Cuff Erosion Research Articles

Diagnostic challenges in the evaluation of persistent or recurrent urinary incontinence after artificial urinary sphincter (AUS) implantation in patients after prostatectomy

There is a lack of information pertaining to the postoperative evaluation in patients with artificial urinary sphincter (AUS) implants who complain and continue to have urinary incontinence (UI). Two types of UI can occur after the activation of an AUS device these are: early or initial (persistent) UI, and delayed (recurrent) UI. There are many causes of persistent and/or recurrent UI and these can sometimes overlap. The potential causes include improper and/or accidental operation of the pump-control unit, overactive bladder, cuff atrophy, cuff erosion, improper cuff size and pressure-regulating balloon unit, as well as device malfunctions. The diagnostic evaluation in men with persistent and/or recurrent UI after AUS implantation requires sufficient understanding of the AUS mechanics and is a step-wise and logical process with careful history and thorough clinical evaluation. Once a diagnosis is made, patients should be counselled and appropriate treatment instituted.

Is Prolonged Catheterization a Risk Factor for Artificial Urinary Sphincter Cuff Erosion?

To evaluate the relative risk of prolonged urethral catheterization (PC), >48 hours, on artificial urinary sphincter (AUS) cuff erosion in a tertiary referral population. All men who had undergone AUS implantation or revision by multiple surgeons at our institution from 2000 to 2010 with≥6 months of follow-up were reviewed for urethral erosion, catheterization after AUS placement, and comorbid conditions. Of the 258 AUS patients reviewed, 200 met the inclusion criteria, with an average follow-up of 24 months. AUS cuff erosions were noted in 24 men (12%) and were diagnosed at a mean of 16.9months (range 0.8-87.1). PC was identified in 44 of the 200 men (22%)-of these men, erosions occurred in 17 (39%, P<.001). The indication for PC was most often major nongenitourinary surgery (36%) or urinary retention (32%). Univariate analysis identified an increased risk of erosion associated with hypertension, diabetes, coronary artery disease, PC, previous radiotherapy, and secondary AUS placement (P<.05). On multivariate analysis, only PC, radiotherapy, and revision surgery were significant (P<.05), but cuff size and concomitant inflatable penile prosthesis were not associated with AUS cuff erosion. PC is an independent risk factor for AUS cuff erosion.

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.

Indications for revision of artificial urinary sphincter and modifiable risk factors for device‐related morbidity

The aim of the study is to evaluate the causes for artificial urinary sphincter (AUS) failure in a contemporary series, and to detect modifiable risk factors for device-related complications. The aim is to also report outcome after AUS revision. We retrospectively reviewed the medical records of consecutive patients who underwent AUS revision at a tertiary care institution by a single surgeon from 2006 to 2011. There were 53 AUS revisions performed on 34 patients at a median age of 69 years. Urethral atrophy was the most common indication for revision. Fourteen patients (41%) underwent more than one revision. Seven patients had urethral catheterization in the setting of an active AUS while admitted to a non-urologic service; these patients all developed cuff erosion. Fifty-four percent of urethral erosions were associated with such traumatic catheterizations. After revision, 80% of patients with an AUS in place were using one or no pad daily at mean follow up of 27 months. Urethral atrophy remains the most common reason for AUS revision. More than half of all urethral erosions are secondary to urethral catheterization in the setting of an active sphincter, suggesting that some of the risk of device-related morbidity may be modifiable.

240 PARTICULAR ASPECTS OF ARTIFICIAL URINARY SPHINCTER IMPLANTATION AFTER URETHROPLASTY

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery III1 Apr 2012240 PARTICULAR ASPECTS OF ARTIFICIAL URINARY SPHINCTER IMPLANTATION AFTER URETHROPLASTY Andre Cavalcanti and Mauricio Rubinstein Andre CavalcantiAndre Cavalcanti Rio de Janeiro, Brazil More articles by this author and Mauricio RubinsteinMauricio Rubinstein Rio de Janeiro, Brazil More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.295AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The artificial urinary sphincter(AUS) is the gold standard procedure to a definitive treatment of urinary incontinence associated with sphincter deficiency in male. The aim of this study is to describe our experience with the AUS implantation in a particular group: patients submitted to previously urethroplasties. METHODS The charts of 22 patients submitted to a AUS implantation after a urethroplasty were observed. The mean follow-up was 23.3 months (range from 6 to 48 months) and the mean patients age was 63 years (range from 25 to 81 years). The majority of the patients were submitted to a urethroplasty to treat an anastomotic stricture after radical prostatectomy (16 patients). 4 patients were submitted to a urethroplasty to treat a posterior stricture after a BPH surgery and 2 to treat a posterior traumatic stricture. The AUS surgical approach was transcorporal in all patients. In 7 patiens we performed a modified transcorporal approach, from the original Webester‘s technique (using two lateral tunica albugínea flaps to cover the urethra and a pericardium bovine graft to close the corporal defect). RESULTS In our initial 6 cases we used a early AUS implantation (3 months after the urethroplasty) and we observed a high urethral erosion rate (50%). In the other 16 cases we performed a late implantation (at least 6 months after the urethroplasty) and we observed an erosion rate decline to 6,2% (1 patient). 2/4 patients with AUS erosion were submitted to a suprapubic continent diversion and 2/4 patients were submitted to a AUS re-implantation with success. The final success rate of the AUS implantation (use of 1 pad per day or less), at least 6 months after the implantation was 75% (16/20 patients) with 65% complete dry (13/20). In 3/20 patients (15%) an improvement of the incontinence was observed with a reduction on the number of pads per day. 10/20 (50%) patients with AUS implanted were submitted to penile prosthesis implantation: 7 semirigid, 1 inflatable (3-pieces) e 2 inflatable (2-pieces). A delay cuff erosion was observed in all (2/2) patients after the implantation of a inflatable (2-pieces) penile prosthesis. CONCLUSIONS The AUS implantation after an urethroplasty is possible with acceptable rates of success. In our opinion the delay transcorporal implantation and the correct penile prosthesis choice (when necessary) are the best approaches to prevent complications. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e98-e99 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andre Cavalcanti Rio de Janeiro, Brazil More articles by this author Mauricio Rubinstein Rio de Janeiro, Brazil More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1191 INDICATIONS FOR REVISION OF ARTIFICIAL URINARY SPHINCTER AND MODIFYING RISK FACTORS FOR DEVICE-RELATED MORBIDITY

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy II1 Apr 20121191 INDICATIONS FOR REVISION OF ARTIFICIAL URINARY SPHINCTER AND MODIFYING RISK FACTORS FOR DEVICE-RELATED MORBIDITY Ifeanyi Anusionwu and E. James Wright Ifeanyi AnusionwuIfeanyi Anusionwu Baltimore, MD More articles by this author and E. James WrightE. James Wright Baltimore, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1436AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The aim of our study is to evaluate the causes for failure of artificial urinary sphincter (AUS) in a contemporary series, and to detect modifiable risk factors for device−related morbidity. We also report our outcome after AUS revision. METHODS We retrospectively reviewed the medical records of consecutive patients who underwent revision of AUS at our institution by a single surgeon over the last 5 years (2006 to 2011). RESULTS There were 53 AUS revisions performed on 34 patients. Median age of the population was 69 years. The indications for AUS revision are shown in Table 1. Urethral atrophy was the most common indication for AUS revision. Fourteen patients (41%) underwent more than one revision. Table 2 shows the number of revisions undergone by patients. Forty−three percent of those who underwent multiple revisions had a history of radiation therapy, as opposed to 25% of those who underwent one revision, but the difference was not statistically significant (P=0.45). Seven patients had urethral catheterization in the setting of an activated AUS while admitted to a non−urologic service; all of these patients developed cuff erosion with or without infection. Fifty four percent of urethral erosions were associated with such traumatic catheterizations. After revision, 80% of patients with an AUS in place were continent at mean follow up 27 months (median 20 months). Table 1. Indications for revision of artificial urinary sphincter Indication for Revision Number of revisions (%) Urethral atrophy 31(58%) Erosion 13(25%) Infection 2(4%) Mechanical failure 1(2%) Patient discomfort 5(9%) Need for transurethral procedure 1(2%) Table 2. Number of revisions undergone by patients Number of revisions Number of patients (%) 1 revision 20(59%) 2 revisions 11(32%) 3 revisions 1(3%) 4 revisions 2(6%) CONCLUSIONS Urethral atrophy remains the most common reason for AUS revision. Forty−one percent of patients undergoing AUS revision will have repeated revisions. More than half of all urethral erosions are secondary to urethral catheterization in the setting of an activated sphincter, suggesting that some of the risk of device−related morbidity may be modifiable. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e482 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ifeanyi Anusionwu Baltimore, MD More articles by this author E. James Wright Baltimore, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Complex Artificial Urinary Sphincter Revision and Reimplantation Cases—How do They Fare Compared to Virgin Cases?

We compared artificial urinary sphincter complication rates, overall reoperative rates, and continence results in virgin cases, revision cases and secondary reimplant cases (with prior erosion or infection). Only male patients with post-prostatectomy stress incontinence with AMS 800™ placement in the bulbar urethra by a single surgeon were included in the study. A total of 169 virgin cases (no prior artificial urinary sphincter surgery), 37 revision cases (eg cuff revision for urethral atrophy, revision of failed components) and 21 secondary reimplant cases (eg after prior explant from urethral erosion or infection) were compared. Secondary artificial urinary sphincter reimplant cases (eg after prior explant from urethral erosion or infection) had fourfold higher future erosion rates compared to virgin cases (p = 0.02, 14.3% vs 3.6%, RR 4.02). In addition, there was no difference in the rates of other complications (device infection, urethral atrophy, mechanical failure, leaks), overall reoperation rates and postoperative continence outcomes (measured by daily pad use) compared to virgin cases. Artificial urinary sphincter revision cases did not have higher complication rates (including subsequent urethral erosion), reoperation rates or worse postoperative continence outcomes compared to virgin cases. Although the difference was not statistically significant, a trend toward higher future device leak rates (10.8% vs 3.6%, RR 3.05, p = 0.063) and higher urethral atrophy rates (16.2% vs 8.9%, RR 1.83, p = 0.18) was noted in artificial urinary sphincter revision cases compared to virgin implant cases. Patients with a history of artificial urinary sphincter explant have a fourfold increased risk of future cuff erosion. Nevertheless, a good functional outcome with an acceptable complication rate may be achieved in most complex reoperative artificial urinary sphincter cases.

Artificial Urinary Sphincter: Long-Term Results and Patient Satisfaction

The published evidence concerning the safety, efficacy, and patient satisfaction for implantation of the current model of the artificial urinary sphincter (AS 800) in men with post prostatectomy urinary incontinence was the objective of this review. A Pub Med English language literature search from 1995 to 2011 was performed. A majority of men who undergo AUS implantation for post prostatectomy urinary incontinence achieve satisfactory results (0 to 1 pad per day). Infection rates range from 0.46 to 7%, cuff erosion rates range from 3.8 to 10%, and urethral atrophy ranges from 9.6 to 11.4%. Kaplan-Meier 5 year projections for freedom from any reoperation were 50% for a small series and 79.4% for a larger series. Kaplan-Meier projections for freedom from mechanical failure were 79% at 5 years and 72% at 10 years. In another series 10 year projections for freedom from mechanical failure were 64%. Although the artificial urinary sphincter (AUS) is the gold standard for the treatment of this disorder, most men will continue to need at least one pad per day for protection, and they are subject to a significant chance of future AUS revision or replacement.

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.

1348 HYPERCONTINENCE AND CUFF EROSION AFTER ARTIFICIAL URINARY SPHINCTER INSERTION: A COMPARISON OF CUFF SIZES AND PLACEMENT TECHNIQUES

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence—Evaluation & Therapy1 Apr 20111348 HYPERCONTINENCE AND CUFF EROSION AFTER ARTIFICIAL URINARY SPHINCTER INSERTION: A COMPARISON OF CUFF SIZES AND PLACEMENT TECHNIQUES Paul Smith, Steven Hudak, and Allen Morey Paul SmithPaul Smith Dallas, TX More articles by this author , Steven HudakSteven Hudak Dallas, TX More articles by this author , and Allen MoreyAllen Morey Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1169AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We have noted that a small percentage of men who undergo placement of an artificial urinary sphincter (AUS) for stress urinary incontinence (SUI) develop transient post-operative urinary retention. Some of these patients become “hypercontinent” requiring prolonged urethral catheterization and/or placement of a suprapubic catheter (SPT). In this study, we evaluated the AUS cuff sizes and techniques associated with hypercontinence. METHODS We analyzed the outcomes of AUS cases performed by a single surgeon from 2007–2010. All patients underwent cuff placement in the most proximal bulb via a perineal incision. Cases were analyzed in three groups according to cuff size–3.5 cm, ≥4.0 cm, or transcorporal cuff (TC). Newer techniques developed for men with periurethral atrophy (3.5 cm cuff and TC cuff) were compared against the traditional cuff size group (≥4 cm). Outcomes relating to urinary retention, SPT placement, and cuff erosion were analyzed. RESULTS Among 138 patients who underwent AUS placement from 2007–2010, 108 cases met inclusion criteria—those placed via a penoscrotal approach or with incomplete follow up data were excluded: 41 men received a 3.5 cm cuff, 46 received a ≥4 cm cuff, and 21 received a TC cuff (all ≥4 cm). TC patients had a significantly higher rate of urinary retention requiring SPT placement compared to the ≥4.0 cm group [5/21 (24%) vs. 2/46 (4%), p = 0.03] and a slightly higher rate than the 3.5 cm group [5/41 (12%), p = 0.3]. The 3.5 cm, ≥4 cm, and TC groups all exhibited similar rates of cuff erosion [3/41 (7%), 2/46 (4%), and 1/21 (5%), p>0.05]. Cuff erosions were much more common in hypercontinent men compared to those without hypercontinence [4/21 (19%) vs 2/87 (2%), p = 0.01], especially in the 3.5 cm and TC group. No significant differences were found between these groups in the rates of diabetes, erectile dysfunction, previous radiation therapy, or previous SUI surgical intervention. CONCLUSIONS Transcorporal AUS placement is associated with a higher rate of postoperative urinary retention and need for suprapubic tube placement compared to traditional 4.0 cm cuff placement. Hypercontinence is a potential risk factor for cuff erosion, likely due to recurrent transurethral instrumentation or prolonged catheterization. The risk of urinary retention requiring further instrumentation and/or SPT placement should be discussed with candidates for TC AUS. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e538-e539 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Paul Smith Dallas, TX More articles by this author Steven Hudak Dallas, TX More articles by this author Allen Morey Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

2303 ULTRASOUND IMAGING OF ARTIFICIAL SPHINCTER PRESSURE REGULATING BALLOON

You have accessJournal of UrologyImaging/Radiology: Uroradiology1 Apr 20112303 ULTRASOUND IMAGING OF ARTIFICIAL SPHINCTER PRESSURE REGULATING BALLOON Benjamin Brucker, Abdullah Demirtas, Eva Fong, Chris Kelly, and Victor Nitti Benjamin BruckerBenjamin Brucker New York, NY More articles by this author , Abdullah DemirtasAbdullah Demirtas New York, NY More articles by this author , Eva FongEva Fong New York, NY More articles by this author , Chris KellyChris Kelly New York, NY More articles by this author , and Victor NittiVictor Nitti New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2549AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Traditionally, plain radiography has been used to assess artificial urinary sphincter (AUS) integrity when there is failure or a change is patient continence status to determine if fluid has leaked from the system. This requires that the pressure regulating balloon (PRB) is filled with a contrast medium at the time of implantation. We propose that the device can be filled with injectable saline and office based abdominal ultrasound (US) can be used to determine the volume in the PRB when needed. The aim of this study was to assess the sensitivity and specificity of US in identifying PRB fluid status. METHODS A retrospective review was carried out on patient identified by a CPT 53447 (removal/replacement Urinary Sphincter)(R/R) limited to service dates 4/1/07–4/1/10. Data regarding clinical scenario, imaging, and intra-operative findings were recorded. US were all done in an office setting by a radiology technologist and reviewed by a Urologist. A Seimen's ACUSON Sequoia C512 was used with an 8C4(4–8 mHz) or a 9L4 probe (4–9 mHz) in all studies. The AMS 800 AUS was utilized in all cases. Sensitivity and specificity were calculated with a 2x2 table. In cases of under filled PRB, the point of leakage was determined, and the device was R/R. In cases of a full PRB, patients had a cuff downsizing or total R/R. RESULTS 27 patients were identified as having had a R/R of an AUS in the 3 year period analyzed. 14 patients underwent an US as part of their work-up prior to the R/R. Reasons for not obtaining an US included the following: advanced age of device (4), cuff erosion (2), confirmation of volume status on other imaging modality (2), cuff site pain (1), isolated pump malfunctions (1), other (3). Of the 14 patient, an AUS was placed after radical prostatectomy in 10, benign prostectomy in 1, TURP in 2 and neobladder 1 patients. 43% (n=6) of the US were read as the PRB being full (21–23 ml) and 57% (n=8) were noted to be empty/under filled (0-6 ml). By comparing these results to intra-operative findings US was 100% sensitive and 100% specific for determining fluid status of the PRB. AUS noted to be full on US were managed with downsizing of cuff (3), transcorporal cuff placement (1) and total removal/replacement (2). The devices that were empty were all entirely R/R. 50% (4/8) of leaks identified at the cuff site and the remaining AUS, though empty, did not have a leak sites identified. CONCLUSIONS Office based abdominal US is an effective and accurate way of determining the fluid status of the AMS 800 AUS. Given the accuracy of this modality, the system can be filled with saline solution without losing the ability to diagnose a fluid leak in the system. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e923-e924 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin Brucker New York, NY More articles by this author Abdullah Demirtas New York, NY More articles by this author Eva Fong New York, NY More articles by this author Chris Kelly New York, NY More articles by this author Victor Nitti New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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Most cuff erosions occur on the dorsal aspect of the urethra, suggesting missed injury during mobilization of the urethra from tissues behind it as a common etiology. We agree that most early urethral erosions result from inadvertent injury. However, preservation of urethral blood supply by minimizing mobilization is felt to be a positive attribute of this narrower cuff device. Preservation of urethral vascularity is thought to be of prime importance, especially in cases with an initial compromise to the blood flow secondary to radiation, trauma, or previous urethral surgeries. Of course, using meticulous surgical technique during circumferential mobilization of the urethra and being cognizant of the possibility of injury are prudent practices for minimizing early erosion. Editorial CommentUrologyVol. 77Issue 1PreviewIn comparing the tape mechanical occlusive device (TMOD) with the artificial urinary sphincter, the authors mention that the narrow width of the occlusion tape requires less dissection around the bulbar urethra. They believe this might reduce the risk of urethral injury during urethral mobilization, and this, in turn, might encourage more urologists to use this device. Full-Text PDF

EROSION RATE OF REPLACEMENT AND REDO ARTIFICIAL URINARY SPHINCTER COMPARED WITH PRIMARY IMPLANTATION

management of sphincter weakness incontinence (SWI). More and more patients are either reaching the end of the lifespan of the device or are presenting with late cuff erosion requiring placement of a new device. METHODS: From October 2004 to October 2007 a series 104 successive artificial urinary sphincters were implanted and outcomes were recorded prospectively with a follow-up of 1-37 months (median 7). The age range of the patients at the time of implantation was 13-91 years (mean 55, median 63). 76 bulbar AUS (59 primary-,

Long-Term Durability and Functional Outcomes Among Patients With Artificial Urinary Sphincters: A 10-Year Retrospective Review From the University of Michigan

The artificial urinary sphincter continues to be one of the most effective and commonly used surgical treatments for severe urinary incontinence. The long-term durability and functional outcome remains unclear. This study sought to report the artificial urinary sphincter complication rates, associated risk factors with complications, and long-term quality of life and durability. This single institution study reports the outcomes of 124 consecutive index cases of artificial urinary sphincter from 1996 to 2006 for complications (infection, erosion, and mechanical failure). Bivariate statistics and multivariable logistic models were used to identify patient and artificial urinary sphincter characteristics associated with complications. Functional outcomes and long-term durability were assessed using a cross sectional analysis of a validated health related quality of life survey and a product limit estimates, respectively. Among the 124 male patients median followup was 6.8 years. The overall complication rate for patients undergoing an artificial urinary sphincter was 37.0%, with mechanical failure the most common cause (29), followed by erosion (10) and then infection (7). Significant differences between complications and specific patient and artificial urinary sphincter characteristics risk factors were not found. Functional outcomes appeared stable with similar mild-moderate urinary incontinence severity and 0 to 1 daily pad use at intervals of 0 to 4 years, 4 to 8 years and more than 8 years. Long-term durability was notable with 36% having complications (requiring surgical revision or removal) within 10 years and most events occurring within the first 48 months. Long-term durability and functional outcomes are achievable for the AMS 800, but there are appreciable complication rates for erosion, mechanical failure and infection in the first 48 months from implantation.

Perineal Approach for Artificial Urinary Sphincter Implantation Appears to Control Male Stress Incontinence Better Than the Transscrotal Approach

Traditionally cuff placement of an artificial urinary sphincter is done through a perineal approach. A new approach through a penoscrotal incision or transscrotal approach is reportedly more rapid and easier than the traditional incision. These 2 approaches were evaluated to determine which one controlled male stress urinary incontinence better. We performed a retrospective chart review of 94 patients who underwent artificial urinary sphincter placement procedures from April 1987 to March 2004. A total of 126 artificial urinary sphincter cuffs (120 procedures, including double cuff placement in 6) were placed in 94 patients with 63 placed penoscrotally and 63 placed perineally. Of the double cuff placements 1 was perineal and 5 were transscrotal. In patients with a single initial or revision cuff the self-reported completely dry rate was 28.6% with the penoscrotal approach and 56.5% with the perineal approach (p = 0.01), while for initial cuffs only the dry rate was 28.0% and 56.7% for the penoscrotal and perineal approach, respectively (p = 0.03). Five of 28 patients (17.9%) with initial penoscrotal placement later underwent tandem cuff placement for continued incontinence, whereas only 1 of 32 (3.1%) with initial perineal placement later had a tandem cuff added (p = 0.06). There was no difference in the estimated failure-free survival (failure for any reason) of the device. When the artificial urinary sphincter cuff is placed through a perineal approach, there appears to be a higher completely dry rate and fewer subsequent tandem cuff additions than when the artificial urinary sphincter cuff is placed through a penoscrotal incision.

The Technique of Vessel Sparing Excision and Primary Anastomosis for Proximal Bulbous Urethral Reconstruction

We present a technique not previously described for proximal bulbous or bulbomembranous urethral reconstruction of excision and primary anastomosis. The technique has the potential advantages of preserving the proximal urethral blood supply. From June 2003 to October 2006, 10 patients underwent vessel sparing urethral reconstruction including 3 after radical prostatectomy, 6 following straddle trauma and 1 potentially with a congenital stricture. A plane was developed between the urethra and the proximal blood supply at the bulbospongiosum, allowing for division of the urethra without dividing the spongy tissue of the corpus spongiosum or the arteries to the bulb. Only 7 patients are presented for data analysis because the other 3 have not had sufficient followup to date. Patient age range was 15 to 72 years (mean 47). The patient with a congenital stricture was 2 years old. Stricture length ranged from 0.5 to 2.5 cm (mean 1.5). The patients who had undergone radical prostatectomy were either incontinent or were believed to be possibly rendered incontinent after the urethral reconstruction. At a mean followup of 12.5 months (range 6 to 38) all 7 patients had patent urethras, 2 were incontinent and 1 underwent implantation with an AMS 800 sphincter using a transcorporal approach. As of this writing all 10 patients are apparently stricture-free. Preservation of blood supply is always a noble achievement in surgery. However, it technically often requires significant effort. In patients after radical prostatectomy with proximal anterior urethral or bulbomembranous strictures, preserving the blood supply possibly decreases cuff erosion when undergoing later implantation Many patients (approximately 12% lifetime risk of prostate cancer) will require radical prostatectomy and may later require a sphincter. Further studies are warranted to evaluate the benefit of applying this technique in all suitable patients.

Outcomes Following Erosions of the Artificial Urinary Sphincter

Artificial urinary sphincter urethral cuff erosion occurs in up to 5.0% of cases, presenting a complex management problem. We examine our experience with the eroded AUS, relating to preoperative risk factors, operative management and outcomes. We reviewed the medical records of 637 patients undergoing bulbar urethral AUS implantation from 1990 to 2003 for demographic and surgical variables. Of the 637 records reviewed, 46 patients underwent 54 explantations of the AUS device for erosions, including 13 who had the primary implant performed at our institution and 33 being referred for management of erosion after implantation elsewhere. Our institution erosion rate was 2.2%. Mean followup after AUS reimplant following erosion was 27.8 months (range 1 to 180). Comorbidities were more prevalent in patients with erosions included hypertension (p = 0.006), coronary artery disease (p = 0.03), prior radiation therapy (p = 0.006) and prior AUS revisions (p = 0.0001). A majority of patients had persistent mild incontinence (0 to 1 pad daily in 29 or 56.8%), moderate (1 to 3 pads daily in 9 or 17.4%) and severe (more than 3 pads daily in 6 or 11.8%) incontinence after secondary AUS implantation. Patients who underwent reimplantation after AUS cuff erosions have a significantly higher rate of second erosions (in 16, 34.8%) within an average of 6.7 months (range 3 to 24), including our own 11.8% institutional rate (in 4). Our study suggests that patients with comorbidities including hypertension, coronary artery disease, prior radiation therapy and prior AUS revisions are more likely to have erosions of their AUS. Nevertheless, continence can still be salvaged using various strategies which optimize use of the remaining healthy urethral tissue.

OUTCOMES FOLLOWING REVISIONS AND SECONDARY IMPLANTATION OF THE ARTIFICIAL URINARY SPHINCTER

Durable success with the artificial urinary sphincter (AUS) is common but device revision and replacement are often needed for various reasons. We examined indications and outcomes following these secondary procedures with comparisons to outcomes after primary procedures. The medical records of all patients undergoing primary and secondary bulbar urethral AUS implantation and revision from January 1990 to September 2002 were reviewed for various demographic and surgical variables. Female patients and males with bladder neck cuffs were excluded from study. Of 554 men undergoing AUS implantation or revision 119 (21.4%) underwent a total of 159 secondary procedures. Reasons for revision were mechanical failure in 31 cases (25.2%) and nonmechanical failure in 88 (73.9%). The latter included recurrent incontinence due to urethral atrophy in 63 cases (52.9%) and erosion in 21 (17.6%). Total device replacement was performed in 75 cases (47.2%). Of 119 patients undergoing secondary implantation 91 (76.5%) needed no additional surgical intervention, while 28 (23.5%) required a total of 40 surgical revisions for new mechanical (15 or 37.5%) and nonmechanical (25 or 62.5%) problems. Five-year durability outcomes for primary and secondary AUS implantation were comparable at 80% and 88%, respectively. Similarly excellent continence outcomes (0 to 1 pad daily) were noted in 90% and 82% of patients undergoing primary and secondary AUS implantation, respectively. Secondary and tertiary AUS revisions resulted in the restoration of baseline continence in 106 cases (89%). Our study suggests that outcomes for secondary AUS reimplantation are comparable to those of primary AUS implantation and salvage of a good outcome is always probable, even following multiple prior revisions and cuff erosion.

The CARI guidelines. Evidence for peritonitis treatment and prophylaxis: timing of commencement of dialysis after peritoneal dialysis catheter insertion.

NephrologyVolume 9, Issue S3 p. S76-S77 Free Access 9. Timing of commencement of dialysis after peritoneal dialysis catheter insertion First published: 06 October 2004 https://doi.org/10.1111/j.1440-1797.2004.00304.xCitations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat GUIDELINES No recommendations possible BACKGROUND Delayed use of the peritoneal dialysis (PD) catheter may reduce catheter-related complications such as peritonitis. SEARCH STRATEGY Databases searched: MeSh terms and text words for PD were combined with MeSH terms and text words for catheter insertion, and then combined with MeSH terms and text words for peritonitis. The search was carried out in Medline (1966 – October Week 5 2002). The Cochrane Renal Group Trials Register was also searched for trials not indexed in Medline Date of search/es: 25 November 2002. WHAT IS THE EVIDENCE? No randomised controlled trials (RCTs) are available which address this issue. SUMMARY OF THE EVIDENCE There are no RCTs. SUGGESTIONS FOR CLINICAL CARE (Suggestions are based on level III and IV sources) • When possible, peritoneal dialysis should not be commenced until at least 2 weeks after the insertion of the dialysis catheter. Cheng et al. compared delayed start (haemodialysis support) with intermittent PD for 4 weeks after catheter insertion in an adult population, before commencing continuous ambulatory peritoneal dialysis (CAPD). They found there was no difference in peritonitis between the two groups but there were more dialysate leaks, cuff erosions and delay in CAPD training in the immediate group.1 A retrospective analysis by Patel et al. of 33 paediatric patients reported that delayed use of the catheter (average of 20 days) in 22 patients compared with immediate use in 11 patients resulted in a higher rate of peritonitis at 3 months in the delayed group (0.36 vs. 0.18) [and more ESI and tunnel infections]. Dialysate leaks were more common in the immediate group (0.36 vs. 0.09).2 WHAT DO THE OTHER GUIDELINES SAY? Kidney Disease Outcomes Quality Initiative: No recommendations. British Renal Association: No recommendations. Canadian Society of Nephrology: No recommendations. European Dialysis and Transplant Association–European Renal Association: Whenever possible the implantation should be at least 2 weeks before starting peritoneal dialysis. Small dialysate volumes in the supine position can be used when this is impossible. (Evidence C) International Society for Peritoneal Dialysis 1998: Commencement of CAPD is dependent on the implantation technique, but generally the catheter should be capped for at least 2 weeks before initiating CAPD. Peritoneal dialysis in this interim period should be intermittent, using small volumes and with the patient in a supine position. The exchange volumes can be gradually increased. IMPLEMENTATION AND AUDIT All renal units should maintain data on the date of catheter insertion and time of commencement of dialysis in addition to all PD-related problems including exit-site infections, tunnel infections, peritonitis, catheter malfunction rates and catheter survival times. This data should be submitted to the ANZDATA registry. SUGGESTIONS FOR FUTURE RESEARCH An RCT addressing the issue of timing of the commencement of dialysis after insertion of a PD catheter may help resolve this question. REFERENCES 1 Cheng YL, Chau KF, Choi KS et al. Peritoneal catheter related complications: a comparison between hemodialysis and intermittent peritoneal dialysis in the break-in period. Adv. Perit.Dial. 1996; 12: 231– 5. 2 Patel UD, Mottes TA, Flynn JT. Delayed compared with immediate use of peritoneal catheter in pediatric peritoneal dialysis. Adv. Perit. Dial. 2001; 17: 253– 9. Citing Literature Volume9, IssueS3October 2004Pages S76-S77 ReferencesRelatedInformation

Tandem Cuff Artificial Urinary Sphincter as a Salvage Procedure Following Failed Primary Sphincter Placement for the Treatment of Post-Prostatectomy Incontinence

Management of post-artificial urinary sphincter (AUS) urethral atrophy can be difficult for the treating physician, yielding unsatisfactory results for the patient. As with many incontinence procedures, initial results are generally encouraging. We determined the durability and success of tandem cuff placement for urethral atrophy following AUS placement. We reviewed the records of 18 patients with a mean age 74 years who underwent tandem AUS placement from 1994 to 2001. Mean followup was 3.3 years. All patients originally underwent AUS placement for post-prostatectomy stress urinary incontinence and they had subsequent incontinence secondary to urethral atrophy. Adjuvant radiation in 3 cases, hormone therapy in 3, cuff size and pressure, and multiple continence procedures prior to tandem cuff placement in 5 were evaluated as risk factors for cuff erosion. Long-term followup was obtained through office examination and telephone interview using a standardized questionnaire regarding voiding habits and satisfaction. Following tandem cuff placement mean +/- SD pad use daily decreased from 4.3 +/- 0.35 (median 3) to 1.6 +/- 0.42 (median 1) (p <0.0001). Overall 10 of the 18 patients (56%) needed 1 pad or less daily, 16 (88%) would have the tandem cuff placed again and 17 (94%) would recommend the procedure. Median subjective improvement and satisfaction was 4.7 and 4.0, respectively, on a scale of 0 to 5. Reoperation was required for cuff leakage in 1 case and cuff erosion in 2. One patient with erosion had 3 prior AUS revisions, including placement of a 71 to 80 cc balloon reservoir. Placement of tandem urethral cuff as a salvage procedure for recurrent stress urinary incontinence provides marked sustained improvement in leakage and overall high patient satisfaction in the difficult setting of urethral atrophy.