Artificial Urinary Sphincter Insertion Research Articles

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 robot-assisted laparoscopic revision of an artificial urinary sphincter in a patient with spinal cord injury.

This step-by-step article demonstrates our approach to robot-assisted laparoscopic revision of a bladder neck sited artificial urinary sphincter (AUS) for a spinal cord injured patient. The bladder neck location of an AUS in the spinal cord injured demographic is ideal to minimise urethral complications and urinary tract infections, whilst the transabdominal approach reduces the risk of wound breakdown that can occur via the typical perineal incision for AUS insertion. The accompanying video will guide viewers as to our minimally invasive technique for cuff revision in the event of secondary surgery for recurrent urinary incontinence.

(312) Area Deprivation Index in Men Undergoing AUS Placement– Community Resource Limitations Do Not Correlate with Poorer Device or Satisfaction Outcomes

Abstract Introduction Outcomes following artificial urinary sphincter (AUS) placement have been associated with non-urologic health metrics including hemoglobin A1c and BMI, as well as with health literacy and frailty. Concerns about these patient factors may lead urologic prosthetic surgeons to alter their recommendations for stress urinary incontinence treatment to avoid poor patient outcomes. The Area Deprivation Index (ADI) is a ranking system to measure socioeconomic disadvantage between neighborhoods and correlates with rates of chronic medical conditions such as diabetes and cardiovascular disease, as well as healthcare service utilization and death. This ranking system includes a composite score of patient income, education level, employment status and housing quality. Evaluating socioeconomic disadvantage may help implanters tailor their patient counseling and improve patient pre- and postoperative education. Objective We sought to characterize variability in functional, subjective, and objective outcomes following AUS placement according to ADI. Methods Patients were identified by CPT codes for AUS insertion, removal/replacement, and revision from 2014 to 2022 at our institution. National percentile ADI was obtained using the Neighborhood Atlas® (Madison, WI) based on patient home address. Higher ADI scores indicate greater socioeconomic disadvantage. Associations of ADI with post-AUS satisfaction, device survival, and complications including (I) any Clavien-Dindo complication and (II) complications requiring surgical intervention. Patient satisfaction was assessed on a 1-5 Likert scale based on telephone interviews. Results 284 patients met inclusion criteria with 232 having data available regarding complications. Median ADI scores in our cohort was 59 (41-75), and we divided the cohort according to high (>58) and low socioeconomic deprivation groups based on this cutoff. Of these, 53 (22.8%) experienced any complication following AUS procedure, over a median of 6.3 months follow up. Device survival at last follow up was similar between low (88.8%) and high ADI groups (92%, P=0.41). Patients with low and high ADI scores had similar overall complication rates (21.6% vs. 24.4%; P=0.64) of any Clavien-Dindo score. Device survival was high at last follow up regardless of ADI score (88.8% vs. 92.0%; P=0.41) with total follow up also being similar between groups (5.64 mo vs. 8.01 mo; P=0.23). Time from prostatectomy to AUS implantation was also similar between high and low ADI groups (4.23 years vs. 4.17 years, P=0.70) Finally, patient satisfaction was very high in both the low and high ADI groups (5 vs. 5; P=0.41). Conclusions ADI was not associated with time to sphincter implantation, postoperative complications, patient satisfaction or device survival. Despite ADI capturing several factors that potentially impact a patient’s ability to optimally access medical care-including income, education and housing quality, we found no evidence that socioeconomic disadvantage by ADI scores was predictive of poorer outcomes, satisfaction, or suboptimal follow up. Disclosure No

(543) Antibiotic Prophylaxis for Artificial Urinary Sphincter Surgery - Trends in AUA Best Practices Guideline Adherence

Abstract Introduction Infections involving an artificial urinary sphincter (AUS) can be devastating and costly. Antibiotic use during implantation is a mainstay in preserving the implant as well as reducing morbidity for patients. While antibiotic guidelines regarding urologic procedures have been published, it remains unclear how widespread these recommendations adoption or use is in practice especially with regards to AUS implantation. Objective Using the premier healthcare database (PHD), a large national database, we assessed trends in antibiotic prophylaxis for AUS in conjunction with the AUA Best Practice Guidelines on urologic procedures and antimicrobial prophylaxis. Methods The premier healthcare database (PHD) was queried from Q1 of year 2000 to Q1 of 2020. Encounters involving AUS insertion, removal, and/or associated complications were identified via ICD diagnosis, ICD procedure, and CPT codes. Premier charge codes were used to identify antibiotics administered during the insertion encounter. Antibiotics were grouped into categories based on antibiotic classification. Information pertaining to the day a particular item was billed was used to identify whether administration was ‘guidelines based’ or not. Antibiotic administration was considered guidelines based if they consisted of either Aminoglycosides and 1st/2nd generation Cephalosporin or Monobactam (Aztreonam) and 1st/2nd generation Cephalosporin. Removal or complications associated with AUS were identified on subsequent encounters and linked via the patients’ hospital identifier. Differences in removal and complication rates between patients with guidelines-based antibiotic administration at insertion were assessed via chi-squared tests. The association of guidelines-based administration with other categorical variables was also assessed via chi-squared tests. Differences between groups in continuous variables were assessed via Mann-Whitney U tests. Results A total of 9,976 patients having undergone AUS surgery were identified between 2000 and 2020, of which 1548 (16%) received AUA-adherent antibiotics. Six thousand six hundred and twenty six (66%) encounters were isolated since 2011. Mean age was 69.8 with 7485 (75%) Caucasian, 7158 (71%) utilizing Medicare. Mean length of hospital stay (LOS) was 0.4 days overall and 0.2 days compared to 0.5 (p<0.001) for patients receiving AUA-adherent to AUA non-adherent antibiotics. Patients receiving AUA-adherent antibiotic regimens (359 [23%]) had fewer complications than those receiving non-adherent regimens (2335 [28%]) (p<0.001) however no statistically significant reduction in encounters for removal or repair were noted (AUA-adherent 307 [20%]) to AUA-non-adherent 1826 [22%]) (p=0.11). No statistical significance was noted with regards to the decade of encounter, age, or race of the patient, or if the patient had received AUS teaching. Only 4.95% of patients received antibiotic therapy beyond the recommended 24-hour prophylactic recommendations. Conclusions Adherence to AUA-recommended, best practice antimicrobial guidlines, with regards to AUS implantation appears low. This is likely multifactorial and dependent on individual surgeon preferences, local antibiograms and resistance patterns as well as individual patient sensitivities and tolerances. Disclosure No

O047 Outcomes of bulbar artificial urinary sphincter in older men following prostate cancer

Abstract Introduction The gold standard treatment for stress urinary incontinence (SUI) in men is a bulbar artificial urinary sphincter (AUS). With an aging population, we must ensure efficacious solutions for older men with SUI are available. Our study assessed whether age influenced the outcomes of AUS for SUI post-prostate cancer (PCa) treatment. Methods Retrospective notes review of all patients having AUS for SUI following PCa treatment between 2006-2019. A 7-point Patient Global Impression of Improvement assessment (PGII) comparing pre-operative and post-operative conditions (1: very much better, 4: the same and 7: very much worse). This was completed a minimum of 6 months following AUS insertion. PGII score of 1 or 2 was recorded as a successful AUS. Older men were defined as ≥75 years. Statistical analysis was via Students T-Test, Chi-Square, and Mann Whitney with significance determined as P<0.5. Results 184 men, median 69 years (range 31-87) were included. 150 men were aged <75 years and 34 were ≥75 years. Patients had prior prostatectomy and/or radiotherapy. No significant difference in median PGII score (score 2) or overall AUS success between the 2 groups. Overall AUS success was 73.3% in <75 years and 73.5% in ≥75 years. Conclusions No significant difference was seen in success between older and younger men. Bulbar AUS had an overall success rate of 73.4%, described as very much improved or much improved condition, a minimum of 6 months after insertion. Older age should not be a deterrent to offering AUS surgery.

A narrative review: evaluation and surgical management of persistent and recurrent urinary incontinence after previous surgical treatment.

Urinary incontinence after prostate treatment is associated with significant morbidity and impact on quality of life. Stress urinary incontinence can be treated by insertion of a urethral sling or artificial urinary sphincter. Persistent or recurrent urinary incontinence after such treatment can be frustrating and require specific evaluation and approach to management to optimize chance of successful outcomes and patient satisfaction whilst avoiding further patient morbidity. The aim of this review is to outline the evaluation and management of persistent and recurrent urinary incontinence in men after previous surgical treatment for stress urinary incontinence by way of narrative review. A literature review was performed using PubMed, MEDLINE, and Google Scholar between 2010 to 2023. The search strategy included the following MeSH terms: device, men, urinary incontinence, persistence, recurrence, and revision. A total of 140 English-language articles were identified and reviewed; 68 articles were considered relevant to the aims and the findings have been outlined in this narrative review. There are many approaches currently practiced by surgeons in continence revision surgery. There is not clear consensus regarding optimum revision strategy for persistent and recurrent incontinence post urethral sling and artificial urinary sphincter insertion. Whilst small observational studies have reviewed different surgical approaches, there is a paucity of high volume comparative data from which to draw conclusions. However, there have been recent studies enabling a paradigm shift in the understanding of incontinence post artificial urinary sphincter insertion that may lead to improved revision strategies in future. There are various surgical modalities used to manage incontinence following urethral sling and artificial urinary sphincter insertion. There is currently no clear consensus on the optimal surgical technique for persistent or recurrent urinary incontinence after surgery. Further comparative studies would be beneficial to help guide surgeons as to which revision approaches would be suitable for select patients.

PD35-02 RETROSPECTIVE MULTICENTER ANALYSIS OF LONG-TERM OUTCOMES AFTER ARTIFICIAL URINARY SPHINCTER FOLLOWING URETHROPLASTY

You have accessJournal of UrologyCME1 Apr 2023PD35-02 RETROSPECTIVE MULTICENTER ANALYSIS OF LONG-TERM OUTCOMES AFTER ARTIFICIAL URINARY SPHINCTER FOLLOWING URETHROPLASTY Meghan Davis, Erin Hays, Peter Kolyvas, Margaret Higgins, Derek Wengryn, Brian Flynn, Reynaldo Gomez, Joshua Sterling, Alexander Chartier, Dmitriy Nikolavsky, Akio Horiguchi, Matthias Hofer, Jose Bernal, Francisco Martins, Felix Campos Juanatey, Henriette Veiby Holm, Jay Simhan, Stuart Boyd, Javier Angulo, Jeffrey Loh Doyle, and Krishnan Venkatesan Meghan DavisMeghan Davis More articles by this author , Erin HaysErin Hays More articles by this author , Peter KolyvasPeter Kolyvas More articles by this author , Margaret HigginsMargaret Higgins More articles by this author , Derek WengrynDerek Wengryn More articles by this author , Brian FlynnBrian Flynn More articles by this author , Reynaldo GomezReynaldo Gomez More articles by this author , Joshua SterlingJoshua Sterling More articles by this author , Alexander ChartierAlexander Chartier More articles by this author , Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author , Akio HoriguchiAkio Horiguchi More articles by this author , Matthias HoferMatthias Hofer More articles by this author , Jose BernalJose Bernal More articles by this author , Francisco MartinsFrancisco Martins More articles by this author , Felix Campos JuanateyFelix Campos Juanatey More articles by this author , Henriette Veiby HolmHenriette Veiby Holm More articles by this author , Jay SimhanJay Simhan More articles by this author , Stuart BoydStuart Boyd More articles by this author , Javier AnguloJavier Angulo More articles by this author , Jeffrey Loh DoyleJeffrey Loh Doyle More articles by this author , and Krishnan VenkatesanKrishnan Venkatesan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The artificial urinary sphincter (AUS) is generally accepted as the gold standard for male stress urinary incontinence (SUI). There is limited and conflicting evidence on outcomes when urethroplasty precedes AUS insertion, and even less scrutiny of whether and how urethroplasty technique affects these outcomes. We sought to evaluate complications of AUS insertion after urethroplasty in a multi-institutional cohort. We hypothesize that complications occur at higher rates in this population and vary between augmentation and anastomotic urethroplasty. METHODS: 108 patients were identified who underwent AUS after urethroplasty. Demographic and clinical variables were analyzed. Urethroplasties were categorized as either transecting or non-transecting. Long term complications included AUS infection, erosion, and mechanical failure. Analysis was performed using Stata/BE 17.0. For descriptive statistics, continuous variables were presented as the mean or median and categorical variables were presented as absolute numbers and percentages. Chi squared test was used for categorical variables. Tests performed were two-sided and p<0.05 was considered to indicate statistical significance. RESULTS: 108 cases were identified that were performed by 13 surgeons (range 2-26). Characteristics of the sample are included in Table 1. Long term AUS complication risk including AUS infection, erosion, and mechanical failure following transecting urethroplasty was 53% compared to 29% following non-transecting urethroplasty (p=0.01). Among 59 patients who had non-transecting urethroplasty, 10 experienced erosion, 3 infection, and 3 mechanical failure. Among 49 patients who had transecting urethroplasty, 16 experienced erosion and 10 mechanical failure. Median follow-up was 30 months following AUS insertion. CONCLUSIONS: For patients undergoing AUS insertion after urethroplasty, complications occur at higher rates than outcomes in the general population. Patients who undergo transecting urethroplasty are twice as likely to experience AUS complications compared to patients who had undergone non-transecting urethroplasty. Non-transecting urethroplasty may be advisable if a subsequent need for AUS is anticipated. Source of Funding: N/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e974 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Meghan Davis More articles by this author Erin Hays More articles by this author Peter Kolyvas More articles by this author Margaret Higgins More articles by this author Derek Wengryn More articles by this author Brian Flynn More articles by this author Reynaldo Gomez More articles by this author Joshua Sterling More articles by this author Alexander Chartier More articles by this author Dmitriy Nikolavsky More articles by this author Akio Horiguchi More articles by this author Matthias Hofer More articles by this author Jose Bernal More articles by this author Francisco Martins More articles by this author Felix Campos Juanatey More articles by this author Henriette Veiby Holm More articles by this author Jay Simhan More articles by this author Stuart Boyd More articles by this author Javier Angulo More articles by this author Jeffrey Loh Doyle More articles by this author Krishnan Venkatesan More articles by this author Expand All Advertisement PDF downloadLoading ...

MP78-14 INTERNATIONAL EXPERT CONSENSUS ON DEVELOPMENT OF A STATE OF THE ART MALE GENITAL SIMULATION MODEL FOR URETHROPLASTY AND ARTIFICIAL URINARY SPHINCTER INSERTION

You have accessJournal of UrologyCME1 Apr 2023MP78-14 INTERNATIONAL EXPERT CONSENSUS ON DEVELOPMENT OF A STATE OF THE ART MALE GENITAL SIMULATION MODEL FOR URETHROPLASTY AND ARTIFICIAL URINARY SPHINCTER INSERTION Andrew Cohen, Marc (Toto) Abalajon, Katherine Anderson, Nima Baradaran, Cooper Benson, William Boysen, Benjamin Breyer, Arthur Burnett, Felix Campos, Lindsay Hampson, Ty Higuchi, Niels Johnsen, Nicolaas Lumen, Dmitriy Nikolavsky, Joseph Pariser, Jay Simhan, Alex Vanni, Nick Warner, E. James Wright, and Ahmed Ghazi Andrew CohenAndrew Cohen More articles by this author , Marc (Toto) AbalajonMarc (Toto) Abalajon More articles by this author , Katherine AndersonKatherine Anderson More articles by this author , Nima BaradaranNima Baradaran More articles by this author , Cooper BensonCooper Benson More articles by this author , William BoysenWilliam Boysen More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Arthur BurnettArthur Burnett More articles by this author , Felix CamposFelix Campos More articles by this author , Lindsay HampsonLindsay Hampson More articles by this author , Ty HiguchiTy Higuchi More articles by this author , Niels JohnsenNiels Johnsen More articles by this author , Nicolaas LumenNicolaas Lumen More articles by this author , Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author , Joseph PariserJoseph Pariser More articles by this author , Jay SimhanJay Simhan More articles by this author , Alex VanniAlex Vanni More articles by this author , Nick WarnerNick Warner More articles by this author , E. James WrightE. James Wright More articles by this author , and Ahmed GhaziAhmed Ghazi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The number of available simulation-based models for technical skills training in urology is rapidly increasing, and development of training around these procedures should follow a structured approach. Utilizing modern education theory previously used to develop a hydrogel model for penile prosthesis placement, we aim to establish the criteria for development of a hydrogel male genital simulation model for Urethroplasty and Artificial Urinary Sphincter Insertion using international expert consensus. METHODS: 19 international experts of genitourinary reconstructive surgery were invited to participate in a three phase consensus building approach (modified Delphi technique). A total of 39 unique questions with 155 sub questions over three rounds were included in 4 categories 1) Overall utility of the model 2) anatomical and procedural components, 3) tissue fidelity and 4) evaluation of performance. Components reaching a content validity index (CVI) ≥0.80 were utilized to fabricate a prototype model. RESULTS: 106 of the 155 (68.3%) questions reached the consensus benchmark. Regarding utility, consensus was reached that a non-biohazardous urethral model and simulation-based platform would be very beneficial and should be developed using a validated educational approach. The expert panel agreed the simulator should allow for surgical practice in a risk free environment and allow performance evaluation. Consensus was reached on key anatomical components (Table 1) including an initial training focus of a 2 cm proximal bulbar stricture. The panel agreed a model should allow flexible application of urethroplasty techniques such as grafts. The addition of an obturator canal was prompted from the group given desires for future urethral sling simulation. Furthermore, the experts approved a framework for a standardized evaluation metric for urethroplasty. They agreed motion analysis wearables for efficiency of movement and retrograde infusion test for anastomotic integrity have value as objective standardized feedback. CONCLUSIONS: Harnessing the consensus of 19 international experts, the framework for a robust and bio-safe model for reconstructive urethral surgery with proposed objective evaluation parameters of surgical performance was achieved. Fabrication of the prototype based on this consensus statement is in development. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1137 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Cohen More articles by this author Marc (Toto) Abalajon More articles by this author Katherine Anderson More articles by this author Nima Baradaran More articles by this author Cooper Benson More articles by this author William Boysen More articles by this author Benjamin Breyer More articles by this author Arthur Burnett More articles by this author Felix Campos More articles by this author Lindsay Hampson More articles by this author Ty Higuchi More articles by this author Niels Johnsen More articles by this author Nicolaas Lumen More articles by this author Dmitriy Nikolavsky More articles by this author Joseph Pariser More articles by this author Jay Simhan More articles by this author Alex Vanni More articles by this author Nick Warner More articles by this author E. James Wright More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

MP62-12 PARIETEX MINI MALE SLING FOR STRESS URINARY INCONTINENCE AT THE TIME OF THREE PIECE PENILE PROSTHESIS: TECHNIQUE AND OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP62-12 PARIETEX MINI MALE SLING FOR STRESS URINARY INCONTINENCE AT THE TIME OF THREE PIECE PENILE PROSTHESIS: TECHNIQUE AND OUTCOMES Shirin Razdan, Alexandra Siegal, and Robert Valenzuela Shirin RazdanShirin Razdan More articles by this author , Alexandra SiegalAlexandra Siegal More articles by this author , and Robert ValenzuelaRobert Valenzuela More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Male stress urinary incontinence (SUI) and climacturia are often comorbid with erectile dysfunction (ED) post prostatectomy. While the inflatable penile prosthesis (IPP) is the gold standard surgical option for ED, there are many surgical options for male SUI as well as climacturia including bulking agents, Virtue® male sling, AdVance™ male sling, mini Jupette with IPP, and artificial urinary sphincter (AUS). We present our technique and outcomes for mini male sling (MMS) with IPP insertion for mild SUI and climacturia using a hydrophilic monofilament polyester mesh. METHODS: After obtaining IRB approval, a retrospective review of all IPPs performed by a single high volume surgeon was performed. Those men who underwent IPP insertion with concomitant MMS were analyzed. The technique of MMS placement involves measurement of an approximately 5x3cm Parietex™ mesh (Covidien, MN) and overlying this ventrally over the bulbar urethra. The Parietex™ mesh includes a hydrophilic absorbable collagen film to minimize tissue reaction and risk of erosion. The lateral edges of the mesh are sutured to the 3- and 9 o’clock positions on the left and right corporal bodies, respectively, using a nonabsorbable, braided suture in an interrupted fashion. Mesh is sutured just proximal to the corporotomy sites. Tightness of mesh was measured using the proximal end of a Debakey forceps, with ease of passage when IPP deflated and inability to pass forceps when IPP inflated indicative of proper sizing. RESULTS: A total of 63 men underwent IPP with MMS between January 2018 and October 2022. All patients had ED after radical prostatectomy. Average patient age was 67 years old, and average IPP size was 21cm with 1cm rear tip extender (RTE). A total of 59 men had SUI, with average pad per day (PPD) of 1.5. Twenty-five men with SUI had comorbid climacturia, and 4 men had preoperative climacturia without SUI. Average PPD post IPP with MMS was 0.1. Of the 29 men with preoperative climacturia, only one did not have resolution of his symptoms post MMS. There was only one reported complication of acute urinary retention requiring temporary foley catheter placement. Two patients required subsequent AUS insertion for persistent SUI. There were no reported cases of infection or mesh erosion. CONCLUSIONS: The hydrophilic Parietex™ mesh is a safe, easy to use, nonreactive, and effective material for mini male sling insertion at the time of IPP placement for men with ED and mild/moderate SUI or climacturia. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e866 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shirin Razdan More articles by this author Alexandra Siegal More articles by this author Robert Valenzuela More articles by this author Expand All Advertisement PDF downloadLoading ...

Does Medicaid cover artificial urinary sphincter and male urethral sling surgery?-a state-by-state analysis.

Information regarding the Medicaid coverage of artificial urinary sphincter (AUS) and male suburethral slings (MS) placement in the United States (US) is not readily available. In this manuscript, we seek to elucidate the state-by-state Medicaid coverage of these two procedures in the US. State Medicaid websites were utilized to access publicly available physician fee schedules for the calendar year 2020. Fee schedules were searched for current procedural terminology (CPT) codes. CPT codes representing insertion of tandem cuff, insertion of AUS, removal of AUS, removal and replacement AUS, sling operation for correction of male stress urinary incontinence (SUI), and removal or revision of sling for male SUI were utilized. Data were recorded by the procedure for each device, including the coverage status and physician fees. Of the 50 US states analyzed, 49 publish publicly accessible physician fee schedules. All 49 of these states reported coverage for removal with and without revision of the AUS, and 48 states reported coverage for insertion of an AUS, and insertion of a tandem cuff. The median reimbursement for each AUS related procedure was $624.00 ($181.84-$10,960.90) for tandem cuff, $665.54 ($199.89-$11,949.86) for AUS insertion, $528.03 ($146.90-$1,893.12) for AUS removal, and $630.29 ($208.55-$11,586.74) for AUS revision. All 49 states reported coverage for placement of MS, and 48 states reported coverage for removal or revision of MS. The median reimbursement was $652.57 ($198.00-$5,237.35) for MS placement and $554.47 ($104.27-$2,288.93) for MS revision. AUS and MS procedures in the Medicaid population are covered by nearly all states. Therefore, surgical treatment of SUI may be offered to Medicaid patients in most states without reimbursement concerns.

Complicated artificial urinary sphincter insertion using the transcorporal cuff: keys to the tunical flap technique.

Urethral sphincter insufficiency following radical prostatectomy (RP) is a common cause of non-neurogenic stress urinary incontinence (SUI). Artificial urinary sphincter (AUS) insertion remains the standard of care for fit patients with SUI refractory to non-operative interventions. The proximal urethra is a common location for uncomplicated AUS placement. However, previous failed AUS, urethroplasty, or pelvic radiotherapy (RT) may compromise urethral tissue requiring technique modifications that optimise outcomes. In these situations, transcorporal cuff (TC) placement has been well described to facilitate continence restoration in men where there is no other feasible option other than urinary diversion or permanent incontinence. In the traditional TC approach, the procedure may be complicated by haematoma due to difficulty in completely closing the corporal defects behind the urethra. This narrated video demonstrates the tunical flap (TF) modification for transcorporal AUS implantation via a perineal and penoscrotal approach in patients with prior failed AUS placements secondary to urethral erosion. The TF technique for transcorporal AUS insertion provides circumferential reinforcement with tunica albuginea from the corpora cavernosa. Here, we show how this technique provides additional urethral support for compromised urethral tissue to help prevent cuff erosion. The TF preserves the corporal volume and does not limit candidacy for future penile prosthesis implantation. In our early results, there have been no postoperative haematoma formation with this technique.

Early activation of artificial urinary sphincter for stress incontinence is safe: A pilot study

Background: Artificial urinary sphincter (AUS) activation is usually deferred until 6 weeks following insertion. However, this timeframe for activation is based on traditional dogma. This study aims to assess the feasibility, efficacy and safety of earlier activation of AUS. Methods: A prospective database was established on consecutive patients undergoing AUS implantation (AMS-800 Boston Scientific) from March 2019 to March 2022 by a single fellowship-trained urologist. Early activation was defined as &lt;30 days from the date of implantation. Results: Twenty-one patients were included in the study with a median follow-up of 34 (range: 3–96) months. The most common indication for AUS insertion was post-prostatectomy stress urinary incontinence ( n = 19, 90%). All 21 patients had their AUS successfully activated and used before 30 days, with a median of 14 (range: 9–28) days. Median (range) pre-operative continence pad numbers were 3 (2–6) and 0 (0–1) at 4 weeks post-operatively. Median (range) pad weight per day was 600 g (190–1310 g) pre-operatively and 6 g (0–6 g) at 4 weeks post-operatively. There were no adverse events associated with early activation. Conclusion: To our knowledge, this is the first description of the early activation of the AMS-800 AUS device. Our preliminary experience indicates early activation is safe and acceptable for patients. Level of evidence: II

Abdominal vs Sub-Inguinal Placement of Pressure Regulating Balloon for Artificial Urinary Sphincter

ObjectivesTo compare peri- and postoperative outcomes following artificial urinary sphincter (AUS) insertion using an abdominal versus a sub-inguinal counterincision for pressure regulating balloon (PRB) placement. MethodsThis was a retrospective review of all AUS placements by a single surgeon from 2010-2020. Demographic, clinical, and surgical details were obtained from chart review. The cohorts were divided by PRB placement technique (sub-inguinal, abdominal, and attempted sub-inguinal converted intra-operatively to abdominal [“conversion group”]). ResultsThere were 182 AUS devices placed. The sub-inguinal approach was successfully completed in 132/144 (92%) and converted to abdominal PRB placement in 12/144 (8.3%). The risk of conversion was not increased by prior laparoscopically-assisted robotic prostatectomy (LRP) or radiotherapy (RT). Median operative time was 62, 75, and 77 minutes for sub-inguinal, abdominal, and conversion groups, respectively ( P = 0.30). Time to device activation was 25.0, 32.0, and 37.5 days for abdominal, sub-inguinal, and conversion groups, respectively (P<0.01). There were no bowel or bladder injuries and no PRB herniation in any group; however, there were five instances of pump migration superiorly, all in the sub-inguinal or conversion groups (P = 0.05). ConclusionsThe sub-inguinal approach to PRB placement during AUS is safe and can be successfully completed over 90% of the time. However, it is not faster than the abdominal approach to PRB placement and it is associated with an increased risk of pump migration, though the latter may be confounded by the sub-dartos pouch for pump placement that was used in all sub-inguinal cases.

Presenting signs and symptoms of artificial urinary sphincter cuff erosion.

ABSTRACTPurpose To characterize the most common presentation and clinical risk factors for artificial urinary sphincter (AUS) cuff erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these patients.Materials and Methods We retrospectively reviewed our tertiary center database to identify men who presented with AUS cuff erosion between 2007 – 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for symptom comparison. Risk factors for cuff erosion – pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) – were recorded for each patient. Presenting signs and symptoms of cuff erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (SI).Results Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) sustained cuff erosion. Most erosion patients (40/61, 66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling. Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with SI or obstructive symptoms presented significantly earlier than those with worsening incontinence (SI 14 ± 18 vs. obstructive symptoms 15 ± 16 vs. incontinence 37 ± 48 months after AUS insertion, p<0.01). Relative to the non-erosion control group (n=61), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 49%, p=0.02).Conclusion AUS cuff erosion most commonly presents as SI symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion.

300 Patient Experience with Same Day Surgery for Artificial Urinary Sphincter Insertion - A Safe and Efficient Option

ABSTRACT Introduction Prior research has questioned the need for overnight observation (OBS) following artificial urinary sphincter (AUS) surgery. Objective We sought to analyze our institutional experience transitioning from OBS to same day surgery (SDS) for AUS surgery. Methods We retrospectively reviewed AUS surgeries performed by a single surgeon at our tertiary academic medical center between 08/2013 and 03/2020. Medical records were reviewed for patient demographics, immediate postoperative complications, timing of postoperative discharge, need for readmission, emergency department (ED) visit, outpatient phone call, or non-routine clinic visit within 7 days of discharge, and need for device explant or revision within 90 days of discharge. Patients were grouped based on discharge status: OBS vs. SDS. Catheters were removed prior to discharge (OBS group) or self-removed at home (SDS group) on the morning of postoperative day 1 (POD1). Cost savings associated with SDS were estimated using room and bed charges from a contemporary group of AUS patients (09/2017 through 08/2020). Student's t and Chi-squared tests were used to compare groups. Results We identified 528 men who met inclusion criteria. Men in the SDS group (n = 308) were more likely to have undergone a virgin AUS insertion and were slightly younger and healthier (Table). Men in the OBS group (n = 220) were more likely to suffer an immediate postoperative complication and to be readmitted within 90 days of surgery. The groups did not vary with respect to multiple other perioperative outcomes measures. Among patients who underwent AUS surgery between 09/2017 and 08/2020, those with OBS status (n = 39) had mean additional room and bed charges of $ 745 ± 302 vs. none for SDS patients (n = 183). Conclusions SDS for AUS insertion is safe, effective, and associated with significant cost savings. Routine overnight observation after AUS insertion appears to be unnecessary. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Perioperative Morbidity of Penile Prosthesis Placement with Concurrent Surgery: Analysis of the National Surgical Quality Improvement Program Database

ABSTRACT Introduction There is always a concern whether performing concurrent surgery along with penile prosthesis (PP) placement may increase the risk of complications, specifically postoperative infection. Contemporary reports on perioperative morbidity of PP placement with concurrent surgery are scarce. Objective To assess the 30-day postoperative morbidity in patients undergoing insertion of PP with concurrent surgery utilizing the National Surgical Quality Improvement Program (NSQIP). Methods From 2005-2016, the NSQIP database was queried to identify males who underwent placement of PP combined with other procedure. Patient demographics, postoperative morbidity including complications, readmission and re-operation rates were recorded and compared between the two groups. Student t test and Chi-square or Fischer's exact test were used as appropriate. Results 142 patients were identified and included in the study. The most prevalent concurrent procedures were surgical correction of Peyronie's disease (n=54, 38%), insertion of artificial urinary sphincter (n=27, 19%), and repair of inguinal or abdominal hernia (n=25, 17.6%). A majority of patients were white (65.5%), aged 60-69 (42.9%) and received the combined procedure in 2016 (30.3%). Fifty percent of patients were ASA class I/II and 50% were class III-V. Mean body mass index (±SD) was 30.1±4.8. Mean operating time (±SD) and length of stay (±SD) were 139.4±62.7 minutes and 2.0±1.0 days, respectively. Overall, postoperative complications occurred in 7 patients (4.9%) only. Specifically, there were urinary tract infection (n=4, 2.8%), superficial surgical site infection (n=2, 1.4%) and unplanned intubation (n=1, 0.7%). Similarly, reoperation and readmission rates were low (0.7% and 2.8%, respectively). Conclusions Overall the 30-day postoperative morbidity, reoperation and readmission rates of PP insertion with concurrent surgery were low. The majority of the reported complications were minor. Concurrent surgery with PP insertion does not seem to significantly increase the risk of postoperative morbidity. Disclosure No

When to Suspect Artificial Urinary Sphincter Cuff Erosion: An Analysis of Presenting Signs and Symptoms

ABSTRACT Introduction Presenting signs and symptoms of artificial urinary sphincter (AUS) cuff erosion are not well established in the urological literature. Objective We sought to characterize the most common presentation and clinical risk factors for erosion to distinguish the relative frequency of symptoms that should trigger further evaluation in these unfortunate patients. Methods We retrospectively reviewed our large tertiary center database to identify men who presented with cuff erosion between 2007 and 2020. A similar cohort of men who underwent AUS placement without erosion were randomly selected from the same database for comparison. Risk factors for cuff erosion – pelvic radiation, androgen deprivation therapy (ADT), high-grade prostate cancer (Gleason score ≥ 8) – were recorded for each patient. Presenting signs and symptoms of erosion were grouped into three categories: obstructive symptoms, worsening incontinence, and localized scrotal inflammation (“pump-itis”). Results Of 893 men who underwent AUS placement during the study interval, 61 (6.8%) suffered cuff erosion. The vast majority of erosion patients (66%) presented with scrotal inflammatory changes including tenderness, erythema, and swelling (Figure). Fewer men reported obstructive symptoms (26/61, 43%) and worsening incontinence (21/61, 34%). Men with worsening incontinence presented significantly later than those with pump-itis or obstructive symptoms (37 ± 48 vs. 14 ± 18 vs. 15 ± 16 months after AUS insertion, p&amp;lt;0.01). Relative to the non-erosion control group (n=95), men who suffered erosion had a higher prevalence of pelvic radiation (71 vs. 53%, p=0.03). Rates of ADT (41 vs. 40 %, p = 0.96) and high-grade prostate cancer (39 vs. 38 %, p = 0.91) were similar. There was no difference in age at AUS placement (73 ± 7 vs 68 ± 7 years, p=0.70). Conclusions AUS cuff erosion most commonly presents as scrotal inflammatory symptoms. Obstructive voiding symptoms and worsening incontinence are also common. Any of these symptoms should prompt further investigation of cuff erosion. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Artificial Urinary Sphincter Reverses Weight Gain Associated with Post-Prostatectomy Incontinence

ABSTRACT Introduction Post-prostatectomy stress urinary incontinence (PPI) is associated with decreased physical activity, a known risk factor for weight gain and negative health outcomes. The relationships of PPI severity and its surgical correction to body mass index (BMI) are unknown. Objective We sought to examine the association between urinary incontinence severity and BMI changes before and after artificial urinary sphincter (AUS) insertion. Methods We performed a single-institution, retrospective review of 1513 AUS and inflatable penile prosthesis (IPP) insertion cases performed between 2008 and 2020. Inclusion criteria included a history of radical prostatectomy (RP) and complete data on PPI and BMI. The IPP cohort served as a surgical control. PPI severity was assessed by pads per day (PPD). BMI data were reviewed at the following three time points: (a) at RP, (b) at urologic prosthetic surgery (UPS), and (c) 12 months post-UPS. Multivariable linear regression assessed the associations between (a) PPI severity and BMI change from RP to UPS and (b) AUS insertion and BMI change 12 months post-UPS. Results We identified 250 men (187 AUS and 63 IPP) who met selection criteria. Men in the AUS group had a mean BMI increase between RP and UPS of + 1.0 kg/m2 versus - 0.6 kg/m2 in the IPP group (p &amp;lt; 0.01, duration 26.0 ± 21.8 months). Higher PPD use was associated with greater BMI gain after RP (Figure 1A, p = 0.03). On multivariable analysis, higher PPD use at the time of UPS was positively associated with BMI gain (Rho coeff. 0.50 kg/m2, p &amp;lt; 0.01), independent of RT and ADT. AUS insertion was independently associated with a decrease in BMI of -2.83 kg/m2 12 months post-UPS (p = 0.02) on multivariable analysis. Magnitude of incontinence improvement after AUS insertion was associated with greater BMI reduction at 12 months (Figure 1B, p = 0.04). Conclusions PPI is associated with weight gain, and its correction via AUS insertion is associated with weight loss. Because severe PPI is a potential risk factor for weight gain and subsequent negative health outcomes, timely anti-incontinence surgery is prudent for prostate cancer survivorship care. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific and Coloplast

Prior Placement of Male Urethral Slings Can Increase the Need for Revision of Artificial Urinary Sphincters.

Background: Recurrent stress urinary incontinence (SUI) following male sling can be managed surgically with artificial urinary sphincter (AUS) insertion. Prior small, single-center retrospective studies have not demonstrated an association between having failed a sling procedure and worse AUS outcomes. The aim of this study was to compare outcomes of primary AUS placement in men who had or had not undergone a previous sling procedure. Methods: A retrospective review of all AUS devices implanted at a single academic center during 2000–2018 was performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 19 (14.1%) patients had undergone prior sling procedures. Results: There was no significant difference in demographic characteristics between patients undergoing AUS placement with or without a prior sling procedure. Average follow up time was 28.0 months. Prior sling was associated with shorter overall device survival, with an increased likelihood of requiring revision or replacement of the device (OR 4.2 (1.3–13.2), p = 0.015) as well as reoperation for any reason (OR 3.5 (1.2–9.9), p = 0.019). While not statistically significant, patients with a prior sling were more likely to note persistent incontinence at most recent follow up (68.8% vs. 42.7%, p = 0.10). Conclusions: Having undergone a prior sling procedure is associated with shorter device survival and need for revision or replacement surgery. When considering patients for sling procedures, patients should be counseled regarding the potential for worse AUS outcomes should they require additional anti-incontinence procedures following a failed sling.

PD04-06 ARTIFICIAL URINARY SPHINCTER REVERSES WEIGHT GAIN ASSOCIATED WITH POST-PROSTATECTOMY INCONTINENCE

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I (PD04)1 Sep 2021PD04-06 ARTIFICIAL URINARY SPHINCTER REVERSES WEIGHT GAIN ASSOCIATED WITH POST-PROSTATECTOMY INCONTINENCE Raj Bhanvadia, Benjamin Dropkin, Avery Wolfe, Linley Diao, Sarah Sanders, Gregory Joice, Claus Roehrborn, Steven Hudak, and Allen Morey Raj BhanvadiaRaj Bhanvadia More articles by this author , Benjamin DropkinBenjamin Dropkin More articles by this author , Avery WolfeAvery Wolfe More articles by this author , Linley DiaoLinley Diao More articles by this author , Sarah SandersSarah Sanders More articles by this author , Gregory JoiceGregory Joice More articles by this author , Claus RoehrbornClaus Roehrborn More articles by this author , Steven HudakSteven Hudak More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001968.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Post-prostatectomy stress urinary incontinence (PPI) is associated with decreased physical activity, a known risk factor for weight gain and negative health outcomes. The relationships of PPI severity and its surgical correction to body mass index (BMI) are unknown. We examined the association between urinary incontinence severity and BMI changes before and after artificial urinary sphincter (AUS) insertion. METHODS: We performed a single-institution, retrospective review of 1513 AUS and inflatable penile prosthesis (IPP) insertion cases performed between 2008 and 2020. Inclusion criteria included a history of radical prostatectomy (RP) and complete data on PPI and BMI. The IPP cohort served as a surgical control. PPI severity was assessed by pads per day (PPD). BMI data were reviewed at the following three time points: (a) at RP, (b) at urologic prosthetic surgery (UPS), and (c) 12 months post-UPS. Multivariable linear regression assessed the associations between (a) PPI severity and BMI change from RP to UPS and (b) AUS insertion and BMI change 12 months post-UPS. RESULTS: We identified 250 men (187 AUS and 63 IPP) who met selection criteria. Men in the AUS group had a mean BMI increase between RP and UPS of +1.0 kg/m2 versus - 0.6 kg/m2 in the IPP group (p<0.01, duration 26.0 +21.8 months). Higher PPD use was associated with greater BMI gain after RP (Figure 1A, p=0.03). On multivariable analysis, higher PPD use at the time of UPS was positively associated with BMI gain (Rho coeff. 0.50 kg/m2, p<0.01), independent of RT and ADT. AUS insertion was independently associated with a decrease in BMI of -2.83 kg/m2 12 months post-UPS (p=0.02) on multivariable analysis. Magnitude of incontinence improvement after AUS insertion was associated with greater BMI reduction at 12 months (Figure 1B, p=0.04). CONCLUSIONS: PPI is associated with weight gain, and its correction via AUS insertion is associated with weight loss. Because severe PPI is a potential risk factor for weight gain and subsequent negative health outcomes, timely anti-incontinence surgery is prudent for prostate cancer survivorship care. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e51-e52 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Raj Bhanvadia More articles by this author Benjamin Dropkin More articles by this author Avery Wolfe More articles by this author Linley Diao More articles by this author Sarah Sanders More articles by this author Gregory Joice More articles by this author Claus Roehrborn More articles by this author Steven Hudak More articles by this author Allen Morey More articles by this author Expand All Advertisement Loading ...