Artificial Urinary Sphincter Placement Research Articles

Synchronous placement of penile prosthesis and artificial urinary sphincter: a systematic review with cumulative analysis

Radical prostatectomy is a life saving treatment for localised prostate cancer but may come with debilitating consequences, such as incontinence and erectile dysfunction. Penile Prosthesis Implants (PPI) are the gold standard of treatment for patients with refractory Erectile Dysfunction (ED) resistant to conservative management. Likewise, an Artificial Urinary Sphincter (AUS) is gold standard for those with refractory severe urinary incontinence. This systematic review with cumulative analysis assesses the efficacy and complications rates for synchronous placement of PPI and AUS as a single-stage procedure. Systematic literature review was performed using the US National Library of Medicine's life science database (MEDLINE) (2000 to May 2021), EMBASE (2000 to May 2021), Cochrane Central Register of Controlled Trials-CENTRAL (in the Cochrane Library-2021), Google Scholar and Individual journals. 5 studies were included for analysis, with total of 112 patients. The overall revision/replacement rate was 12.5% (n = 14). The revision rate for PPI alone was 4.5% (n = 5), for AUS was 6.5% (n = 9). The overall removal rate was 5.4% (n = 6). Removal rate for PPI alone was 0.9% (n = 1), for AUS was 1.4% (n = 3). There were only 2 case of dual prosthesis removal (1.4%). Our cumulative analysis has revealed that revision and removal rates for synchronous dual implants may be lower than previously believed. However, our review has highlighted the low quality of available data and stresses that more robust studies are required to validate the high satisfaction and low complication rates reported by small studies.

Changing Trends in Management Following Artificial Urinary Sphincter Surgery for Male Stress Urinary Incontinence: An Analysis of the National Surgical Quality Improvement Program Database

To characterize the safety and practice patterns of artificial urinary sphincter (AUS) placement on a population level. Increasingly AUS implantation has shifted to be an outpatient surgery; however, there is a lack of large-scale research evaluating factors associated with early (≤ 24 hours) versus late (>24 hours) discharges and complications in men following AUS placement. We utilized the National Surgical Quality Improvement Program (NSQIP) database to identify and compare factors and outcomes associated with each approach. NSQIP database was queried for men undergoing AUS placement between 2007 and 2016. Patients were classified as either early discharge (ED ≤ 24 hours) and late discharge (LD > 24 hours). Baseline demographics, operating time, and complications were compared between the 2 groups. Multivariate logistic regression evaluated factors associated with discharge timing and 30-day complications. A total of 1176 patients were identified and were classified as ED in 232 and LD in 944 patients. Operative time was shorter in ED (83 minutes) compared to LD (95 minutes, P < .001). Hypertension was more prevalent among LD patients (60.3% vs 69.1% for ED and LD respectively, P < .001). The 30-day complication rate was similar in both groups (ED: 4.3% vs LD: 3.4%, P = .498). Multivariable analysis revealed that surgery after 2012 was associated with ED (OR = 3.66, P < .001). At the national level, there are no differences in postoperative morbidity between early and late discharges. There is a trend toward more ED, specifically after 2012. A prospective study on the feasibility and safety of outpatient AUS is needed.

Single perineal incision for artificial urinary sphincter: analysis of technique, outcomes, and experience.

BackgroundTo describe a large series of male patients who underwent a minimally invasive single perineal incision artificial urinary sphincter (AUS) placement in patients with stress urinary incontinence.MethodsA retrospective cohort study was performed with data collected from men undergoing AUS placement by a single high-volume surgeon over a 12-year period (2005 to 2017). Demographic and outcomes data related to AUS placement were recorded from electronic medical records, which included subjective histories and questionnaires. Institutional ethics approval was received.ResultsA total of 145 AUS were placed over the study period. Of these, 84 were performed through a single perineal incision for both device and reservoir placement. Almost all (n=81, 96%) reported pre-operative incontinence of more than 3 pads per day. Postoperatively, 75% were satisfied with their continence, with 21 (25%) complaining of recurrent incontinence. A total of 5 (6%) patients developed a post-operative infection, 10 (12%) had device erosion and 11 (13%) had device malfunction, but only 3 (4%) had reservoir dysfunction. A total of 24 (29%) patients required revision of their device at median of 20 months (IQR, 6–32.5 months).ConclusionsSingle perineal incision is a feasible, safe, and potentially superior approach for AUS placement and warrants consideration as an accepted approach due to its more rapid surgical times, lower morbidity related to a single incision with minimal fascial defect, and favorable complication rates.

Factors effecting the outcomes of artificial urinary sphincter placement: a single-center study

Objectives: To evaluate the patients who underwent artificial urinary sphincter (AUS) placement and report outcomes of the procedure.Methods: From March 2008 to February 2017, the data of patients who have undergone AUS placement were evaluated retrospectively. Age, body-mass index (BMI), comorbidities, education level, previous radiotherapy (RT) history of the patients were recorded. Cognitive status was examined using the Mini Mental Status Examination test (MMSE). International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) was completed pre- and post-operatively. Quality of life and satisfaction of patients were evaluated using Patient Global Impression of Improvement (PGI-I) scale. To analyze factors effecting success and revision rates, patients were grouped according to age, BMI, comorbidities, smoking habbit, previous RT history and etiology of incontinence. Treatment success was defined as requirement of ≤ 1/day.Results: A total of 61 patients were included in the study and each were cognitive intact (MMSE &amp;gt; 25). ICIQ-SF significantly improved in postoperative period (p &amp;lt; 0.001). PGI-I median score was 1 (1-4) in postoperative period. Success rate was 96.7% (n = 59) and 47 (77%) patients were complete dry. Revision requirement occured in 10 (16.4%) patients. When patient groups were compared according to the success and revision rates; presence of BMI &amp;gt; 25 kg/m2 was the only significant factor associated with revision requirement and there was no significant factor associated with success status.Conclusion: AUS placement is a safe and effective method in the treatment of post-prostatectomy incontinence (PPI). Success and revision rates are similar regardless the etiology of PPI. Cognitive functions of patients may be crucial in the postoperative satisfaction status.

Overactive bladder and urgency urinary incontinence in men undergoing artificial urinary sphincter placement.

To assess persistent and de novo rates of overactive bladder (OAB) and urgency urinary incontinence (UUI) in patients with incontinence after prostate treatment (IPT) focusing on differences between surgical intervention vs radiation. We performed a retrospective review of 79 patients who underwent primary artificial urinary sphincter (AUS) placement and activation from a single surgeon between February 2012 and November 2017. Four patients with neurogenic bladder were excluded and two with insufficient follow-up. The primary outcome measures were persistent OAB, persistent UUI, and pad usage before and after AUS placement. After activation of the AUS, 67% of non-radiated patients had resolution of urgency incontinence vs only 31% of the radiated patients (P = .096). After activation of the AUS, resolution of OAB symptoms was more common in the non-radiated group. We found 53% of the non-radiated group vs only 22% of the radiated group had resolution of their urinary urgency (P = .045). Previous history of radiation was a risk factor for OAB after implantation of AUS (odds ratio [OR], 3.63; P = .010). Postoperative oral medical pharmacotherapy for OAB was higher in those with previous radiation vs those without prior radiation (66.7% vs 25.7%, P = .001). A history of OAB or UUI did not affect social continence after AUS placement. Radiation is a risk for continued OAB after AUS activation. Appropriate counseling is necessary pre- and postoperatively to manage patient expectations and provide additional medical therapies. Mixed urinary incontinence or OAB symptoms should not exclude patients from undergoing AUS placement.

Concurrent Penile Prosthesis and Artificial Urinary Sphincter versus Penile Prosthesis and Male Sling: A National Multi-Institutional Analysis of National Surgical Quality Improvement Program Database Comparing Postoperative Morbidity.

PurposeWe aimed to assess the 30-day morbidity in patients undergoing combined insertion of penile prosthesis (PP) and artificial urinary sphincter (AUS) vs. PP and male sling (MS).Materials and MethodsThe National Surgical Quality Improvement Program database was queried to identify patients who underwent placement of AUS or MS combined with PP. Patient demographics, postoperative morbidity including complications, readmission and reoperation rates were recorded. Student t-test and chi-square or Fischer's exact test were used as appropriate.ResultsForty-one patients met selection criteria between 2010 and 2016. Overall, 26 patients received PP and AUS vs. 15 that received PP and MS. Average age was similar in both groups (64.8±6.6 years vs. 62.3±6.3 years, p=0.254). Diabetes mellitus was more prevalent in PP+MS group compared to AUS+PP group (46.7% vs. 11.5%, p=0.022). Average length of stay was higher in PP+AUS group compared to PP+MS group (2.2±0.6 days vs. 1.8±0.4 days, p=0.017). Postoperative morbidity was reported in four patients in PP+AUS group. No reported complications in PP+MS group. In PP+AUS group, complications included one patient who developed urinary tract infection, one developed surgical site infection, readmission in two for postoperative infection, and one return to the operating room. No reported prosthesis explantation or revision in either groups.ConclusionsOur results showed that 30-day morbidity was recorded in the PP+AUS group and none in the PP+MS group. The complication and readmission rates remain comparable to the previous reports in both groups.

MP40-08 PREDICTORS AND PERIOPERATIVE MORBIDITY ASSOCIATED WITH EARLY VERSUS LATE DISCHARGE FOLLOWING ARTIFICIAL URINARY SPHINCTER PLACEMENT

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I (MP40)1 Apr 2020MP40-08 PREDICTORS AND PERIOPERATIVE MORBIDITY ASSOCIATED WITH EARLY VERSUS LATE DISCHARGE FOLLOWING ARTIFICIAL URINARY SPHINCTER PLACEMENT Benjamin Schurhamer*, Mahmoud I. Khalil, Naleen Raj Bhandari, Bruno Machado, Sherif Mourad, Rodney Davis, and Omer Raheem Benjamin Schurhamer*Benjamin Schurhamer* More articles by this author , Mahmoud I. KhalilMahmoud I. Khalil More articles by this author , Naleen Raj BhandariNaleen Raj Bhandari More articles by this author , Bruno MachadoBruno Machado More articles by this author , Sherif MouradSherif Mourad More articles by this author , Rodney DavisRodney Davis More articles by this author , and Omer RaheemOmer Raheem More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000889.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The artificial urinary sphincter (AUS) is currently the gold standard management option for men with post-prostatectomy incontinence. However, nationwide data on discharge patterns after surgery and complication rates is sparse. We investigated factors that were associated with a likelihood of early discharge (≤1 day) versus late (>1 day) following AUS placement. We also compared 30-day complications between the two groups. METHODS: The National Surgical Quality Improvement Program database (NSQIP) was queried from 2005-2016 to identify male patients who underwent AUS placement with same day discharge and those who stayed >1 day. Patient demographics and complications within 30 days of receiving AUS were recorded and compared between the two groups using student t or Chi-square tests. Multivariable logistic regressions were used to determine factors associated with “early discharge” (vs. late) and the likelihood of having each 30-day complication among those who were discharged early. RESULTS: Of 1,176 males who underwent AUS placement, 232 (19.7%) were discharged early and 944 (80.3%) were discharged late. The majority of patient in both groups were ≥65 years old (76.5%) and with ASA Class III (52.5%). Unadjusted analysis suggested that patients in both groups differed significantly on race (p<0.001), year of surgery (p<0.001), and operating time (p<0.001). A trend towards early discharge was observed across the studied period (Figure 1). Patients who received AUS after the year 2012 were more likely to be discharged early (OR=3.66 [2.24, 5.81]). However, increased operating time (10-minute increment) were associated with a lower likelihood of early discharge (OR=0.92 [0.86, 0.95]). On comparing 30-day complications (4.3% vs. 3.4%, p=0.498), readmission (4% vs. 3.8%, p=0.888) and reoperation rates (3% vs. 2.5%, p=0.65) between early vs. late discharged patients, we did not find statistically significant difference. Overall, removal of the AUS (40%) and superficial wound infection (13.8%) were the most prevalent causes of reoperation and readmission respectively. CONCLUSIONS: Early discharge following AUS placement does not seem to increase the perioperative morbidity. Shorter operating time and year of surgery after 2011 were significantly associated with “early discharge”. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e588-e588 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benjamin Schurhamer* More articles by this author Mahmoud I. Khalil More articles by this author Naleen Raj Bhandari More articles by this author Bruno Machado More articles by this author Sherif Mourad More articles by this author Rodney Davis More articles by this author Omer Raheem More articles by this author Expand All Advertisement PDF downloadLoading ...

MP60-01 ANATOMICAL CHARACTERISTICS OF ARTIFICIAL URINARY SPHINCTER CUFF EROSIONS ARE SIMILAR FOR TRANSCORPORAL AND STANDARD APPROACH: WHITHER THE PROTECTIVE EFFECT?

INTRODUCTION AND OBJECTIVE:Although transcorporal (TC) placement of artificial urinary sphincter (AUS) has traditionally been used as a protective strategy in patients at risk for urethral erosion,...

MP40-13 ECTOPIC RESERVOIR PLACEMENT IN THE LATERAL RETROPERITONEUM DURING ARTIFICIAL URINARY SPHINCTER PLACEMENT: A REVIEW OF 729 CASES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I (MP40)1 Apr 2020MP40-13 ECTOPIC RESERVOIR PLACEMENT IN THE LATERAL RETROPERITONEUM DURING ARTIFICIAL URINARY SPHINCTER PLACEMENT: A REVIEW OF 729 CASES Jeffrey Loh-Doyle*, Azadeh Nazemi, Akbar Ashrafi, Eli Thompson, Mukul Patil, David Ginsberg, and Stuart Boyd Jeffrey Loh-Doyle*Jeffrey Loh-Doyle* More articles by this author , Azadeh NazemiAzadeh Nazemi More articles by this author , Akbar AshrafiAkbar Ashrafi More articles by this author , Eli ThompsonEli Thompson More articles by this author , Mukul PatilMukul Patil More articles by this author , David GinsbergDavid Ginsberg More articles by this author , and Stuart BoydStuart Boyd More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000889.013AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The artificial urinary sphincter (AUS) remains the gold standard treatment for male stress urinary incontinence (SUI).Conventionally, the pressure regulating balloon (PRB) is placed in the retropubic space. After extirpative pelvic surgery or radiotherapy, this space can be scarred and placing the reservoir in this space can lead to complications during initial placement and subsequent extraction, including significant vascular injury. To prevent this, several strategies for placing prosthetic reservoirs in alternate locations have been devised. We describe our technique that facilitates safe placement, simplifies subsequent interrogation and exchange, and avoids the reservoir-related complications associated with other locations. METHODS: We retrospectively reviewed an institutional review board approved prosthetic database of male patients that underwent placement of an AUS (AMS 800TM, Boston Scientific, Marlborough, MA) from 2005 to 2019. Patients with follow-up duration less than 6 months were excluded. All patients underwent ectopic placement of the PRB in the lateral retroperitoneum. The medical record of each patient was then specifically queried for reservoir-related complications including bladder and bowel injury, erosion into adjacent structures, vascular injury, herniation, palpability, leak, and tubing torsion during initial implantation and subsequent follow-up. RESULTS: From 2005-2019, 729 male patients with stress incontinence underwent implantation of an AUS. A total of 11 (1.5%) PRB-related complications were identified. No injuries to bowel or major vasculature occurred during placement or removal of the reservoir during subsequent revision. There were no instances of erosion into adjacent structures. Two patients had herniation of the reservoir into the subcutaneous space. 3 other patients were noted to have a palpable reservoir. There were no cases of mechanical failure attributed to torsion or twisting of tubing. 7 patients experienced failure of the device due to an identified leak that in the PRB. All patients underwent successful reservoir replacement without complication. One patient developed an infection of the PRB. The patient underwent immediate salvage removal and replacement of the entire device. CONCLUSIONS: Ectopic placement of the PRB in the lateral retroperitoneum during AUS placement is quick, safe, and avoids reservoir-related complications during implantation and future exchange. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e591-e591 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Loh-Doyle* More articles by this author Azadeh Nazemi More articles by this author Akbar Ashrafi More articles by this author Eli Thompson More articles by this author Mukul Patil More articles by this author David Ginsberg More articles by this author Stuart Boyd More articles by this author Expand All Advertisement PDF downloadLoading ...

PD20-02 SAFETY OF SYNCHRONOUS PENILE PROSTHESIS AND ARTIFICIAL URINARY SPHINCTER IMPLANTATION

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy I (PD20)1 Apr 2020PD20-02 SAFETY OF SYNCHRONOUS PENILE PROSTHESIS AND ARTIFICIAL URINARY SPHINCTER IMPLANTATION Eric Kirshenbaum*, Parth Patel, Marc Nelson, Petar Bajic, Kevin McVary, Larissa Bresler, Ahmer Farooq, and Christopher Gonzalez Eric Kirshenbaum*Eric Kirshenbaum* More articles by this author , Parth PatelParth Patel More articles by this author , Marc NelsonMarc Nelson More articles by this author , Petar BajicPetar Bajic More articles by this author , Kevin McVaryKevin McVary More articles by this author , Larissa BreslerLarissa Bresler More articles by this author , Ahmer FarooqAhmer Farooq More articles by this author , and Christopher GonzalezChristopher Gonzalez More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000870.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Synchronous penile prosthesis (PP) and artificial urinary sphincter (AUS) implantation for the treatment of erectile dysfunction (ED) and stress urinary incontinence allows for avoidance of a secondary surgical procedure, however the safety of this approach has been challenged by existing literature. We sought to determine whether synchronous PP and AUS implantation increases the risk of intraoperative, perioperative, or postoperative complications. METHODS: The Healthcare Cost and Utilization Project State Inpatient and Ambulatory Databases for California (2007-2011) and Florida (2009-2014) were utilized. Patients were identified as having undergone AUS, IPP or combined AUS/IPP by ICD-9 and CPT codes. Baseline patient characteristics were assessed. We compared outcomes in patients undergoing combination AUS/PP versus those undergoing PP or AUS alone. Outcomes of interest include 90-day readmissions, 90-day ER visits, surgical complications, and 90-day device complications. RESULTS: A total of 20,593 patients were identified who underwent PP or AUS, 245 of whom underwent combined PP and AUS. Patients undergoing prosthesis placement primarily had Medicare insurance and were Caucasian. Patients undergoing AUS placement alone were older (70.5 years), compared to IPP alone (65.7 years) or synchronous (67.2 years). Patients undergoing a synchronous procedure had higher 90-day readmission rates compared to PP or AUS alone (13.9% vs 7.2%, p<0.001). Additionally, patients undergoing a synchronous procedure had higher rates of device complications within 90 days (6.1% vs 3.4%, p=0.021). Lastly, patients undergoing a combined PP and AUS procedure were more likely to have minor/moderate complications (8.89% vs 2.35%, p<0.001). No significant difference was seen in the rate of ER visits within 90 days. CONCLUSIONS: Synchronous PP and AUS implantation is feasible, but is associated with higher readmission rates, 90-day device complications and surgical complications. Caution should be considered in this higher risk population. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e447-e447 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eric Kirshenbaum* More articles by this author Parth Patel More articles by this author Marc Nelson More articles by this author Petar Bajic More articles by this author Kevin McVary More articles by this author Larissa Bresler More articles by this author Ahmer Farooq More articles by this author Christopher Gonzalez More articles by this author Expand All Advertisement PDF downloadLoading ...

MP40-12 USE OF ISOTONIC CONTRAST SOLUTION IN PRESSURE REGULATING BALLOON DOES NOT IMPACT ARTIFICIAL URINARY SPHINCTER LONGEVITY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy I (MP40)1 Apr 2020MP40-12 USE OF ISOTONIC CONTRAST SOLUTION IN PRESSURE REGULATING BALLOON DOES NOT IMPACT ARTIFICIAL URINARY SPHINCTER LONGEVITY Brian Inouye*, William Boysen, and Andrew Peterson Brian Inouye*Brian Inouye* More articles by this author , William BoysenWilliam Boysen More articles by this author , and Andrew PetersonAndrew Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000889.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Artificial urinary sphincter (AUS) is the gold standard for treatment of male stress urinary incontinence. The device can be filled with normal saline (NS) or isotonic contrast solution. Contrast can be useful for trouble shooting an AUS failure, to assess for fluid leak or sub-cuff atrophy. Many surgeons are hesitant to use contrast in the device due to concerns about the impact on device malfunction and longevity, but no studies have addressed this issue. We used industry data to identify differences in outcomes between NS and contrast-filled AUS. METHODS: Each AUS placement requires the submission of a patient information form that is sent to the manufacturer in order to track outcomes. This includes details of device preparation and the filling fluid. All patients in the industry database (Boston Scientific) from 2001 to 2016 were included. Groups were divided into AUS filled with NS and AUS filled with contrast. Patient demographics were recorded. Longevity of the device was defined as time to the need for reoperation (device removal, revision, or replacement). The groups were compared using t-test and chi-square test. A Kaplan Meier curve was created to compare device survival between AUS with filled NS versus contrast. RESULTS: A total of 39,591 patients were included in the cohort, of which 39,363 (99.5%) were male. 34,920 (88.2%) devices were filled with NS while 4,671 (11.8%) were filled with contrast. The reoperation rate overall was 16.1%, with no difference between groups (15.8% NS versus 18.1% contrast). The rate of fluid loss and device malfunction precipitating device removal did not differ between the groups (3.3% NS vs 4.1% contrast; 0.8% NS vs 0.9% contrast). The infection rate was similar between groups (1.9% NS vs 2.7% contrast). The mean time to reoperation overall was 3.9 years (± 3.4), and was significantly longer in the contrast filled cohort (3.8 ± 3.3 years NS vs 5.1 ± 3.9 years contrast, p<0.01). On Kaplan Meier analysis, the time to reoperation was longer in the contrast filled cohort (Figure 1). CONCLUSIONS: The use of contrast in the AUS did not change rates of device malfunction or fluid loss, and devices filled with contrast lasted longer than those filled with NS. We find that contrast in the device is useful for troubleshooting when a patient returns with recurrent incontinence, and should be considered by AUS implanters since this practice does not impact outcomes. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e590-e590 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Inouye* More articles by this author William Boysen More articles by this author Andrew Peterson More articles by this author Expand All Advertisement PDF downloadLoading ...

Pressure Regulating Balloon Herniation: A Correctable Cause of Artificial Urinary Sphincter Malfunction

ObjectiveTo report our experience with isolated pressure regulating balloon (PRB) replacement for artificial urinary sphincter (AUS) malfunction in the setting of PRB herniation. MethodsA retrospective review of our large single-surgeon male AUS database was completed. We analyzed men with herniated PRBs palpable in the groin within an otherwise intact system. Patients with evidence of AUS fluid loss were excluded. PRBs were replaced in a submuscular location through a lower abdominal incision. Continence was defined as requiring ≤1 pad per day. Cystoscopic improvement of sphincter coaptation was confirmed intraoperatively. ResultsOf the 725 patients who underwent AUS surgery between 2011 and 2019, we identified 23 (3.2%) with PRB herniation and persistent or bothersome stress urinary incontinence who underwent isolated PRB replacement (median age 72 years, interquartile range 66-80). Four of the 23 patients were excluded from the analysis for subsequent explant unrelated to PRB replacement. At a mean follow-up of 21.7 months (range 2-99 months), 94.7% of patients (18/19) noted significant improvement in their stress urinary incontinence, and 78.9% of patients (15/19) achieved continence. Median time between AUS placement and PRB revision was 13 months (interquartile range 6-34 months). ConclusionPRB replacement appears to be a safe and effective salvage therapy for AUS patients with PRB herniation and persistent incontinence without mechanical failure. Intraoperative cystoscopic confirmation of enhanced sphincter coaptation appears to be a reliable predictor of treatment success.

Long-term device survival and quality of life outcomes following artificial urinary sphincter placement.

Artificial urinary sphincter (AUS) placement is the standard for treatment of severe male stress urinary incontinence (SUI). While there is evidence to suggest satisfactory device survival, there is a paucity of data addressing long-term quality of life outcomes. We identified patients who underwent primary AUS placement from 1983 to 2016. We assessed rates of secondary surgery (overall, device infection/erosion, urethral atrophy, malfunction) and factors associated with these endpoints. Quality of life was evaluated by pad usage and Patient Global Impression of Improvement (PGI-I) at various time points from primary surgery. Follow-up was obtained in clinic or by phoned/mailed correspondence. During the study time frame, 1,154 patients were eligible and included in the analysis. Patients had a median age of 70 years (IQR, 65-75 years) and median follow up of 5.4 years (IQR, 1.6-10.5 years). Overall device survival was 72% at 5 years, 56% at 10 years, 41% at 15 years, and 33% at 20 years. On univariate analysis, variables associated with need for secondary surgery were prior cryotherapy (HR 2.7; 95% CI, 1.6-4.6; P<0.01) or radiation therapy (HR 1.4; 95% CI, 1.1-1.7; P=0.01). On multivariable analysis, only cryotherapy remained significantly associated with this endpoint (HR 2.4; 95% CI, 1.3-4.2; P<0.01). While 36% and 23% of patients 5-10 years out from surgery and >10 years out from surgery, respectively, reported using a security pad or less per day, 78% and 81% of those patients, respectively, reported their PGI-I as at least "much better". AUS placement has excellent long-term outcomes, and is associated with sustained improvement in patient quality of life.

A pilot study of autologous rectus fascial wrap at the time of artificial urinary sphincter placement in patients at risk of cuff erosion.

Cuff erosion is one of the dreaded complications of artificial urinary sphincter (AUS) implantation. Patients with a history of pelvic irradiation are at increased risk of erosion. To reduce the risk of erosion we describe a novel technique and report theresults in our initial series of patients. A prospective analysis of patients treated with AUS and rectus fascial wrap was performed. Inclusion criteria were severe urinary incontinence (UI) and previous pelvic radiation therapy (RTX). Primary outcomes were erosion rate, complications and continence rate. Secondary outcomes were patient satisfaction. Twenty-three patients were analysed. The median age was 70years. Nine (39%) had previous surgery; 6/9 had an Advance sling, 2/9 had a Virtue sling, and 1/9 had an AUS which had eroded. Median pad use was five pads/day IQR, (4-6). Median pad weight was 630ml, 6cm of fascia was harvested in every case, but cuff size varied. Complications occurred in 6/23 (26%): two patients with Clavien 1 and four patients with Clavien 3B (urinary retention requiring suprapubic catheter). In all cases, the retention resolved. One patient presented at 3months post-op with erosion (4.3% erosion rate). Median follow-up was 32months, IQR (24-37). Excluding the patient with erosion, 17/22 (77.3%) of patients achieved complete continence, while 5/22 (22.7%) achieved social continence. The autologous fascial wrap technique is efficient and easy to harvest, with comparable clinical outcomes to other techniques. The medium-term results have been encouraging, but longer-term follow up is needed.

023 The Impact Of Obesity On Perioperative Outcomes Following Placement Of Artificial Urinary Sphincter: National Multi-institutional Analysis of the National Surgical Quality Improvement Program (NSQIP) Database

Obesity and its associated comorbidities are risk factors for post-surgical complications. However, perioperative morbidity of Artificial Urinary Sphincter (AUS) placement in obese patients is poorly reported. We utilized the National Surgical Quality Improvement Program (NSQIP) database to evaluate the impact of obesity (BMI≥30) on the rates of “any complication” within 30 days of Placement of AUS. NSQIP database was queried to identify patients underwent AUS placement. Patients were classified into groups; Obese group (OG-BMI≥30) and Non obese group (NOG-BMI <30). Patient demographics, comorbidities, American Society of Anesthesiologists (ASA) classification, operating time (OPTIME), length of stay (LOS) and complication rate were recorded and compared between the two groups using Chi-square or t tests. Multivariable analysis was performed to determine the impact of obesity on development of “any complication” adjusting for age, gender, race and ASA class. A total of 1,216 patients were identified between Female Genital Self-image 7 and 2016. Of these patients, 510 were OG and 706 were NOG. In both groups, the most common age group was 65-74 years and the majority of patients were males (98.4%) and white (77.5%). Most patients of the OG (60.3%) were ASA class III while those of NOG (51.8%) were class I/II. Hypertension and diabetes were the most prevalent comorbidities in both groups (74.7% vs 61.8% and 29% vs 18.1% for OG and NOG respectively, P<0.001). Compared to NOG, the OG showed longer mean OPTIME (97.5 (SD=41.3) vs 91.6 (SD=39.1) minutes, p=0.012) and mean LOS (2.2 (SD=4.3) vs 2 (SD=1.4) days, p=0.25). Overall, the complication rate was similar in both groups (OG: 6.08% vs NOG: 6.37%, p=0.83). Comparing OG to NOG, the rates of specific complications were: superficial/deep wound infection and wound disruption in 1.37% vs 1.84%, p=0.52, readmission 2.83% vs 5.03%, p=0.08, return to operating room 2.55% vs 2.83%, p=0.73, urinary tract infection 0.78% vs 1.84%, p=0.12 and DVT/thrombophlebitis 0.98% vs 0%, p=0.013. In a multivariable analysis, obesity was not independently associated with increased postoperative complication rate (OR=0.98 (95%CI: 0.60-1.60).

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.

Re: The Impact of Frailty on Artificial Urinary Sphincter Placement and Removal Procedures.

Re: The Impact of Frailty on Artificial Urinary Sphincter Placement and Removal Procedures.

Re: Efficacy of Pressure Regulating Balloon Exchange in Men with Post Artificial Urinary Sphincter Persistent or Recurrent Stress Urinary Incontinence.

Abstract Objective To assess the efficacy of exchanging the pressure regulating balloon (PRB) to 71-80 cm H2O in patients with persistent or recurrent stress urinary incontinence (SUI) following artificial urinary sphincter (AUS) placement. Methods Patients with SUI following AUS placement who underwent PRB replacement between 2011 and 2017 in the absence of urethral cuff malfunction, atrophy, stricture, or erosion were reviewed. Primary outcomes included changes in pad per day (PPD), Incontinence Symptom Index score, and Incontinence Quality of Life (I-QOL). Secondary outcomes included rates of device erosion and all-cause explant or revision. Differences were compared between patients with and without erosion, explant, or revision. Kaplan Meier device survival analysis was performed. Results Twenty two patients (67 ± 9 years, body mass index of 30 ± 5 kg/m2) with a median follow up of 22.4 months (IQR 9.3, 47.3) were included. Incontinence etiology included radical prostatectomy in 60% of patients. After PRB exchange, the average number of PPD decreased from 4.0 ± 3.0 to 1.0 ± 1.6 PPD (P = .01), as did Incontinence Symptom Index scores (21.6 ± 8.5 vs 16.3 ± 8.1, P Conclusion PRB exchange can transiently alleviate persistent or recurrent post-AUS SUI in the absence of mechanical failure or urethral pathology. Caution is warranted in patients with prior radiation as this was a risk factor for urethral erosion. Although many patients may require device revision within 2 years, it can be a temporizing solution that avoids urethral manipulation and periprocedural device deactivation.

Re: Combined Placement of Artificial Urinary Sphincter and Inflatable Penile Prosthesis Does Not Increase Risk of Perioperative Complications or Impact Long-Term Device Survival

Re: Combined Placement of Artificial Urinary Sphincter and Inflatable Penile Prosthesis Does Not Increase Risk of Perioperative Complications or Impact Long-Term Device Survival