Artificial Urinary Sphincter Research Articles

Eighteen years of experience in laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency

Introduction and objectives: Artificial urinary sphincter (AUS) is a treatment option for women with stress urinary incontinence (SUI) after failure of previous surgery or as a primary procedure in severe intrinsic sphincter deficiency (ISD). The aim of the study was to assess the long-term efficacy and risk factors for surgical revision and definitive explantation of AUS laparoscopic implantation in female patients.Methods: A retrospective review of all women submitted to AUS implantation between April 2005 and March 2023 was conducted. The AUS was implanted via transperitoneal laparoscopic approach, by two experienced surgeons. The primary endpoint was postoperative continence. Continence was defined as no leakage and no pad usage or leakage and/or pad usage with no impact on social life and failure as leakage and/or pad usage impacting social life. As secondary outcomes, clinical predictive factors for AUS revision and definitive explantation were evaluated.Results: In the last 18 years, females with a mean age of 68±12 years-old were submitted to laparoscopic implantation of AUS. Early overall complication rate was 16%, but only one case was Clavien-Dindo ≥3. After a median follow-up of 67 months, 22.2% of the patients needed a device revision, the majority due to mechanical device dysfunction. AUS definitive explantation was performed in 16%, mainly due to urethral/vaginal erosion (9.9%) and infection (6.2%). Patients with age ≥70 years and follow-up ≥10 years significantly predisposed for device revision. At the time of the last follow-up, 72% of the patients were keeping the urinary continency.Conclusions: Laparoscopic AUS implantation in females is an effective treatment for SUI due to ISD. Meanwhile, adequate patient selection, multidisciplinary evaluation and careful expectation management are essential to achieving good results, concerning their significant complication rate.

(177) Androgen Deprivation Therapy Does Not Increase Rates for Reintervention, Complication, or Infection in Penile Implant or Artificial Urinary Sphincter Surgery

Abstract Introduction Prostate cancer treatment carries significant quality of life implications, namely erectile dysfunction and stress urinary incontinence. Treatment options include genitourinary implants such as inflatable penile prosthesis (IPP) or artificial urinary sphincter (AUS). Given the association with androgens and penile and urethral health, there may be concern patients on androgen deprivation therapy (ADT) could have worse outcomes following IPP and AUS. Objective To evaluate whether patients on ADT undergoing IPP and AUS surgery are at increased risk for reintervention, complication, and infection. Methods We queried TriNetX, a collaborative research enterprise, for all adult male patients undergoing AUS or IPP. Cohorts were defined by those taking ADT 3 months before or anytime after surgery and those not taking ADT. ADT medications included: leuprolide, bicalutamide, flutamide, nilutamide, apalutamde, and darolide. We performed sub-analysis for leuprolide and bicalutamide, the two most prescribed ADT medications. Cohorts and outcomes were defined using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-10) codes. We used the impact of age, prostate cancer, history of prostatectomy and history of radiation to generate propensity score matching (PSM). Our primary outcome was need for reintervention (revision, removal, or replacement surgery based on CPT codes). Secondary outcomes included infection rate and complication rate based on ICD-10 codes. Analytics were performed via TriNetX on demographic data which calculated Risk Ratios and were run July 2023. Results There were 12,143 patients who received an IPP and 5487 who received an AUS (Table 1), with. 401 and 635 patients on ADT, respectively. Patients on ADT had similar rates of reintervention (9.4% vs 12.9%, RR = 0.72, p = 0.11), complication (17.7% vs 22.8%, RR =0.78, p=0.08), and infection (4.1% vs 4.8%, RR =0.84, p=0.60) for IPP. For bicalutamide, patients had lower complication rates (11.3% vs 18.2%, RR = 0.62, p=0.04) and similar reintervention rates (5.2% vs 9.9%, RR = 0.52, p=0.07). There were less than 10 instances of infection and thus TriNetX rounded these numbers to 10 (denoted by *) as part of a patient safety mechanism. Rates were similar for patients on leuprolide (reintervention: 9.8% vs 8.9%, RR =1.1, p = 0.69, complication: 17.5% vs 17.8%, RR = 0.98, p=0.92, infection: 4.0% vs 4.9%, RR = 0.81, p=0.57). Patients receiving an AUS showed similar rates for reintervention (20.8% vs 24.0% RR =0.87, p=0.17), complications (26.1% vs 25.6%, RR=1.0, p=0.85), and infections (2.3% vs 3.7%, RR=0.61, p=0.13) regardless of ADT. This held true for subanalyses for bicalutamide (reintervention: 22.7% vs 22.3%, RR =1.0, p = 0.92, complication: 27.7% vs 24.6%, RR = 1.1, p=0.43, infection: 3.8%* vs 3.8%*, RR = 1, p=1)., and leuprolide (reintervention: 19.8% vs 23.3%, RR =0.85, p = 0.18, complication: 25.3% vs 28.7%, RR = 0.8, p=0.21, infection: 1.9%* vs 3.2%, RR = 0.59, p=0.17). Conclusions Patients with IPP or AUS seemingly do no worse on ADT and in some comparisons even seemed to fare better. Further evaluation into the duration of ADT may provide clinical context, but based on these results, ADT should not limit implant surgery. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast.

(222) Simultaneous Inflatable Penile Prosthesis and Adjustable Male Sling: A Step-by-Step Surgical Technique

Abstract Introduction Erectile dysfunction (ED) and urinary incontinence (UI) are common complications following radical prostatectomy (1). At twenty-four months post-surgery, approximately 43% of men experience some degree of ED, while UI affects around 15% of patients between twelve to twenty-four months (2, 3). Notably, nearly 20% of patients experience both ED and UI complications (4). Initial conservative management strategies include the use of PDE-5 inhibitors, intercavernosal injections, or a vacuum erectile device for ED and pelvic floor muscle training for UI (5). However, symptoms that persist or worsen beyond six months can be considered for surgical intervention (6). Surgical options include penile prosthesis implantation for ED and diverse techniques such as the Artificial Urinary Sphincter (AUS) or adjustable male urethral sling, depending on symptom severity, for UI management. Limited evidence suggests that a simultaneous surgical approach addressing both conditions can be a cost-effective and a safe alternative to separate surgeries (7, 8). Objective In this context, the objective of this video presentation is to illustrate a detailed, step-by-step technique for the simultaneous implantation of an inflatable penile prosthesis (IPP) and an adjustable male sling (AMS), while also discussing its feasibility, safety, and functional outcomes. Methods The combined IPP and AMS surgery is a safe, viable, and cost-effective option for patients who need to address both ED and UI. Rhee (2005) initially described the concurrent placement of a penile prosthesis (PP) and male sling (MS) in a series of four post-prostatectomy patients. Results The results demonstrated successful restoration of erections and complete continence in all patients, with no postoperative complications. Our previous systematic review, comparing the outcomes of simultaneous surgical placement of PP and MS versus PP and artificial urethral sphincter (AUS), found no clinically significant differences in outcomes between the two groups (Raheem 2021). Therefore, the simultaneous placement of IPP and AMS should be considered an option for patients, as it shows comparable effectiveness to other concurrent surgical interventions. Dual implantation of PP and male sling have also demonstrated cost savings of approximately $9,000 for patients, further enhancing its advantages in managing both ED and UI (Gorbatiy 2010). Ultimately, a collaborative discussion between patients and their urologist is crucial in determining the most suitable approach for patient individual needs. Conclusions The simultaneous surgical placement of an inflatable penile prosthesis (IPP) and adjustable male sling (AMS) presents a favorable and viable solution for managing erectile dysfunction (ED) and urinary incontinence (UI) in patients who exhibit an inadequate response to conservative management following prostatectomy. Disclosure No.

(360) National Trends in Male Artificial Urinary Sphincters: 2016-2019

Abstract Introduction The artificial urinary sphincter (AUS) remains the gold standard for male stress urinary incontinence. However, current understanding of which patient- and facility-level characteristics that are associated with inpatient versus (vs.) outpatient AUS procedures is limited on a national scale. Objective We therefore sought to evaluate contemporary national trends of AUS procedures. Methods We performed a retrospective review of male AUS procedures using the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample – the largest publicly available all-payer inpatient and ambulatory healthcare databases in the United States – from 2016 to 2019. AUS insertion, repair, replacement, and removal were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes. Our unit of analysis was inpatient or outpatient encounters, and we performed stratified cluster sampling to create weighted national estimates. The primary outcome was the proportion of AUS procedures performed in the inpatient and outpatient settings over time. We performed multivariable logistic regression to evaluate factors associated with an inpatient encounter. Results There were 21,916 weighted AUS procedures analyzed from 2016 to 2019 (6% inpatient vs. 94% outpatient). There was a 15% increase in total number of annual surgeries (n=5066 to n=5843), and the proportion performed outpatient increased from 92% to 95% over the study period [Figure]. Mean total charge for inpatient AUS surgery was $92,045 vs. $72,887 for outpatient (p<0.05). Inpatient AUS surgery was associated with greater Elixhauser Comorbidity Index, non-private insurance, and Western hospital region (vs. Northeast) (p<0.05) [Table]. Predictors of outpatient AUS procedures included older age, 3rd quartile of median income by Zip Code (vs. 1st quartile), and Midwest/Southern hospital region (vs. Northeast) (p<0.05). Conclusions With an increasing rate of AUS procedures in the United States, the majority of these procedures continue to be performed on an outpatient basis. Outpatient procedures have lower hospital charges compared to inpatient encounters, and outpatient AUS is associated with private insurance in older patients with fewer comorbidities. Hospital geographic region appears to affect encounter type, and further work may elucidate how these factors affect patient outcomes nationally. Disclosure No.

(286) Gender Disparities Exist in the Surgical Management of Peyronie's Disease and Urologic Prosthetics: An Evaluation of American Board of Urology (ABU) Surgical Case Logs

Abstract Introduction Urology has been predominantly male-dominated, although recent trends indicate increased female representation among urology residents, physicians and advanced-practitioner providers. While progress has been made, gender disparities persist due to societal perceptions and biases. The goal of this study was to investigate whether a provider gender gap exists in the field of reconstructive urology using American Board of Urology (ABU) case logs. Objective To examine case volume characteristics for provider gender disparities in Peyronie’s disease and urologic prosthetic surgery. Methods Retrospective review of surgical case log data from 2003 to 2023 of certified urologists was performed for 11 Current Procedural Terminology (CPT) codes for the surgical management of Peyronie’s disease (penile plication CPT 54360, plaque excision/incision with grafting CPT 54111, 54112), male urethral sling or artificial urinary sphincter (CPT 53440, 53445), and placement of penile implant (CPT 54400, 54401, 54405). Inclusion criteria included male patients who were 18 years old or older. Data collected included patient and surgeon demographics, surgical procedure, and surgeon fellowship training status. Cases were analyzed using descriptive statistics and regression testing. Results From 2003 to 2023, a total 2,852 urologists performed 15,171 Peyronie’s disease and urologic prosthetic surgical procedures. Among these procedures, 1,910 (13%) Peyronie’s disease, 8,940 (59%) penile implant, and 4,321 (28%) incontinence procedures were identified. Out of the total practicing urologists, 2,626 were male and 226 were female; the distribution of cases revealed 5 cases performed per male surgeon and 4 cases per female surgeon. Over two decades, there was a significant positive trend in the proportion of cases performed by female surgeons (p < 0.001). 169 (6%) surgeons completed fellowships in Andrology or Male Reconstruction, and performed 2,129 (14%) of total procedures. Across surgeons with Andrology or Male Reconstruction fellowship-training, there were 13 cases performed per male surgeon and 7 cases per female surgeon. Conclusions Our study confirms underrepresentation of female surgeons in the field of Peyronie's disease and prosthetic urology. Although there is a trend of increasing female representation over time, further research can be done to identify barriers to gender equality in the field. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast.

(220) Does Complication and Continence Rates Differ When Combining Inflatable Penile Prosthesis with Post Prostatectomy Incontinence Procedures Inserted Via Perineal Approach? An Updated Pilot Study

Abstract Introduction Artificial urinary sphincter (AUS) and bulbourethral male sling are used frequently in the management of post prostatectomy urinary incontinence (UI) in men. Some surgeons used to combine an inflatable Penile Prosthesis (IPP) procedure at the same setting to treat concurrent erectile dysfunction (ED). Recent clinical trials have aimed to determine the comparative effectiveness between the male sling and the artificial urinary sphincter (AUS) in men with urodynamic stress urinary incontinence (SUI) after prostate surgery, focusing on non-inferiority. Objective We aim to compare continence control and complications rates in patients who underwent bulbourethral slings or AUS during IPP surgery via perineal approach. Methods A retrospective chart review was done in a large tertiary center. Post prostatectomy patients who underwent perineal dual implantation IPP and AUS or bulbourethral sling for ED and UI purposes, between 2014 and 2022 were included. Clinical data, patients’ demographics were retrieved. Post-operative outcomes with regards to IPP complication rates, revision rates for IPP/ AUS / Male sling, and continence control at 6 weeks, 6 months and 1 year were collected and included in the analysis. Continence control rates were assessed by the number of pads used per day on subsequent follow up visits for both groups. Results A total of 32 patients met the inclusion criteria. 16 Patients underwent synchronous IPP and AUS insertion, whereas another 16 patients underwent IPP with bulbourethral sling procedure. Patient demographics, median follow up & complication rates are summarized below in Table 1. In both groups the procedure was done through a perineal approach. There was no significant difference in baseline data among groups. Complication rates between AUS devices and bulbourethral slings showed no statistically significant differences (12.5% vs 6.25% p= 0.22 respectively). Infection rates and need for revision also did not show any statistically significant differences. With regards to post-operative continence rates, both groups had comparable outcome with no significant differences (P = 0.81). Upon the 6 months follow up visit, the AUS group, 56% were pad free, 19% used 1 pad per day, 19% used 2 pads per day, and 6% used 3 pads or more per day, while in the sling group, 50% were pad free, 25% used 1 pad per day, 19% used 2 pads per day, and 6% used 3 pads or more per day. Patients were followed for a total of 1 year after the surgery. Conclusions The combined insertion of IPP with either AUS or sling procedures has comparable outcomes with regards to continence rate and device- related complications. Each incontinence surgery should be chosen according to surgeon experience and specific patient indications. Further prospective studies on a larger sample of patients with longer follow up period are needed to solidify these findings and will guide patient's decision and preference for incontinence surgeries along with IPP once indicated. Disclosure No.

(373) Economic Benefits of Patient Care for Prostate Cancer Survivors with Stress Urinary Incontinence and/or Erectile Dysfunction: A Physician Reimbursement Analysis

Abstract Introduction Reconstructive urological procedures play a vital role in enhancing the satisfaction and quality of life of patients with prostate cancer (PCa) following radical prostatectomy (RP). Providing comprehensive postoperative care for common side effects of post-RP, including stress urinary incontinence (SUI) and erectile dysfunction (ED), may result in a greater number of patients with PCa receiving needed consultations and therapies. This analysis sought to explore the potential economic benefits of offering men’s health consultations and reconstructive care for PCa survivors. Objective This study quantified the relative value units (RVUs) generated from providing patient care to PCa survivors covered by Medicare Fee-for-Service who may experience SUI and/or ED due to RP. Methods This physician reimbursement analysis was based on typical patient care pathway scenarios for patients at risk of developing SUI or ED post-RP. Current Procedural Terminology (CPT) codes were utilized to identify and describe the care provided to patients in each scenario, leading to an artificial urinary sphincter (AUS) or male sling for SUI and/or an inflatable penile prosthesis (IPP) for ED. The 2023 CMS Physician and Clinical Laboratory Fee Schedule and Medicare reimbursement rates were used to obtain the most recent RVUs and reimbursement for each CPT. RVUs represent the value assigned to a service or procedure performed by a physician and are used to capture the relative cost values associated with patient care. For each scenario, we reported the total RVUs, which include work, non-facility or facility, and malpractice RVUs, and the total physician reimbursement. The 2023 Physician Conversion Factor was used to calculate the Medicare physician reimbursement. The Medicare physician reimbursement was used as a conservative estimate. Results The four clinical pathway scenarios were patients who did not experience recurrent SUI or ED (no recurrent SUI/ED), patients who only experienced SUI (only SUI), patients who only experienced ED (only ED), and patients who experienced both SUI and ED (SUI + ED). For the no SUI/ED scenario, the total RVUs from providing patient care were 5.26 RVUs, resulting in $205 in physician reimbursement. For the only SUI scenario, the total RVUs were 56.20 RVUs with an average of $1,996 in physician reimbursement for those receiving AUS and 55.54 RVUs with an average of $1,974 in physician reimbursement for those receiving male sling. For the only ED scenario, the total RVUs were 42.51 RVUs, resulting in $1,550 in physician reimbursement. For the SUI + ED scenario, the total RVUs were 98.71 RVUs with an average of $3,547 in physician reimbursement for those receiving AUS and 98.05 RVUs with an average of $3,524 in physician reimbursement for those receiving male sling. Conclusions This study justified the economic benefits of expanding patient care to men who underwent RP for PCa and provided urology practice insight into the potential physician reimbursement when PCa survivors were seen by reconstructive urologists. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

(362) Stress Urinary Incontinence Rates in Men Undergoing Optilume Balloon Dilation for Radiation-Induced Posterior Urethral Stenosis: A Single Center Experience

Abstract Introduction While radiation can be a viable treatment option for prostate cancer, development of radiation-induced urethral stenosis occurs in approximately 2% of patients. Optilume, a paclitaxel-coated urethral dilation balloon was FDA approved in 2021 and has shown improved urethral patency and reduced rates of reintervention for anterior urethral strictures relative to standard endoscopic procedures. As the utility of Optilume expands into posterior urethral stenosis, it is important to identify the associated potential complications. Incidence of stress urinary incontinence (SUI) has been reported to be as high as 33% following urethroplasty for patients with radiation-induced urethral stenoses. Rates of SUI following Optilume balloon dilation have yet to be evaluated in this high-risk population. Objective To evaluate rates of SUI in patients undergoing Optilume balloon dilation for radiation-induced posterior urethral stenosis. Methods From March 2022 to February 2023, select men with radiation-induced posterior urethral stenoses underwent Optilume balloon dilation. Initial evaluation included retrograde urethrogram and/or diagnostic cystoscopy. Dilation was performed with a 30-French Optilume and left inflated for five minutes per standard protocol. A 16-French catheter was inserted and left in place for three to five days. Patients were scheduled for a three-month post-dilation cystoscopy. Pre- and post-dilation continence rates were compared. Results A total of 16 men with confirmed radiation-induced posterior urethral stenoses underwent Optilume balloon dilation. Of the 16 patients, 12 patients had documentation regarding their pre- and post-treatment continence status. No patients developed de novo SUI. Baseline pre-treatment SUI was noted in one patient (8.3%) requiring an average of 4 Depends per day. This patient noted no change in his degree of SUI following Optilume dilation and the dilation site was found to be widely patent on his follow up cystoscopy. He is scheduled for artificial urinary sphincter in the near future. Mean follow up was 77 days (range 30-180 days). Repeat intervention was required in three patients (18.8%) for repeat stenosis. Conclusions Optilume balloon dilation for radiation-induced posterior urethral stenosis does not appear to lead to de novo SUI in short to intermediate term follow up. Further prospective studies with a larger group of patients and longer follow up duration are warranted in this complex population. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Laborie.

Neurological sphincter deficiency: is there a place for artificial urinary sphincter?

PurposeNeurogenic stress urinary incontinence (N-SUI) is a condition with serious impact on the quality of life. There are several treatment modalities of which the artificial urinary sphincter (AUS) stands out as the most suitable technique for addressing sphincter insufficiency. In this article, the purpose is to describe practical considerations, outcomes, and complications of the artificial urinary sphincter in neurological sphincter deficiency in both males and females.MethodsA narrative review of the current literature.ResultsThe outcomes of AUS are reasonably good in patients with NLUTD, the surgical technique is discussed as well as the limitations and special considerations in this complex and heterogeneous patient population.ConclusionThe available evidence suggests that its efficacy and functional durability may be lower in patients with neurogenic lower urinary tract dysfunction (NLUTD) compared to those without neurological deficits. However, studies have shown that AUS can still provide effective and safe continence outcomes in both male and female patients, with long-term device survival rates ranging from several years to over a decade.

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes

IntroductionRecto-urethral fistulas (RUF) remain a difficult management problem. To assess the impact of posterior urethral stenosis on outcomes following RUF repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. MethodsWe identified 130 men who underwent RUF repair at our institution between 2003-2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months pre-operatively), and 20 men suprapubic catheter placement (median, 5.5 months pre-operatively). ResultsRUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intra-operatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%).At a median follow up of 55.7 months (IQR, 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. ConclusionsPosterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis.

The tearing of an artificial urinary sphincter ZSI 375 as a rare complication - clinical case report

The tearing of an artificial urinary sphincter ZSI 375 as a rare complication - clinical case report

Prior male sling does not affect outcomes of artificial urinary sphincter.

To investigate the outcomes of artificial urinary sphincter (AUS) placement in patients with post-prostatectomy urinary incontinence (PPUI) with or without a prior male sling. We performed a retrospective chart review of patients who underwent AUS for PPUI from 2007 to 2022. The primary endpoint was to determine the proportion of patients who achieved social continence, defined as self-reported use of 0-1 pad/day. The secondary endpoints were device failure rates and device failure-free survival. The analysis included 210 patients, with 30 (14.3%) having had prior slings and 180 (85.7%) without prior slings. After AUS insertion, 80.0% of patients with prior slings and 76.7% of those without prior slings achieved continence (0-1 pad/day). There were six (20.0%) and 53 (29.4%) device failures in patients with and without prior slings, respectively. The median device failure-free survival was not reached in patients with prior slings and was 8.9 years in patients without prior slings (P = 0.048). Limitations include retrospective nature and small sample size. The efficacy and safety of AUS in patients with prior slings are similar to those without. Prior sling is associated with a longer device failure-free survival. AUS remains a viable option in patients who have persistent PPI after prior slings.

A Full Bladder Is Not Needed for the Male Stress Incontinence Grading Scale.

Our objectives were to evaluate the Male Stress Incontinence Grading Scale to stratify male patients with stress urinary incontinence for either artificial urinary sphincter or sling using a standing cough test and determine if an emptier bladder at the time of assessment carries increased risk of treatment failure. Retrospective chart review of male patients undergoing sling and artificial urinary sphincter placement. The standing cough test score and bladder scan results were documented at initial evaluation. Forty patients underwent sling and 43 underwent naïve artificial sphincter placement. Median follow-up was 7.11 months. Thirty-six/forty slings had complete incontinence resolution or reduction to a safety pad vs 40/43 after sphincter (90% vs 93%, P = .62). Four sling patients (10%) had persistence or recurrence of incontinence. Cough test scores were similar between sling failure (67% grade 0, 33% grade 1) and success groups (83% grade 0, 3% grade 1, 14% grade 2). Bladder scan mean was 18.5 cc in the sling failure (SD 21.1) and 38.0 cc in the success groups (38.3), with 32% of success patients having bladder scans of 0 cc, and 63% of < 50 cc. Mean for sphincter patients was 45 cc (56.9). Ten patients with scan = 0 and 7 patients with scans < 30 cc demonstrated grade 4 incontinence. Cough test is a noninvasive, reliable tool to assess stress urinary incontinence severity. Our data suggest it is reliable even when bladders are nearly empty and can effectively stratify patients for sling vs artificial urinary sphincter with a high rate of success.

Characterizing patient experiences with repeat artificial urinary sphincter revisions through quantitative surveys and qualitative patient interviews.

Artificial urinary sphincter (AUS) placement remains the gold-standard treatment for post-prostatectomy urinary incontinence (PPUI), despite their need for periodic surgical revision. To understand the experiences of patients who undergo repeat AUS revisions. Mixed design including quantitative surveys and qualitative interviews for thematic analysis. Men with ⩾2 revisions were collected from a single-institution, retrospective database of AUS patients. Participants were interviewed about their prostatectomy, incontinence, AUS placement, and revisions. A survey was administered utilizing validated tools (e.g., Decision Regret Scale (DRS), Incontinence Impact Questionnaire-7) for quantitative analysis. Interview transcripts were used for qualitative thematic analysis. Of 26 respondents, 20 completed the interview. Twenty-three men completed the survey. The mean DRS score for prostatectomy was 24 (standard deviation (SD) = 27), indicating low regret. Median Incontinence Impact Questionnaire score was 54 (SD = 27), with 70% of participants describing their PPUI as "severe." Participants experienced a significant decrease in daily pad usage with AUS placement (5.5 pre-AUS vs 1.4 post-AUS, p < 0.0001). Qualitative analysis revealed themes involving prostatectomy urgency, physician-patient relationships, expectation setting, and quality of follow-up. Most participants (96%) were satisfied with their initial AUS placement and endorsed a positive relationship with their urologist. However, 22% of participants were unaware of device limitations, including the need for revision. Some participants (26%) were uncertain of the status of their AUS, while some participants (35%) desired improved follow-up. Initial improvement and positive experiences with urologists motivate patients to undergo AUS repeat revision. Urologists should emphasize the limitations of the AUS before placement and follow up with patients to evaluate their needs for future care.

Zephyr 375 urinary sphincter implant by unical perineal incision. Initial experience.

The treatment of male severe stress incontinence (MUI) after surgery is the implantation of an artificial urinary sphincter (AUS). Traditionally you need two incisions: perineal and inguinal. Our objetive is present a series of patients treated with the Zephyr 375 EUA implant through a single perineal incision. We present six men operated on for MUI after Transuretral resection of the prostate (TURP) (1) and radical prostatectomy (5). Preoperatively we perform Pad-Test and cystoscopy. Under epidural anesthesia, a vertical perineal incision was made and dissection up to the bulbospongiosus muscle was divided and we dissected the bulbar urethra. After removing the probe, we place the cuff, checking that it reaches the appropriate pressure, leaving it deactivated. To place the pump-reservoir, we digitally develop a scrotal dartos pocket from the perineum that we close with Vicryl 3/0. After closing the muscle with 3/0 Vicryl, we left a suction drain and a bladder catheter. The mean age was 63 years (55-72). Mean surgical time was 68 minutes (60-85). All were discharged the next day without catheter and drain. All patients comfortably palpated the scrotal reservoir-pump. After activation, all patients were continent without needing additional adjustment, using 3 a safety pad. The degree of satisfaction was very high, all of them affirmed that they would undergo the same intervention again. The Zephyr 375 urinary sphincter allows placement through a single perineal incision, reducing surgical time, simplifying the technique, and reducing morbidity without compromising the functional outcome.

No-Opioid Discharge Following Artificial Urinary Sphincter Placement Does Not Significantly Increase Health Care System Burden.

Postoperative opioid prescriptions are associated with an increased risk of opioid dependance. While studies on no-opioid discharge strategies have been assessed following many urologic procedures, the effect of no-opioid discharges on health care utilization following artificial urinary sphincter placement is unknown. We performed a single-surgeon retrospective comparison of health care system interactions following artificial urinary sphincter implantation between patients who received an opioid prescription on discharge to those who did not. We identified 101 male patients who underwent 3-piece artificial urinary sphincter placement or revision by 1 provider between 2015 and 2022. All patients were discharged with acetaminophen and ibuprofen; none received intraoperative local anesthetic. Demographic information, preprocedural opioid use, opioid prescriptions following the procedure, postoperative office communications, unplanned office visits, and emergency department (ED) visits were recorded for each patient for 90 days. Forty-five patients (45%) were discharged without an opioid prescription and 56 patients (55%) were discharged with an opioid prescription. No differences in age, race, BMI, operative time, or presence of a preoperative opioid prescription were observed. Discharge without an opioid did not significantly increase the number of office communications (55% vs 40%, P = .11), unplanned office visits (36% vs 23%, P = .19), or ED visits (20 vs 12, P = .41) within 90 days of implantation/revision. Opioids can be omitted from the discharge analgesic regimen following artificial urinary sphincter placement without increasing burden to surgical office staff or local EDs. Providers should consider no-opioid discharges for patients undergoing uncomplicated sphincter placement to limit risk of opioid-related morbidity.

Editorial Comment: Androgens and Urethral Health–How Hypogonadism Affects Postoperative Outcomes of Patients Undergoing Artificial Urinary Sphincter or Inflatable Penile Prosthesis Placement (# URL-D-23-01259R1)

Editorial Comment: Androgens and Urethral Health–How Hypogonadism Affects Postoperative Outcomes of Patients Undergoing Artificial Urinary Sphincter or Inflatable Penile Prosthesis Placement (# URL-D-23-01259R1)

Post-prostatectomy incontinence: a guideline of guidelines.

To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI). The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018). In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well. This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

Robotic-assisted laparoscopic surgeries in functional and reconstructive urology

The adoption of robotic-assisted laparoscopic surgery in urology is becoming increasingly frequent. Initially, its use was essentially limited to oncological surgery, such as radical prostatectomy. Its success lies in the enhanced dexterity, the three-dimensional vision, and the ability to easily suture intracorporeally. All these advantages have enabled many pioneer surgeons to develop techniques in the field of functional surgery, such as artificial urinary sphincter implantation and sacrocolpopexy, and as for reconstructive surgery, ureteral reconstructions and enterocystoplasties. This article provides a brief yet rich review of the recently innovated techniques and the now minimally invasive feasibility of previously highly complex procedures in conventional laparoscopy.

Longitudinal deterioration in lower urinary tract symptoms after artificial urinary sphincter implantation in patients with a history of pelvic radiation therapy.

To evaluate longitudinal changes in lower urinary tract symptoms (LUTS) after artificial urinary sphincter (AUS) implantation in patients undergoing radiation therapy (RT) in comparison to those in non-irradiated patients. This retrospective study included 20 and 51 patients with and without a history of pelvic RT (RT and non-RT group, respectively) who were treated with primary AUS implantation for post-radical prostatectomy incontinence between 2010 and 2020. Longitudinal changes in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the International Prostate Symptom Score (IPSS), and the Overactive Bladder Symptom Score (OABSS) were calculated with a linear mixed model. In the RT and non-RT group, 18 (90%) and 48 (94%) patients achieved social continence, defined as daily pad use ≤1 at 1 month after activation of AUS, respectively (p = .555). During the mean follow-up of 38 months, ICIQ-SF, IPSS, and OABSS significantly improved after AUS implantation in both the RT and non-RT groups. In the RT group, ICIQ-SF, IPSS, and OABSS subsequently deteriorated with a slope of 0.62/year (p = .010), 0.55/year (p = .025), and 0.30/year (p = .007), respectively. In the non-RT group, no significant longitudinal changes in subsequent IPSS and OABSS were observed, although ICIQ-SF significantly deteriorated (0.43/year, p = .006). Comparing between the groups, the slopes of IPSS and OABSS were significantly greater in the RT group than in the non-RT group (p < .001, and .015, respectively). Longitudinal deterioration in LUTS that improved immediately after AUS implantation was observed in patients with a history of pelvic RT, but not in patients without a history of pelvic RT.