Artificial Urinary Sphincter Placement Research Articles

Potential risk factors and outcomes of artificial urinary sphincter placement after radical cystectomy and orthotopic neobladder urinary diversion

Stress urinary incontinence (SUI) is a known possibility after radical cystectomy (RC) and orthotopic neobladder (ONB) urinary diversion. We retrospectively reviewed the outcomes and complications of patients who underwent artificial urinary sphincter (AUS) placement for treatment of SUI and evaluated potential risk factors (PRFs) for AUS failure. Patients who underwent AUS placement after RC/ONB from 1994 to 2009 were identified. Variables evaluated included: demographics, cancer type, AUS characteristics, urinary incontinence (UI), revision procedures data, and PRFs for AUS failure. Demographic data was reviewed on 36 patients. Mean age at AUS placement was 72 (58-79) years. Mean time to AUS after RC/ONB was 28 (2-120) months. Mean follow up after AUS was 40 (2-132) months. TCC was the indication for RC in 94% of patients. The most commonly placed AUS cuff and reservoir size was 4.5 cm and 61-70 H2 O, respectively. Incontinence data was available in 29 patients. Pre-AUS placement 22, 3, and 4 patients were totally, daytime and nighttime only incontinent, respectively. Post-AUS placement, incontinence persisted in 5, 1, and 2 patients with total, daytime and nighttime incontinence, respectively. Prior to AUS placement 11/36 patients received chemotherapy and 10/36 had radiation. Mean time to the first revision/explantation due to UI/erosion/infection/malfunction was an average of 28 (3-96) months after AUS placement and occurred in 21/35 (60%) patients. There was no significant correlation noted between PRFs and UI pre-/post-AUS or between PRFs and the need for AUS revision. AUS is a safe, effective treatment with an acceptable complication rate for patients after RC/ONB with SUI.

Quality of life and patient satisfaction after artificial urinary sphincter

Background: We assessed satisfaction and quality of life (QOL) inmen with artificial urinary sphincter (AUS) placement.Methods: We identified 39 men who had AUS placement. Aretrospective chart review was conducted. Validated questionnaires,including the International Consultation on IncontinenceQuestionnaire-Short Form (ICIQ-SF), Post-Operative PatientGlobal Impression of Improvement (PGI-I), Incontinence ImpactQuestionnaire-Short Form (IIQ-SF), and Urogenital Distress Index(UDI-SF), were used to measure patient-reported outcome. Globalsatisfaction was also assessed.Results: At chart review, 34 of 39 questionnaires were assessedfor QOL, satisfaction and surgical outcome. Follow-up rangedfrom 7 to 60 months (median = 24 months). Surgical revisionswere required in 6 (17.6%) patients due to infection (1), erosion(1), combined infection and erosion (1), device failure (1) andsecond cuff placement (2). Quality of life was assessed using theIIQ-SF and UDI-SF, with mean scores of 15.4 and 24.8, respectively;these scores indicated a low negative impact on QOL. TheICIQ-SF mean score was 8.2, well below the worst possible score.The number of men using more than 1 pad per day dropped from27 preoperatively to 10 postoperatively. Most patients (31/34)described their urinary condition as better, 2 had no changeand 1 was worse. Most patients (31/34, 91.2%) would be willingto undergo the procedure again, 2 were undecided, and 1would not. Similarly, 28 patients (82.4%) would recommend theprocedure to a friend, 3 respondents would “with reservation,”1 respondent was undecided, and 2 would not recommend theAUS placement.Conclusion: Treatment of urinary incontinence with the AUS hasa positive effect on QOL with high patient satisfaction and reasonablylow complication rates.

95 DEEP TRANSURETHRAL INCISION ALONE FOR REFRACTORY BLADDER NECK CONTRACTURE WITH OR WITHOUT STRESS URINARY INCONTINENCE: IS INJECTION THERAPY NECESSARY?

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery (II)1 Apr 201395 DEEP TRANSURETHRAL INCISION ALONE FOR REFRACTORY BLADDER NECK CONTRACTURE WITH OR WITHOUT STRESS URINARY INCONTINENCE: IS INJECTION THERAPY NECESSARY? Daniel Ramirez, Aditya Bagrodia, Steven J. Hudak, Lee C. Zhao, and Allen F. Morey Daniel RamirezDaniel Ramirez Dallas, TX More articles by this author , Aditya BagrodiaAditya Bagrodia Dallas, TX More articles by this author , Steven J. HudakSteven J. Hudak Dallas, TX More articles by this author , Lee C. ZhaoLee C. Zhao Dallas, TX More articles by this author , and Allen F. MoreyAllen F. Morey Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1473AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Injection of mitomycin C during transurethral incision of recurrent bladder neck contracture (RBNC) has been reported to produce a 72% success rate after one treatment (J Urol 186; 156-160, 2011). We evaluated results of deep transurethral incision of bladder neck contracture (TUIBNC) alone and identified risk factors associated with RBNC. For patients with concomitant stress urinary incontinence (SUI), we assessed timing between TUIBNC and placement of a subsequent artificial urinary sphincter (AUS). METHODS We reviewed 50 consecutive men undergoing standardized deep TUIBNC from 2007 to 2012. TUIBNC involved dilation with a 4 cm X 24 Fr balloon followed by deep transurethral incisions at 3 and 9 o'clock with a Collings knife. No urethral injections of any kind were performed. We examined patient records for smoking history, radiation, diabetes, previous TUIBNC, and prostate surgery. We reviewed failure rates, time to AUS placement, need for AUS revision, and recurrence of BNC after AUS. Univariate analysis was performed to identify risk factors for RBNC. RESULTS Of the 50 patients studied, 80% had failed previous BNC procedures. After deep TUIBNC, 72% required no further surgery for obstruction at a mean follow-up of 12.9 months. Of the 14 patients who failed initial TUIBNC, 7 underwent repeat TUIBNC with success. Patients most likely to fail initial deep TUIBNC were those having two or more prior BNC procedures or ≥10 pack/year smoking history [failure rates 40.7% (P = 0.03) and 71.4% (P = 0.04), respectively]. A total of 39 men (78%) presented with concomitant SUI; two-thirds of these underwent AUS placement after an average of 2.9 months following TUIBNC. SUI occurred de novo after TUIBNC in 1 /11 (9%) patients. Only 2/26 patients required repeat transurethral procedures after AUS placement for recurrent BNC. CONCLUSIONS Deep lateral TUIBNC alone is a highly effective treatment modality for RBNC, and produces results comparable to those reported after mitomycin C injection. The majority of men with RBNC can be stabilized with deep lateral TUIBNC alone, although smokers and those having 2 or more prior RBNC procedures are at greater risk for failure. Subsequent AUS placement can be safely performed after a 3-month rest period with > 90% urethral patency rate. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e38-e39 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Ramirez Dallas, TX More articles by this author Aditya Bagrodia Dallas, TX More articles by this author Steven J. Hudak Dallas, TX More articles by this author Lee C. Zhao Dallas, TX More articles by this author Allen F. Morey Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

762 ENDOSCOPIC MANAGEMENT OF RECURRENT POSTERIOR URETHRAL STRICTURES (PUS) WITH VISUAL INTERNAL URETHROTOMY (VIU) AND INJECTION OF MITOMYCIN C (MMC)

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease (II)1 Apr 2013762 ENDOSCOPIC MANAGEMENT OF RECURRENT POSTERIOR URETHRAL STRICTURES (PUS) WITH VISUAL INTERNAL URETHROTOMY (VIU) AND INJECTION OF MITOMYCIN C (MMC) James Rybak and Laurence Levine James RybakJames Rybak Chicago, IL More articles by this author and Laurence LevineLaurence Levine Chicago, IL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.325AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrent posterior urethral strictures pose a challenging therapeutic dilemma. Surgery is complex and difficult. MMC has been shown to reduce fibroblast and scar proliferation. It has been previously studied to be a safe minimally invasive approach for recurrent bladder neck contractures (BNC) following radical prostatectomy. This study assessed patient outcomes following VIU and injection with MMC in a patient population with a variety of complex and radiation induced PUS. METHODS Retrospective chart review from our database of reconstructive surgery with PUS between 2010 and 2012 that had failed previous intervention with at least 1 prior VIU. Quadrant cold knife incisions of the scar were performed followed by 0.3-0.5mg/ml injections of MMC at each incision site; a total of 10 mL was used in each scar. Postoperative flexible cystoscopy and post void residual (PVR) assessed urethral patency postoperatively at 1,3,6,12 months. RESULTS 14 patients were treated with VIU and injection of MMC. All pt's had failed a mean of 2.5 prior procedures (1-4) Mean follow-up was at 8 months (1-14). Average scar length was 1.5cm (1-2.5cm). 42% (6/14) had post brachytherapy induced strictures. 2 patients had strictures from previous RALP, 1 had postoperative external beam radiation s/p RRP. 2 patients had a BNC after holmium laser ablation of the prostate, 1 after TUNA, 2 had strictures from prior failed urethroplasties. Complications were seen in 2/14 patients, 1 needed surgical intervention for a urethral false passage after self catheterization, 1 experienced gross hematuria necessitating clot evacuation. 11/14 patients were continent at baseline and 11/14 remained continent post procedure. 14/14 pt's had patent posterior urethral stricture confirmed by flexible cystoscopy at follow up. Average PVR improved from mean 148ml to 31.25ml post procedure. 3/14 (21%) needed repeat procedure for stricture recurrence. 2/14 patients had successful placement of artificial urinary sphincter with a patent urethra seen intraoperatively. CONCLUSIONS Management of recurrent proximal urethral strictures is one of the most challenging reconstructive problems. In our series it appears that VIU or resection of PUS with injection of MMC can provide a minimally invasive tool to manage these strictures without significant morbidity, even in patients with radiation-induced disease. In those men who have urinary incontinence, successful sphincter placement is offered when there is no stricture recurrence or > 6 months. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e313 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Rybak Chicago, IL More articles by this author Laurence Levine Chicago, IL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1373 THE IMPACT OF INHIBIZONE® ON ARTIFICIAL URINARY SPHINCTER INFECTION RATE

INTRODUCTION AND OBJECTIVES: The artificial urinary sphincter (AUS) has been established as the gold standard for treating male stress urinary incontinence since its introduction in 1972. In April 2008, InhibiZone® (IZ, Minocycline and Rifampin) coated AUS devices were introduced. IZ-coating increased the cost of the device by approximately $1300 per AUS. To date, there is no data to support the assertion that IZ-coating reduces the risk of AUS infection. Therefore, we compared our infection rates before and after the introduction of the IZ-coated AUS, to determine if the added cost of the impregnated device conferred any benefit by reducing AUS infection rates. METHODS: We performed a retrospective review of 426 consecutive patients who underwent AUS implantation by a single surgeon (DSE) from January 2005 through June 2012. The patients were divided equally into two groups: a control group of 213 consecutive male patients who underwent non–IZ AUS implantation (January 2005March 2008) and a study population of 213 consecutive male patients who underwent IZ-coated AUS insertion (April 2008 June 2012). Demographics, comorbidities, previous procedures, and infection rates were compared between the two populations. A cost analysis between the two groups was also performed. RESULTS: Mean age (IZ 71.7, non-IZ 70.9, p 0.103), coronary artery disease (IZ 23% (n 49), non–IZ 16% (n 35), p 0.08) and diabetes mellitus (IZ 19% (n 40), non–IZ 20% (n 42), p 0.81) were comparable between the two groups. The complexity of the AUS cases was similar in the two groups also, with 23% (n 50) of the IZ and 18% (n 38) of the non-IZ group being AUS revision patients (p 0.15). The infection rates in the two groups were identical (IZ 3.3% (n 7), non-IZ 3.3% (n 7), p 0.99). Further, in the more complex subgroup of revision patients, IZ coating did not impact infection rates (IZ 5% (n 2/50), non-IZ 6% (n 3/38), p 0.42). CONCLUSIONS: InhibiZone® impregnation of the AUS did not alter infection rates in our study. The significant added cost of the IZ-coated AUS ( $276,000 more for all 213 IZ-AUS devices) was of no benefit in our series. At our institution, copious antibiotic irrigation has been standard during AUS placement, regardless of the type of device. We feel that the most cost-effective means of avoiding AUS infections is frequent and copious wound and AUS irrigation with antibiotic solution, along with perioperative IV antibiotic therapy. Based on this assessment, we will transition to using non-IZ AUS devices in our practice.

1222 “DRAIN AND RETAIN” STRATEGY FOR UROGENITAL PROSTHETIC BALLOONS AND RESERVOIRS DURING AUS AND IPP REVISION SURGERY

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Evaluation (I)1 Apr 20131222 “DRAIN AND RETAIN” STRATEGY FOR UROGENITAL PROSTHETIC BALLOONS AND RESERVOIRS DURING AUS AND IPP REVISION SURGERY Christopher A. Cefalu, Xiangrong Deng, J. Francis Scott, Sandeep Mehta, Lee C. Zhao, and Allen F. Morey Christopher A. CefaluChristopher A. Cefalu Dallas, TX More articles by this author , Xiangrong DengXiangrong Deng Dallas, TX More articles by this author , J. Francis ScottJ. Francis Scott Dallas, TX More articles by this author , Sandeep MehtaSandeep Mehta Dallas, TX More articles by this author , Lee C. ZhaoLee C. Zhao Dallas, TX More articles by this author , and Allen F. MoreyAllen F. Morey Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2576AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Artificial Urinary Sphincter (AUS) and/or Inflatable Penile Prosthesis (IPP) reoperation is not uncommon due to device malfunction or consequent tissue atrophy. Removal of the urogenital prosthetic balloon or reservoir (UPBR) often requires tedious dissection into the retropubic space, a practice we have abandoned in routine uninfected cases at our tertiary center. We present our experience using a “drain and retain” strategy, wherein the UPBR was not removed during routine AUS/IPP re-operative cases. We hypothesize that there is no difference in the infection rates between retained UPBR patients and those receiving their first prosthesis. METHODS A retrospective chart review was performed identifying all patients undergoing genitourinary prosthetics by a single surgeon from July 2007 to September 2012. Patients were included in the “drain and retain” study group if they underwent prosthetic replacement (with contralateral new UPBR placement) or subtotal device removal while having their original UPBR drained and retained. Outcomes were compared to patients receiving their first prosthesis (control group). Complete removals and revision cases utilizing the original UPBR were excluded from this analysis. Post-operative complications with specific attention to infection were reviewed and compared using chi-square analysis. RESULTS A total of 551 urologic prostheses (251 AUS and 300 IPP) were inserted in 433 evaluable patients having complete data during the study period. Among 120 reoperative procedure, UPBR were drained and retained in 55 study group patients (16 with subtotal device removal, 39 with contralateral UPBR placement). A control group of 390 patients having their first AUS and/or IPP placement was identified. No difference in infection rate was identified between the control group (6/390, 1.5%) and the drain and retain study group (1/55, 1.8%, chi-square=0.024, p=0.88). A total of 65 other cases were excluded, including those having complete removal (17 due to infection, 7 UPBR herniation, 2 in conjunction with cystectomy) or revision using the original UPBR (39 cases). CONCLUSIONS The drain and retain strategy for genitourinary prosthetic revisions and/or removals has a low rate of infection similar to routine AUS and/or IPP surgery. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e500-e501 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher A. Cefalu Dallas, TX More articles by this author Xiangrong Deng Dallas, TX More articles by this author J. Francis Scott Dallas, TX More articles by this author Sandeep Mehta Dallas, TX More articles by this author Lee C. Zhao Dallas, TX More articles by this author Allen F. Morey Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

568 ARTIFICIAL URINARY SPHINCTER CUFF DOWNSIZING VERSUS PRESSURE REGULATING BALLOON GRADIENT INCREASE AS REVISION TECHNIQUES: A FREEDOM FROM COMPLICATION ANALYSIS

You have accessJournal of UrologyUrodynmaics/Incontinence/Female Urology: Incontinence, Evaluation & Therapy (I)1 Apr 2013568 ARTIFICIAL URINARY SPHINCTER CUFF DOWNSIZING VERSUS PRESSURE REGULATING BALLOON GRADIENT INCREASE AS REVISION TECHNIQUES: A FREEDOM FROM COMPLICATION ANALYSIS O. Lenaine Westney, H. Henry Lai, Timothy B. Boone, Jerilyn Latini, and Edward J. McGuire O. Lenaine WestneyO. Lenaine Westney Houston, TX More articles by this author , H. Henry LaiH. Henry Lai St. Louis, MO More articles by this author , Timothy B. BooneTimothy B. Boone Houston, TX More articles by this author , Jerilyn LatiniJerilyn Latini Ann Arbor, MI More articles by this author , and Edward J. McGuireEdward J. McGuire Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1964AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The longevity of artificial urinary sphincter survival is compromised by mechanical failures, urethral atrophy and erosion. Techniques for improving or restoring incontinence after initial AUS are focused on manipulation of the cuff or the reservoir. Our aim is determine if there is a difference in the rate and timing of subsequent complications between patients who undergo cuff downsizing or a pressure regulating balloon change as a mechanism of AUS revision. METHODS The AUS databases from 4 institutions were reviewed for male patients with the following characteristics: 1) First revision of artificial urinary sphincter consisting of either cuff downsizing at the original cuff site or replacement of a higher pressure regulating balloon and 2) Patients who underwent replacement of all components including a downsized cuff and the same reservoir pressure with preservation of the original cuff site. Statistical analysis was performed using STATA/SE v. 12.1 for descriptive statistics and mean difference analysis. Freedom from complications was computed using Kaplan-Maier survival analysis. RESULTS 73 patients met the inclusion criteria. Four patients were excluded on the basis of missing critical data. 38 patients underwent cuff down sizing while 29 underwent PRB increase with a mean time from original AUS to revision of 43.9 (SD +/− 38.3) and 28.7 (SD +/− 35.4) months, respectively. A total of 24 patients (12 per group) had complications during the post revision follow-up period at a median of 20 months (range, 2.4 - 127.2). Patients in both groups were equally likely to experience a complication. (p=0.536) The mean time from revision to complication was not statistically different between the groups. (p=0.312) The freedom from complication curves were similar. (p=0.614) (Figure 1). CONCLUSIONS Cuff downsizing and PRB increase represent alternative methods to correcting persistent or recurrent urinary incontinence after initial artificial urinary sphincter placement. This data does not demonstrate a difference in number of complications, mean time to complications or freedom from complication. The distribution of complication types in each group appear different, however, the number of events limited analysis. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e233 Peer Review Report Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information O. Lenaine Westney Houston, TX More articles by this author H. Henry Lai St. Louis, MO More articles by this author Timothy B. Boone Houston, TX More articles by this author Jerilyn Latini Ann Arbor, MI More articles by this author Edward J. McGuire Ann Arbor, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Augmentation vs No Augmentation for Neurogenic Bladder Incontinence: No Augmentation

No AccessJournal of UrologyOpposing View1 May 2013Augmentation vs No Augmentation for Neurogenic Bladder Incontinence: No Augmentation Warren T. Snodgrass Warren T. SnodgrassWarren T. Snodgrass More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.068AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Augmentation vs No Augmentation for Neurogenic Bladder Incontinence: No Augmentation." The Journal of Urology, 189(5), pp. 1628–1629 References 1 : Artificial urinary sphincter in the treatment of urinary incontinence: preoperative urodynamics do not predict the need for future bladder augmentation. J Urol1998; 160: 1093. Link, Google Scholar 2 : Is long-term bladder deterioration inevitable following successful isolated bladder outlet procedures in children with neuropathic bladder dysfunction?. J Urol2008; 179: 1991. Link, Google Scholar 3 : Use of the fascial sling for neurogenic incontinence: lessons learned. J Urol1993; 150: 683. Link, Google Scholar 4 : Biological response of bladders rendered continent by insertion of artificial sphincter. J Urol1987; 138: 1116. Link, Google Scholar 5 : A single-centre long-term outcome analysis of artificial urinary sphincter placement in children. BJU Int2002; 89: 82. Google Scholar Department of Urology, UT Southwestern Medical Center, Dallas, Texas© 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 5May 2013Page: 1628-1629 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Warren T. Snodgrass More articles by this author Expand All Advertisement PDF downloadLoading ...

High Submuscular Placement of Urologic Prosthetic Balloons and Reservoirs via Transscrotal Approach

Traditional placement of inflatable penile prosthesis (IPP) reservoirs and/or artificial urinary sphincter (AUS) balloons into the space of Retzius may be challenging following major pelvic surgery. The aim of this study is to report our 1-year experience using a novel technique for high balloon/reservoir placement beneath the rectus abdominus muscle, thus completely obviating deep pelvic dissection during prosthetic urologic surgery. A retrospective review of all patients who underwent IPP and/or AUS placement between June 2011 and June 2012 was performed. All had AUS balloons and/or IPP reservoirs placed in a submuscular location by bluntly tunneling through the external inguinal ring into a potential space between the transversalis fascia and the rectus abdominus muscle using a long, angled, lung grasping clamp. Patient demographics, perioperative outcomes, and initial follow-up patient-reported outcomes were reviewed. During the study period, 120 submuscular balloons/reservoirs were inserted in 107 consecutive patients who underwent placement of an IPP (61 patients), AUS (33 patients), or both (13 patients). Among our 48 most recent patients, 41 (85%) reported they were totally unable to feel their balloon/reservoir, and all but two patients reported no bother from the submuscular balloon/reservoir placement. Of the 120 total submuscular balloons and reservoirs, surgical time and outcomes of the prosthetic procedures appeared similar to those placed using traditional methods; two reservoirs required revision surgery for repositioning. High submuscular placement of genitourinary prosthetic balloons and reservoirs via a transscrotal approach is both safely and effective, while avoiding deep retropubic dissection.

An Innovative Wound Retractor/Protector for Prosthetic Urologic Surgery

Objective: We demonstrate an innovative use of a barrier surgical wound retractor/protector system for use in a variety of prosthetic urologic procedures (penile prosthetics, artificial urinary sphincters, male slings). Materials and Methods: We demonstrate the use of a self-retaining ring wound retractor in a multitude of prosthetic urological procedures: insertion of an inflatable penile prosthesis through an infrapubic approach as well as penoscrotal approach, placement of a transperineal artificial urinary sphincter, and placement of a male urethral sling. Results: The self-retaining ring wound retractor facilitated a more rapid setup and takedown, provided 360 degrees of atraumatic retraction as well as 360 degrees of wound protection, allowed for maximum exposure with a minimum incision size, significantly shortened the operating wound depth thus maximizing exposure, and isolated the surgical field minimizing prosthesis to skin contact. Conclusion: Our experience shows that prosthetic urologic surgeries can be enhanced with the use of the self-retaining ring wound retractor as it provides better surgical exposure, lowers wound infection risks, sets up more quickly as a safer retraction system with substantial cost savings.

Trends in the Use of Incontinence Procedures After Radical Prostatectomy: A Population Based Analysis

Urinary incontinence is a frequent complication of radical prostatectomy with a detrimental impact on quality of life. We identified predictors and trends in the use of procedures for post-prostatectomy incontinence. Using SEER (Surveillance, Epidemiology and End Results) cancer registry data linked with Medicare claims, we identified men 66 years old or older who were treated with radical prostatectomy in 2000 to 2007. The primary outcome was performance of an incontinence procedure. Demographic and clinical predictors of incontinence surgery were evaluated by multivariable regression analysis. Of 16,348 men treated with radical prostatectomy 1,057 (6%) had undergone at least 1 incontinence procedure by a median of 20 months after the procedure, including 61% who underwent the first incontinence procedure within 2 years of prostatectomy. Older age and residence in the South were associated with greater probability of an incontinence procedure. Black men and those living in nonmetropolitan areas were less likely than their peers to undergo an incontinence procedure. Of men treated with any incontinence procedure 15% underwent more than 1 type. Of those treated with bulking agents 39% also received a urethral sling or artificial urinary sphincter and 13% who received a sling also had an artificial urinary sphincter. In 34% of the men who underwent any incontinence surgery artificial urinary sphincter placement was the only procedure performed. In this population based cohort of older men with prostate cancer only 6% underwent an incontinence procedure after prostatectomy. This low rate may reflect the underuse of potentially beneficial procedures.

Anatomical and Manometric Comparison of Perineal and Transscrotal Approaches to Artificial Urinary Sphincter Placement

We compared cuff sites and assessed anatomical and manometric differences between the transscrotal and perineal approaches to artificial urinary sphincter placement in fresh male cadavers. Artificial urinary sphincter implantation using perineal and transscrotal incisions was performed in 15 fresh male cadavers. The artificial urinary sphincter cuffs were placed as proximal as possible using each approach. After measuring urethral circumference at each cuff site, an appropriately sized cuff was placed at each location. The 61 to 70 cm H(2)O pressure reservoir and control pump were then connected to the cuffs. Retrograde leak point pressure was assessed sequentially across each cuff. The paired t test was used to compare urethral circumference and retrograde leak point pressure between the 2 approaches. Mean urethral circumference using the perineal and transscrotal approaches was 5.38 (range 3.2 to 7.5) and 3.81 cm (range 3 to 4.5), respectively (p <0.0001, 95% CI of difference 0.99-2.13). Mean retrograde leak point pressure using the perineal and transscrotal approaches was 90.1 and 64.9 cm H(2)O, respectively (p = 0.0002, 95% CI of difference 13.7-33.5). On visual inspection of cuff sites, the perineal approach was more proximal on the urethra than the transscrotal approach. While the transscrotal approach to artificial urinary sphincter placement has the advantage of technical ease, the anatomical and manometric findings of this cadaver study suggest that the perineal approach offers a more proximal cuff location, more robust urethral size and more effective urethral coaptation than the transscrotal approach.

Surgical Implantation of Artificial Urinary Device and Penile Prosthesis Through Trans-scrotal Incision for Postprostatectomy Urinary Incontinence and Erectile Dysfunction: Synchronous or Delayed Procedure?

To compare simultaneous and 2-stage surgical implantation of an artificial urinary sphincter (AUS) and penile prosthesis (PP) for patients with severe urinary incontinence and erectile dysfunction after prostatectomy. The data from 23 patients were reviewed, 15 (group 1) underwent simultaneous implantation and 8 (group 2) underwent 2-stage surgery. The operative time, complications, postoperative pain, incidence of pre- and postoperative urinary incontinence, erectile dysfunction rating (International Consultation on Incontinence questionnaire, Incontinence Quality of Life, International Index of Erectile Function, and Erectile Dysfunction Inventory of Treatment Satisfaction), and patient satisfaction were evaluated. The mean operative time was 140 minutes for the simultaneous procedure (group 1) and 105 minutes for AUS placement and 65 minutes for PP placement (group 2). No major postoperative complications were recorded. The average postoperative hospital stay was 2.5 days after the double-implant procedure and 2.4 days after AUS and 1.2 days after PP placement. The visual analog scale score at 6 and 24 hours after surgery was 5 and 3 in group 1, and 4 and 3 after AUS and 3 and 2 after PP (group 2; P > .05). At 1 year, all patients were socially continent, with an average International Consultation on Incontinence score of 2 in group 1 and 2 in group 2. Of the patients in groups 1 and 2, 65% and 68% were completely dry, respectively (P > .05). The Incontinence Quality of Life score increased from 37 to 84 in group 1 and from 41 to 82 in group 2. The Patient Global Impression of Improvement revealed that 92% of group 1 and 95% of group 2 experienced "great improvement" (P > .05). The International Index of Erectile Function and Erectile Dysfunction Inventory of Treatment Satisfaction score was 70 of 75 and 87 of 100 in group 1 and 72 of 75 and 86 of 100 in group 2, respectively (P > .05). Group 1 patients were completely satisfied, and all group 2 patients stated they would have preferred synchronous surgery. AUS and PP synchronous placement is feasible and safe and as effective as the 2-stage procedure, with better acceptance by patients.

Intermediate outcomes after transcorporal placement of an artificial urinary sphincter

To report the intermediate outcomes of a transcorporally placed artificial urinary sphincter. Medical records of 16 consecutive patients treated with transcorporal placement of artificial urinary sphincter from March 2003 to October 2008 were reviewed. The indications for surgery, operative logs, postoperative evaluations, complication rate and postoperative questionnaire assessment utilizing the International Continence Society short form for men were analyzed. Eight patients each underwent primary transcorporal cuff placement and revision surgery. Complete data for analysis were available in 15 patients at a median follow up of 45 months (range 23-91 months). The success rate (defined as use of 0-1 pads per day) was 80% (12/15 patients). Average voiding score was 2/20 (standard deviation 1.88), average irritative score was 3/24 (standard deviation 4.92) and the mean Quality-of-Life score was 0.66 (standard deviation 1.04). Transcorporal placement of an artificial urinary sphincter is both safe and efficacious in patients with a small caliber or atrophic urethra, either as a primary or salvage procedure. Efficacy and level of satisfaction in this subset of patients is equivalent to those undergoing traditional artificial urinary sphincter cuff placement.

Use of Solovov–Badenoch principle in treating severe and recurrent vesico‐urethral anastomosis stricture after radical retropubic prostatectomy: technique and long‐term results

What's known on the subject? and What does the study add? Many different approaches have been used to treat bladder neck strictures and urinary incontinence after radical prostatectomy in the past. Most techniques are highly invasive and carry a high risk of complications. The present study describes the use of the Solovov-Badenoch 'pull-through urethroplasty' as well as artificial urinary sphincter implantation. • To report our experience in the management of patients with combined urinary incontinence and stricture after radical prostatectomy with a two-step approach: urethroplasty with a 'pull-through' technique after the Solovov-Badenoch principle; and artificial urinary sphincter (AUS) insertion after 8-10 months. • We retrospectively evaluated a cohort of 11 patients treated between September 2001 and January 2010. • There were no intraoperative complications in either procedure. • After urethroplasty one patient was unable to empty the bladder with complete urine retention without urethral stricture (treatment failure). • At 6 months after the urethroplasty 10 patients were completely incontinent and received AUS. • One previously irradiated patient developed urethral erosion 6 months after AUS implantation and underwent complete removal of the device. • After a mean (range) follow-up of 65 (19-119) months, nine patients (81.8%) were continent with no post-void residual urine and a perfectly functioning AUS. • Our experience with a two-step approach (combined suprapubic/transperineal redo anastomosis and AUS placement) shows that redo vesico-urethral anastomosis is easier than pure transperineal approaches with good results in restoring patency and that the transperineal step provides a dedicated operative field for AUS implantation with reduced risks of perioperative complications.

239 ARTIFICIAL URINARY SPHINCTER PLACEMENT IN PATIENTS WITH ORTHOTOPIC NEOBLADDER URINARY DIVERSION AFTER RADICAL CYSTECTOMY: RETROSPECTIVE REVIEW OF CLINICAL OUTCOMES

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery III1 Apr 2012239 ARTIFICIAL URINARY SPHINCTER PLACEMENT IN PATIENTS WITH ORTHOTOPIC NEOBLADDER URINARY DIVERSION AFTER RADICAL CYSTECTOMY: RETROSPECTIVE REVIEW OF CLINICAL OUTCOMES Michael Vainrib, Vannita Simma-Chiang, Stuart Boyd, and David Ginsberg Michael VainribMichael Vainrib Los Angeles, CA More articles by this author , Vannita Simma-ChiangVannita Simma-Chiang Los Angeles, CA More articles by this author , Stuart BoydStuart Boyd Los Angeles, CA More articles by this author , and David GinsbergDavid Ginsberg Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.294AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Stress urinary incontinence (SUI) is a known possibility after radical cystectomy (RC) and orthotopic neobladder (ONB) urinary diversion. Our primary aim was to retrospectively review the outcomes and complications of patients who have elected to undergo artificial urinary sphincter (AUS), AMS-800 (American Medical Systems, Minnetonka, MN) placement for treatment of post-ONB SUI in a single institution. The secondary objective was to evaluate possible risk factors for AUS failure. METHODS From 1994 - 2009, as part of IRB-approved Bladder Cancer Database, 64 patients (pts) who had undergone AUS placement after RC/ONB were identified. Comparative variables were analyzed using Fisher exact test. RESULTS 36 male pts were eligible to review. Mean age at RC/ONB was 70 years (range 55-82) and at AUS placement 72 years (58-79). Mean time to AUS after RC/ONB was 28 (2-120) months. Mean follow up after AUS was 3.2 years (0.5-10). TCC was the indication for RC in 94% of pts. Mean BMI was 28 kg/m2 and 19% of patients had diabetes. Pelvic floor physiotherapy was attempted in 17% of pts prior to undergoing AUS placement. Timing of incontinence in these patients included: complete (day and night) - 76%, daytime only - 10% and nighttime only - 14% pts. Post-AUS placement, 82% pts reported good (dry/social) continence. 11/36 received chemotherapy on average of 3.7 (1-10) years prior to AUS and 10/36 had radiation on average of 2.5 (0.5-10) years prior to AUS. There were no perioperative complications observed during AUS placement. Mean time to further surgical intervention was an average 2.6 (1-6) years after AUS placement and occurred due to: erosion - 9 patients, device malfunction - 5 patients, infection - 5 patients. There was no significant correlation between pathological stage of bladder cancer, presence of concomitant prostate cancer and degree of incontinence pre- or post-AUS. In addition, there was no correlation found between chemo- or radio-therapy and degree of incontinence or the need for AUS erosion or revision. CONCLUSIONS With intermediate follow-up, patients undergoing AUS after RC/ONB were found to have an acceptable complication rate that is comparable to previous series. AUS is a safe, effective treatment for high risk patients after RC/ONB with severe SUI. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e98 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Vainrib Los Angeles, CA More articles by this author Vannita Simma-Chiang Los Angeles, CA More articles by this author Stuart Boyd Los Angeles, CA More articles by this author David Ginsberg Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes of Artificial Urinary Sphincter Placement in Men After Radical Cystectomy and Orthotopic Urinary Diversions for the Treatment of Stress Urinary Incontinence: The University of Southern California Experience

To examine the outcomes of male patients who have undergone artificial urinary sphincter (AUS), AMS-800 (American Medical Systems Minnetonka, MN) placement for iatrogenic stress urinary incontinence after radical cystectomy (RC) and orthotopic neobladder (ONB) diversion in a single institution. From 2002-2009, patients were prospectively randomized to undergo RC and Studer vs T-pouch neobladder reconstruction. We received IRB- approval to retrospectively review the charts of patients who underwent AUS placement for symptoms of SUI. Patients were mailed 2 validated questionnaires, International Continence Society Male-Short Form, the Incontinence Symptom Severity Index, and a pad questionnaire. Twelve male patients were identified. Average age at time of AUS placement was 73.8 years (range 52-82). Mean time between RC/ONB and AUS placement was 1.53 years (range 1-4). Mean follow-up time after initial AUS placement was 21.7 months (range 12-72). Ten patients (10/12; 83.3%) returned the validated questionnaires. In comparing pre-AUS to post-AUS continence, 90% of patients reported improvement in continence. Three patients deactivated their AUS during the day and activated it at night. There were no erosions (0%) or any mechanical malfunctions of the device (0%) in our cohort. There were no complications or injuries to the ONB during placement of the AUS components. AUS is a safe, effective continence procedure for patients with ONB and SUI. Complication rate, urinary symptoms, and quality of life these patients have as determined by validated questionnaires is acceptable.

289 Artificial urinary sphincter placement preserving the bulbospongiosus muscle: Is it possible to decrease urethral erosion/atrophy rate?

289 Artificial urinary sphincter placement preserving the bulbospongiosus muscle: Is it possible to decrease urethral erosion/atrophy rate?

Small Intestinal Submucosa Urethral Wrap at the Time of Artificial Urinary Sphincter Placement as a Salvage Treatment Option for Patients With Persistent/Recurrent Incontinence Following Multiple Prior Sphincter Failures and Erosions

Patients with persistent and/or recurrent stress urinary incontinence (SUI) after multiple artificial urinary sphincter (AUS) revisions for erosion and infection represent a very challenging treatment population. Available management options are limited, with poor overall outcomes. We assess another treatment option. A retrospective analysis was performed of 8 patients presenting with severe, recurrent incontinence after multiple prior failed AUS procedures. All patients were treated with small intestinal submucosa (SIS) "urethral wrap" with subsequent AUS cuff placement to provide additional urethral bulk and serve as a "buffer" between the cuff and urethra. Eight patients (median age 76 years, range 55-81) presented with near-total (4-5 pads) to total urinary incontinence, having previously undergone a combined 19 AUS procedures with 6 tandem cuffs and 8 prior urethral erosions. At a median follow-up of 12.4 months, 38% (3/8) of patients were dry, requiring no pads. Three patients underwent AUS explantation for sphincter erosion (n = 2) and infection (n = 1). Two patients had recurrent incontinence, with one occurring after wrap revision for urinary retention. Patients with prior radiation accounted for 80% (4/5) of procedure failures. All patients had temporary postoperative urinary retention. SIS urethral wrap with AUS placement for severe SUI after multiple previous AUS placements and erosion/infection is a viable treatment option in appropriately selected patients for this very complicated issue. However, because of the complexity of the underlying problem, patients should be counseled about the expected risks and outcomes of surgery.

End-Stage Renal Disease Due to Hydronephrosis in a Patient with Artificial Urinary Sphincter

In this report we describe the case of a 65-year-old diabetic patient who developed hydronephrosis and irreversible end-stage renal disease nine years after the placement of an AMS 800™ artificial urinary sphincter. This was due to non-compliance with the voiding regime and lack of follow-up after the placement of the urinary sphincter.