Male Urethral Sling Research Articles

A global, propensity-score matched analysis of patients receiving inflatable penile prostheses and the risk of complications, infections, and re-interventions.

Over 25,000 men undergo inflatable penile prosthesis (IPP) placement yearly to treat erectile dysfunction (ED). Although various comorbidities are hypothesized risk factors for complications, this remains incompletely understood. Our objective was to utilize multi-institutional data to characterize risk for reintervention, complications, and infections in patients with common suspected risk factors undergoing IPP placement. We queried the TriNetX database for adult men who underwent IPP placement from 2003-2023 utilizing Current Procedural Terminology (CPT) codes. We examined the impact of diabetes mellitus (DM), hypertension (HTN), nicotine use, radiation therapy (RT), radical prostatectomy (RP), and urethral surgery [urethroplasty, artificial urinary sphincter (AUS), male urethral sling (MS)] on clinical outcomes defined by International Classification of Diseases 10th Revision (ICD-10) codes. Our primary outcome was need for reintervention based on CPT codes. Secondary outcomes included overall rates of complication and infection utilizing ICD-10 codes. Analytics were performed using TriNetX to calculate risk ratios (RRs) and Kaplan-Meier (KM) survival. We evaluated outcomes overall and for each individual comparison cohort using the remaining demographic variables to perform propensity score matching (PSM). In a total of 11,026 patients there was an overall 13.5% risk of undergoing at least one reintervention, with some undergoing multiple based on CPT codes. KM analysis showed a median IPP survival of 18.2 years and a projected 10- and 20-year survival probability at 70.6% and 48.4% respectively. Overall complication rate was 19.3% with a 5.2% rate of infection based on ICD codes. Patients with history of urethral surgery were at higher risk of both IPP complication and re-intervention. When further analyzing type of re-intervention, patients with a history of smoking, prior RP, and prior AUS/MS placement had higher rates of device removal. Patients with a history of diabetes were less likely to undergo IPP replacement at the time of explant. There were no identified risk factors for IPP infection. This is the largest cohort of patients ever evaluated and can help guide patient selection and counseling. There was a higher rate of IPP complications than previously reported, but this may be due to different reporting parameters. History of prior urethral surgery conferred a higher risk of complications and re-intervention. These results can help guide patient selection and counseling.

(211) Comparable Continence Rates Following Male Urethral Sling Surgery in “Standard” versus “Nonstandard” Patients

Abstract Introduction Transobturator male urethral slings are a surgical option for the management of stress urinary incontinence (SUI). Historically, patient continence and satisfaction rates are influenced by several variables, including: baseline incontinence severity, prior surgical interventions, and exposure to radiation. Ideal or “standard” patients for sling placement have mild or moderate incontinence and no prior incontinence procedures or radiation exposure. Standard patients have been proposed to have better postoperative continence and satisfaction rates than their “nonstandard” counterparts. Objective In this study we sought to compare the efficacy and complication rates of transobturator male sling placement between standard and nonstandard patients. Methods A retrospective, single-institution review was performed of all patients who underwent either an AdVance™ or an AdVanceXP™ sling insertion between October 2016 and May 2023. Patient demographics, preoperative and postoperative continence rates, and complication rates were collected. Patients were then stratified as “standard’ vs “nonstandard”. Standard patients were defined as having a history of radical prostatectomy (robotic or open) and no prior radiation or prior incontinence procedure. Nonstandard patients had prior history of transurethral resection of the prostate, simple prostatectomy, radical cystectomy, prior sling insertion, or prior radiation. The continence and complication rates were compared between groups. Continence was measured in pads per day (PPD). Improvement in continence was defined as a reduction of at least 50% in PPD at 6 weeks postoperatively. Baseline and postoperative PPD were tabulated with median and 25th-75th percentiles, then compared using Wilcoxon signed-rank test. Other variables were summarized with frequency and percentages, and compared using Fisher’s exact test. Results 62 patients were included in this study, of which 48 and 14 were standard and nonstandard, respectively. Mean age was 66 (52-85) years and body mass index (BMI) was 29 (20.3-39.8) kg/m2. No difference in baseline characteristics were noted between the groups (Table 1). 77% of patients had an improvement in SUI following sling placement: 38/48 (79%) patients in the standard group and 10/14 (71%) patients in the non standard group. The most common complication among both groups was urinary retention requiring catheterization (29%), which resolved spontaneously within two weeks in all patients. In the nonstandard group, one patient developed an abscess, one had a scrotal hematoma, and two patients had urinary tract infections (UTI). One patient with history of radiation developed a urethrocutaneous fistula requiring sling removal. There was no significant difference in overall complication rates between standard and nonstandard patients. Comparable rates of improvement in preoperative to postoperative SUI were noted: 2.5 to 0.8 PPD in the standard group and 3.3 to 1.0 PPD in the nonstandard group (Figure 1). Conclusions In this study, nonstandard and standard patients had similar continence and complication rates following urethral sling placement. Future prospective studies are warranted to assess the safety and long-term outcomes of standard and nonstandard patients. Disclosure No.

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

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

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

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

Surgical Management of Male Stress Incontinence: Techniques, Indications, and Pearls for Success.

Male stress urinary incontinence (SUI) has detrimental and long-lasting effects on patients. Management of this condition is an evolving field with multiple options for surgical treatment. We sought to review the pre-operative evaluation, intra-operative considerations, post-operative care, and future directions for treatment of male SUI. A literature review was performed using the PubMed platform to identify peer-reviewed, English-language articles published within the last 5 years pertaining to management of male stress urinary incontinence with an emphasis on devices currently on the market in the United States including the artificial urinary sphincter (AUS), male urethral slings, and the ProACTTM system. Patient selection criteria, success rates, and complications were compared between the studies. Twenty articles were included in the final contemporary review. Pre-operative workup most commonly included demonstration of incontinence, PPD, and cystoscopy. Definition of success varied by study; the most common definition used was social continence (0-1 pads per day). Reported rates of success were higher for the AUS than for male urethral slings (73-93% vs 70-90%, respectively). Complications for these procedures include urinary retention, erosions, infections, and device malfunction. Newer treatment options including adjustable balloon systems and adjustable slings show promise but lack long-term follow-up. Patient selection remains the primary consideration for surgical decision-making for management of male SUI. The AUS continues to be the gold standard for moderate-to-severe male SUI but comes with inherent risk of need for revision. Male slings may be a superior option for appropriately selected men with mild incontinence but are inferior to the AUS for moderate and severe incontinence. Ongoing research will shed light on long-term results for newer options such as the ProACT and REMEEX systems.

(499) Exploring Risk Factors for Re-Operation Following Male Artificial Urinary Sphincter and Urethral Sling Implantation in a Multiethnic, Diverse Academic Center

Abstract Introduction New onset stress urinary incontinence (SUI) is the second most common complication following a prostatectomy, significantly affecting an estimated 10-20% of patients. Severe cases of SUI are often managed surgically by artificial urinary sphincter (AUS) or urethral sling implantation, depending on patient preference and incontinence severity. However, despite a large portion of these patients requiring surgical revision, there is a lack of information regarding the risk factors associated with reoperation, particularly in diverse populations. Thus, in this study, we analyzed the impact of demographic and intraoperative characteristics on reoperation risk following sling and AUS device implantation. Objective To identify risk factors for reoperation following primary AUS and urethral sling implantation. Secondarily, we aim to see if there was a difference in reoperation rates between the two procedures. Methods We performed a retrospective review of primary AUS and urethral slings implanted at a single academic center from July 2015 to May 2022. Demographic data, SUI severity (measured in pads per day), intraoperative characteristics, and 30-day safety outcomes were collected. Baseline characteristics were analyzed using a two-sample t-test, chi-square, or Mann-Whitney U test depending on distribution normality. Reoperation risk factors were analyzed utilizing Cox proportional hazard models for univariate and multivariate analysis, and a Kaplan Meier curve was used to depict re-operation time between sling and AUS. Results A total of 116 patients were included, 72 (62.1%) of which underwent urethral sling placement and 44 (37.9%) AUS implantation. The reoperation rate was 19.4% for urethral slings and 34.1% for AUS (p=0.077). Baseline characteristics between slings and sphincters differed in mean age (64.0 [7.1] vs 67.2 [7.5], p=0.024), median preoperative pads per day (2 [1-3] vs 3 [2-5], p<0.001), and history of XRT (11.1% vs 29.5%, p=0.012). After controlling for factors significant on univariate analysis (age, cardiovascular disease, and hyperlipidemia), multivariate analysis revealed that higher pads per day (OR=1.71, p=0.027) significantly increased the likelihood of sling reoperation, while age (OR=1.17, p=0.005) significantly increased the likelihood of AUS reoperation. Cardiovascular disease (CVD) (OR=0.10, p=0.003) and former smoking status (OR=0.17, p=0.018) were protective of AUS reoperation. There was no difference between sling and AUS reoperation on a log rank test (p=0.21). Conclusions A greater number of preoperative pads per day is associated with increased rates of reoperation following sling implantation, while age, CVD, and former smoking status are associated with AUS reoperation. Further research is warranted to identify patient-specific risk factors, particularly to clarify the effects of CVD and former smoking status on reoperation. Disclosure No

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.

Patient decision-making for surgical treatment of post-prostatectomy stress urinary incontinence: a mixed-methods exploratory pilot study.

Male stress urinary incontinence (SUI) is a known complication following surgical intervention on the prostate, particularly following surgery for prostate cancer. Effective surgical treatments for SUI include artificial urinary sphincter (AUS) and male urethral sling. Prior data suggest that men may forego available treatment despite bothersome symptoms. The objective was to explore how men who underwent surgical correction for post-prostatectomy SUI navigated SUI treatment decisions. Mixed method study was employed. Semi-structured interviews, participant surveys and objective clinical assessment of SUI were performed among a group of men living with incontinence after prostate cancer surgery who underwent surgery for SUI at the University of California in 2017. Eleven men were interviewed after consultation for SUI and all had complete quantitative clinical data. Surgery for SUI included AUS (n=8) and sling (n=3). There was a decrease in pads per day from 3.2 to 0.9 and no major complications. Most patients found that the impact on activities and their treating urologist were of great importance. Sexual and relationships played a variable role with some participants ranking these as "great deal of influence" and others "little or no influence". Participants who underwent AUS were more likely to cite a higher importance on "being very dry" in choosing that surgery while sling patients had more variable ranking of important factors. Participants found a variety of inputs helpful in hearing information about SUI treatment options. Among a group of 11 men who underwent surgical correction for post-prostatectomy SUI, there were identifiable themes on how men make decisions, evaluate quality of life (QoL) changes and approach treatment options. Men value more than being dry with measures of individual success that can include sexual and relationship health. Furthermore the role of the Urologist remains crucial as patients relied heavily on input and discussion with their Urologist to assist in treatment decisions. These findings can be used to inform future studies of the experience of men with SUI.

Does Medicaid Cover Male Urethral Sling Surgery? A State-by-State Analysis

ABSTRACT Introduction Male suburethral slings are one treatment option for stress urinary incontinence (SUI) due to intrinsic sphincter deficiency post-prostatectomy in appropriately selected patients. Some studies report up to 55% social continence, and 23% of respondents reduced use of pads by greater than 50%. Male slings may be preferred in men with limited manual dexterity who have difficulty manipulating an artificial urinary sphincter, or in men with more mild SUI, particularly if there is no history of prior radiation. Existing literature regarding insurance coverage and physician reimbursement overwhelmingly focuses on Medicare and commercial plans, leaving a knowledge gap with respect to the Medicaid population which may contribute to inequitable utilization of this treatment modality for SUI. Objective To quantify Medicaid coverage for placement and revision of male suburethral slings for correction of male SUI by state. Methods State Medicaid websites were utilized to access publicly available physician fee schedules. Individual search queries were performed for CPT codes 53440 and 53442, which represent sling operation for correction of male urinary incontinence and removal or revision of sling for male urinary incontinence, respectively. Data were recorded for each device, including the coverage status and physician fees. Results Medicaid physician fee schedules were accessible for 49 out of 50 US states. All 49 of these states reported coverage for placement of a male urethral sling, and 48 states reported coverage for removal or revision of a male urethral sling. Means and range of physician reimbursement for each procedure were $834.26 ($198.00-$5,237.35) for placement of a male urethral sling (53440) and $616.88 ($104.27-$2,288.93) for removal or revision of a male urethral sling (53442). Conclusions Male suburethral sling placement and revision for SUI in the Medicaid population are covered by nearly all states as confirmed by publicly available data. Knowledge of Medicaid coverage for SUI related surgery may result in improvement in the utilization of this treatment option for male SUI and may improve quality of life in the Medicaid cancer survivorship population. Disclosure No

AdVance and AdVance XP Male Sling Comparison, an Institutional Experience

ABSTRACT Introduction The AdVance male sling has been used for many years for the treatment of male stress urinary incontinence with multiple previous studies evaluating its efficacy. More recently, a new generation AdVance XP was designed with modifications in its design and surgical tools in hopes to improve patient outcomes. Objective The aim of our study was to provide our institution's outcomes comparing objective and patient-reported outcomes of the AdVance male sling to the AdVance XP. Methods All patients who have had placement of an AdVanceXP male urethral sling were retrospectively reviewed. Inclusion criteria included the necessity of one year post-operative follow up. We then identified a comparative cohort who had the most recent placement of the AdVance sling. We compared patient demographics, baseline characteristics, functional outcomes, voiding studies and complications. Results A total of 11 patients who received the AdVanceXP were compared to 11 patients who received the AdVance male sling. There were no statistically significant differences in baseline demographics between the two groups (Table1). When comparing the AdVance XP to Advance, there was no difference in change in average flow rate (-1.26mL/s vs -5mL/s, p=0.476) or peak flow (-5.11mL/s vs -5.73mL/s, p=.936). Patient's pre-surgical pad usage was greater in the AdVanceXP than the AdVance sling groups (2.64 vs 1.60, p=0.019). The mean decrease in pad usage was 1.95 pads in those with the AdVanceXP compared to 1.36 pads with the AdVance (p=.227). There were no statistically significant differences in operative times between the AdVanceXP and the AdVance male sling (64.5min vs 68.8min, p=.249). Both groups had one patient who had issues with post-operative pain and neither group had any patients with post-operative retention, infection or need for reoperation within one year. Conclusions Patient's who had placement of the AdVanceXP were found to have a greater reduction in pad usage when compared to the AdVance sling, though not reaching statistical significance. Disclosure No

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.

Narrative review of male urethral sling for post-prostatectomy stress incontinence: sling type, patient selection, and clinical applications.

Male stress urinary incontinence (SUI) following prostate treatment is a devastating complaint for many patients. While the artificial urinary sphincter is the gold standard treatment for male SUI, the urethral sling is also popular due to ease of placement, lack of mechanical complexity, and absence of manual dexterity requirement. A literature review was performed of male urethral sling articles spanning the last zz20 years using the PubMed search engine. Clinical practice guidelines were also reviewed for comparison. Four categories of male urethral sling were evaluated: the transobturator AdVance and AdVance XP, the bone-anchored InVance, the quadratic Virtue, and the adjustable sling series. Well selected patients with mild to moderate urinary incontinence and no prior history of radiation experienced the highest success rates at long-term follow up. Patients with post-prostatectomy climacturia also reported improvement in leakage after sling. Concurrent penile prosthesis and sling techniques were reviewed, with favorable short-term outcomes demonstrated. Male urethral sling is a user-friendly surgical procedure with durable long-term outcomes in carefully selected men with mild stress urinary incontinence. Multiple sling types are available with varying degrees of efficacy and complication rates. Longer follow-up and larger cohort sizes are needed for treatment of newer indications such as climacturia as well as techniques involving dual placement of sling and penile prosthesis.

Коррекция недержания мочи после радикальной простатэктомии. Хирургическая техника шаг за шагом

Introduction. The main cause of stress urinary incontinence in men is prostate surgery - radical prostatectomy, transurethral resection of the prostate (TURP), enucleation, etc. The gold standard for the surgical treatment of urinary incontinence after prostate surgery is the implantation of an artificial urinary sphincter. For the treatment of mild/moderate urinary incontinence, implantation of synthetic urethral male slings is recommended. For the treatment of severe urinary incontinence, implantation of artificial urinary sphincter recommended. According to the Decree of the Moscow Government dated 12.24.2019 N 1822-PP, surgical interventions on the organs of the genitourinary system with the implantation of synthetic complex and mesh prostheses are included in the standards for the provision of high-tech medical care. Materials and methods. The paper presents a surgical technique for implantation of an artificial urinary sphincter model AMS 800 (Boston Scientific, Boston, MA, USA) and a male urethral sling AdVance XP (Boston Scientific, Boston, MA, USA). The indications for surgical treatment of stress urinary incontinence in men are listed, the criteria for selecting patients for the implantation of an artificial bladder sphincter and the installation of a urethral sling are described, and described in detail. Conclusion. The materials presented in the lecture will help urologists in mastering the technique of implantation of an artificial bladder sphincter and urethral sling in men.

Safety and efficacy of male urethral slings for management of persistent stress urinary incontinence after holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate gland (HoLEP) is an alternative to the traditional transurethral resection of the prostate, especially for large-volume prostates. One complication is urinary incontinence, which is usually stress urinary incontinence (SUI). Little data exist on surgical interventions for SUI after HoLEP. This retrospective case series examined the safety and possible efficacy of a midurethral sling (MUS) following HoLEP. Between January 2016 and February 2019, 610 HoLEPs were performed at our institution. Three (0.5%) had persistent, overly bothersome symptoms of SUI. All three underwent MUS placement with a transobturator AdVance® male sling after failed pelvic floor rehabilitation. The degree of SUI was evaluated by pad use pre-HoLEP, post-HoLEP, and post-MUS placement. Surgical times for HoLEP and MUS were evaluated. No patients were using pads for incontinence before HoLEP. The average pad use was 7 post-HoLEP and 0.3 post-MUS. The average morcellated prostate was 48 g, and surgical time was 68 min (52 for enucleation and 15 for morcellation). No complications were reported with MUS placement intraoperatively or postoperatively. MUS for persistent and bothersome SUI after HoLEP shows promise as a safe and effective surgical option.

V06-10 FLUOROSCOPY FOR TEACHING PLACEMENT AND MECHANISM OF THE MALE URETHRAL SLING

You have accessJournal of UrologyLower-Tract Reconstruction I: Sling/ Sphincter/ Penile & Urethral Reconstruction (V06)1 Apr 2020V06-10 FLUOROSCOPY FOR TEACHING PLACEMENT AND MECHANISM OF THE MALE URETHRAL SLING Ethan Matz*, Kyle Scarberry, and Ryan Terlecki Ethan Matz*Ethan Matz* More articles by this author , Kyle ScarberryKyle Scarberry More articles by this author , and Ryan TerleckiRyan Terlecki More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000885.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The transobturator male sling is an established option for mild to moderate stress urinary incontinence, which is most commonly seen after radical prostatectomy. Teaching sling surgery to residents and fellows can be challenging since the small incision can limit visualization. Also, the proposed mechanism of action for the male urethral sling has been largely based on theory rather than adequate dynamic visualization. We present a video to highlight our use of fluoroscopy to better educate learners on this operation. METHODS: This video highlights the three-dimensional pelvic anatomy relevant to placement of a male sling. The surgery is done through a standard perineal approach, but with use of fluoroscopy at key steps. These include needle passage to locate the trocar target within the obturator foramen, live visualization of trocar rotation, and the conformational change of the urethra during sling tensioning. RESULTS: The operation is successfully demonstrated with high-quality fluoroscopic images for better understanding of both the key surgical steps and mechanism of action for the male urethral sling. CONCLUSIONS: Placement of the male urethral sling is an important technique for surgeons to master in order to effectively manage men with stress urinary incontinence. The technique presented is novel based on the use of fluoroscopy to offer a more comprehensive educational experience for learners in the operating room. This approach may be suited for adoption at other academic training centers. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e559-e559 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Matz* More articles by this author Kyle Scarberry More articles by this author Ryan Terlecki More articles by this author Expand All Advertisement PDF downloadLoading ...

Impact of obesity on male urethral sling outcomes.

Background:The impact of obesity on AdVance male urethral sling outcomes has been poorly evaluated. Anecdotally, male urethral sling placement can be more challenging due to body habitus in obese patients. The objective of this study was to evaluate the impact of obesity on surgical complexity using operative time as a surrogate and secondarily to evaluate the impact on postoperative pad use.Methods:A retrospective cohort analysis was performed using all men who underwent AdVance male urethral sling placement at a single institution between 2013 and 2019. Descriptive statistics comparing obese and non-obese patients were performed.Results:A total of 62 patients were identified with median (IQR) follow up of 14 (4–33) months. Of these, 40 were non-obese and 22 (35.5%) were obese. When excluding patients who underwent concurrent surgery, the mean operative times for the non-obese versus obese cohorts were 61.8 min versus 73.7 min (p = 0.020). No Clavien 3–5 grade complications were noted. At follow up, 47.5% of the non-obese cohort and 63.6% of the obese cohort reported using one or more pads daily (p = 0.290). Four of the five patients with a history of radiation were among the patients wearing pads following male urethral sling placement.Conclusion:Obese men undergoing AdVance male urethral sling placement required increased operative time, potentially related to operative complexity, and a higher proportion of obese compared with non-obese patients required postoperative pads for continued urinary incontinence. Further research is required to better delineate the full impact of obesity on male urethral sling outcomes.

Orgasm-associated urinary incontinence (climacturia) following radical prostatectomy: a review of pathophysiology and current treatment options.

Orgasm-associated urinary incontinence, or climacturia, is a common side effect after radical prostatectomy (RP) that is gaining more attention due to the distress it causes to patients. A range of treatment options have been reported in the literature and are outlined in this review. The goal of our study is to review the pathophysiology and current management options for climacturia following RP. A PubMed search was used to review the current literature relating to the pathophysiology and the treatment of postprostatectomy climacturia. We reviewed the currently available treatment options and their success rates for climacturia. Several techniques were found to subjectively help improve the amount and bother of patients' climacturia. These include pelvic floor muscle training (PFMT), penile variable tension loop, soft silicone occlusion loop, artificial urethral sphincter, male urethral sling, and the Mini-Jupette graft. Success rates ranged from 48% to 100% depending on the modality used. For patients with erectile dysfunction and climacturia, the Mini-Jupette graft could be a valuable option. Given the lack of validated measurement tools and management options, climacturia has become a challenge for urologists. Albeit a condition that has not garnered much attention, there are several management options from conservative to invasive treatments that have shown a hopeful promise for the treatment of climacturia. These options should be discussed with patients to determine the best treatment for each individual. More clinical trials are needed to assess the efficacy and impact of the different treatment options before a definitive recommendation regarding management can be made.

021 Do Prior Anti-incontinence Procedures Influence the Success of Artificial Urinary Sphincter Placement?

Male urethral slings offer a less invasive surgical approach to manage stress urinary incontinence (SUI) compared to the gold standard artificial urinary sphincter (AUS) insertion. Recurrent or incompletely treated SUI following male sling can be managed surgically with repeat sling operation or with AUS insertion. Prior small, single-center retrospective studies demonstrated no 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. A retrospective review of all artificial urinary sphincters implanted at a single academic center during 2000-2018 was performed with attention to patient demographics, urologic history, surgical specifics, postoperative continence, complications, and patient follow up. A total of 225 AUS implantations were performed. After excluding secondary AUS placements, revision and explant procedures, 135 patients were included in this study, of which 20 (14.8%) patients had undergone prior sling procedures. Prior slings included Stamey, AdVance, InVance, and Virtue devices.

Low Serum Albumin Correlates With Adverse Events Following Surgery for Male Urinary Incontinence: Analysis of the American College of Surgeons National Surgical Quality Improvement Project

OBJECTIVETo investigate the incidence and risk factors associated with artificial urinary sphincter (AUS) and male urethral sling placement (MUS), revision, and removal. METHODSWe identified CPT codes of patients undergoing AUS and sling placement, revision, and removal in the American College of Surgeons National Surgery Quality Improvement Program database. Bivariate analysis was used to compare preoperative parameters against adverse events of interest (Length of stay (LOS) >1, readmission, reoperation, other postoperative complications, and death). Variables that were significant or neared significance (P <.1) in the univariate analysis were entered into multivariable logistic regression models. Multivariable models were used to estimate the probability of adverse events. RESULTSAbout 2792 patients underwent surgical treatment for stress urinary incontinence in the American College of Surgeons National Surgery Quality Improvement Program database from 2008 to 2016. Increased length of stay was the most common adverse event (12.7%), followed by other postoperative complications (4.9%), readmission (4%), reoperation (2.3%), and death (0.3%). We noted an association between perioperative adverse events and preoperative hypoalbuminemia. Patients with preoperative hypoalbuminemia compared with patients with normal preoperative serum albumin had an increase predicted probability of LOS >1 day (42% vs 10%), readmission (10% vs 4%), reoperation (6% vs 2%), other postoperative complications (18% vs 4%) after adjusting for other factors. CONCLUSIONSurgical treatment for stress urinary incontinence is well tolerated with acceptable levels of perioperative adverse events. Low serum albumin (<3.5 ng/dL) was associated with perioperative adverse events. These data may affect preoperative decision making and direct future quality improve efforts at the highest risk patients to help minimize perioperative morbidity and mortality.

031 Modified-Approach for "Mini Male Urethral Sling" Placement with Inflatable Penile Prosthesis for Erectile Dysfunction and Climacturia or Mild Stress Urinary Incontinence: A Two-center Experience

Climacturia with or without stress urinary incontinence (SUI) is commonly encountered with erectile dysfunction (ED) after prostate cancer treatment. Previous work has suggested that placement of the Adrianne mini-jupette graft with inflatable penile prosthesis can significantly improve these bothersome symptoms. We sought to describe our modified technique for placement of a “mini male sling” (MMS) at the time of penile prosthesis (PP) placement for men with ED and climacturia with or without mild SUI and assess early postoperative outcomes from two centers. A retrospective review was performed for patient who underwent IPP and MMS placement with Virtue sling mesh or Tutoplast human pericardium (Coloplast Corp, Minneapolis, MN) by two high-volume prosthetic surgeon between 2016-2018 using a similar technique. After proximal exposure, the MMS is sutured to the corpora at the level of the bulbar urethra, proximal to the planned corporotomies. Care is taken to avoid excessive tension on the urethra. Changes in patient-reported climacturia and pads per day (PPD) for SUI assessed pre-operatively and at each post-operative visit were compared for each patient using McNemar’s test with a statistical significance threshold of p<0.05.