Artificial Urinary Sphincter Research Articles

Management of Post-RALP SUI and ED - What are and What Should we be Doing?

Although there have been advancements in minimally invasive surgical techniques for radical prostatectomy, surgery can still significantly impact continence and erectile function (EF), resulting in considerable quality-of-life impairment. This review critically evaluates existing treatment options for male stress urinary incontinence (SUI) and erectile dysfunction (ED) post-robotic-assisted laparoscopic prostatectomy (RALP), alongside exploring emerging trends and discussing future directions for managing and preventing both conditions. Patient history is pivotal in guiding surgical decisions, with the intensity of symptoms and their impact on the patient's life being primary influences for deciding the best treatment options for both SUI and ED. Penile rehabilitation strategies (PR) show promise in mitigating the effects of prostate cancer treatments on EF and improving overall health, though consensus is lacking on specific programs or initiation of timing for optimal recovery post-surgery. All patients undergoing RALP should receive preoperative counseling about SUI and early pelvic floor physical therapy. Fixed and adjustable slings effectively treat mild-to-moderate post-RALP SUI, while the artificial urinary sphincter is the gold standard for men with moderate or severe SUI. EF recovery after RALP faces obstacles such as patient characteristics, compliance, and cost, with no standardized PR approach. Future research should prioritize studies aiming to optimize treatment methods and enhance patient compliance.

Efficacy and Safety of Artificial Urinary Sphincters in Female Patients With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

Efficacy and Safety of Artificial Urinary Sphincters in Female Patients With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

Novel Utilization of a Penrose Drain as a Spacer During Temporary Artificial Urinary Sphincter Explantation and Rectourethral Fistula Repair

Novel Utilization of a Penrose Drain as a Spacer During Temporary Artificial Urinary Sphincter Explantation and Rectourethral Fistula Repair

Augmentation cystoplasty in children with neuropathic bladder: long-term outcomes after 30 years experience.

Augmentation cystoplasty (AC) is a useful alternative for the treatment of neuropathic bladder, although there are few studies reporting long-term results. We assess our experience over the last 30-years. A retrospective study was conducted in patients with neuropathic bladder in whom AC was performed in our institution between 1990-2020. Demographic variables, pre- and post- AC urodynamic studies, long-term outcomes and postoperative complications were collected. Eighty-six patients (43 males and 43 females) underwent AC surgery with a median age of 12.8 years (interquartile range 9.6-15.1). Bladder augmentation was performed with ileum in 49 cases (57%), sigma in 32 cases (37.2%) and ureter in 5 cases (5.8%). In 27 patients an artificial urinary sphincter (AUS) was placed at the same intervention. The mean preoperative bladder capacity was 117 mL (SD 40), which was increased to 430 mL (SD 64) one year after surgery, this difference being statistically significant (P<0.001). Median follow-up was 24.5 years (interquartile range 17.5-26). Vesico-ureteral reflux improved after AC in 78.9% with no other surgical interventions. Seven mechanical complications associated with AUS were reported. Bladder lithiasis was reported in 9 patients. No bladder perforations were described. One patient developed bladder squamous cell carcinoma 16 years after AC, requiring radical cystectomy and Hautmann neobladder. Long-term results of this study demonstrate that AC is an effective surgical treatment in patients with neuropathic bladder patients without proper response to medical treatment. The risk of developing complications long after bladder augmentation makes close clinical follow-up of these patients essential.

Vessel-sparing non-transecting anastomotic reconstruction of the posterior urethra: Single center experience with long-term follow-up

OBJECTIVETo discuss the long-term results of our vessel-sparing non-transecting approach (vspEPA) to perform anastomotic urethroplasty at the posterior urethra. We avoid transecting the bulbar arteries to preserve the antegrade vascularization of the urethra. We hypothesize that vspEPA is feasible, safe and not inferior to the traditional transecting technique. Additionally, it may provide benefits if an artificial urinary sphincter (AUS) implantation be required in the future. METHODSThe bulbar urethra was elevated from the corpus cavernosum, released distally, retracted laterally, and approached dorsally at the bulbo-membranous junction. This exposure allows removal of the scar and perform the anastomotic reconstruction as in the standard transecting technique, while avoiding division of the bulbar arteries. RESULTS127 patients, median age 58 years (IQR 35-67), were reconstructed since 2008. Etiology of the stenosis was BPH surgery (n=48), pelvic fracture urethral injury (PFUI) (n=61), prostate cancer treatment (n=14) and instrumentation (n=4). With a median follow-up of 43 months (IQR 17-74) stenosis repair success was observed in 121 patients (95%). High grade complications (Clavien ≥III) occurred in 6 (5%) of cases and overall stress incontinence was observed in 24 (19%) of patients. 14 patients subsequently received an AUS and notably none of them suffered cuff erosion after a median follow up of 36 months, CONCLUSIONSparing of the bulbar arteries during anastomotic reconstruction of the posterior urethra is feasible and safe. Although slightly more elaborated, it will not compromise the surgical results and may be instrumental to avoid AUS cuff-related erosion in the future.

Editorial Comment on "Persistent Opioid Use following Artificial Urinary Sphincter Placement: A Large Claims Database Analysis"

Editorial Comment on "Persistent Opioid Use following Artificial Urinary Sphincter Placement: A Large Claims Database Analysis"

Robot‐assisted laparoscopic continent cutaneous urinary diversion in adults: A single‐centre study

AbstractObjectivesTo show that robot‐assisted laparoscopic cutaneous continent urinary diversion (RALCCUD) is feasible and safe; however, data on clinical outcomes in adults are lacking.Materials and methodsWe conducted a retrospective study of all adults who underwent RALCCUD between 2017 and 2022 at a single tertiary reference centre.Patient characteristics, clinical information and perioperative outcomes were recorded. All patients underwent pre‐ and postoperative urodynamic evaluations.Functional outcomes were evaluated at 3 months, then yearly. Continence was defined as no stomal or urethral leakage.ResultsTwelve patients, mostly women (n = 11), median (IQR) age 47.4 (19–57) years underwent RALCCUD (four Mitrofanoff, four Yang‐Monti and four Casale). The main indication for surgery was inability to perform intermittent self‐catheterization through the native urethra.Eleven patients (92%) had neurogenic lower urinary tract disease caused by spinal cord injury or spinal dysraphism.Median (IQR) operative time was 313 (285–367) min. Four patients (33%) underwent concomitant procedures: three supratrigonal cystectomy (SC) with augmentation cystoplasty (AC) and one artificial urinary sphincter (AUS). No conversions to an open approach were required. Median (IQR) follow‐up was 51 (40–61) months. One early postoperative complication occurred (Clavien grade III). The late postoperative complication rate was 17%, with three complications occurring in three patients.At the last follow‐up, all patients could self‐catheterize through the tube, and the stomal and urethral continence rate was 100%.ConclusionRALCCUD is feasible and safe in adults, with a high rate of stomal and urethral continence and a low complication rate.

Outcomes of transperineal reanastomosis as a salvage treatment for recurrent vesicourethral anastomosis stenosis after radical prostatectomy

Purpose: To evaluate transperineal reanastomosis (TRPA) combined with incontinence surgery as a complex treatment for recurring vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy (RP). Methods: Retrospective analysis of 8 patients who underwent TRPA for recurring VUAS. Detailed preoperative and follow up data were assessed. Results: Mean follow up lasted 47 months (range 17-77) with mean age being 63.4 years (range 61-70). All patients achieved patency and 87.5% (7/8) maintained it to the end of follow up. However, four of them required additional procedures to retain patency. Six underwent incontinence surgery – artificial urinary sphincter (AUS) implantation – after which one cuff erosion occurred. In the end 62.5% (5/8) of patients achieved patent urethra and continence. Conclusions: TRPA combined with incontinence surgery is a reasonable treatment for patients with recurrent VUAS. Nonetheless, this is a set of difficult surgeries that may ultimately end in failure, i.e. the inability to restore urethral patency, urinary incontinence or urinary diversion, hence they should be performed by experienced surgeons.

Determining the Severity of Benign Urologic Health States in Men Using Utilities Measures

ObjectivesTo assess a population level perceived health status of common reconstructive urologic conditions using health utilities. MethodsHealth utilities are generic quality of life measures that can help describe overall health status and can quantitatively compare different disease states and the perceived benefits of various interventions. An a priori determined, representative sample of adult men were recruited by Qualtrics™ to review standardized scenarios describing typical patients with reconstructive urologic conditions, surgeries to treat conditions, and control conditions (e.g. blindness, osteoarthritis). Condition-specific health status was measured using four tools: visual analog scale, standard gamble, time-trade off and willingness-to-pay and reported in Quality-adjusted Life Years (QALY; range 0.0 (death) to 1.0 (perfect health)). ResultsWe analyzed 562 completed surveys from condition-naive participants. Condition-specific health status ranged from a mean of 0.52 QALY to 0.66 QALY, with all reconstructive conditions perceived to be worse than osteoarthritis and monocular blindness (QALY 0.68). Health status was lowest for adult acquired buried penis (0.52 QALY) and pelvic radiation disease (0.53 QALY), comparable to binocular blindness (QALY 0.52). Treatment of erectile dysfunction with inflatable penile prosthesis (∆QALY +0.02; p<0.001) and stress urinary incontinence with artificial urinary sphincter (∆QALY +0.04; p<0.001) offered only nominal perceived gain in health status. ConclusionsHealth utilities may improve the ability to discriminate between heterogeneous reconstructive urologic disease states. For non-oncologic disease states in which mortality is not measured, health utilities could improve the ability to measure societal impact and justification for clinical and research investment.

Persistent Opioid Use Following Artificial Urinary Sphincter Placement: A Large Claims Database Analysis

ObjectiveTo assess risk of persistent opioid use and emergency department (ED) and office/outpatient visits following post-operative prescriptions of common opioids in patients following artificial urinary sphincter (AUS) implantation using a nationwide claims database. MethodsThe TriNetX US Collaborative Network, which encompasses over 115 million patients from 66 healthcare organizations was used to identify males who underwent first-time AUS placement between 2010-2024. Patients with history of opioid dependence/abuse, opioid use within six months prior to AUS placement, or surgery within 9 months post-operation were excluded. Patients were distributed into two cohorts: those who received opioids post-operatively or those that did not. Cohorts were propensity score matched on demographic characteristics, pain, mental health, and substance-related diagnoses. Primary outcome was risk of persistent opioid use 3-9 months post-operatively. Secondary outcomes included risk of ED or office/outpatient visit 30- and 90- days post-operatively. ResultsEach cohort contained 1,036 patients following application of exclusion criteria and propensity score matching. Post-operative Oxycodone, Hydrocodone, or Codeine had a three-fold increase in risk of persistent opioid use at 3-9 months (15.15% vs. 4.92%, RR=3.08, 95% CI=[2.27-4.17]). Risk of ED or office visits was not significantly lower in patients receiving these opioids. ConclusionOpioid prescriptions following AUS placement increases risk of persistent opioid use without lowering the risk of ED or outpatient visits. These findings highlight the necessity for opioid-sparing approaches to post-operative pain control following AUS placement.

Artificial Urinary Sphincter Implants in Men: A National Health Care Data System-Based Study to Assess Reinterventions in France.

Significant concerns remain regarding the long-term outcomes of AMS 800 artificial urinary sphincter (AUS) implants in men. The objective was to assess the long-term AUS reintervention (replacement or removal) rates after a first-ever AUS implantation. This population-based retrospective cohort study included all men age ≥ 18 years in France who underwent a first-ever AUS implantation (identified using a unique device identifier) for male stress urinary incontinence (SUI) after prostate cancer (PCa) or benign prostatic hyperplasia (BPH) treatment, between January 1, 2006, and December 31, 2018. The primary outcome was reintervention-free survival rates (replacements and removals), estimated using the Kaplan-Meier method. Secondary outcomes were replacement and removal. A multivariable Cox proportional hazards model was used to assess associations between patient and hospital factors and the hazard of reintervention. The study included 8475 men with a median age of 69 years (IQR, 65-74) and a median follow-up time of 6 years (IQR, 3-9). Reintervention-free survival was 71% (95% CI, 70-72) at 2 years, 57% (95% CI, 55-58) at 5 years, and 40% (95% CI, 38-41) at 10 years. Reintervention-free survival was lower after BPH surgery, after radiotherapy combined with RP, and in centers performing fewer implantations. Removal-free survival was 83% (95% CI, 83%-84%) at 2 years, 75% (95% CI, 74%-76%) at 5 years, and 66% (95% CI, 65%-68%) at 10 years. Among men undergoing AUS implantation for SUI because of PCa or BPH treatment, the probability of reintervention was 29% within 2 years after implantation. The median time to reintervention was 6.6 years (IQR, 6.4-7.1), and the reintervention-free survival rate at 10 years was 40%. These insights can inform therapeutic decision making for patients and surgeons during the management of male SUI.

Long-term results of artificial urinary sphincter in women: A retrospective monocentric study

BackgroundStress urinary incontinence (SUI) is a public health issue, with major impact on quality of life. An efficient treatment for intrinsic sphincter deficiency (ISD) is the artificial urinary sphincter (AUS). ObjectivesAnalyzing patient survival in terms of revision-free survival, removal-free survival and global survival without reintervention long-term results concerning continence status and complications. DesignWomen with severe ISD and negative Bonney test who were treated with AUS first implantation between 1987 and 2022 were included. ResultsIn our study, 478 patients were treated by AUS first implantation with a mean age of 59.7. The median follow-up time was 13.2years. The median revision-free survival was 19.5years with survival rates at 10, 20 and 30years were 86%, 47% and 32% respectively. Removal-free survival rates at 10, 20 and 30years were 84%, 80% and 60% respectively. Median reintervention-free survival was 17.5years. Survival was negatively affected by neurological etiology of the ISD, history of previous incontinence treatment and intraoperative complications with more early removals in the latter group. The absence of previous incontinence surgery was a protecting factor. Continence status was assessed at 10, 20 and 30years follow-up with a fully continence rate of respectively 83%, 68% and 61%. Intraoperative complication rate was 17.7%, explantation rate was 14% and the revision rate was 23%. ConclusionWomen treated with AUS have an excellent revision-free, removal-free and global survival rate. AUS is a very efficient treatment for women with ISD in terms of continence results with an acceptable intraoperative and long-term complication rate of which patients should be well informed before choosing this treatment for their SUI.

Robotic female artificial urinary sphincter implantation vs. male artificial urinary sphincter implantation for non-neurogenic stress urinary incontinence

PurposePrevious studies suggested better functional outcomes and longer device survival for female artificial urinary sphincter (AUS) implantation compared to male AUS implantation. We hypothesized that the adoption of robotic approaches for female implantation might have influenced these comparisons. This study aimed to compare the outcomes of robotic female AUS and male AUS implantation for non-neurogenic stress urinary incontinence (SUI).MethodsWe retrospectively reviewed charts of male patients who had AUS implantation and female patients who underwent robotic AUS implantation for non-neurogenic SUI between 2010 and 2022 at a single center. Prior AUS implantations were exclusion criteria. The primary endpoint was continence status at 3 months, categorized as complete resolution of SUI (0 pad), improved SUI (1pad), or unchanged SUI (>1pad).ResultsAfter excluding 79 patients, 171 were included: 70 women and 101 men. Operative time was shorter in males (126.9 vs. 165.5 min; p < 0.0001). Postoperative complication rates were similar (17.3% vs. 22.9%; p = 0.38). Continence status at 3 months and last follow-up favored females. The ICIQ-SF decrease at 3 months was greater in females (-7.2 vs. -4.6; p < 0.001). The 5-year estimated explantation-free survival was similar (78.6% vs. 73.7%; p = 0.94) as was the revision-free survival (67.4% vs. 61.7%; p = 0.89). Multivariate analysis showed that female gender was associated with better continence at last follow-up (OR = 4.3; p = 0.03).ConclusionRobotic female AUS implantation is associated with better functional outcomes than male AUS implantation, with similar morbidity and survival rates.

Single-component artificial urinary sphincter: Outcomes from one centre in Portugal.

Radical prostate cancer treatment is the predominant cause of iatrogenic stress urinary incontinence (SUI) in men, significantly impacting their quality of life (QoL). This prospective single-center study in Portugal aimed to evaluate the outcomes of men with moderate-to-severe SUI treated with a single-component artificial urinary sphincter (AUS). Male patients with iatrogenic moderate-to-severe SUI, determined by a 24-hour pad weight test, were included. The single-component device comprises a cuff linked to a pump unit through a kink-resistant tube. The implantation involved perineal incision for cuff placement and an inguinal incision for pump and tank positioning within the scrotum. Complications, pad usage, perioperative complications (Clavien-Dindo classification), and quality of life assessment using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire were documented. Between May 2021 and March 2023, 20 consecutive single-component AUS insertions were conducted at a Portuguese urology department. Follow-up concluded in July 2023, with a mean follow-up duration of 15 months (range: 5-27). Four patients experienced complications necessitating device revision or removal (erosion = 2, infection = 1, mechanical failure = 1). Social continence (0/1 pad/day) was achieved in 70% (14/20 patients), while 30% (6/20 patients) experienced incontinence. Perioperatively, one patient was classified as grade 2, while the remaining were grade 0/1 in the Clavien-Dindo classification. The mean ICIQ-SF score reduction was 10.5 points. The single-component AUS shows promising efficacy in managing moderate-to-severe male SUI, offering a good success rate, acceptable complications, improved QoL, and a straightforward surgical procedure.

Skin preparation before artificial urinary sphincter surgery: is there a difference between protocols?

Artificial urinary sphincter (AUS) is the gold standard for severe male stress urinary incontinence (SUI). This study aims to evaluate the interest of a new cutaneous preparation regarding the risk of early device infection. A retrospective review of medical records has been built with all patients who underwent an AUS, implanted by experienced surgeons, between January 2010 and January 2023. Before January 2015, all AUS received a standard protocol (SP) of cutaneous cleansing with soap povidone iodine and disinfection with alcoholic povidone iodine. After January 2015, all AUS received the new protocol (NP) with two cleansings with soap povidone iodine and two disinfections with alcoholic povidone iodine. The primary focus was to compare the risk of early device infection between the two protocols. Multivariate analyses were done with several risk factors such as age, diabetes, underlying pathology (prostate cancer surgery, surgical treatment of benign prostatic hyperplasia or others), past history of pelvic radiation therapy and past AUS implantation. One hundred and fifty-six cases were enrolled, with 34 following the SP and 122 following the NP. In the univariate analysis, there were 15 explantations in the SP arm versus 8 for the NP arm due to infection (45.5% vs. 25%, P=0.09). The was no difference between the NP and the SP in multiparametric analysis [odds ratio (OR): 0.97; P=0.96]. No other risk factors were associated with increased risk of AUS removal. Our study showed no correlation between the two types of skin preparation and the risk of AUS removal or revision. Future studies are needed to highlight the legitimate risk factors.

Evaluating the impact of artificial intelligence-based assessment of body composition on primary artificial urinary sphincter placement outcomes.

Sarcopenia, characterized by low muscle mass, and aberrant adiposity changes, including visceral fat accumulation, has been associated with impaired physiologic stress response and wound healing. Artificial urinary sphincter (AUS) placement is the preferred surgical treatment for men with severe post-prostatectomy incontinence. Given the higher rates of maladaptive body composition changes in this older, high comorbidity population, this study explores their impact on AUS outcomes. A retrospective analysis was performed including men who underwent primary AUS placement at the Mayo Clinic from 1999 to 2023 for post-prostatectomy incontinence and had cross sectional imaging available within 12 months prior to AUS implant. Sarcopenia and body composition were assessed from the available computed tomography (CT) scan using an algorithm that measures the area of different tissues at the L3 abdominal cross-section. The study investigated the association between sarcopenia [defined as skeletal muscle index (SMI) <52.4 cm2/m2] and adiposity (defined by total visceral and subcutaneous fat area) with all-cause reoperation, including specific etiologies of device infection/erosion, urethral atrophy, and device malfunction, using Cox proportional hazards models. There were 111 patients who had available imaging within the study timeframe, 61 (55%) of whom were classified as sarcopenic. Follow-up did not differ significantly between the two groups [2.11 (0.53-4.78) vs. 2.52 (0.36-5.80) years, P=0.52]. Sarcopenic patients had a lower body mass index (BMI) (29.1 vs. 32.7 kg/m2; P<0.001). No significant difference in overall device survival was observed between sarcopenic and non-sarcopenic patients (P=0.94) on Cox survival analysis. Sarcopenic patients had higher device infection rates, accounting for 16.7% (3/18) of device failures in the sarcopenic cohort compared to none in the non-sarcopenic cohort. Sarcopenia was prevalent among AUS patients but did not significantly impact overall device survival. These findings suggest that AUS placement may be feasible to perform in well-selected sarcopenic patients.

Indwelling Urological Device Biofilm Composition and Characteristics in the Presence and Absence of Infection

ObjectiveTo characterize microbial biofilms associated with different device types used in the urological field including ureteral stents, sacral neuromodulation (SNM) devices, penile prostheses, and artificial urinary sphincters (AUS). Materials and MethodsData from four studies, each reporting biofilm composition of a particular device type, were pooled and included for inter-device analysis. Studies recruited adults scheduled for ureteral stent, SNM, IPP, or AUS removal/revision. Device (n=115) biofilms and controls were analyzed with multi-omics approaches, and compositions were compared across device types and clinical factors. ResultsMicrobiota present on each device type was distinct from that of perineal, rectal, or urine flora (p<0.01). Biofilm microbial counts (p<0.001) and diversity (p=0.024) differed by device type. Ureteral stents had greater microbial counts than other device types (p<0.001). Staphylococcus, Pseudomonas, Lactobacillus, Ureaplasma were commonly detected across devices. Device biofilms harbored a greater proportion of Proteobacteria phylum, and the rectal, perineal, and urine flora harbored a greater proportion of Firmicutes. Unique microbe-metabolite interaction networks were identified in presence and absence of infection. Antibiotic resistance genes including sul2 (sulfonamide resistance) and rpoB (rifampin resistance) were detected in biofilms across device types. Biofilm reconstitution in vitro differed by device type from which strains were isolated. ConclusionsUreteral stents, sacral neuromodulation devices, penile prostheses, and artificial urinary sphincters harbored unique microbial and metabolite profiles that differed from those of skin, urine, and rectal flora. The findings of this study set the groundwork for investigation of novel strategies to reduce device-associated infection risk within and outside urology. Data availability statementData are available from corresponding author upon reasonable request.

144 - A prospective analysis of Satisfaction with decision and Decisional Regret in men implanted with an artificial urinary sphincter

144 - A prospective analysis of Satisfaction with decision and Decisional Regret in men implanted with an artificial urinary sphincter

140 - Is it reasonable to implant third artificial urinary sphincters in male patients after two previous implants?

140 - Is it reasonable to implant third artificial urinary sphincters in male patients after two previous implants?

183 - How to manage vaginal injury during robotic artificial urinary sphincter implantation in female patients ? The role of peritoneal flap interposition

183 - How to manage vaginal injury during robotic artificial urinary sphincter implantation in female patients ? The role of peritoneal flap interposition