reservoir placement. Men treated with combined implantation had greater mean age and were at greater risk for prostate cancer diagnosis and treatment, and at lesser risk for Peyronie disease than men who received an inflatable penile prosthesis alone (each p<0.05). Although operative time was significantly longer for the combined procedure than for the inflatable penile prosthesis alone and the AUS alone (mean 218.1 vs 145.9 and 114.7 minutes, respectively, p<0.0001), the rate of device infection, erosion or malfunction was not increased irrespective of combined or staged procedures (p>0.05). Combined inflatable penile prosthesis-artificial urinary sphincter implantation and staged prosthesis implantation are feasible without an increased risk of adverse outcomes compared to implantation of a single prosthesis. Patients with concomitant erectile dysfunction and stress urinary incontinence should be counseled about the possible advantages of this surgical option, which include a single anesthesia event and faster resumption of sexual activity and urinary control.

564 OUTCOMES OF COMBINED INFLATABLE PENILE PROSTHESIS-ARTIFICIAL URINARY SPHINCTER VS. INDIVIDUAL DEVICE INSERTION-A RETROSPECTIVE SINGLE INSTITUTION STUDY

You have accessJournal of UrologyUrodynmaics/Incontinence/Female Urology: Incontinence, Evaluation & Therapy (I)1 Apr 2013564 OUTCOMES OF COMBINED INFLATABLE PENILE PROSTHESIS-ARTIFICIAL URINARY SPHINCTER VS. INDIVIDUAL DEVICE INSERTION-A RETROSPECTIVE SINGLE INSTITUTION STUDY Robert Segal, Marcelo Cabrini, Elaine Harris, Zhaoyong Feng, Bruce Trock, Jacek Mostwin, Trinity Bivalacqua, and Arthur Burnett Robert SegalRobert Segal Baltimore, MD More articles by this author , Marcelo CabriniMarcelo Cabrini Baltimore, MD More articles by this author , Elaine HarrisElaine Harris Baltimore, MD More articles by this author , Zhaoyong FengZhaoyong Feng Baltimore, MD More articles by this author , Bruce TrockBruce Trock Baltimore, MD More articles by this author , Jacek MostwinJacek Mostwin Baltimore, MD More articles by this author , Trinity BivalacquaTrinity Bivalacqua Baltimore, MD More articles by this author , and Arthur BurnettArthur Burnett Baltimore, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1960AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is a relative paucity of data on outcomes for combined 3-piece Inflatable Penile Prosthesis (IPP) and Artificial Urinary Sphincter (AUS) Insertion for the definitive treatment of erectile dysfunction and male stress incontinence, respectively. The objective of this study was to assess and compare patient demographics and outcomes for combined procedures vs. procedures wherein 1 individual device is implanted at a single institution. METHODS A retrospective review of all patients undergoing IPP and AUS insertion at the Johns Hopkins Hospital from January 2000-December 2011 was performed. A total of 54 combined procedures were performed, compared with 337 IPP and 281 AUS procedures. Comparisons between groups were performed using Chi-square tests for categorical data; the means of continuous data were compared by using the t test and non-parametric alternate if the distribution could not be normalized or the variance was not equal. All statistical tests were two sided and P < 0.05 was considered statistically significant. RESULTS The surgical approaches consisted of midline penoscrotal incisions for IPP, and transperineal incisions for AUS cuff placement with a secondary lower abdominal incision for AUS reservoir placement. Significant demographic differences between groups included those men undergoing combined implantation having a higher mean age (65.3 years vs. 59.9 years), risk of prostate cancer, prostatectomy and radiation therapy, and a lesser risk of Peyronie's disease, compared to men undergoing IPP alone (all P < 0.05). Although the duration of surgery was significantly longer for the combined procedure (mean 218.1 minutes vs. 145.9 minutes for IPP alone and 114.7 minutes for AUS alone, P < 0.0001), there was no increased risk of device infection, erosion or malfunction requiring surgical revision in the patients who received combined procedures (P = 0.37). Mean hospitalization duration for the combined procedure was 1.2 days (with 45/54 [83.3%] staying <24 hours), and mean follow-up for the combined procedure was 1.62 years, for IPP alone was 1.47 years, and for AUS alone, 2.98 years. CONCLUSIONS Combined IPP-AUS insertion is a safe procedure with no increased risk of adverse outcomes compared to individual prosthetic implantation. Patients should be counseled about this surgical option given the clear benefits of this approach, which include a single anesthesia event and faster restoration of erectile function and continence. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e231-e232 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Segal Baltimore, MD More articles by this author Marcelo Cabrini Baltimore, MD More articles by this author Elaine Harris Baltimore, MD More articles by this author Zhaoyong Feng Baltimore, MD More articles by this author Bruce Trock Baltimore, MD More articles by this author Jacek Mostwin Baltimore, MD More articles by this author Trinity Bivalacqua Baltimore, MD More articles by this author Arthur Burnett Baltimore, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intermediate outcomes after transcorporal placement of an artificial urinary sphincter

To report the intermediate outcomes of a transcorporally placed artificial urinary sphincter. Medical records of 16 consecutive patients treated with transcorporal placement of artificial urinary sphincter from March 2003 to October 2008 were reviewed. The indications for surgery, operative logs, postoperative evaluations, complication rate and postoperative questionnaire assessment utilizing the International Continence Society short form for men were analyzed. Eight patients each underwent primary transcorporal cuff placement and revision surgery. Complete data for analysis were available in 15 patients at a median follow up of 45 months (range 23-91 months). The success rate (defined as use of 0-1 pads per day) was 80% (12/15 patients). Average voiding score was 2/20 (standard deviation 1.88), average irritative score was 3/24 (standard deviation 4.92) and the mean Quality-of-Life score was 0.66 (standard deviation 1.04). Transcorporal placement of an artificial urinary sphincter is both safe and efficacious in patients with a small caliber or atrophic urethra, either as a primary or salvage procedure. Efficacy and level of satisfaction in this subset of patients is equivalent to those undergoing traditional artificial urinary sphincter cuff placement.

Small Intestinal Submucosa Urethral Wrap at the Time of Artificial Urinary Sphincter Placement as a Salvage Treatment Option for Patients With Persistent/Recurrent Incontinence Following Multiple Prior Sphincter Failures and Erosions

Patients with persistent and/or recurrent stress urinary incontinence (SUI) after multiple artificial urinary sphincter (AUS) revisions for erosion and infection represent a very challenging treatment population. Available management options are limited, with poor overall outcomes. We assess another treatment option. A retrospective analysis was performed of 8 patients presenting with severe, recurrent incontinence after multiple prior failed AUS procedures. All patients were treated with small intestinal submucosa (SIS) "urethral wrap" with subsequent AUS cuff placement to provide additional urethral bulk and serve as a "buffer" between the cuff and urethra. Eight patients (median age 76 years, range 55-81) presented with near-total (4-5 pads) to total urinary incontinence, having previously undergone a combined 19 AUS procedures with 6 tandem cuffs and 8 prior urethral erosions. At a median follow-up of 12.4 months, 38% (3/8) of patients were dry, requiring no pads. Three patients underwent AUS explantation for sphincter erosion (n = 2) and infection (n = 1). Two patients had recurrent incontinence, with one occurring after wrap revision for urinary retention. Patients with prior radiation accounted for 80% (4/5) of procedure failures. All patients had temporary postoperative urinary retention. SIS urethral wrap with AUS placement for severe SUI after multiple previous AUS placements and erosion/infection is a viable treatment option in appropriately selected patients for this very complicated issue. However, because of the complexity of the underlying problem, patients should be counseled about the expected risks and outcomes of surgery.

Impact of 3.5 cm Artificial Urinary Sphincter Cuff on Primary and Revision Surgery for Male Stress Urinary Incontinence

We report our initial clinical experience with the new 3.5 cm artificial urinary sphincter cuff. We reviewed the records of all men who underwent artificial urinary sphincter placement done by a single surgeon since September 2009. A perineal approach was used to ensure cuff placement around the most proximal corpus spongiosum after precise spongiosal measurement with a redesigned measuring tape. Clinical factors and cuff sizes were analyzed. During the 14-month study period 45 of 67 patients (67%) with an artificial urinary sphincter received the 3.5 cm cuff with no difference between primary and revision surgery (73% vs 58%, p = 0.29). Transcorporal cuff placement was reserved for 8 select patients (12%) after prior artificial urinary sphincter cuff erosion or complex urethroplasty. A tandem cuff artificial urinary sphincter was not used. Erectile dysfunction (89% vs 77%, p = 0.28) and prior radiation (47% vs 27%, p = 0.12) were more common in men who received a 3.5 vs a 4.0 cm or greater cuff. A similar proportion of men with a 3.5 cm vs a larger cuff (4 of 45 or 9% vs 2 of 22 or 9%) required explantation for infection and/or erosion. At our center the 3.5 cm cuff has become the predominant size used for primary and revision artificial urinary sphincter placement. Liberal use of the 3.5 cm cuff has simplified and improved artificial urinary sphincter placement without additional morbidity.

Correlation of Penile and Bulbospongiosus Measurements: Implications for Artificial Urinary Sphincter Cuff Placement

We assessed penile and bulbospongiosus measurements to develop a quantitative guide to select the surgical approach (perineal vs transscrotal vs transcorporeal) to artificial urinary sphincter cuff placement. We retrospectively reviewed the intraoperative records of 100 men who underwent artificial urinary sphincter placement (43) or anastomotic urethroplasty (57) from February 2008 to June 2009. Correlations between penile (stretched length and circumference at the shaft base) and bulbospongiosus (distal and proximal circumference) measurements were assessed. Cases were analyzed according to 2 penile circumference groups, including group 1-8.0 cm or less and group 2-8.5 or more. Mean proximal bulbospongiosus circumference was uniformly larger than distal bulbospongiosus circumference (4.5 vs 3.9 cm). It was about 50% of the penile shaft circumference (mean 8.9 cm, r = 0.70). In group 1 men the average distal bulbospongiosus circumference was 3.4 cm. They were more likely to undergo transcorporeal artificial urinary sphincter cuff placement than those in group 2, who had an average distal bulbospongiosus circumference of 4.1 cm (8 of 22 or 36% vs 1 of 21 or 5%, OR 11.4). Penile length correlated less robustly with distal and proximal bulbospongiosus circumference (r = 0.39 and 0.43, respectively). Patients with urethroplasty had significantly larger urethral measurements than those with the artificial urinary sphincter (proximal and distal bulbospongiosus circumference 4.9 vs 3.7 and 4.1 vs 3.2, respectively) but were significantly younger (47 vs 67 years), and less likely to have erectile dysfunction (11 of 57 vs 34 of 43) or to have undergone radical prostatectomy (0 of 57 vs 37 of 43). Bulbospongiosus circumference appears to be proportional to penile circumference. The distal bulbospongiosus is uniformly smaller than the proximal bulbospongiosus. The potential need for a perineal or transcorporeal approach to artificial urinary sphincter placement can be anticipated by penile circumference measurements and a combination of clinical factors, such as older patient age, history of radical prostatectomy and impotence.

A Multicenter Study on the Perineal Versus Penoscrotal Approach for Implantation of an Artificial Urinary Sphincter: Cuff Size and Control of Male Stress Urinary Incontinence

In a single center retrospective study we previously reported superior dry rates and fewer artificial urinary sphincter revisions when the sphincter cuff was placed via the traditional perineal approach compared with a penoscrotal approach. A multicenter study was performed to compare the approaches further and explain the disparity in outcomes. We performed a retrospective review of 158 patients who underwent these procedures from April 1987 to October 2007 at 4 centers. During 184 surgeries in 158 patients 201 artificial urinary sphincter cuffs were placed (90 penoscrotal and 111 perineal). Among patients with known followup the completely dry rate for single cuff artificial urinary sphincters was 17 of 62 (27.4%) in the penoscrotal group and 41 of 93 (44.1%) in the perineal group (p = 0.04). Continued incontinence necessitated subsequent tandem cuff in 7 of the 62 (11.3%) penoscrotal cases compared to only 5 of the 93 (5.4%) perineal cases. Cuff size in the penoscrotal group was 5.0 cm in 1 patient (1.1%), 4.5 cm in 11 (12.2%) and 4.0 cm in 78 (86.7%). Cuff size in the perineal group was 5.5 cm in 1 patient (0.9%), 5.0 cm in 8 (7.2%), 4.5 cm in 30 (27.0%) and 4.0 cm in 72 (64.9%). There appears to be a higher completely dry rate with fewer subsequent tandem cuff additions with the perineal approach compared to the penoscrotal approach. This disparity may be explained by a more proximal artificial urinary sphincter cuff placement in the perineal group as evidenced by a larger cuff size.

S41 A multicenter study on perineal versus penoscrotal approach for implantation of an artificial urinary sphincter: cuff size and control of male stress urinary incontinence

In a single center retrospective study we previously reported superior dry rates and fewer artificial urinary sphincter revisions when the sphincter cuff was placed via the traditional perineal approach compared with a penoscrotal approach. A multicenter study was performed to compare the approaches further and explain the disparity in outcomes.We performed a retrospective review of 158 patients who underwent these procedures from April 1987 to October 2007 at 4 centers.During 184 surgeries in 158 patients 201 artificial urinary sphincter cuffs were placed (90 penoscrotal and 111 perineal). Among patients with known followup the completely dry rate for single cuff artificial urinary sphincters was 17 of 62 (27.4%) in the penoscrotal group and 41 of 93 (44.1%) in the perineal group (p = 0.04). Continued incontinence necessitated subsequent tandem cuff in 7 of the 62 (11.3%) penoscrotal cases compared to only 5 of the 93 (5.4%) perineal cases. Cuff size in the penoscrotal group was 5.0 cm in 1 patient (1.1%), 4.5 cm in 11 (12.2%) and 4.0 cm in 78 (86.7%). Cuff size in the perineal group was 5.5 cm in 1 patient (0.9%), 5.0 cm in 8 (7.2%), 4.5 cm in 30 (27.0%) and 4.0 cm in 72 (64.9%).There appears to be a higher completely dry rate with fewer subsequent tandem cuff additions with the perineal approach compared to the penoscrotal approach. This disparity may be explained by a more proximal artificial urinary sphincter cuff placement in the perineal group as evidenced by a larger cuff size.