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The “fragile” urethra as a predictor of early artificial urinary sphincter erosion. Urology 2022; 169:233-236. [DOI: 10.1016/j.urology.2022.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/18/2022]
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Reoperative Anti-incontinence Surgery. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-021-00642-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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3
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Kuhlencord K, Dahlem R, Vetterlein MW, Abrams-Pompe RS, Maurer V, Meyer CP, Riechardt S, Fisch M, Ludwig TA, Marks P. Urethral Stricture Formation Following Cuff Erosion of AMS Artificial Urinary Sphincter Devices: Implication for a Less Invasive Explantation Approach. Front Surg 2022; 9:829517. [PMID: 35223979 PMCID: PMC8863868 DOI: 10.3389/fsurg.2022.829517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/06/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives The objective of this study is to describe a standardized less invasive approach in patients with artificial urinary sphincter (AUS) explantation due to cuff erosion and analyze success and urethral stricture rates out of a prospective database. Evidence regarding complication management is sparse with heterogenous results revealing high risk of urethral stricture formation despite simultaneous urethroplasty in case of AUS explantation. Patients and Methods Data of all patients undergoing AUS implantation due to stress urinary incontinence (SUI) in our tertiary center were prospectively collected from 2009 to 2015. In case of cuff erosion, AUS explantation was carried out in an institutional standardized strategy without urethroplasty, urethral preparation or mobilization nor urethrorrhaphy. Transurethral and suprapubic catheters were inserted for 3 weeks followed by radiography of the urethra. Further follow-up (FU) consisted of pad test, uroflowmetry, postvoiding residual urine (PVR), and radiography. Primary endpoint was urethral stricture rate. Results Out of 235 patients after AUS implantation, 24 (10.2%) experienced cuff erosion with consecutive explantation and were available for analysis. Within a median FU of 18.7 months after AUS explantation, 2 patients (8.3%) developed a urethral stricture. The remaining 22 patients showed a median Qmax of 17 ml/s without suspicion of urethral stricture. Median time to reimplantation was 4 months (IQR 3-4). Conclusion We observed a considerably low stricture formation and could not prove an indication for primary urethroplasty nor delay in salvage SUI treatment possibilities. Therefore, the presented standardized less invasive explantation strategy with consequent urinary diversion seems to be safe and effective and might be recommended in case of AUS cuff erosion.
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Affiliation(s)
- Katharina Kuhlencord
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte W. Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raisa S. Abrams-Pompe
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Maurer
- Department of Urology, Asklepios Medical Center Harburg, Hamburg, Germany
| | - Christian P. Meyer
- Department of Urology, Clinic Herfurt, University of Bochum, Herfurt, Germany
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim A. Ludwig
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Marks
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Phillip Marks
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Chertack NA, Caldwell KM, Joice GA, Kavoussi M, Dropkin BM, Ortiz NM, Baumgarten AS, Shakir NA, Sanders SC, Hudak SJ, Morey AF. Long-term lower urinary tract sequelae following AUS cuff erosion. Neurourol Urodyn 2021; 41:229-236. [PMID: 34559913 DOI: 10.1002/nau.24801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/26/2021] [Accepted: 09/02/2021] [Indexed: 11/10/2022]
Abstract
AIMS To examine the rate of lower urinary tract complications (LUTC) and urinary diversion (UD) after artificial urinary sphincter (AUS) explantation with the acute reconstruction of AUS cuff erosion defects. METHODS We performed a retrospective study of patients who underwent in-situ urethroplasty (ISU) for AUS cuff erosion from June 2007 to December 2020. Outcomes included LUTC (urethral stricture, diverticulum, fistula), AUS reimplantation, and UD. Defect size was prospectively estimated acutely and a subanalysis was performed to determine the impact of erosion severity (small erosions [<33% circumferential defect] and large erosions [≥33%]) on these outcomes. Kaplan-Meier curves were created to compare survival between the two groups. RESULTS A total of 40 patients underwent ISU for urethral cuff erosion. The median patient age was 76 years old with a median erosion circumference of 46%. The overall LUTC rate was 30% (12/40) with 35% (14/40) of patients requiring permanent UD. Secondary AUS placement occurred in 24/40 (60%) patients with 11/24 (46%) leading to repeat erosion. On subanalysis, small erosion was associated with improved LUTC-free and UD-free survival but not associated with AUS reimplantation. CONCLUSIONS Lower urinary tract complications are common after AUS cuff erosion and can lead to the need for permanent UD. Patients with larger erosions are more likely to undergo UD and reach this end-stage condition earlier compared to patients with small erosions.
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Affiliation(s)
- Nathan A Chertack
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kelly M Caldwell
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gregory A Joice
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mehraban Kavoussi
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin M Dropkin
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolas M Ortiz
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Adam S Baumgarten
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nabeel A Shakir
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah C Sanders
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven J Hudak
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Allen F Morey
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Redmond E, Tong S, Zemp L, Hoy N, Rourke KF. Improved artificial urinary sphincter outcomes using a transcorporal cuff placement in patients with a "fragile urethra". Can Urol Assoc J 2020; 14:E621-E624. [PMID: 32569562 PMCID: PMC7704083 DOI: 10.5489/cuaj.6431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The artificial urinary sphincter (AUS) is the most effective treatment option for incontinence after prostate cancer treatment. However, patients with a "fragile urethra" (defined as prior radiotherapy, previous failed AUS, or previous urethroplasty) are at increased risk of AUS failure. The aim of this study was to evaluate outcomes using standard and transcorporal cuff placement in this group of patients. METHODS A retrospective review was performed on patients with a fragile urethra who underwent AUS insertion between 2004 and 2017. The primary outcome was the need for AUS revision. Secondary outcome measures included change in pad use, patient satisfaction, continence (≤1 pad/day), improvement (≥50% change in pad use), and cuff erosion rates. RESULTS Seventy-six patients met the criteria for inclusion, with a mean age of 71.6 years and a mean followup of 37.9 months. A total of 42.1% had prior radiotherapy, 56.6% had a history of failed AUS, and 19.7% had previous urethroplasty. Transcorporal cuff placement was performed in 31.6% (n=24). These patients had lower revision (20.8% vs. 36.5%; p=0.05) and erosion rates (8.3% vs. 17.3%; p=0.09). There was no significant difference in functional outcomes such as continence (66.7% vs. 73.1%; p=0.57), improvement (100% vs. 90.4%;p=0.17), or satisfaction (82.6% vs. 69.4%; p=0.26), nor for 90-day complications (4.2% vs. 9.6%; p=0.41). CONCLUSIONS AUS insertion is an effective treatment option for post-prostatectomy incontinence in the setting of a fragile urethra. Transcorporal cuff placement in this subset of patients may be recommended, as it is associated with lower revision and erosion rates compared to standard cuff placement.
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Affiliation(s)
- Elaine Redmond
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Steven Tong
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Logan Zemp
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Nathan Hoy
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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The impact of surgical sequence on outcome rates of artificial urinary sphincter implantation: comparative effectiveness of primary, secondary and repeat implantation. World J Urol 2019; 38:2289-2294. [DOI: 10.1007/s00345-019-03029-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022] Open
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Impact of Radiation and Transcorporeal Artificial Sphincter Placement in Patients with Prior Urethral Cuff Erosion: Results from a Retrospective Multicenter Analysis. J Urol 2018; 200:1338-1343. [DOI: 10.1016/j.juro.2018.06.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2018] [Indexed: 11/13/2022]
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Is Removal of the Pressure-regulating Balloon Necessary After Artificial Urinary Sphincter Cuff Erosion? Urology 2018; 113:225-229. [DOI: 10.1016/j.urology.2017.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/27/2017] [Accepted: 11/02/2017] [Indexed: 11/22/2022]
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9
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Truzzi JC, Sacomani CR, Prezotti J, Silvinato A, Bernardo WM. Male urinary incontinence: Artificial sphincter. Rev Assoc Med Bras (1992) 2017; 63:664-680. [PMID: 28977103 DOI: 10.1590/1806-9282.63.08.664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 11/22/2022] Open
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Urethral Stricture Outcomes After Artificial Urinary Sphincter Cuff Erosion: Results From a Multicenter Retrospective Analysis. Urology 2017; 104:198-203. [DOI: 10.1016/j.urology.2017.01.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/19/2022]
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Agarwal DK, Linder BJ, Elliott DS. Artificial urinary sphincter urethral erosions: Temporal patterns, management, and incidence of preventable erosions. Indian J Urol 2017; 33:26-29. [PMID: 28197026 PMCID: PMC5264188 DOI: 10.4103/0970-1591.195758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction: The artificial urinary sphincter (AUS) is the mainstay of surgical treatment for male stress urinary incontinence. Although urethral erosions are a known complication, their temporal distribution and optimal management have not been well characterized. We seek to evaluate the timing, etiologies, and management of urethral erosions in primary AUS implantations. Materials and Methods: 1802 male patients underwent AUS procedure at Mayo Clinic (Rochester) from 1983 to 2011, including 1082 primary placements. Of primary placements, 63 had a urethral erosion of their device requiring explanation and were included in our analysis. All cases of urethral erosion were confirmed at the time of explantation through cystoscopy and direct visualization. At our institution, explantation is typically performed without primary urethral repair. Results: There were 63 cases (5.8%) of urethral erosions of primary AUS devices during the study time frame. The median age at AUS implantation was 74 years (interquartile range [IQR] 68–77 years) and median time to explantation was 21 months (IQR 5–59 months). The temporal trend of AUS erosions demonstrates a peak in the 1st year, with a gradual tapering of cases thereafter, persisting beyond 10 years. Three of 36 (8.3%) patients with follow-up developed a urethral stricture. Overall, 32/63 patients (51%) underwent salvage AUS reimplantation at a median of 7.1 months (IQR 3.1–12.9 months). Conclusions: Urethral erosions tend to occur early (within 1–2 years), with gradual tapering over time. However, continued vigilance is needed after AUS placement to decrease late erosions. These data can be used for counseling and to help guide follow-up care of patients with AUS.
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Biardeau X, Aharony S, Campeau L, Corcos J. Artificial Urinary Sphincter: Report of the 2015 Consensus Conference. Neurourol Urodyn 2017; 35 Suppl 2:S8-24. [PMID: 27064055 DOI: 10.1002/nau.22989] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE The AMS800™ device, by far the most frequently implanted artificial urinary sphincter (AUS) worldwide, is considered to be the "gold-standard" when male incontinence surgical treatment is contemplated. Despite 40 years of experience, it is still a specialized procedure with a number of challenges. Here, we present the recommendations issued from the AUS Consensus Group, regarding indications, management, and follow-up AMS800™ implantation or revision. MATERIALS AND METHODS Under ICS auspices, an expert panel met on July 10, 2015 in Chicago, IL, USA in an attempt to reach a consensus on diverse issues related to the AMS800™ device. Participants were selected by the two co-chairs on the basis of their practice in a University hospital and their experience: number of implanted AUSs according to AMS (American Medical System Holdings Inc., Minnetonka, MN) records and/or major published articles. Topics listed were the result of a pre-meeting email brainstorming by all participants. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short evidence-based presentation, when possible. RESULTS A total of 25 urologists were invited to participate, 19 able to attend the conference. The present recommendations, based on the most recent and relevant data available in literature as well as expert opinions, successively address multiple specific and problematic issues associated with the AMS800™ trough a eight-chapter structure: pre-operative assessment, pre operative challenges, implantation technique, post-operative care, trouble-shooting, outcomes, special populations, and the future of AUSs. CONCLUSION These guidelines undoubtedly constitute a reference document, which will help urologists to carefully select patients and apply the most adapted management to implantation, follow-up and trouble-shooting of the AMS800™.
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Affiliation(s)
- X Biardeau
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - S Aharony
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | | | - L Campeau
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - J Corcos
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Québec, Canada
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Biardeau X, Aharony S, Campeau L, Corcos J. Overview of the 2015 ICS Consensus Conference. Neurourol Urodyn 2016; 35:437-43. [DOI: 10.1002/nau.22999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 02/28/2016] [Indexed: 11/06/2022]
Affiliation(s)
- X. Biardeau
- Department of Urology, Jewish General Hospital; McGill University; Montreal Quebec Canada
| | - S. Aharony
- Department of Urology, Jewish General Hospital; McGill University; Montreal Quebec Canada
| | - L. Campeau
- Department of Urology, Jewish General Hospital; McGill University; Montreal Quebec Canada
| | - J. Corcos
- Department of Urology, Jewish General Hospital; McGill University; Montreal Quebec Canada
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Hoy NY, Rourke KF. Artificial Urinary Sphincter Outcomes in the “Fragile Urethra”. Urology 2015; 86:618-24. [DOI: 10.1016/j.urology.2015.05.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 05/04/2015] [Accepted: 05/08/2015] [Indexed: 12/24/2022]
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Singla N, Singla AK. Review of single-surgeon 10-year experience with artificial urinary sphincter with report of sterile cuff erosion managed nonsurgically. Urology 2015; 85:252-6. [PMID: 25530393 DOI: 10.1016/j.urology.2014.08.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/24/2014] [Accepted: 08/26/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To review our experience with artificial urinary sphincter (AUS) and to consider the role of nonsurgical management of sterile AUS cuff erosion. METHODS We retrospectively reviewed our 10-year experience with AUS implantation, including complication rates. We focus on the outcomes of eroded sphincters including 2 unique patients who were managed nonsurgically for sterile cuff erosion. RESULTS Between 2002 and 2012, 126 AUS units were implanted in 79 adult male patients by single surgeon (A.K.S.). Twenty-five patients (31.6%) required at least 1 additional procedure because of urethral atrophy (22.8%) or erosion or infection (8.9%). In addition, 2 patients with congenital anomalies underwent AUS implantation at bladder neck and were followed up nonsurgically for several years after cuff erosion. Both refused surgical management and have since remained continent and infection-free despite chronic erosion for 15 years' duration in 1 patient and for 5 years' duration in the other. Of note, the patient with the longer duration of erosion developed bladder stones requiring surgical removal. CONCLUSION Our AUS complication rates are consistent with those of prior series. Our unique experience with 2 patients suggests that immediate removal of AUS after sterile cuff erosion may occasionally be instituted only in difficult cases where repeat AUS implantation is not possible. To our knowledge, this is the first report of nonsurgical management of eroded AUS cuff in the literature. Larger prospective series concerning patient selection for salvaging eroded AUS may be warranted.
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Affiliation(s)
- Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ajay K Singla
- Department of Urology, University of Toledo Medical Center, Toledo, OH.
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McGeady JB, McAninch JW, Truesdale MD, Blaschko SD, Kenfield S, Breyer BN. Artificial urinary sphincter placement in compromised urethras and survival: a comparison of virgin, radiated and reoperative cases. J Urol 2014; 192:1756-61. [PMID: 25014577 DOI: 10.1016/j.juro.2014.06.088] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE Although long-term outcomes after initial placement of artificial urinary sphincters are established, limited data exist comparing sphincter survival in patients with compromised urethras (prior radiation, artificial urinary sphincter placement or urethroplasty). We evaluated artificial urinary sphincter failure in patients with compromised and noncompromised urethras. MATERIALS AND METHODS We performed a retrospective analysis of 86 sphincters placed at a single institution between December 1997 and September 2012. We assessed patient demographic, comorbid disease and surgical characteristics. All nonfunctioning, eroded or infected devices were considered failures. RESULTS Of the 86 patients reviewed 67 (78%) had compromised urethras and had higher failure rates than the noncompromised group (34% vs 21%, p=0.02). Compared to the noncompromised group, cases of prior radiation therapy (HR 4.78; 95% CI 1.27, 18.04), urethroplasty (HR 8.61; 95% CI 1.27, 58.51) and previous artificial urinary sphincter placement (HR 8.14; 95% CI 1.71, 38.82) had a significantly increased risk of failure. The risk of artificial urinary sphincter failure increased with more prior procedures. An increased risk of failure was observed after 3.5 cm cuff placement (HR 8.62; 95% CI 2.82, 26.36) but not transcorporal placement (HR 1.21; 95% CI 0.49, 2.99). CONCLUSIONS Artificial urinary sphincter placement in patients with compromised urethras from prior artificial urinary sphincter placement, radiation or urethroplasty had a statistically significant higher risk of failure than placement in patients with noncompromised urethras. Urethral mobilization and transection performed during posterior urethroplasty surgeries likely compromise urethral blood supply, predisposing patients to failure. Patients with severely compromised urethras from multiple prior procedures may have improved outcomes with transcorporal cuff placement rather than a 3.5 cm cuff.
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Affiliation(s)
- James B McGeady
- Department of Urology, University of California, San Francisco, San Francisco, California; Urologic Specialists of Oklahoma, Tulsa, Oklahoma
| | - Jack W McAninch
- Department of Urology, University of California, San Francisco, San Francisco, California
| | - Mathew D Truesdale
- Department of Urology, University of California, San Francisco, San Francisco, California
| | - Sarah D Blaschko
- Department of Urology, University of California, San Francisco, San Francisco, California
| | - Stacey Kenfield
- Department of Urology, University of California, San Francisco, San Francisco, California
| | - Benjamin N Breyer
- Department of Urology, University of California, San Francisco, San Francisco, California.
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Singla N, Singla AK. Post-prostatectomy incontinence: Etiology, evaluation, and management. Turk J Urol 2014; 40:1-8. [PMID: 26328137 PMCID: PMC4548645 DOI: 10.5152/tud.2014.222014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/10/2014] [Indexed: 11/22/2022]
Abstract
Urinary incontinence after prostatectomy or radiation is a devastating problem in men and remains the most feared complication following the treatment of localized prostate cancer. With an increasing number of radical prostatectomies performed globally for prostate cancer, the impact of urinary incontinence on quality of life assumes an even greater importance. With the advent of male sling procedures, more men are now seeking treatment for incontinence. Since the introduction of the artificial urinary sphincter almost four decades ago, several surgical procedures have emerged to manage post-prostatectomy incontinence, including the male sling for milder forms of incontinence. Several of the newer procedures have shown promise in the United States; many others have been developed and utilized in other parts of the world, though they have not yet gained FDA approval in the United States. The present review seeks to illuminate the etiology, evaluation, and management of post-prostatectomy incontinence. An effort has been made to provide an algorithm to clinicians for appropriate surgical management. The surgical techniques of commonly performed procedures and their outcomes are described.
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Affiliation(s)
- Nirmish Singla
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Ajay K. Singla
- Department of Urology, University of Toledo Medical Center, Toledo, OH, USA
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James MH, McCammon KA. Artificial urinary sphincter for post-prostatectomy incontinence: a review. Int J Urol 2014; 21:536-43. [PMID: 24528387 DOI: 10.1111/iju.12392] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 12/05/2013] [Indexed: 12/01/2022]
Abstract
The artificial urinary sphincter remains the gold standard for treatment of post-prostatectomy urinary incontinence. The AMS 800 (American Medical Systems, Minnetonka, MN, USA) is the most commonly implanted artificial urinary sphincter. Having been on the market for almost 40 years, there is an abundance of literature regarding its use, but no recent review has been published. We reviewed the current literature regarding the indications, surgical principles, outcomes and complications of artificial urinary sphincter implantation for stress urinary incontinence after prostatectomy. A PubMed search was carried out for articles on the artificial urinary sphincter from 1995 to present. The review was centered on articles related to the use of the AMS 800 for stress urinary incontinence in males after prostatectomy. Relevant articles were reviewed. The majority of patients will achieve social continence (1 pad per day) after artificial urinary sphincter implantation; however, rates of total continence (no pad usage) are significantly lower. Patient satisfaction outcomes average greater than 80% in most series. Potential complications requiring reoperation include infection (0.5-10.6%) and urethral erosion (2.9-12%). Revision surgeries are most commonly as a result of urethral atrophy, which ranges from 1.6 to 11.4%. The 5-year Kaplan-Meier freedom from reoperation ranges from 50 to 79%, while the 10-year Kaplan-Meier freedom from mechanical failure is 64%. The artificial urinary sphincter is a reliable device with good outcomes. As expected with any prosthetic device, complications including mechanical failure, infection, erosion and recurrent incontinence remain significant concerns. Despite known complications, the patient satisfaction rates after artificial urinary sphincter implantation remain high. Appropriate patient counseling and adherence to surgical principles are imperative.
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Rozanski AT, Tausch TJ, Ramirez D, Simhan J, Scott JF, Morey AF. Immediate urethral repair during explantation prevents stricture formation after artificial urinary sphincter cuff erosion. J Urol 2014; 192:442-6. [PMID: 24512955 DOI: 10.1016/j.juro.2014.02.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE We compare stricture outcomes in patients with artificial urinary sphincter cuff erosion managed with and without synchronous urethral repair. MATERIALS AND METHODS Records of patients who underwent artificial urinary sphincter removal for cuff erosion from 2007 to 2013 were retrospectively reviewed. Two cohorts of patients were evaluated, with those in group 1 treated with in situ urethroplasty and those in group 2 treated with a Foley catheter only. We compared demographic, clinical and radiological data to assess resultant stricture disease, and compared operative times between the cohorts. RESULTS Of the 26 artificial urinary sphincter cuff erosion cases identified 13 underwent in situ urethroplasty while 13 did not. Mean patient age was 73 years (range 61 to 83) with a mean followup of 24 months (range 8 to 69). The rate of urethral stricture formation after artificial urinary sphincter explantation was significantly reduced among patients treated with in situ urethroplasty (5 of 13, 38%) compared to those treated with Foley catheter only (11 of 13, 85%; p=0.047). Mean operative times were similar at 78 minutes (50 to 133) for the in situ urethroplasty group vs 70 minutes (51 to 92) for the Foley catheter only group (p=0.39). Those treated with in situ urethroplasty underwent significantly fewer procedures per patient before artificial urinary sphincter replacement (0.4 vs 1.1, p=0.004) and had a much higher rate of eventually undergoing secondary artificial urinary sphincter implantation (7 of 13, 54% vs 2 of 13, 15%, p=0.04) compared to those with cuff erosion treated with Foley catheter only. CONCLUSIONS Urethral repair at the time of artificial urinary sphincter explantation for cuff erosion appears to prevent stricture development, thus facilitating successful artificial urinary sphincter replacement.
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Affiliation(s)
- Alexander T Rozanski
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Timothy J Tausch
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Daniel Ramirez
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jay Simhan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - J Francis Scott
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Allen F Morey
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department. Emerg Med Clin North Am 2013; 31:237-60. [PMID: 23200334 PMCID: PMC5554872 DOI: 10.1016/j.emc.2012.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The evaluation and management of genitourinary emergencies is a fundamental component of the training and practice of emergency physicians. Urologic procedures are common in the emergency room. Emergency physicians play a vital role in the initial evaluation and treatment because delays in management can lead to permanent damage. This article discusses the most common urologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. An overview of each procedure is discussed as well as indications, contraindications, equipment, technique, and potential complications.
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Affiliation(s)
- Maria R Ramos-Fernandez
- Department of Emergency Medicine, University of Puerto Rico School of Medicine, 65th Infantry Avenue Km 3.8, Carolina, PR 00985, USA.
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Margreiter M, Farr A, Sharma V, Schauer I, Klingler HC. Urethral buttressing in patients undergoing artificial urinary sphincter surgery. J Urol 2012. [PMID: 23206425 DOI: 10.1016/j.juro.2012.11.152] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We evaluated the safety and feasibility of what we believe to be a novel technique of buttressing the urethra with a fibrin coated collagen fleece in patients undergoing artificial urinary sphincter surgery in the presence of urethral atrophy. MATERIALS AND METHODS A total of 17 consecutive men were treated with urethral buttressing for urethral atrophy during artificial urinary sphincter surgery. Continence, complications and patient reported outcomes were assessed by preoperative and postoperative pad use, chart review, patient interview and validated questionnaires. RESULTS Mean ± SD followup was 38 ± 3.0 months (median 34, range 23 to 71). One patient was excluded from further evaluation due to accidental iatrogenic urethral injury elsewhere. At 3-month followup the mean improvement in pad use was 5 ± 0.5 pads (median 5, range 2 to 9). Of 16 patients 9 (56%) and 2 (13%) used 1 and 0 pad per day, respectively. According to the Patient Global Impression of Improvement questionnaire, 12 of 16 patients (75%) described their condition as much or very much better after surgery. Mean ± SD postoperative Incontinence Impact Questionnaire and Urogenital Distress Index scores were 2 ± 0.8 (median 1, range 0 to 11) and 4 ± 1.0 (median 3, range 0 to 11), respectively. No intraoperative complications were observed. During followup 2 of 16 patients (13%) underwent placement of a second cuff due to unsatisfactory postoperative continence, 1 (6%) underwent artificial urinary sphincter revision for clean urethral erosion and 1 (6%) underwent revision for pump malfunction. CONCLUSIONS Urethral buttressing with a collagen fleece appears to be a safe, feasible option for urethral atrophy in patients treated with artificial urinary sphincter implantation or revision.
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Affiliation(s)
- Markus Margreiter
- Department of Urology, Medical University of Vienna, Vienna, Austria.
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22
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Lai HH, Boone TB. Complex artificial urinary sphincter revision and reimplantation cases--how do they fare compared to virgin cases? J Urol 2012; 187:951-5. [PMID: 22264456 DOI: 10.1016/j.juro.2011.10.153] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Indexed: 12/01/2022]
Abstract
PURPOSE We compared artificial urinary sphincter complication rates, overall reoperative rates, and continence results in virgin cases, revision cases and secondary reimplant cases (with prior erosion or infection). MATERIALS AND METHODS Only male patients with post-prostatectomy stress incontinence with AMS 800™ placement in the bulbar urethra by a single surgeon were included in the study. A total of 169 virgin cases (no prior artificial urinary sphincter surgery), 37 revision cases (eg cuff revision for urethral atrophy, revision of failed components) and 21 secondary reimplant cases (eg after prior explant from urethral erosion or infection) were compared. RESULTS Secondary artificial urinary sphincter reimplant cases (eg after prior explant from urethral erosion or infection) had fourfold higher future erosion rates compared to virgin cases (p = 0.02, 14.3% vs 3.6%, RR 4.02). In addition, there was no difference in the rates of other complications (device infection, urethral atrophy, mechanical failure, leaks), overall reoperation rates and postoperative continence outcomes (measured by daily pad use) compared to virgin cases. Artificial urinary sphincter revision cases did not have higher complication rates (including subsequent urethral erosion), reoperation rates or worse postoperative continence outcomes compared to virgin cases. Although the difference was not statistically significant, a trend toward higher future device leak rates (10.8% vs 3.6%, RR 3.05, p = 0.063) and higher urethral atrophy rates (16.2% vs 8.9%, RR 1.83, p = 0.18) was noted in artificial urinary sphincter revision cases compared to virgin implant cases. CONCLUSIONS Patients with a history of artificial urinary sphincter explant have a fourfold increased risk of future cuff erosion. Nevertheless, a good functional outcome with an acceptable complication rate may be achieved in most complex reoperative artificial urinary sphincter cases.
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Affiliation(s)
- H Henry Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine and St. Louis Veterans Affairs Medical Center, St. Louis, Missouri 63110, USA.
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[Treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff]. Prog Urol 2008; 18:114-9. [PMID: 18396239 DOI: 10.1016/j.purol.2007.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2007] [Accepted: 12/01/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aims of this study are to describe the implantation technique of an artificial urinary sphincter (AUS) with intracavernous cuff, define the indications and report the preliminary results of this technique. MATERIAL AND METHOD A single-centre retrospective study was carried out in 10 patients with a median age of 66 years. The aetiology of urinary incontinence was radical prostatectomy alone in four cases, combined with radiotherapy in four cases and transurethral resection of the prostate in two cases. The initial treatment consisted of AUS in seven cases and suburethral tape in two cases and the last patient had not been previously treated. Failure of AUS was due to atrophy in three cases and urethral erosion in four cases. Six patients needed to use more than three pads per day. Erections were absent in all patients. All patients were treated by insertion of an intracavernous cuff according to the same technique: perineoscrotal incision on the median raphe, dissection of the bulbar urethra and inferior aspect of the corpora cavernosa, vertical incision of the tunica albuginea on either side of the urethra, passage of the cuff from one incision to the other behind the tunica albuginea and leaving the tunica albuginea against the urethra, and closure of the tunica albuginea by interrupted sutures leaving a passage for the cuff. The median follow-up was 15.5 months. RESULTS The median operating time was 90 min. No intraoperative complication was observed. Two patients had to be explanted because of infection of the material. Seven of the remaining eight patients were satisfied and six of them needed less than one pad per day. A history pelvic irradiation did not appear to have any impact on the results. CONCLUSION The treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff is a simple technique that improves the trophicity and calibre of the urethra underneath the cuff. This technique achieved good results in patients with a history of pelvic irradiation.
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Chartier-Kastler E, Ayoub N, Richard F, Ruffion A. Chapitre C-2 E - Chirurgie prothétique de l’incontinence urinaire d’effort par insuffisance sphinctérienne neurologique. Prog Urol 2007; 17:600-8. [PMID: 17622097 DOI: 10.1016/s1166-7087(07)92375-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neurogenic sphincter incompetence, in the absence of detrusor dysfunction, results in stress urinary incontinence. Management is exclusively surgical. The available artificial sphincters ensure continence, provided intermittent self-catheterization is performed when necessary for neurogenic bladder. Artificial urinary sphincter is the reference treatment, historically and based on published cohort studies. However, it is associated with a higher morbidity in this population than in the non-neurological population. Although the surgical implantation technique is not modified in females as a result of the neurological disorder it is modified in males, as periprostatic implantation may be necessary, requiring specific training in this technique and rigorous patient selection. Other more recent prosthetic treatments are being developed, but are still at the stage of evaluation: periurethral fascia sling, periurethral injections and periurethral balloon implantation. These techniques eliminate the need to manipulate a pump to open the sphincter for self-catheterization. They appear to be promising, but their long-term results are unknown. In conclusion, operative indications for SUI due to neurogenic sphincter incompetence must be based on a multidisciplinary diagnostic assessment and explicit patient information.
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Raj GV, Peterson AC, Webster GD. Outcomes following erosions of the artificial urinary sphincter. J Urol 2006; 175:2186-90; discussion 2190. [PMID: 16697836 DOI: 10.1016/s0022-5347(06)00307-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2005] [Indexed: 11/26/2022]
Abstract
PURPOSE Artificial urinary sphincter urethral cuff erosion occurs in up to 5.0% of cases, presenting a complex management problem. We examine our experience with the eroded AUS, relating to preoperative risk factors, operative management and outcomes. MATERIALS AND METHODS We reviewed the medical records of 637 patients undergoing bulbar urethral AUS implantation from 1990 to 2003 for demographic and surgical variables. RESULTS Of the 637 records reviewed, 46 patients underwent 54 explantations of the AUS device for erosions, including 13 who had the primary implant performed at our institution and 33 being referred for management of erosion after implantation elsewhere. Our institution erosion rate was 2.2%. Mean followup after AUS reimplant following erosion was 27.8 months (range 1 to 180). Comorbidities were more prevalent in patients with erosions included hypertension (p = 0.006), coronary artery disease (p = 0.03), prior radiation therapy (p = 0.006) and prior AUS revisions (p = 0.0001). A majority of patients had persistent mild incontinence (0 to 1 pad daily in 29 or 56.8%), moderate (1 to 3 pads daily in 9 or 17.4%) and severe (more than 3 pads daily in 6 or 11.8%) incontinence after secondary AUS implantation. Patients who underwent reimplantation after AUS cuff erosions have a significantly higher rate of second erosions (in 16, 34.8%) within an average of 6.7 months (range 3 to 24), including our own 11.8% institutional rate (in 4). CONCLUSIONS Our study suggests that patients with comorbidities including hypertension, coronary artery disease, prior radiation therapy and prior AUS revisions are more likely to have erosions of their AUS. Nevertheless, continence can still be salvaged using various strategies which optimize use of the remaining healthy urethral tissue.
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Affiliation(s)
- Ganesh V Raj
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Raj GV, Peterson AC, Toh KL, Webster GD. Outcomes following revisions and secondary implantation of the artificial urinary sphincter. J Urol 2005; 173:1242-5. [PMID: 15758761 DOI: 10.1097/01.ju.0000152315.91444.d0] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Durable success with the artificial urinary sphincter (AUS) is common but device revision and replacement are often needed for various reasons. We examined indications and outcomes following these secondary procedures with comparisons to outcomes after primary procedures. MATERIALS AND METHODS The medical records of all patients undergoing primary and secondary bulbar urethral AUS implantation and revision from January 1990 to September 2002 were reviewed for various demographic and surgical variables. Female patients and males with bladder neck cuffs were excluded from study. RESULTS Of 554 men undergoing AUS implantation or revision 119 (21.4%) underwent a total of 159 secondary procedures. Reasons for revision were mechanical failure in 31 cases (25.2%) and nonmechanical failure in 88 (73.9%). The latter included recurrent incontinence due to urethral atrophy in 63 cases (52.9%) and erosion in 21 (17.6%). Total device replacement was performed in 75 cases (47.2%). Of 119 patients undergoing secondary implantation 91 (76.5%) needed no additional surgical intervention, while 28 (23.5%) required a total of 40 surgical revisions for new mechanical (15 or 37.5%) and nonmechanical (25 or 62.5%) problems. Five-year durability outcomes for primary and secondary AUS implantation were comparable at 80% and 88%, respectively. Similarly excellent continence outcomes (0 to 1 pad daily) were noted in 90% and 82% of patients undergoing primary and secondary AUS implantation, respectively. Secondary and tertiary AUS revisions resulted in the restoration of baseline continence in 106 cases (89%). CONCLUSIONS Our study suggests that outcomes for secondary AUS reimplantation are comparable to those of primary AUS implantation and salvage of a good outcome is always probable, even following multiple prior revisions and cuff erosion.
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Affiliation(s)
- Ganesh V Raj
- Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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GURALNICK MICHAELL, MILLER ELIZABETH, TOH KHAILEE, WEBSTER GEORGED. Transcorporal Artificial Urinary Sphincter Cuff Placement in Cases Requiring Revision for Erosion and Urethral Atrophy. J Urol 2002. [DOI: 10.1016/s0022-5347(05)65088-4] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- MICHAEL L. GURALNICK
- From the Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - ELIZABETH MILLER
- From the Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - KHAI LEE TOH
- From the Division of Urology, Duke University Medical Center, Durham, North Carolina
| | - GEORGE D. WEBSTER
- From the Division of Urology, Duke University Medical Center, Durham, North Carolina
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Transcorporal Artificial Urinary Sphincter Cuff Placement in Cases Requiring Revision for Erosion and Urethral Atrophy. J Urol 2002. [DOI: 10.1097/00005392-200205000-00031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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FRANK IGOR, ELLIOTT DANIELS, BARRETT DAVIDM. SUCCESS OF DE NOVO REIMPLANTATION OF THE ARTIFICIAL GENITOURINARY SPHINCTER. J Urol 2000. [DOI: 10.1016/s0022-5347(05)67524-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- IGOR FRANK
- From the Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | - DAVID M. BARRETT
- From the Department of Urology, Mayo Clinic, Rochester, Minnesota
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30
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SUCCESS OF DE NOVO REIMPLANTATION OF THE ARTIFICIAL GENITOURINARY SPHINCTER. J Urol 2000. [DOI: 10.1097/00005392-200006000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To determine the influence of radiotherapy on the outcome of artificial urinary sphincter implantation. PATIENTS AND METHODS A series of 72 men who had an artificial urinary sphincter inserted were reviewed retrospectively, analysing in detail the information from 15 patients with a past history of pelvic radiotherapy. RESULTS In those who had undergone radiotherapy, the complication rate was higher, both for re-operation (eight of 15) and infection (three); 11 of the 15 patients were continent after surgery, compared with 51 (89%) of the 57 in the unirradiated group. CONCLUSIONS An artificial sphincter can be inserted after pelvic radiotherapy reasonably successfully, but at the cost of a high complication and re-operation rate. Patients with a previous history of radiotherapy should be informed of the higher risk of surgical revision associated with insertion of the prosthesis.
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Affiliation(s)
- A Manunta
- Department of Urology, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
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