Artificial sphincter insertion after radiotherapy: is it worthwhile?

The effectiveness of adjustable trans-obturator male system (ATOMS) in radiated patients is reduced: A propensity score-matched analysis

Objectives

This study aimed to compare the effectiveness and safety of the adjustable trans-obturator male system (ATOMS®) to treat post-prostatectomy incontinence (PPI) in radiated patients compared with non-radiated patients, using propensity score-matching analysis to enhance the validity of the comparison.

Patients and methods

Consecutive men with PPI treated with silicone-covered scrotal port ATOMS (A.M.I., Feldkirch, Austria) in nine different institutions between 2016 and 2022 were included. Preoperative assessment evaluated 24-h pad usage, urethroscopy and urodynamics, if indicated. Propensity score-matching analysis was based on age, length of follow-up, previous PPI treatment, previous bladder neck stricture, androgen deprivation and pad usage. The primary endpoint was dry rate, defined as no pads post-operatively with a security pad allowed. The secondary endpoints were complications, device removal and self-perceived satisfaction with the Patient Global Impression of Improvement (PGI-I) scale.

Results

Of the 710 included patients, 342 were matched, and the study groups were balanced for the baseline matched variables. The mean baseline 24-h pad was 4.8 in both groups (p = 0.48). The mean follow-up was 27.5 ± 18.6 months, which was also equivalent between groups (p = 0.36). The primary outcome was achieved in 73 (42.7%) radiated patients and in 115 (67.3%) non-radiated patients (p < 0.0001). The mean pad count at the last follow-up was 1.5 and 0.8, respectively (p < 0.0001). There was no significant difference in complications (p = 0.94), but surgical revision and device explant rates were higher (p = 0.03 and p = 0.01, respectively), and the proportion of patients highly satisfied (PGI-I = 1) was lower in the radiated group (p = 0.01). At sensitivity analysis, the study was found to be reasonably robust to hidden bias.

Conclusion

ATOMS implantation significantly outperformed in patients without adjuvant radiation over radiated patients.

Longitudinal deterioration in lower urinary tract symptoms after artificial urinary sphincter implantation in patients with a history of pelvic radiation therapy

OBJECTIVES

To evaluate longitudinal changes in lower urinary tract symptoms (LUTS) after artificial urinary sphincter (AUS) implantation in patients undergoing radiation therapy (RT) in comparison to those in non-irradiated patients.

METHODS

This retrospective study included 20 and 51 patients with and without a history of pelvic RT (RT and non-RT group, respectively) who were treated with primary AUS implantation for post-radical prostatectomy incontinence between 2010 and 2020. Longitudinal changes in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the International Prostate Symptom Score (IPSS), and the Overactive Bladder Symptom Score (OABSS) were calculated with a linear mixed model.

RESULTS

In the RT and non-RT group, 18 (90%) and 48 (94%) patients achieved social continence, defined as daily pad use ≤1 at 1 month after activation of AUS, respectively (p = .555). During the mean follow-up of 38 months, ICIQ-SF, IPSS, and OABSS significantly improved after AUS implantation in both the RT and non-RT groups. In the RT group, ICIQ-SF, IPSS, and OABSS subsequently deteriorated with a slope of 0.62/year (p = .010), 0.55/year (p = .025), and 0.30/year (p = .007), respectively. In the non-RT group, no significant longitudinal changes in subsequent IPSS and OABSS were observed, although ICIQ-SF significantly deteriorated (0.43/year, p = .006). Comparing between the groups, the slopes of IPSS and OABSS were significantly greater in the RT group than in the non-RT group (p < .001, and .015, respectively).

CONCLUSIONS

Longitudinal deterioration in LUTS that improved immediately after AUS implantation was observed in patients with a history of pelvic RT, but not in patients without a history of pelvic RT.

Results of Adjustable Trans-Obturator Male System in Patients with Prostate Cancer Treated with Prostatectomy and Radiotherapy: A Multicenter Study

(1) Background: Treatment of male stress incontinence in patients with prostate cancer treated with radical prostatectomy and adjuvant pelvic radiation is a therapeutic challenge. The efficacy and safety of the adjustable trans-obturator male system (ATOMS) in these patients is not well established, despite the general belief that outcomes are worse than in patients without radiation. (2) Methods: Retrospective multicenter study evaluating patients treated with silicone-covered scrotal port (SSP) ATOMS implant after radical prostatectomy and radiotherapy in nine different institutions between 2016 and 2022. The primary endpoint was dry patient rate, defined as pad-test ≤ 20 mL/day. The secondary endpoints were complication rate (defined using Clavien-Dindo classification), device removal and self-perceived satisfaction using the Patient Global Impression of Improvement (PGI-I) scale. Wilcoxon rank-sum test, Fisher's exact test and logistic regression were performed using stepwise method with a 0.15 entry and 0.1 stay criteria. (3) Results: 223 patients fulfilled the criteria for inclusion and 12 (5.4%) received salvage prostatectomy after radiation and 27 (12.1%) previous devices for stress incontinence. After ATOMS adjustment, 95 patients (42.6%) were dry and 36 (16.1%) had complications of any grade (grade I, n = 20; grade II, n = 11; grade III, n = 5) during the first 3 months postoperatively. At a mean of 36 ± 21 months follow-up, the device was explanted in 26 (11.7%) patients. Regarding self-perceived satisfaction with the implant, 105 of 125 patients (84%) considered themselves satisfied (PGI-I 1 to 3). In the univariate analysis, dryness was associated to younger age (p = 0.06), primary prostatectomy (p = 0.08), no previous incontinence surgery (p = 0.02), absence of overactive bladder symptoms (p = 0.04), absence of bladder neck stricture (p = 0.001), no need of surgical revision (p = 0.008) and lower baseline incontinence severity (p = 0.0003). Multivariate analysis identified absence of surgical revision (p = 0.018), absence of bladder neck stricture (p = 0.05), primary prostatectomy (p = 0.07) and lower baseline incontinence severity (p < 0.0001) were independent predictors of dryness. A logistic regression model was proposed and internally validated. (4) Conclusions: ATOMS is an efficacious and safe alternative to treat male incontinence after radical prostatectomy and adjuvant radiotherapy. Factors predictive of dryness are identified in this complex scenario to allow for better patient selection.

Impact of Radiation Therapy on Outcomes of Artificial Urinary Sphincter: A Systematic Review and Meta-Analysis

Background

To compare incontinence rates and complications in patients receiving artificial urinary sphincter (AUS) with or without radiotherapy (RT).

Methods

PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched for studies comparing outcomes of AUS between patients with and without RT. Search limits were from 1st January 2002 to 15th September 2021.

Results

Eighteen studies were included. Meta-analysis revealed statistically significant reduced odds of the absence of incontinence in the RT group (OR: 0.35 95% CI: 0.21, 0.59 I2 = 51% p &lt; 0.0001) as compared to the no-RT group. We also noted statistically significant increased risk of revision surgery in the RT group (OR: 1.74 95% CI: 1.16, 2.60 I2 = 73% p = 0.07). There was increased risk of infections (OR: 2.51 95% CI: 1.00, 6.29 I2 = 46% p = 0.05) and erosions (OR: 2.00 95% CI: 1.15, 3.45 I2 = 21% p = 0.01) in the RT group, but the difference was significant only for erosions. Meta-analysis revealed a statistically significant increased risk of explantation in patients with RT (OR: 3.00 95% CI: 1.16, 7.75 I2 = 68% p = 0.02) but there was no difference in the risk of urethral atrophy (OR: 1.18 95% CI: 0.47, 2.94 I2 = 46% p = 0.72) and mechanical failure (OR: 0.90 95% CI: 0.25, 3.27 I2 = 54% p = 0.87) between the two groups.

Conclusions

Our meta-analysis of recent studies indicates that RT significantly reduces the odds of achieving complete continence after AUS placement. History of RT does not increase the risk urethral atrophy or mechanical failure in patients with AUS. However, the risk of revision surgery, erosions and explantations is significantly increased in patients with RT with a non-significant but increased tendency of infections.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: NCT02612389.

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

PURPOSE

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 the results in our initial series of patients.

MATERIALS AND METHODS

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.

RESULTS

Twenty-three patients were analysed. The median age was 70 years. 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 630 ml, 6 cm 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 3 months post-op with erosion (4.3% erosion rate). Median follow-up was 32 months, 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.

CONCLUSION

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.

Risk factors for resurgery in men with artificial urinary sphincter: Role of urethral strictures

OBJECTIVE

The aims of the present study were to evaluate the outcome of implantation of an artificial urinary sphincter (AUS) in male patients with iatrogenic urinary incontinence and to analyse possible risk factors for resurgery, with particular focus on the effects of posterior urethral strictures (US).

METHODS

The outcomes of AUS implantation surgeries performed by 2 surgeons on consecutive patients between January 1999 and 2015 were evaluated retrospectively. Univariate analysis with Cox proportional hazard regression was used to assess correlations between resurgery (explantation or substitution of the urethral cuff) and risk factors. Hazard ratios (HR) associated with AUS survival and 95% confidence intervals (CI) were calculated and Kaplan-Meier were constructed. Patients who underwent resurgery for mechanical failure were excluded from the study.

RESULTS

In all, 73 male patients were monitored for a maximum of 190 months (median follow-up duration 36 months). The risk of resurgery was 3.75-fold greater in patients with than without stenosis (HR 3.75; 95% CI 1.47-9.59). In addition, Kaplan-Meier survival curves showed a significantly shorter AUS survival time in patients with than without stenosis treatment.

CONCLUSIONS

Prior treatment for US increases the relative risk of AUS failure. Despite not being an absolute contraindication for AUS implantation, we suggest that patients with previous treatment for US are informed of potential risks.

Transcorporal artificial urinary sphincter in radiated and non - radiated compromised urethra. Assessment with a minimum 2 year follow-up

Purpose

to assess the efficacy of transcorporal artificial urinary sphincter (AUS) implantation on continence for male stress urinary incontinence in cases of prior surgical treatment or/and radiation failure, and as a first option in radiation patients.

Materials and Methods

From March 2007 to August 2012, 37 male patients were treated with transcorporal AUS AMS™ 800. Twelve patients had primary placement of transcorporal cuff, a surgical option due to a previous history of radiation and 25 patients had secondary procedure after failure of AUS or urinary incontinence surgery. Functional urinary outcomes were assessed by daily pad use, 24-hour Pad-test and ICIQ-SF questionnaire. Quality of life and satisfaction were assessed based on I-QoL and PGI-I questionnaires.

Results

After a median of 32 months, the continence rate (0 to 1 pad) was 69.7%. Median pad test was 17.5g (0-159), mean ICIQ-SF score was 7.3/21 (±5.4) and mean I-QoL score was 93.9/110. A total of 88% of the patients reported satisfaction with the AUS. The 5-year actuarial revision-free for AUS total device was 51%. Patients for primary implant for radiation were not more likely to experience revision than non-radiation patients. Preservation of erections was reported in half of the potent patients.

Conclusions

Transcorporal AUS cuff placement is a useful alternative procedure option for severe male UI treatment, especially in patients with a compromised urethra after prior surgery or radiation. A high continence rate was reported and implantation as first option in radiation patients should be considered.

Is Risk of Artificial Urethral Sphincter Cuff Erosion Higher in Patients with Penile Prosthesis?

INTRODUCTION

Frequently encountered morbidities after prostatectomy include stress urinary incontinence and erectile dysfunction. Patients with severe disease may undergo placement of both a penile prosthesis (PP) and an artificial urethral sphincter (AUS).

AIM

We hypothesized that concomitant PP may promote AUS cuff erosion by impaired corporal blood flow and/or direct pressure on the cuff. The aim of this study was to compare the rate of AUS cuff erosion in patients with and without a PP.

METHODS

We reviewed 366 AUS operations at our tertiary center between 2007 and 2015 with a mean follow-up of 41 months (range 6-104). Included in the analysis were first-time AUS cuff erosions. Patients with recurrent erosions, AUS revisions, and iatrogenic erosions were excluded. In a separate analysis, we analyzed AUS explantations for all causes. Cohorts were compared by demographic information, preoperative characteristics, and rates of erosion and explantation.

MAIN OUTCOME MEASURES

Erosion confirmed by cystourethroscopy and explantation of the AUS for all causes.

RESULTS

Among 366 AUS surgeries at a mean follow-up of 41 months, there were 248 (67.8%) AUS alone cases compared to 118 (32.2%) AUS and PP cases (AUS/PP). Sixty-two patients met exclusion criteria for first-time cuff erosion. Among 304 evaluable AUS patients, we found a significantly higher rate of erosion in the AUS/PP group (11/95, 11.6%) compared to the AUS alone group (9/209, 4.3%, P = .037). When examining explantations for all causes in the entire cohort (n = 366), we observed a significantly higher rate of device removal, (20/118, 17%) in the AUS/PP group compared to the AUS group (23/248, 9.2%, P = .044).

CONCLUSION

AUS/PP patients appear to have a higher risk of AUS cuff erosion and explantation compared to men with AUS alone.

Artificial Urinary Sphincter: Report of the 2015 Consensus Conference

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™.

Radiotherapy is associated with reduced continence outcomes following implantation of the artificial urinary sphincter in men with post-radical prostatectomy incontinence

Objectives:

The objective of this study is to present the outcomes of men undergoing implantation of artificial urinary sphincter, after treatment for prostate cancer and also to determine the effect of radiotherapy on continence outcomes after artificial urinary sphincter (AUS) implantation.

Materials and Methods:

A prospectively acquired database of all 184 patients having AUS insertion between 2002 and 2012 was reviewed, and demographic data, mode of prostate cancer treatment(s) before implantation, and outcome in terms of complete continence (pad free, leak free) were assessed. Statistical analysis was performed by Chi-squared and Fisher's exact tests.

Results:

A total of 58 (32%) men had bulbar AUS for urodynamically proven stress urinary incontinence consequent to treatment for prostate cancer in this period. Median follow-up post-AUS activation was 19 months (1–119). Forty-eight (83%) men had primary AUS insertion. Twenty-one (36%) men had radiotherapy as part of or as their sole treatment. Success rates were significantly higher in nonirradiated men having primary sphincter (89%) than in irradiated men (56%). Success rates were worse for men having revision AUS (40%), especially in irradiated men (33%).

Conclusion:

Radiotherapy as a treatment for prostate cancer was associated with significantly lower complete continence rates following AUS implantation.

Durability of Artificial Urinary Sphincter With Prior Radiation Therapy

BACKGROUND

The aim of this study was to investigate the effect of prior radiation therapy on artificial urinary sphincter.

METHODS

Group 1 was comprised of 63 men who underwent prior radical prostatectomy, and Group 2 was comprised of 31 men who received prior radiation therapy with or without prior radical prostatectomy. Social incontinence was defined as requiring to use > 1 pad per day and/or catheter-dependent at the time of last follow-up.

RESULTS

The median age at artificial urinary sphincter placement was 71 years (interquartile range, 55-74 years). The median and mean follow-up was 62 months (interquartile range, 37-106 months) and 75 months (range, 2-205 months), respectively. At the time of last follow-up, 67% (63 of 94) of the men in the entire cohort (73% [46 of 63] and 55% [17 of 31] in Group 1 and Group 2, respectively [P = .078]) were socially continent. Sphincter revision, erosion, infection, and removal rates were 20%, 20%, 7%, and 10%, respectively, in Group 1, and 26%, 13%, 7%, and 23%, respectively, in Group 2. The differences in these rates were not statistically significant between the 2 groups.

CONCLUSION

We found no significant difference in functionality (incontinence rates) and outcomes (rates of sphincter revision, erosion, infection, and removal) between the 2 groups. The message for patients is that prior radiation does not significantly alter the outcomes of artificial urinary sphincter.

Outcomes of Ventral Onlay Buccal Mucosa Graft Urethroplasty in Patients after Radiotherapy

PURPOSE

We evaluated stricture-free survival and functional outcomes of buccal mucosa graft urethroplasty in patients with urethral stricture disease after radiotherapy.

MATERIALS AND METHODS

We reviewed our urethroplasty database for patients with a radiotherapy history who underwent buccal mucosa graft urethroplasty between January 2009 and October 2013. We reviewed patient charts and the institutional, standardized, nonvalidated questionnaires administered to each patient postoperatively. Study end points included 1) the success rate, 2) continence status, 3) erectile function and 4) patient satisfaction postoperatively. Success was defined as stricture-free survival.

RESULTS

Of 38 men included in the study prostate cancer was the most common indication for radiotherapy in 35 (92.1%). External beam radiotherapy was performed in 24 cases (64.9%), brachytherapy was done in 8 (21.6%) and a combination of the 2 treatments was performed in 6 (13.5%). Strictures were in the bulbar/bulbomembranous urethra and had a median length of 3.0 cm (range 1.0 to 8.0). The overall success rate was 71.1% at a median followup of 26.5 months (range 1.0 to 50.0). Median time to stricture recurrence was 17.0 months (range 3.0 to 44.0). De novo urinary incontinence was observed in 4 patients (10.5%). Erectile function remained mostly unchanged compared to preoperative status. Study limitations include the small sample size and the lack of validated questionnaires.

CONCLUSIONS

At short-term to mid-term followup the success rate of ventral onlay buccal mucosa graft urethroplasty in patients with radiotherapy history seems acceptable. However, patients must be counseled about the increased risk of urinary incontinence. Longer followup is warranted to address long-term outcomes.

Complications following artificial urinary sphincter placement after radical prostatectomy and radiotherapy: a meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of artificial urinary sphincter (AUS) placement after radical prostatectomy (RP) and external beam radiotherapy (EBRT).

PATIENTS AND METHODS

There were 1 886 patients available for analysis of surgical revision outcomes and 949 for persistent urinary incontinence (UI) outcomes from 15 and 11 studies, respectively. The mean age (sd) was 66.9 (1.4) years and the number of patients per study was 126.6 (41.7). The mean (sd, range) follow-up was 36.7 (3.9, 18-68) months. A systematic database search was conducted using keywords, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Published series of AUS implantations were retrieved, according to the inclusion criteria. The Newcastle-Ottawa Score was used to ascertain the quality of evidence for each study. Surgical results from each case series were extracted. Data were analysed using CMA statistical software.

RESULTS

AUS revision was higher in RP + EBRT vs RP alone, with a random effects risk ratio of 1.56 (95% confidence interval [CI] 1.02-2.72; P < 0.050; I(2) = 82.0%) and a risk difference of 16.0% (95% CI 2.05-36.01; P < 0.080). Infection/erosion contributed to the majority of surgical revision risk compared with urethral atrophy (P = 0.020). Persistent UI after implantation was greater in patients treated with EBRT (P < 0.001).

CONCLUSIONS

Men receiving RP + EBRT appear at increased risk of infection/erosion and urethral atrophy, resulting in a greater risk of surgical revision compared with RP alone. Persistent UI is more common with RP + EBRT.

Review of single-surgeon 10-year experience with artificial urinary sphincter with report of sterile cuff erosion managed nonsurgically

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.

[Diagnosis and surgical treatment of postprostatectomy stress incontinence: recommendation of the working group Urologische Funktionsdiagnostik und Urologie der Frau]

Today, for the surgical treatment of postprostatectomy incontinence, several treatment options are available, e.g., adjustable and functional sling systems, artificial sphincter, bulking agents, and balloons. However, no recommendations in terms of specific diagnostic tools and differentiated treatment options for everyday life are available. Our aim is to provide some clinically relevant recommendations for the necessary diagnostic workup and different treatment options of postprostatetectomy incontinence to support clinical decisions in everyday life. Treatment selection should be based on contraindications. However, there is a broad overlap of the various surgical options.

Long-term functional outcomes after artificial urinary sphincter implantation in men with stress urinary incontinence

OBJECTIVE

To evaluate long-term functional outcomes of artificial urinary sphincters (AUSs) and to determine how many men required explantation because of stress urinary incontinence (SUI) caused by sphincter deficiency after prostate surgery.

PATIENTS AND METHODS

Men who had undergone placement of an AUS (American Medical Systems AMS 800®) between 1984 and 1992 to relieve SUI caused by sphincter deficiency after prostate surgery were included. Continence, defined as no need for pads, was assessed at the end of the follow-up. Kaplan-Meier survival curves estimated the survival rate of the device without needing explantation or revision.

RESULTS

In all, 57 consecutive patients were included with a median (interquartile range, IQR) age of 69 (64-72) years. The median (IQR) duration of follow-up was 15 (8.25-19.75) years. At the end of follow-up, 25 patients (43.8%) still had their primary AUS. The AUS was explanted in nine men because of erosion (seven) and infection (two). Survival rates, without AUS explantation, were 87%, 87%, 80%, and 80% at 5, 10, 15, and 20 years, respectively. Survival rates, without AUS revision, were 59%, 28%, 15%, and 5% at 5, 10, 15, and 20 years, respectively. At the end of the follow-up, in intention-to-treat analysis, 77.2% of patients were continent.

CONCLUSION

In the long term (>10 years) the AMS 800 can offer a high rate of continence to men with SUI caused by sphincter deficiency, with a tolerable rate of explantation and revision.

Complications after artificial urinary sphincter implantation in patients with or without prior radiotherapy

OBJECTIVE

To compare complications after implantation of an artificial urinary sphincter (AUS) in patients with or without prior radiotherapy (RT).

PATIENTS AND METHODS

Between January 2000 and December 2011, 160 patients underwent AMS 800 AUS implantation in our institution. We excluded neurological and traumatic causes, implantation on ileal conduit diversion, penoscrotal urethral cuff position and those lost to follow-up. In all, 122 patients were included in the study, 61 with prior RT and 61 without prior RT. All patients underwent the same surgical technique by two different surgeons. All AUS were implanted with a bulbar urethral cuff position. The mean (range) follow-up was 37.25 (1-126) months.

RESULTS

In the patients without prior RT and those with prior RT, revision rates were 32.8% vs 29.5%, respectively (P = 0.59). The median time to first revision was 11.7 months. Early complications were similar in the two groups (4.9% vs 6.5%, P = 1). Erosion rates were not significantly different (4.9% vs 13.1%, P = 0.13). However, infection and explantation were more prevalent in patients with prior RT [two (3.2%) vs 10 (16.3%), P = 0.018 and three (4.9%) vs 12 (19.6%), P = 0.016, respectively]. Finally, continence rates were not significantly different [75.4% (without prior RT) vs 63.9% (with prior RT), P = 0.23].

CONCLUSION

AUS is the 'gold standard' treatment of male urinary incontinence after re-education failure in patients with or without prior RT. Our experience showed similar functional outcomes in both groups but a higher rate of major complications in the group with prior RT.

Stemming the tide of mild to moderate post-prostatectomy incontinence: A retrospective comparison of transobturator male slings and the artificial urinary sphincter

INTRODUCTION

The AUS remains the gold standard treatment for post-prostatectomy incontinence (PPI), although most patients with mild-moderate PPI prefer a sling without strong evidence of procedural equivalence. This study compares outcomes of 2 procedures for the treatment of mild-moderate PPI.

METHODS

A retrospective review of 124 patients (76 transobturator sling, 48 AUS) with mild-moderate PPI requiring intervention over an 8-year period. The primary outcome was continence. Secondary outcomes included global patient satisfaction, improvement, and complication rates. Mild to moderate incontinence was defined as requiring ≤5 pads/day.

RESULTS

There was no significant difference in age (66.2 vs. 68.1 years; p = 0.17) or prostate cancer characteristics for slings and AUS, respectively. AUS patients had higher Charlson comorbidity scores and were more likely to have previous radiotherapy. Median length of follow up was 24 months for slings and 42 months for AUS. There was no difference in continence rates, 88.2% vs. 87.5% (p = 0.79), rate of improvement, 94.7% vs. 95.8% (p = 1.00), or patient satisfaction, 93.4% vs. 91.7% (p = 0.73), for slings and AUS, respectively. Complication rates were equivalent (19.7% vs. 16.7%; p = 1.00), though a significantly higher proportion of complications with AUS were Clavien Grade 3 (0% vs. 75%; p = 0.006).

CONCLUSIONS

For mild to moderate PPI there is no difference in continence, satisfaction, or improvement rates, between AUS and slings. AUS complications tend to be more severe. Our study supports the use of slings as first-line treatment for mild-moderate PPI.

Artificial urinary sphincter placement in compromised urethras and survival: a comparison of virgin, radiated and reoperative cases

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.

Artificial urinary sphincter for post-prostatectomy incontinence: a review

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.

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

AIMS

Stress urinary incontinence (SUI) is a known possibility after radical cystectomy (RC) and orthotopic neobladder (ONB) urinary diversion. We retrospectively reviewed the outcomes and complications of patients who underwent artificial urinary sphincter (AUS) placement for treatment of SUI and evaluated potential risk factors (PRFs) for AUS failure.

METHODS

Patients who underwent AUS placement after RC/ONB from 1994 to 2009 were identified. Variables evaluated included: demographics, cancer type, AUS characteristics, urinary incontinence (UI), revision procedures data, and PRFs for AUS failure.

RESULTS

Demographic data was reviewed on 36 patients. Mean age at AUS placement was 72 (58-79) years. Mean time to AUS after RC/ONB was 28 (2-120) months. Mean follow up after AUS was 40 (2-132) months. TCC was the indication for RC in 94% of patients. The most commonly placed AUS cuff and reservoir size was 4.5 cm and 61-70 H2 O, respectively. Incontinence data was available in 29 patients. Pre-AUS placement 22, 3, and 4 patients were totally, daytime and nighttime only incontinent, respectively. Post-AUS placement, incontinence persisted in 5, 1, and 2 patients with total, daytime and nighttime incontinence, respectively. Prior to AUS placement 11/36 patients received chemotherapy and 10/36 had radiation. Mean time to the first revision/explantation due to UI/erosion/infection/malfunction was an average of 28 (3-96) months after AUS placement and occurred in 21/35 (60%) patients. There was no significant correlation noted between PRFs and UI pre-/post-AUS or between PRFs and the need for AUS revision.

CONCLUSIONS

AUS is a safe, effective treatment with an acceptable complication rate for patients after RC/ONB with SUI.

[Pelvic radiotherapy and artificial urinary sphincter in women]

OBJECTIVES

A retrospective evaluation of artificial urinary sphincter (AUS) implantation in women with previous pelvic radiotherapy (PR).

POPULATION AND METHODS

From May 1987 to December 2009, on the 215 women implanted with AUS, nine (4.2%) had previous PR. We compared two groups of women, the first one without PR (group 1; n=206) and the other group with PR (group 2; n=9). Previous preop. urodynamics were realized. Patients using more than one pad per day at the end of follow-up were considered in failure.

RESULTS

Mean follow-up for these two groups was 6 years (SD: 5.6 years), with a mean age of 62.8 years. Mean delay between PR and surgery was 14 years. PR was indicated for cervix cancer in 78% (7/9), endometrial cancer and ovarian cancer in 9% (1/9) each. PR was responsible of an increased rate of AUS erosion and explantation (P<0.001). In group 2, more than half of women had AUS failure and 60% for AUS erosion, versus 22% and 26% respectively in group 1. In group 2, all the AUS eroded were explanted, one third of women, with a mean delay of 59.8 months (4-140) with AUS implantation.

CONCLUSION

AUS implantation in a female population with previous PR is not necessary inconsistent, but the failure rate is high. This difficult surgery should be reserved for specialized centres.

Contemporary management of postprostatectomy incontinence

CONTEXT

In recent years, despite improvement in the surgical technique, the prevalence of postprostatectomy incontinence has increased due to a rise in the number of radical prostatectomies performed annually.

OBJECTIVE

The aim of this review is to evaluate contemporary noninvasive and invasive treatment options for postprostatectomy incontinence.

EVIDENCE ACQUISITION

In August 2010, a review of the literature was performed using the Medline database.

EVIDENCE SYNTHESIS

All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included.

CONCLUSIONS

No randomised controlled trials exist to compare currently used noninvasive and invasive treatments for postprostatectomy incontinence. Pelvic floor muscle training is recommended for the initial treatment of stress urinary incontinence (SUI). Additionally, antimuscarinic therapy should be applied for urgency or urge incontinence. For decades, the artificial urinary sphincter was the reference standard for persistent SUI. Nowadays, male slings are an alternative for men with mild to moderate postprostatectomy SUI.

[AMS 800 artificial urinary sphincter implantation: can the penoscrotal approach constitute an alternative to the perineal approach?]

OBJECTIVE

To compare the short-term results of penoscrotal and perineal artificial urinary sphincter implantation.

PATIENTS AND METHODS

From May 2005 to February 2007, 37 artificial urinary sphincters were implanted successively, via a penoscrotal approach in 16 cases and via a perineal approach in 21 cases. Incontinence was secondary to prostate surgery (n=36) and pelvic trauma (n=1). Seventeen patients had a history of external beam radiotherapy. The times and modalities of activation of the sphincter were identical in the two groups.

RESULTS

The mean age of the patients, the mean operating time, the mean catheterization duration, the mean hospital stay and the mean postoperative follow-up were equivalent in the two groups. Six urethral erosions (37.5%) and one scrotal erosion due to the pump (6.6%) were observed in the penoscrotal group and infection of the sphincter in two patients (9.5%) and pump migration in another two patients (9.5%), but no urethral erosions were observed in the perineal group. The success rate without revision was 56% in the penoscrotal group and 71.5% in the perineal group.

CONCLUSION

The perineal approach is the reference incision, as the penoscrotal approach is associated with a high rate of erosion. The penoscrotal urethral approach can constitute an alternative when the bulbar urethra cannot be used.

[Treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff]

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.

13 years of experience with artificial urinary sphincter implantation at Baylor College of Medicine

PURPOSE

We reviewed 13 years of experience with artificial urinary sphincter implantation (narrow backed cuff) at a single institution.

MATERIALS AND METHODS

Between 1992 and 2005, 270 patients underwent artificial urinary sphincter implantation, as performed by a single surgeon at Baylor College of Medicine, and followup data were available on 218 of them. Mean followup was 36.5 months (maximum 151.4). Of the 218 patients 60 underwent prostatectomy and pelvic radiation, 116 underwent prostatectomy without radiotherapy, 11 had neurogenic bladder and 31 underwent secondary artificial urinary sphincter implantation.

RESULTS

The complication rate did not differ among the 4 treatment groups. Complication rates were infection in 5.5% of cases, erosion in 6.0%, urethral atrophy in 9.6%, mechanical failure in 6.0% and surgical removal or revision in 27.1%. Median time to complications was 3.7 months for infection, 19.8 months for erosion, 29.6 months for atrophy, 68.1 months for failure and 14.4 months for surgery. At 5 years 75% of patients were free from revision or removal. A history of failed injectable or male sling, or of Valsalva voiding did not adversely impact the outcome. The rate of bladder neck contracture was high in artificial urinary sphincter candidates, especially in irradiated patients (36% and 57%, respectively). Patients with prior pelvic radiation continued to be at higher risk for contracture recurrence after artificial urinary sphincter implantation (12%). Two-stage UroLume stent and artificial urinary sphincter placement offered long-term contracture and continence control in 8 of 11 patients with recurrent anastomotic contractures.

CONCLUSIONS

An artificial urinary sphincter is durable treatment for sphincter deficiency even in patients with a history of complications, neurogenic bladder, pelvic radiation, bladder neck contracture, Valsalva voiding, or failed injectables or slings.

Quality of life, functional outcome and durability of the AMS 800 artificial urinary sphincter in patients with intrinsic sphincter deficiency

OBJECTIVE

To evaluate the quality of life, functional outcome and durability of the AMS 800 artificial urinary sphincter (AUS) in patients with urinary incontinence due to intrinsic sphincter deficiency of mixed origin.

PATIENTS AND METHODS

Between 1991 and 2000, 34 AUS were implanted in 31 patients (24 males/7 females) with mean age of 59 (range 15-75) years. Using a questionnaire, patients' urinary function and quality of life were assessed in 22 patients with an AUS in situ. To evaluate efficacy and durability of the device, the primary adequate function (P-AF) and additional procedure-assisted adequate function (APA-AF) rates were determined on the basis of a Kaplan-Meier survival analysis.

RESULTS

The social continence rate (0-1 pads/24 h) was 55% with a mean follow-up of 46 months. The revision rate was 26% and the explantation rate 35%. The 5-year P-AF and APA-AF rates were 41 and 44%, respectively. The pad score decreased from 2.95 to 1.23 after AUS implantation (p < 0.0001) leading to a high mean patient satisfaction (rated as 4.0 on a visual analog scale of 0-5). Twenty-one patients (95%) would undergo the procedure again under the same circumstances. Patients with previous anti-incontinence procedures showed a significantly higher explantation rate (p = 0.004).

CONCLUSION

In spite of a relatively high re-operation rate and moderate social continence state, patient satisfaction was found to be great mainly due to the relative improvement in incontinence. The AMS 800 AUS is a reliable device with few mechanical complications. Extensive preoperative counseling is mandatory.

Artificial urinary sphincter placement in men after cystectomy with orthotopic ileal neobladder: continence, complications, and quality of life

OBJECTIVES

To review our experience regarding the overall efficacy and safety of an artificial urinary sphincter (AUS) in men with stress urinary incontinence (SUI) after cystoprostatectomy with an orthotopic ileal neobladder.

METHODS

We performed a retrospective review of 5 men who underwent placement of an AUS (AMS 800) for severe SUI after radical cystectomy with an orthotopic ileal neobladder. Incontinence symptoms and quality of life were quantified using two validated continence questionnaires (Urogenital Distress Inventory Short Form and Incontinence Impact Questionnaire Short Form) and a brief addendum questionnaire. The degree of continence, perioperative and postoperative complications and infections, symptom distress, quality of life, and patient satisfaction were compared before and after AUS placement.

RESULTS

Complete (0 pads per day) or social (1 pad or less per day) continence was reported in 5 of 5 patients after AUS placement. The average pad usage significantly decreased from 6.2 to 0.6 per day (P <0.001). No significant perioperative or postoperative complications or infections were noted. Symptom distress, quality of life, and patient satisfaction were significantly improved after AUS placement (P < 0.01, < 0.0001, and < 0.001, respectively).

CONCLUSIONS

With short-term follow-up and a limited number of patients, the placement of an AUS for treatment of SUI after bladder substitution is well tolerated and reliable and has a positive impact on patients' quality of life.

Artificial urinary sphincter for post-prostatectomy incontinence in men who had prior radiotherapy: a risk and outcome analysis

PURPOSE

We retrospectively reviewed our experience with the artificial urinary sphincter for post-prostatectomy incontinence, comparing the outcome of those patients who did and did not receive previous radiation therapy.

MATERIALS AND METHODS

A total of 86 patients with post-prostatectomy incontinence treated with implantation of artificial urinary sphincter includes 58 who did not (group 1) and 28 who did (group 2) receive prior radiation therapy during treatment of prostate carcinoma. In group 2 radiation was the primary treatment followed by salvage prostatectomy in 5 patients, adjuvant after radical retropubic prostatectomy 20 and after transurethral prostatic resection 3. Mean patient age plus or minus standard deviation was 68.3 +/- 6.6, and 69.7 +/- 6.6 years in groups 1 and 2, respectively. Activation of the sphincter was 4 weeks from the date of surgery, and deactivation at night was not adopted in either group. Patients were followed for a mean period of 31 +/- 23, and 36 +/- 21 months in groups 1 and 2, respectively. Comparison of continence, urodynamic testing, complication rate, overall satisfaction and quality of life was done between both groups.

RESULTS

Reoperation was required in 13 (22.4%) patients in group 1 and 7 (25%) group 2 (p >0.05). Urethral atrophy and/or inadequate compression was seen in 8 (14%) and 4 (14%) patients, and urethral erosion was observed in 1 (2%) and 2 (7%) in groups 1 and 2, respectively (p >0.5). Infection of the device was observed in 4 (7%) patients in group 1 but none group 2 (p >0.05). Continence status was similar in both groups, with 60% and 64% of patients who wore 0 to 1 pad daily in groups 1 and 2, respectively (p >0.05). Urgency with or without urge incontinence was reported after implantation of artificial urinary sphincter in 47%, and 44% of patients in groups 1 and 2, respectively (p >0.05). On a visual analog scale (range 0 to 5, 0-not satisfied at all, 5-extremely satisfied) for satisfaction with the results of the artificial urinary sphincter 86% and 91% of patients reported 4 or greater in groups 1 and 2, respectively (p >0.05).

CONCLUSIONS

The artificial urinary sphincter has a similar outcome in patients with post-prostatectomy incontinence whether or not they have received previous radiation therapy. No special precaution needs to be adopted for the men in group 2 with post-prostatectomy incontinence considering implantation of artificial urinary sphincter.

Urinary incontinence following treatment of localized prostate cancer

BACKGROUND

Urinary incontinence (UI) following treatment for localized prostate cancer is a significant adverse consequence most commonly seen after radical prostatectomy. UI can significantly impair the quality of life of patients who can otherwise expect a long survival.

METHODS

The authors review past and present literature on UI following treatment for localized prostate cancer. Special focus is placed on the rate of UI following different modes of therapy, the effect of posttreatment UI on patients' quality of life, and the success of different methods used to treat the incontinence.

RESULTS

Postprostatectomy UI has been reported in 25%-70% of cases, but few patients report being significantly bothered by the symptom. Postradiation adverse effects are mainly acute inflammatory, while late complications are rare but usually more serious. Comparative studies estimate UI following prostatectomy to be two times more common than following radiation, and surgical patients are three times more likely to continue to use pads. Watchful waiting carries a risk of incontinence related to prostate tumor progression. Several interventions can improve UI.

CONCLUSIONS

UI is the most common adverse consequence from treatment for localized prostate cancer. All of the possible treatment modalities carry some risk of UI. Providing accurate information to patients allows them to make informed decisions regarding treatment and can improve the quality of life in the posttreatment period.

Injury to the genitourinary tract and functional reconstruction of the urethra

In the field of trauma and reconstruction, some aspects have changed significantly, whereas others continue to refine concepts that have developed over recent years. In urethral reconstruction, procedures are becoming more complex. The morbidity of the lithotomy position has been recognized for years. Recent literature has clarified the argument over the 'best stirrup', and time in lithotomy has been identified as a significant contributor to morbidity. Implantation of the AMS-800 sphincter has been examined in irradiated patients. The complication and revision rate is higher but not so high as to preclude consideration of its use. A number of articles have examined the use of cystoscopy in all cases of complicated pelvic surgery and in specific urethral suspension procedures. This has been recognized by urologists for years; it is a new concept in the gynecology literature. Cystoscopy continues to be routinely used, as many 'routine cases' when examined with cystoscopy are found to be associated with complications to the genitourinary tract. The non-operative management of renal trauma is expanded to select blunt grade 5 renal injuries. A series examined the use of computed tomography scan for bladder injuries and found it to be both sensitive and specific.

Current status of urethral occlusive devices in management of urinary incontinence

Treatment of outlet incontinence with urethral occlusive devices encompasses simple and complex modalities. The implantable artificial urinary sphincter has been used for 25 years, and a growing fund of clinical information is available to define its indications. Other simple occlusive devices are available that provide an effective, nonsurgical and reversible treatment. The present review summarizes recent clinical investigations into the safety and efficacy of urethral occlusive devices.