Editorial Comment on "Salvage Artificial Urinary Sphincter Placement After Sling Failure: Long-term Outcomes and Institutional Predictors in a Population-based Cohort".

Abstract Introduction Patients with post-prostatectomy erectile dysfunction (ED) and stress urinary incontinence (SUI) often require dual prosthetic implants. A single-incision penoscrotal approach enables simultaneous AUS and inflatable penile prosthesis (IPP) placement, reducing operative time and morbidity. Objective To demonstrate a streamlined surgical technique for simultaneous AUS and IPP implantation via a single penoscrotal incision in a patient with dual dysfunction after radical prostatectomy. Methods A male patient with persistent SUI and ED underwent combined AUS and IPP placement. The procedure was performed through a midline penoscrotal incision. Following corporal dilation and IPP cylinder placement, the bulbar urethra was exposed, and an AUS cuff was positioned. The IPP pump and AUS pump were placed in the scrotum, and the reservoir and pressure-regulating balloon were inserted through the same incision. Results The surgery was completed without complications. The single-incision technique allowed efficient access to both prosthetic spaces. At follow-up, the IPP was activated at 4 weeks and the AUS at 6 weeks. The patient reported significant improvement in both erectile function and continence, with high satisfaction and no postoperative complications. Conclusions The combined penoscrotal approach for AUS and IPP placement is a practical and effective solution for patients requiring dual prosthetic intervention. This video highlights operative steps and pearls to assist surgeons in adopting this single-incision strategy. Disclosure No

Abstract Introduction Post-prostatectomy stress urinary incontinence (SUI) is a common and distressing complication. The artificial urinary sphincter (AUS) is the gold standard treatment, with the transperineal approach offering excellent exposure and control during cuff placement. Objective To demonstrate the surgical steps, anatomical considerations, and perioperative outcomes of transperineal AUS insertion in a patient with SUI following radical prostatectomy. Methods A male patient with persistent SUI after radical prostatectomy and no history of pelvic radiation underwent AUS placement via a transperineal approach. The procedure was performed under general anesthesia in lithotomy position. The bulbar urethra was dissected, a cuff was sized and placed, and remaining components were positioned in standard fashion. Results The procedure was completed without complications. The transperineal access facilitated direct visualization and safe dissection of the urethra. The cuff was appropriately sized and placed around the bulbar urethra, with the pump inserted in the scrotum and the pressure-regulating balloon in the prevesical space. The patient recovered uneventfully and experienced significant improvement in continence after activation. Conclusions The transperineal approach remains a reliable and effective technique for AUS placement in non-irradiated patients. This video provides a step-by-step overview to assist urologists in mastering this foundational surgical technique. Disclosure No

Abstract Introduction Stress urinary incontinence (SUI) and erectile dysfunction (ED) are known complications following radical prostatectomy. Artificial urinary sphincter (AUS) and inflatable penile prosthesis (IPP) placement are effective surgical treatment options for patients who have persistently bothersome SUI and ED, respectively. Patients with concurrent severe SUI and ED may require placement of both implants, which can be performed either in a synchronous or staged fashion. Objective This study seeks to assess differences in outcomes based on the timing of dual implant placement. Methods We performed a retrospective review using the Merative™ Marketscan® Commercial Database from 2007 to 2021. Men >20 years of age who underwent IPP and/or AUS placement were identified using administrative procedure codes. The procedure date was used to identify patients who underwent synchronous or staggered placement in patients with dual implants. Administrative diagnosis and procedure codes were used to assess subsequent reoperation for infection or revision. Associated conditions were controlled for, including patient age, smoking status, obesity, hyperlipidemia, and hypertension. Results We identified 17,848 men who underwent IPP placement and 4277 men who underwent AUS placement. A total of 623 men in these cohorts received both implants. Of these patients, 344 had synchronous placement while 279 had staged placement. IPP reoperation occurred in 7% of patients in the synchronous group and 8.2% in the staged group. AUS reoperation occurred in 9.3% of men in the synchronous group and 7.9% in the staged group. Synchronous placement of IPP and AUS was not associated with an increased risk of reoperation for IPP (HR 0.98, 95% CI 0.55-1.77, p=0.95) or AUS (HR 1.51, 95% CI 0.87-2.62, p=0.15) when compared to staged placement. Additionally, dual implant status was not associated with a higher risk of reoperation of IPP (HR 1.29, p=0.09) or AUS (HR 1.20, p=0.53) when compared to patients with single implants. Conclusions There was no difference in rates of reoperation when comparing synchronous or staged implant placement in patients who require placement of both IPP and AUS devices. Neither method was associated with increased rates of reoperation compared to single-implant patients. The timing of dual implant placement does not appear to impact the reoperation rate and can be offered based on surgeon and patient preference. Disclosure No

Abstract Introduction Patients with prior pelvic radiation are at increased risk of urethral complications during AUS placement due to fibrosis and tissue fragility. The transcorporeal approach offers additional support to the urethra, reducing the risk of erosion. Objective To illustrate the transcorporeal AUS placement technique in a patient with a history of radical prostatectomy and pelvic radiation, highlighting key steps that enhance safety and reduce complications. Methods A patient with radiation-associated SUI underwent AUS insertion using a transcorporeal approach through a perineal incision. Bilateral corporotomies were performed to create a protective tunnel around the urethra, within which the cuff was placed. All components were inserted using standard techniques. Results The procedure was successful with no intraoperative complications. The transcorporeal placement allowed secure cuff positioning while minimizing pressure on the irradiated urethra. Device activation at 6 weeks showed proper function, and the patient reported improved continence with no early signs of erosion or malfunction. Conclusions The transcorporeal technique is a safe and effective alternative for AUS placement in patients with prior radiation exposure. This video outlines the critical anatomical landmarks and procedural adaptations that urologists should consider when approaching complex prosthetic cases. Disclosure No

Salvage Artificial Urinary Sphincter Placement After Sling Failure: Long-Term Outcomes and Institutional Predictors in a Population-Based Cohort.

Does Saline “Leak Test” Alter Urethral Measurement in Male Artificial Urinary Sphincter Placement?

Outcomes of day case artificial urinary sphincter placement in men: a tertiary centre experience

PurposeRecurrent stress incontinence (SUI) in patients with an artificial urinary sphincter (AUS) is a diagnostic challenge. History, physical exam and office cystoscopy are often inadequate for determining the cause of device related issues. Our objective is to describe our experience with contrast use in the AUS and how this can aid in diagnosing mechanical failure.Materials and MethodsA retrospective evaluation of patients undergoing primary AUS placement from 1983 to 2022 was performed. We present our surgical technique for AUS placement and standard workup algorithm for patients with recurrent SUI. In our practice, standard evaluation includes history and physical, flexible cystoscopy with the cuff deactivated, and X-ray film of the abdomen and pelvis. Patients with device malfunction are identified via loss of contrast from the AUS system on X-ray. Device survival is presented via Kaplan—Meier method.ResultsDuring the study, 1,635 patients underwent primary AUS placement with a median (interquartile range [IQR]) follow-up of 4.26 years (1.0, 9.0). Of these, 220 patients (13.5%) were found to have mechanical failure with loss of contrast from the AUS system on X-ray imaging. The median time to mechanical device failures was 4.98 years (IQR 2.4, 9.2). Devices free of mechanical malfunction was 97.6% at 1 year and 89.6% at 5 years.ConclusionsThe differential diagnosis of recurrent SUI after AUS includes multiple device related issues. Filling the AUS with iso-osmotic contrast is an effective way to diagnose mechanical failure. We present our technique as a useful adjunct for other AUS surgeons.

Robot-assisted Artificial Urinary Sphincter (AUS) placement in women

We developed an innovative 2-stage procedure combining transurethral sphincterotomy (TURS) with artificial urinary sphincter (AUS) implantation to restore voiding in patients with refractory bladder emptying disorders. This proof-of-concept study evaluated its safety and efficacy. We retrospectively reviewed clinical data from patients who underwent combined TURS and AUS implantation between April 7, 2021, and October 31, 2024. Eligible patients had neurogenic bladder with refractory emptying, irreversible neurogenic disease, and no mechanical obstruction (e.g., urethral strictures). In the TURS stage, the entire inner urethral segment corresponding to the external sphincter was resected to induce intrinsic sphincter deficiency; this was followed by AUS placement. We analyzed patient demographics, preoperative and postoperative daily pad usage, clean intermittent catheterization (CIC) frequency, patient-reported outcomes (Life Quality [LQ], International Consultation on Incontinence Questionnaire [ICIQ], Sandvik Severity Index [SAND]), postvoid residual (PVR) urine volume, estimated glomerular filtration rate (eGFR), abdominopelvic ultrasonography, and postoperative complications. Four out of 6 patients (66.7%) successfully achieved CIC-free status, with effective self-voiding achieved through AUS activation and abdominal pressure generation. Significant improvements were documented in LQ scores (P=0.042), ICIQ scores (P=0.004), and SAND scores (P=0.039). Median PVR significantly decreased from 237.5 mL (interquartile range [IQR], 112.5-317.5 mL) preoperatively to 1.5 mL (IQR, 0-85.8 mL) postoperatively (P=0.028). No patient demonstrated upper-tract damage or significant eGFR change. One patient developed an AUS infection requiring explantation; another remained CIC-dependent due to insufficient abdominal pressure. Combining TURS with AUS implantation is a safe and effective surgical option for refractory bladder emptying disorders, yielding significant improvements in voiding autonomy and quality of life while reducing catheter dependence. Future studies with larger cohorts and longer follow-up are warranted to validate safety, long-term durability, and broader applicability. These findings may shift current paradigms in neurogenic bladder management.

Surgical competencies in Urology: Agreement between the perceptions of trainees and practicing professionals in a Latin American country.

Objective: To compare cost-effectiveness of rehabilitation models for patients with urinary incontinence following radical prostatectomy.Materials and methods: We evaluated direct costs of rehabilitation as part of the existing approach in patients with urinary incontinence following radical prostatectomy in the Yaroslavl Region and developed a rehabilitation strategy (artificial urethral sphincter placement). We conducted a comparative analysis of the direct costs of the strategies.Results: The use of absorbent products for rehabilitation of patients with urinary incontinence following radical prostatectomy requires an average of 293300 (US $2650) per patient annually. The rehabilitation strategy with artificial urinary sphincter placement costs 486215 (US $4420) and results in a 65% increase in costs in the first year. However, in the second year of the rehabilitation program, artificial urinary sphincter placement has an obvious economic advantage, and within 10 years rehabilitation of a working-age patient using this strategy can save 2400000 (US $22244) (inflation expectations were not accounted for).Conclusions: The implementation of the rehabilitation program involving artificial urinary sphincter placement for patients with urinary incontinence following radical prostatectomy has significant social and economic impacts.

To evaluate the impact of pelvic radiation therapy on artificial urinary sphincter cuff outcomes and to determine the optimal timing of artificial urinary sphincter insertion after radiation therapy in patients with post-prostatectomy stress urinary incontinence. This retrospective study included 283 patients who underwent artificial urinary sphincter placement between 2003 and 2023. Cuff revision and removal rates were analyzed using Kaplan-Meier survival analyses and competing risk models. Cox proportional hazard regression was used to identify the predictive factors. Restricted cubic spline analysis was used to determine the optimal timing of artificial urinary sphincter insertion after radiation therapy. Over a median of 2.8 years, 54 patients (20.3%) required cuff revision and 17 (7.4%) underwent cuff removal. Radiation therapy was not significantly associated with cuff revision but increased the risk of cuff removal more than threefold (hazard ratio: 3.30, 95% confidence interval: 1.05-10.40, P = 0.041). Patients with prior radiation therapy underwent significantly earlier and more frequent cuff removals than those without prior radiation therapy (P = 0.003) and had a significantly higher cumulative risk of cuff removal (P = 0.04). Additionally, exploratory restricted cubic spline analysis showed a trend suggesting that AUS insertions performed after 635 days (1.74 years) post-radiation therapy were associated with lower rates of cuff removal, though not statistically significant. Previous radiation therapy significantly increased the risk of artificial urinary sphincter cuff removal but not revision. Exploratory analysis suggests that the timing of AUS insertion after RT may influence cuff removal rates, with a trend toward lower risk after 1.74 years post-RT. These findings warrant further prospective investigation.

Artificial Urinary Sphincter (AUS) placement is the preferred treatment for moderate to severe incontinence following prostate cancer treatment. While device related outcomes related to device survival are well reported, literature on quality-of-life outcomes, including the use of validated measures is limited. We queried a prospectively maintained database of male patients undergoing primary AUS implantation from 2015 to 2023 at our institution. All patients completed a preoperative Michigan Incontinence Symptom Index (M-ISI) and Patient Global Impression of Improvement (PGI-I). Postoperative quality of life data was obtained by mailed correspondence. Surveys obtained following AUS reoperation/revision were excluded. Pairwise comparisons were performed between preoperative functional status and the Postoperative responses. Logistic regression analysis was performed to identify preoperative variables associated with a favorable PGI-I score defined as "very much better or much better," or a decrease in pad usage from > 1 pad per day to ≤ 1 pad per day. During the study timeframe, 383 patients underwent primary AUS placement, of which 163 patients (42%) completed a postoperative survey and were included in the study. Median age was 69.0 (IQR: 64-74) and 54.6% of patients had a history of pelvic radiation. The median time from surgery to the postoperative survey was 2.2 years (IQR: 0.9, 4.3). Compared to baseline, following AUS placement there was a significant improvement in the total M-ISI score (10 [6, 16) vs 26 [22, 30]; p < 0.0001) (Minimally Important Difference = 4). This included improvements in the SUI subscore [4 (IQR 2, 6) vs 10 (IQR: 9, 12); p < 0.0001] and bother score [1 (IQR: 0, 3) vs 6 (IQR: 5, 7); p < 0.001)]. Pad usage significantly decreased following device placement (p < 0.0001). The vast majority of patients (90.7%) would "definitely or probably recommend to a friend/family member." On univariable analysis, active smoking (ref. never) was associated with adverse pad use outcomes (OR: 0.1, 95% CI: 0-0.8; p = 0.03) and older age was associated with adverse PGI-I outcome (OR: 0.93, 95% CI: 0.87-0.99; p = 0.02). Following AUS implantation, most patients have significant improvement in validated quality of life outcomes and low pad usage. These findings persist despite multiple preoperative comorbidities and should be considered when counseling patients before AUS placement.

Artificial Urinary Sphincter Placement Before or After Radiation Therapy: Does Timing of Radiation Impact Surgical Complications and Continence?

Reply to Persistent Opioid Use following Artificial Urinary Sphincter Placement: A Large Claims Database Analysis

Robot-assisted Implantation of an Artificial Urinary Sphincter for Females with Stress Urinary Incontinence: State of the Art and Future Perspectives.

Vesicourethral anastomosis stenosis (VUAS) is a well-known complication of prostate cancer treatments, observed in up to 26% of the cases after radical prostatectomy. Conservative management, with single or even repeated transurethral dilation or endoscopic incision of the stenosis, is successful in many cases, but up to 9% of patients are destined to fail after endoscopic treatment. In these cases, a revision of the vesicourethral anastomosis is necessary and can be realized with different surgical approaches. We aim to describe the technique and the outcomes of a new prerectal approach for VUAS repair. Twelve patients with recalcitrant VUAS following radical prostatectomy were enrolled between May 2014 and September 2018 for prerectal transperineal re-anastomosis. The evaluated outcomes were: the rate of successful anatomical repair at 3 months after surgery and at the last follow-up, postoperative incontinence and complications rate, and the need for further treatments. No major intraoperative complications occurred. After a median follow-up of 46 months (IQR 36-55), 10 patients (83.3%) achieved a good anatomical repair even if one man required an endoscopic urethrotomy, while two patients (16.67%) with a history of pelvic radiotherapy developed a surgical site infection that required toilette and external urinary diversion. Among the others, nine (75%) developed severe stress urinary incontinence, with resolution of their condition. No patient reported significant postoperative pain or fecal incontinence. The prerectal approach to VUAS repair allows direct access to the posterior urethra and the anastomosis, providing a better mobilization of the bladder neck for tension-free anastomosis. However, patients with a history of pelvic radiotherapy have a higher risk of complications. Postoperative incontinence is very common, but urinary continence could be restored with subsequent artificial urinary sphincter placement.

Urinary incontinence after radical treatment of prostate cancer causes a significant negative impact on the quality of life. Patients with severe urinary incontinence are most commonly treated with artificial urinary sphincter (AUS) placement. To evaluate the functional results of AUS implantation in patients with severe urinary incontinence at long-term follow-up. Between 2004 and 2023, the AUS was implanted in 62 patients with severe stress urinary incontinence. Urinary losses were assessed using a bladder diary. No need to use pads or use of no more than 1 safety pad per day ("social continence") was considered a success, while use of no more than 2 pads, or a reduction in urine loss of more than 50% was regarded as an improvement. The mean patient age at the time of AUS implantation was 67.4+/-8 years. Urinary incontinence was most often a complication of radical prostatectomy (61.3%). A history of radiation therapy, previous treatment of urethral stricture, and surgical procedures for urinary incontinence were noted in 14.5%, 48.4%, and 19.4% of patients, respectively. The median follow-up was 73.5 months (IQR 14.8-118.3 months). There was a significant decrease in median urine loss from 900 mL (IQR 700-1100 mL) to 7 mL (IQR 0-35 mL; p<0.05), and a decrease in the number of pads used per day from 7 (IQR 6-8) to 1 (IQR 0-2; p<0.05). The criterion for successful implantation was met in 69.4% of patients, while 43.5% of patients did not use pads. According to the correlation analysis, concomitant diabetes mellitus, history of radiation therapy, surgical treatment of the urethral stricture or urinary incontinence did not have any significant effect on functional results. In addition, there were no cases of AUS revision. AUS placement in patients with severe stress urinary incontinence allows to achieve satisfactory functional results during long-term follow-up.