Artificial Urinary Sphincter Placement Research Articles

Incidence of Stress Urinary Incontinence After Posterior Urethroplasty for Radiation-induced Urethral Strictures

To identify the frequency of de novo stress urinary incontinence (SUI) after posterior excision and primary anastomotic (EPA) urethroplasty in patients with radiation-induced urethral strictures (RIUS) and compare with patients with pelvic fracture urethral injuries (PFUIs). A retrospective review was conducted among patients who underwent successful posterior EPA urethroplasty between 2008 and 2016 for RIUS from prostate cancer or PFUI from blunt trauma. Only patients with an intact bladder neck on imaging were included. SUI was defined by patient-reported outcomes and daily pad use. Inclusion criteria were met by 36 patients with RIUS and 33 patients with PFUI. Among the RIUS cohort, mean follow-up was 18 months, mean stricture length was 2.5 cm, and surgical dissection extended to the prostatic urethra in 67% (n = 24). The overall frequency of de novo SUI among patients with RIUS was 33% (n = 12), of which 75% (9 of 12) had prostatic urethral involvement. Two patients with RIUS (17%, n = 12) proceeded with artificial urinary sphincter (AUS) placement, whereas the remaining 10 patients required pads. SUI after urethroplasty in patients with PFUI was less common (12%, n = 4) and the prostatic urethra was involved in only 3% (n = 1) of all patients with PFUI. One patient with PFUI underwent AUS placement, whereas the remaining 3 patients did not require pads. Among RIUS patients with an intact bladder neck, SUI impacts one-third of patients. Subsequent AUS placement is uncommon. Prostatic urethral involvement increases risk of SUI. SUI is less common among patients with PFUI, likely related to a more limited involvement of the proximal bulbomembranous urethra and lack of radiation.

Can time to failure predict the faulty component in artificial urinary sphincter device malfunctions?

Artificial urinary sphincter malfunctions can occur in any of the individual components. Preoperative identification of the malfunctioning component can be valuable for patient counseling and surgical planning. The optimal strategy for repair of failed artificial urinary sphincter components is debated given the relative rarity of the situation. The aim of the present study was to evaluate the relationship of time to failure with failed artificial urinary sphincter component and to compare our outcomes of specific component versus complete device replacement. From 1983 to 2011, 1805 artificial urinary sphincter procedures were carried out at Mayo Clinic (Rochester, Minnesota, USA), of which 1072 patients underwent primary artificial urinary sphincter placement. Clinical variables, including time to failure, were evaluated for association with component failure. Bootstrap analysis was used to estimate the differences in time to reach a fixed percentage of component failure. A total of 115 patients experienced device failure at a median follow up of 4.2 years. Urethral cuff, abdominal reservoir, scrotal pump and tubing malfunction occurred in 53 (4.9%), 26 (2.4%), 11 (1%) and 25 (2.3%) patients, respectively. Increasing age at the time of primary surgery was protective of cuff malfunction (hazard ratio 0.97, P = 0.04). Time to 3% urethral cuff failure outpaced other component failures (P < 0.05). Secondary failure-free rates after whole device versus specific component revisions were comparable (P = 0.38). Clinical predictors for artificial urinary sphincter failure continue to be difficult to establish. Although single component versus entire device replacement have similar outcomes, if pursuing single component revision, we recommend cuff-first interrogation in devices in place for >3 years, as this represents the most likely component to fail.

Evaluating Success Rates After Artificial Urinary Sphincter Placement: A Comparison of Clinical Definitions

To assess success rates of primary artificial urinary sphincter (AUS) implantation using various objective, subjective, or retreatment definitions. We identified 309 male patients who underwent primary AUS placement at the Mayo Clinic from 2010 to 2016. Of those, 214 had not undergone repeat surgery, were sent a mailed survey, and 148 of 214 (69.2%) responded. Eleven definitions of success were evaluated among responders. Associations between the definitions and patient-reported success were assessed via logistic regression and c-statistic. Treatment success rates were highly variable depending on the definition used (14.8%-86.7%). Median follow-up was 24 months (interquartile range [IQR] 8, 40), during which 72% did not undergo reoperation. Among survey respondents, 87% felt at least "much better," and 47% reported surgery was "very successful." Roughly 15% reported zero pad use. Patient-reported success was most strongly associated with the Patient Global Impression of Improvement (PGI-I) score (odds ratio [OR] 0.07, 95% confidence interval [CI] 0.02-0.19; P <.0001; c = 0.88). The largest difference in Michigan Incontinence Symptom Index (M-ISI) score between treatment successes and failures was noted when success was defined by PGI-I as well (success group M-ISI 11 vs failure group M-ISI 24.15; OR 0.48, 95% CI 0.37-0.63; P <.0001; c = 0.97). In terms of pad count, use of a security pad or less was most closely associated with patient-reported success (OR 0.18, 95% CI 0.10-0.35; P <.0001; c = 0.75). The "success rate" after primary AUS implantation varies widely depending on the definition used. Although most patients report that surgery was beneficial, zero pad count was less common. Among definitions evaluated, the PGI-I had the strongest association with patients' evaluation of surgical success.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

Multicenter Analysis of Patient Reported Outcomes Following Artificial Urinary Sphincter Placement for Male Stress Urinary Incontinence

Patient centered data are lacking regarding functional and quality of life improvements after artificial urinary sphincter placement. We analyzed the degree of benefit from artificial urinary sphincter placement using ISI (Incontinence Symptom Index), a validated patient reported outcome measure assessing the severity and bother of urinary incontinence, and IIQ-7 (Incontinence Impact Questionnaire-7), a validated patient reported outcome measure assessing the impact and emotional distress of urinary incontinence. We performed a retrospective review at 4 centers participating in TURNS (Trauma and Urologic Reconstruction Network of Surgeons). Data were available on 51 and 45 patients who underwent artificial urinary sphincter placement, and had preoperative and postoperative ISI and IIQ-7 data, respectively. Mean age was 64.8 years. Median time from surgery to followup questionnaires was 8.5 months. On ISI the median preoperative severity and bother scores were 24 (IQR 20-28.5) and 6 (IQR 4-7), and the median postoperative severity and bother scores were 10 (IQR 4.5-17) and 1 (IQR 0-3), respectively. Improvement on each ISI item was statistically significant. On IIQ-7 the median preoperative impact and distress scores were 9 (IQR 6-13) and 4 (IQR 2-6), and the median postoperative impact and distress scores were 3 (IQR 0-7) and 0 (IQR 0-3), respectively. Improvement on each IIQ-7 item was statistically significant. Artificial urinary sphincter implantation significantly reduces the severity and bother of stress urinary incontinence symptoms. Longer followup and development are needed of a patient reported outcome measure targeting male stress urinary incontinence.

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OBJECTIVES/SPECIFIC AIMS: Perineal urethral sling placement is an option for men with mild to moderate post-prostatectomy stress urinary incontinence (SUI). However, men with persistent incontinence after sling placement often require secondary artificial urinary sphincter (AUS) placement, made difficult by the sling occupying the proximal bulbar urethra. This proximal section has a thicker corpus spongiosum which may mitigate cuff-induced ischemia and subsequent urethral atrophy. The authors report a series of AUS placements after failed sling, using sling revision or removal to access the proximal urethra. METHODS/STUDY POPULATION: Cutting the sling arms during urethral cuff placement increased urethral exposure and mobility. If feasible, completely removing the sling allowed the most proximal cuff site; but if dissection was felt unsafe, the mesh was left in situ and the cuff placed distally. This study is a retrospective cohort design of patients with SUI who underwent AUS placement after failed sling from 2010 to 2016. Variables included baseline patient characteristics, SUI severity, intraoperative variables, and postoperative outcomes. AUS failure, defined as infection, erosion or urethral atrophy, was analyzed at 12 and 96 months using univariate and multivariable logistic regression. RESULTS/ANTICIPATED RESULTS: Over the study period, 29 patients underwent AUS placement after failed sling. At the time of AUS placement, mean urethral circumference was 6.2 cm and 68% of patients had a 4.5 cm cuff placed; no cases required a 3.5 cm cuff. Seventy-three percent of cases were after transobturator sling placement (27% bone-anchored) and 45% of slings were explanted. AUS failure rate at 12 and 96 months was 17.8% and 45%, respectively; atrophy was the most common indication. Prior transobturator sling placement had lower rates of both 12 month (9.1% vs. 57%, p=0.006) and 96 month (36% vs. 71%, p=0.11) failure, though the latter was not statistically significant. Sling explant was not a significant predictor of 12 month (p=0.12) or 96 month failure (p=0.17). DISCUSSION/SIGNIFICANCE OF IMPACT: Sling revision during AUS placement helps expose the wider proximal urethra, allowing larger cuff size placement. This procedure appears safe, with low rates of erosion and short-term failure—albeit with high rates of long-term urethral atrophy possibly due to more significant dissection causing devascularization. However, sling removal was not a significant predictor of failure. The transobturator sling’s smaller profile may result in less trauma to urethra—possibly explaining the improved outcomes.

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OBJECTIVES/SPECIFIC AIMS: Stress urinary incontinence (SUI) significantly affects quality of life and occurs in 60% of men after radical prostatectomy, with 5% requiring surgical treatment. The artificial urinary sphincter (AUS) offers these patients excellent control of their post-prostatectomy SUI. The device contains 3 parts: the pump, urethral cuff, and pressure regulating balloon. Despite the effectiveness of AUS, up to 50% of patients require surgical revision after initial placement due to recurring SUI. Thus far, literature is heterogeneous regarding the causes of mechanical AUS failure and appropriate surgical management. Our study aims to characterize the most common reasons of AUS failure requiring surgical revision and the survival of each AUS component. METHODS/STUDY POPULATION: We report a series of 48 patients who received AUS placement and/or revision by 1 surgeon from 2010 to 2013. Upon presenting for revision, intraoperatively, the surgeon systematically evaluated the device for failure of the balloon, cuff and pump as well as urethral erosion and atrophy. In patients not requiring revision all device components were presumed functional. We conducted retrospective chart review to collect baseline characteristics, intraoperative findings, and postoperative outcomes. Using Kaplan-Meier estimates, we calculated incidence rates of component failure for the cuff, pump, and balloon. To identify risk factors for AUS failure, Cox regression was performed for univariate and multivariable testing. Multivariable modeling included those variables considered biologically plausible and significant in univariate testing. RESULTS/ANTICIPATED RESULTS: In total, 48 patients were studied with median follow up of 4.25 years. All patients received an AMS 800 device with a 61–70 mL balloon filled with 27 cc of isotonic contrast. Cuff sizes ranged from 3.5 to 5.5 cm, with 4.5 cm selected in 33/48 cases (68.8%); 19 of the patients required AUS correction (41.7%). Balloon leak constituted 57.9% (11/19) of failures, followed by cuff failure/urethral atrophy (21.1%), urethral erosion (10.5%), and individual cases of infection and pump failure. Median time to mechanical failure due to balloon leak was 3.67 years (IQR 2.17, 5.33); median time to failure for nonballoon causes was 0.54 years (IQR 0.25, 1.83). Survival of the balloon, cuff, and pump was 100%, 95.7%, and 97.9% at 1 year and 76.9%, 91.0%, and 97.9% at 5 years, respectively. DISCUSSION/SIGNIFICANCE OF IMPACT: Our study identifies fluid leakage from the balloon as the most common cause of AUS failure, particularly in patients presenting between 1 and 5 years after initial placement. For such patients, interrogating the balloon first can decrease infection risk and surgical morbidity as it can avoid manipulation of the urethral cuff. Furthermore, simply replacing lost fluid saves cost and allows for immediate reactivation of the AUS device.

Virtue Quadratic Male Sling for stress incontinence-surgical guide for placement and delayed revision.

The algorithm for surgical management of post prostatectomy incontinence classically includes male slings and artificial urinary sphincter (AUS) placement. The Virtue Quadratic Male Sling was designed to provide both urethral elevation and prepubic compression making it a viable option for a wider spectrum of incontinent men whose symptoms range from mild to severe. With a focus on two key steps of the surgery, (I) sling fixation (II) use of intraoperative retrograde leak point pressure (RLPP), this guide is intended to outline a safe and efficacious treatment for post-prostatectomy incontinence. Intriguingly, the sling can be revised in the event of refractory or worsening leakage, and does not preclude the placement of an AUS should it be needed. This paper describes a step by step approach to performing the procedure as well as expert tips to improve outcomes and avoid/manage complications that have been learned over the years.

Waves of Change: National Trends in Surgical Management of Male Stress Incontinence

To determine the trend in surgical management of male stress urinary incontinence (SUI) in the context of the rate of radical prostatectomy (RP) as reported by a national database. Traditionally, the artificial urinary sphincter (AUS) has been the gold standard, but the male sling represents a newer and popular alternative. Refinements in prostate surgery may reduce the incidence and degree of subsequent SUI. A retrospective cross-sectional analysis was performed using the National Inpatient Survey database, which captures discharge data from inpatient and overnight admissions. Cases were identified by their International Classification of Diseases, Ninth Revision procedure codes. We queried the codes 58.93 (implantation of AUS), 59.4 (suprapubic sling operation), 59.5 (retropubic urethral suspension), and 59.6 (paraurethral suspension). We also queried 60.5 (RP) for comparison. Data were collected from January 2000 to December 2012 and weighted to a national average using National Inpatient Survey guidelines. A total of 32,416 anti-incontinence operations (20,790 AUS and 11,625 sling procedures) were performed over the study period. There was a significant downward trend in the total number of incontinence procedures (F(1,11) = 6.15, P = .03). However, when stratifying the data by procedure type, only AUS placement demonstrated a significant decline (F(1,11) = 21.70, P <.01), whereas sling procedures significantly increased (F(1,11) = 12.95, P <.01). There was no significant change in the annual incidence of RP. Inpatient surgery for male SUI is decreasing overall. Placement of the AUS declined significantly, whereas sling placement became more common. Future study will determine the etiology of these trends.

Robotic-assisted laparoscopic artificial urinary sphincter and MACE procedure on a pediatric patient

To describe robotic-assisted laparoscopic artificial urinary sphincter (RAL-AUS) placement and a Malone antegrade continent enema (MACE) procedure on a 6-year-old girl. Our patient is a 6-year-old girl with myelomeningocele. She was totally incontinent of urine and chronic constipated despite aggressive bowel regimen. Preoperative workup included renal and bladder ultrasound showing normal findings. Video-urodynamics was also obtained showing low leak point pressure (25cm H2O) with no reflux. RAL-AUS was performed totally intra-corporally with no complications. The total operative time was 5h 42min. Estimated blood loss was minimal. The patient was discharged on postoperative day 4 with the AUS deactivated. Follow-up cystoscopy and activation of the AUS was done 6 weeks later. At 3-month follow-up, the patient was fully recovered and remained completely dry between voids. Also her bowel movements improved significantly with the MACE. Both patient and family appeared comfortable in using the AUS. To our knowledge, this is the first case described of RAL-AUS placement in the pediatric population. We believe this can be safely accomplished with good outcomes. The robotic approach provides an advantage in performing deep pelvic surgeries and facilitates concomitant intra-abdominal procedures.

Extended Experience with High Submuscular Placement of Urological Prosthetic Balloons and Reservoirs: Refined Technique for Optimal Outcomes

IntroductionSince 2012, we have routinely placed urological prosthetic balloons and reservoirs in a high submuscular location between the transversalis fascia and rectus abdominis muscle during inflatable penile prosthesis and artificial urinary sphincter surgery. We review our experience of more than 600 high submuscular cases, describe refinements in our technique through time and compare outcomes to prior consecutive space of Retzius prosthetic cases. MethodsWe retrospectively reviewed patients who underwent inflatable penile prosthesis and/or artificial urinary sphincter placement between January 2009 and April 2016. Complications and need for surgical revision were recorded and compared between the 2 placement locations. ResultsDuring the study period 872 prosthetic cases were performed, including 619 high submuscular cases from 2012 to 2016 (inflatable penile prosthesis in 344, artificial urinary sphincter in 275). Of 399 first-time high submuscular implants 54 (14%) required revision, of which 8 (2%) were attributable to the urological balloon or reservoir due to “pain/bother” (4) or herniation (4). Of the 161 space of Retzius urological balloons and reservoirs placed from 2009 to 2011 a similar rate of herniation (3 cases, 1.9%) was noted, although higher rates of deep pelvic complications (3, 1.9%) were noted compared to high submuscular cases (2, 0.5%; p=0.14). Since implementing our refined high submuscular technique, no deep pelvic complications have occurred. ConclusionsExperience with high submuscular placement of urological balloons and reservoirs confirms that it is safe and well tolerated. With refinements in technique the complication rates are similar in frequency to those with space of Retzius but appear to be minor in nature with negligible risk of visceral or vascular injury.

MP36-18 PATTERNS AND TIMING OF ARTIFICIAL URINARY SPHINCTER FAILURE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I1 Apr 2017MP36-18 PATTERNS AND TIMING OF ARTIFICIAL URINARY SPHINCTER FAILURE Andrew Cohen, Kristine Kuchta, Sangtae Park, and Jaclyn Corrine Milose Andrew CohenAndrew Cohen More articles by this author , Kristine KuchtaKristine Kuchta More articles by this author , Sangtae ParkSangtae Park More articles by this author , and Jaclyn Corrine MiloseJaclyn Corrine Milose More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1129AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The gold standard treatment for severe post-prostatectomy incontinence is implantation of an artificial urinary sphincter (AUS). There is a paucity of data regarding the timing of AUS placement after prostatectomy and other factors which predict device failure. METHODS We identified all patients who underwent prostatectomy and subsequent AUS placement in SEER-Medicare from 2002-2011. These patients' demographic, clinical and pathologic characteristics were included in multivariable cox proportional hazard models, to identify predictors for device survival. We also analyzed factors impacting the time to revision or explantation from initial AUS implantation and prostatectomy. RESULTS 841 men underwent AUS placement at a median 23 months (IQR:15-40.6) after prostatectomy. 236 (28%) men ultimately required revision or explantation. There were no differences in age, race or hospital setting for those undergoing reoperation vs. not (p≥0.2). Patients who underwent reoperation were more likely to have had higher clinical stage cancer, undergone open prostatectomy, or had prior sling placement (p<0.01). There were no differences in rates of diabetes, smoking status, prior radiation therapy, or Charlson Comorbidity Index scores between those requiring reoperation vs. not (all p >0.15). Patients with delayed AUS placement (29%), defined as >3 years after prostatectomy, experienced prolonged device survival (Figure). Delayed patients were significantly more likely to have received radiation therapy [36.5% vs. 10.5% (p<0.001)]. Nonetheless, delayed repair was confirmed to be protective on multivariate analysis, after controlling for patient and disease characteristics including radiation history [HR:0.44 (95% CI: 0.32-0.62); p<0.01]. Factors independently associated with a shorter interval time until reoperation included history of radiation [HR: 1.69 (95% CI: 1.16-2.44);p<0.01] and history of prior sling [HR:1.88 (95% CI: 1.19-2.97); p<0.01]. CONCLUSIONS Delayed AUS implantation in the Medicare population is associated with prolonged device survival, while radiation exposure and prior urethral sling surgery predict for early reoperation. Further work is required to identify patient specific factors which may explain variability in timing for AUS after prostatectomy and how such factors contribute to device longevity. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e473 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Andrew Cohen More articles by this author Kristine Kuchta More articles by this author Sangtae Park More articles by this author Jaclyn Corrine Milose More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP46-07 MULTICENTER ANALYSIS OF ARTIFICIAL URINARY SPHINCTER OUTCOMES IN PATIENTS AFTER BOTH RADICAL PROSTATECTOMY AND ANASTOMOTIC URETHROPLASTY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy1 Apr 2017MP46-07 MULTICENTER ANALYSIS OF ARTIFICIAL URINARY SPHINCTER OUTCOMES IN PATIENTS AFTER BOTH RADICAL PROSTATECTOMY AND ANASTOMOTIC URETHROPLASTY Jonathan Wingate, Jeremy Myers, Gregory Murphy, Nejd Alsikafi, Bradley Erickson, Benjamin Breyer, and Bryan Voelzke Jonathan WingateJonathan Wingate More articles by this author , Jeremy MyersJeremy Myers More articles by this author , Gregory MurphyGregory Murphy More articles by this author , Nejd AlsikafiNejd Alsikafi More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , and Bryan VoelzkeBryan Voelzke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1446AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We sought to assess artificial urinary sphincter (AUS) outcomes in a subset of patients who have had a history of radical prostatectomy and anastomotic urethroplasty in order to describe outcomes after having two prior urethral transecting surgeries. Our null hypothesis is that multiple transections of the urethra do not increase the possibility of urethral erosion following artificial urinary sphincter placement. METHODS We performed a retrospective review from five participating centers in the Trauma and Urologic Reconstruction Network of Surgeons. The study period included February 2010 - January 2016. Of the 445 incontinence procedures in our prospective database, there were 35 patients who underwent an AUS and had both a radical prostatectomy and anastomotic urethroplasty. Patients were excluded if they did not have a minimum of 6 months of follow up after AUS placement. Twenty-two patients met inclusion criteria. The surgeon independently determined choice of transcorporal or standard cuff technique. RESULTS Median age was 67.5 years. Mean follow up time was 32.2 months (IQR 16.6 - 44.6 months). Twelve patients had a history of prior pelvic radiation for prostate cancer. Of the 22 patients, twenty patients had transcorporal cuff placement. There were 7 complications - 2 erosions, 3 hematomas, 1 infection, and 1 pump migration. Of these complications, four required additional surgery - the two erosions underwent AUS removal, one hematoma required exploration, and the patient with pump migration had his pump location adjusted. The overall AUS in situ rate in our cohort was 90.9% (20/22). History of prior radiation was not associated with AUS complications (p = 0.23). CONCLUSIONS AUS implantation can be performed in patients after two urethral transecting surgeries with an in situ rate of 90.9% at medium term follow up. Surgeons appear to prefer transcorporal placement in these scenarios. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e621 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jonathan Wingate More articles by this author Jeremy Myers More articles by this author Gregory Murphy More articles by this author Nejd Alsikafi More articles by this author Bradley Erickson More articles by this author Benjamin Breyer More articles by this author Bryan Voelzke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD29-04 INCIDENCE OF STRESS INCONTINENCE FOLLOWING POSTERIOR URETHROPLASTY AMONG RADIATION-INDUCED POSTERIOR URETHRAL STENOSES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II1 Apr 2017PD29-04 INCIDENCE OF STRESS INCONTINENCE FOLLOWING POSTERIOR URETHROPLASTY AMONG RADIATION-INDUCED POSTERIOR URETHRAL STENOSES Paul H Chung, Paige Esposito, Hunter Wessells, and Bryan B Voelzke Paul H ChungPaul H Chung More articles by this author , Paige EspositoPaige Esposito More articles by this author , Hunter WessellsHunter Wessells More articles by this author , and Bryan B VoelzkeBryan B Voelzke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1356AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES No data exists regarding the frequency of de novo stress urinary incontinence (SUI) in patients with an intact bladder neck who undergo excision and primary anastomotic (EPA) urethroplasty for radiation-induced urethral stenoses (RIUS). We identified the risk for SUI in RIUS patients with urethral stenoses between the membranous and mid-prostatic urethra. A secondary aim was to compare the incidence of SIU to patients with pelvic fracture urethral injuries (PFUI) following EPA urethroplasty. METHODS Patients who underwent successful EPA urethroplasty between 2008-2016 were reviewed. Only patients with a history of RIUS from prostate cancer or PFUI from blunt trauma were included. Patients at risk for developing SUI were excluded: open bladder neck on pre-operative fluoroscopy, bladder neck dissection during urethroplasty, prior bladder neck surgery (robotic, open, or endoscopic prostate surgery), urinary tract fistula, failed prior posterior urethroplasty, or SUI at baseline. SUI was defined by patient reported outcome measures and subjective complaints. Cystoscopy was performed to assess for anatomic success of urethroplasty. RESULTS Of the total 135 patients, 47% (36/77) of RIUS and 57% (33/58) of PFUI met the inclusion criteria. Among the RIUS cohort, mean follow up was 18 months and mean stricture length was 2.5 cm. Radiated urethral strictures involved the prostatic urethra in 67% (24/36), and surgical scar excision beyond the prostate apex was necessary in 56% (20/36). The overall incidence of de novo SUI among RIUS patients was 33% (12/36). Among those with de novo SUI, 75% (9/12) had prostatic urethral involvement and 50% (6/12) required dissection beyond the prostate apex. For RIUS patients, 2/12 (17%) underwent artificial urinary sphincter (AUS) placement while the remaining 10 patients reported a mean use of 2.3 pads per day (range 1-4). SUI following urethroplasty in PFUI patients was less common (12%, 4/33). One PFUI patient underwent AUS placement while the remaining 3 patients did not report use of pads. CONCLUSIONS Among RIUS patients with an intact bladder neck, SUI is common following excision of scar in the prostatic urethra, affecting a third of the patients. SUI is less common among PFUI patients, likely related to more a reliable stricture location at the bulbomembranous urethra. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e573 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Paul H Chung More articles by this author Paige Esposito More articles by this author Hunter Wessells More articles by this author Bryan B Voelzke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP46-04 HIGH PREVALENCE OF LOW SERUM TESTOSTERONE LEVELS AMONG ARTIFICIAL URINARY SPHINCTER PATIENTS

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy1 Apr 2017MP46-04 HIGH PREVALENCE OF LOW SERUM TESTOSTERONE LEVELS AMONG ARTIFICIAL URINARY SPHINCTER PATIENTS Travis Pagliara, Jeremy Scott, Boyd Viers, and Allen Morey Travis PagliaraTravis Pagliara More articles by this author , Jeremy ScottJeremy Scott More articles by this author , Boyd ViersBoyd Viers More articles by this author , and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1443AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recent evidence suggests that low serum testosterone (LST) may be associated with artificial urinary sphincter (AUS) cuff erosion. While the role of androgen replacement therapy is currently poorly defined among men receiving AUS placement surgery, the prevalence of LST among AUS patients is also unknown. We report the prevalence of LST relative to other associated risk factors among a large group of men undergoing AUS placement at a single high-volume institution. METHODS We retrospectively reviewed all men undergoing AUS procedures by a single surgeon from 2012-2016 to identify those men with pretreatment total serum testosterone levels. LST was defined as less than 280 ng/dL. All low serum testosterone levels underwent confirmatory testing. Clinical characteristics were compared between men with and without LST levels. RESULTS Among 85 AUS patients having pretreatment serum testosterone levels available for review, nearly half (41/85, 48%) met criteria for LST. After excluding those patients on androgen deprivation therapy (N=13), 28 of 72 (29%) had primary LST levels. AUS cuff erosion was more common among men with LST levels (38% vs 9%, p=0.01). The median total serum testosterone level among men undergoing AUS placement was 331ng/dL (IQR 192-447). Testosterone levels were drawn at a median 1.5 months (IQR 0-5.8) before AUS surgery. Men with LST levels were more likely to have a history of coronary artery disease (88% vs 30%, p=0.002) and a trend in greater body mass index (mean 31 vs 28, p=0.09) relative to those with normal serum testosterone levels. There was no difference in patient age, history of radiation, time from cancer therapy, erectile dysfunction, or other comorbidities. CONCLUSIONS Approximately one-half of men with stress urinary incontinence undergoing AUS placement present with LST levels. Accordingly, given the association between LST and AUS cuff erosion, men with risk factors for LST should undergo further evaluation prior to SUI surgery. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e620 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Travis Pagliara More articles by this author Jeremy Scott More articles by this author Boyd Viers More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V5-07 PERINEAL ARTIFICIAL URINARY SPHINCTER (AUS) WITH HIGH SUBMUSCULAR (HSM) PLACEMENT OF PRESSURE REGULATING BALLOON (PRB)

You have accessJournal of UrologyBPH and Voiding Dysfunction1 Apr 2017V5-07 PERINEAL ARTIFICIAL URINARY SPHINCTER (AUS) WITH HIGH SUBMUSCULAR (HSM) PLACEMENT OF PRESSURE REGULATING BALLOON (PRB) Billy Cordon and Allen Morey Billy CordonBilly Cordon More articles by this author and Allen MoreyAllen Morey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1412AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In patients undergoing Artificial Urinary Sphincter (AUS) placement, with a history of major pelvic surgery, avoidance of the Space of Retzius with traditional placement of the Pressure Regulating Balloon (PRB) may be beneficial. This video presents perineal AUS placement with high submuscular placement (HSM) of the PRB. METHODS A perineal incision provides excellent exposure of the bulbar urethra for proximal bulbar urethral cuff placement. Via a separate 2cm high scrotal incision the external inguinal ring is identified. A pediatric Deaver is placed within the superficial ring and blunt finger dissection used above the transversalis fascia develops a space below the rectus that accommodates the PRB. Using one's index finger the PRB is then easily placed in the HSM space without any additional instrumentation. Finally through this same incision a subdartos pouch is created for pump placement. The AUS is cycled and deactivated and the wound is closed in multiple layers. RESULTS There is no difference in revision rates between HSM PRB placement versus Space of Retzius placement. CONCLUSIONS HSM placement of the PRB at the time of AUS implantation avoids the Space of Retzius with associated potential bladder, bowel, or vascular injury and/or complications. HSM placement avoids peritoneal placement post-robotic prostatectomy. HSM placement is safe, effective, can easily be learned and implemented, and may be used with concomitant IPP placement. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e601 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Billy Cordon More articles by this author Allen Morey More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V1-02 ROBOT ASSISTED LAPAROSCOPIC PLACEMENT OF BLADDER NECK ARTIFICIAL URINARY SPHINCTER.

You have accessJournal of UrologyReconstruction Lower Tract (I)1 Apr 2017V1-02 ROBOT ASSISTED LAPAROSCOPIC PLACEMENT OF BLADDER NECK ARTIFICIAL URINARY SPHINCTER. John Schomburg, Mya Levy, and Sean Elliott John SchomburgJohn Schomburg More articles by this author , Mya LevyMya Levy More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.234AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present our technique of robot assisted laparoscopic placement of bladder neck artificial urethral sphincter (Robot-AUS). Compared to the open approach, the robot assisted laparoscopic technique allows for excellent visualization of the posterior dissection. METHODS Our patient is a 49-year-old male with history of L1 spinal cord injury with stress urinary incontinence between intermittent catheterizations. Using the Da Vinci Xi surgical system, the bladder neck was circumferentially dissected. A 9cm AMS 800 AUS cuff was placed around the bladder neck after confirming appropriate sizing with simultaneous cystourethroscopy. The pressure-regulating balloon was placed in the recreated space of Retzius. Tubing connections were created extracorporeally at the right lower quadrant port site; the pump was passed subcutaneously from this port site to the right hemi-scrotum. RESULTS The patient was discharged home on post-operative day #1, performing intermittent catheterization through a deactivated cuff. His stress urinary incontinence persisted until his device was activated at post-op week 4. Six months post-operatively, he is dry without the use of pads and is able to easily pass his catheter after cycling the AUS. CONCLUSIONS Bladder neck artificial urinary sphincter is effectively placed in a minimally invasive fashion with a robot assisted laparoscopic approach; the approach provides excellent visualization of the posterior dissection. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e68 Advertisement Copyright & Permissions© 2017MetricsAuthor Information John Schomburg More articles by this author Mya Levy More articles by this author Sean Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD29-02 OUTCOMES OF URETHROPLASTY TO TREAT STRICTURES ARISING FROM ARTIFICIAL URINARY SPHINCTER (AUS) EROSIONS AND RATES OF SUBSEQUENT AUS REIMPLANTATION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II1 Apr 2017PD29-02 OUTCOMES OF URETHROPLASTY TO TREAT STRICTURES ARISING FROM ARTIFICIAL URINARY SPHINCTER (AUS) EROSIONS AND RATES OF SUBSEQUENT AUS REIMPLANTATION Sorena Keihani, Jason C. Chandrapal, Andrew C. Peterson, Joshua A. Broghammer, Nathan Chertack, Sean P. Elliott, Keith F. Rourke, Nejd F. Alsikafi, Jill C. Buckley, Thomas G. Smith, Bryan B. Voelzke, Lee C. Zhao, William O. Brant, and Jeremy B. Myers Sorena KeihaniSorena Keihani More articles by this author , Jason C. ChandrapalJason C. Chandrapal More articles by this author , Andrew C. PetersonAndrew C. Peterson More articles by this author , Joshua A. BroghammerJoshua A. Broghammer More articles by this author , Nathan ChertackNathan Chertack More articles by this author , Sean P. ElliottSean P. Elliott More articles by this author , Keith F. RourkeKeith F. Rourke More articles by this author , Nejd F. AlsikafiNejd F. Alsikafi More articles by this author , Jill C. BuckleyJill C. Buckley More articles by this author , Thomas G. SmithThomas G. Smith More articles by this author , Bryan B. VoelzkeBryan B. Voelzke More articles by this author , Lee C. ZhaoLee C. Zhao More articles by this author , William O. BrantWilliam O. Brant More articles by this author , and Jeremy B. MyersJeremy B. Myers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1354AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urethral stricture can result after AUS cuff erosion. There is limited data describing the success of urethroplasty and the rate of AUS reimplantation in these patients. We hypothesized that urethroplasty and AUS reimplantation was feasible in most men. METHODS From 2009-2016, we identified patients from Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database, as well as the Cleveland Clinic, Duke University, and University of Alberta. We included patients with a history of urethral stricture arising from AUS erosion who underwent urethroplasty ± subsequent AUS reimplantation. Information was gathered on demographics, initial AUS placement, stricture and urethroplasty specifics, AUS reimplantation, and outcomes. In results analysis we included men with follow up of > 3 months. RESULTS 31 men were identified. Mean age was 73.2 y (SD: 7.0). Radical prostatectomy was the etiology of incontinence in 87%, with 33% having radiation therapy. Prior to urethroplasty, patients had a median of 3 (range: 2-9) urethral operations. Mean duration of initial AUS was 43.4 months (SD: 39.9, range: 1-144) prior to erosion. Mean stricture length was 1.7 cm (SD: 0.8, range 0.5-4.5) found within the bulbar urethra in all cases (9 proximal, 16 middle, 6 distal). Anastomotic (28) and buccal graft substitution (3) urethroplasty were performed. 3/28 patients who had a urethrogram post-operatively had contrast extravasation; all resolved with observation. Post-operative complications included: wound infection (3), and myocardial infarction (1). 29 men had follow up > 3 months. Follow up cystoscopy was performed in 28 patients at a median of 4.5 months (range 2-42) and showed no recurrences. Overall mean follow up was 28.2 months (SD: 16.2, range 6.5-71). Two men had stricture recurrence, but these occurred after AUS reimplantation and repeat erosion. In 27 men (87%), AUS was replaced at mean of 6.2 months (SD: 2.6, range 3-13) after urethroplasty, with either transcorporal placement (18) or standard technique (9). 25 men had follow-up > 3 months after AUS (mean 23.1 months, SD: 15.1, range 4-57); operative complications occurred in 11/25 patients (44%) and included: pump migration (2), sub-cuff atrophy (3), and erosion (6). The 19 men with AUS remaining reported ≤1 pad per day leakage. CONCLUSIONS In patients with urethral stricture after AUS erosion, urethroplasty is very successful and AUS reimplantation rates are high. However, AUS reimplantation after urethroplasty has a high erosion rate even in the short-term. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e572 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Sorena Keihani More articles by this author Jason C. Chandrapal More articles by this author Andrew C. Peterson More articles by this author Joshua A. Broghammer More articles by this author Nathan Chertack More articles by this author Sean P. Elliott More articles by this author Keith F. Rourke More articles by this author Nejd F. Alsikafi More articles by this author Jill C. Buckley More articles by this author Thomas G. Smith More articles by this author Bryan B. Voelzke More articles by this author Lee C. Zhao More articles by this author William O. Brant More articles by this author Jeremy B. Myers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Systematic Approach to the Evaluation and Management of the Failed Artificial Urinary Sphincter.

In men with post-prostatectomy incontinence, persistent or recurrent urinary leakage following artificial urinary sphincter placement is a frustrating complaint. Surgical failure can be classified as occurring early in the post-operative period vs. late-following a period of established continence-and should be managed according to the time course and severity of urinary leakage. We present a systematic approach for the evaluation and treatment of the failed artificial urinary sphincter. After considering the patient's individualized treatment goals and impact on quality of life, the clinician can more appropriately advise patients on a management strategy for their recurrent or persistent urinary incontinence following artificial urinary sphincter placement.

008 Transcorporal Artificial Urinary Sphincter Placement in Patients with Prior Inflatable Penile Prosthesis Utilizing 6-ply Acellular Graft: A Novel Technique with Resolution of Climacturia

008 Transcorporal Artificial Urinary Sphincter Placement in Patients with Prior Inflatable Penile Prosthesis Utilizing 6-ply Acellular Graft: A Novel Technique with Resolution of Climacturia