Outcomes of single- vs double-cuff artificial urinary sphincter insertion in low- and high-risk profile male patients with severe stress urinary incontinence

Treatment strategies for revision surgery of artificial urinary sphincter: A review

Artificial urinary sphincters (AUS) are an effective treatment for male stress urinary incontinence (SUI). However, infection, erosion, mechanical failure, atrophy, and balloon deterioration cause device malfunction in approximately half of patients by 10 years after implantation. Many patients desire to regain urinary continence and require revision surgery (RS), including device removal and simultaneous or delayed implantation. Patients for whom RS is considered should be examined physically and by interview for signs of infection. Urethral erosion should be assessed using cystoscopy. If there is infection or erosion, all devices should be removed first, and a new device should be implanted several months later. During the RS, after strong adhesion around the urethra, transcorporal cuff implantation is a safe choice. Device removal and simultaneous implantation can be performed in the absence of infection or erosion. If a long time has passed since device implantation, the entire device should be replaced due to device aging and deterioration; however, if the time is short, only the defective component need be replaced. Intraoperative assessment of urethral health is necessary for device removal and implantation. If the urethra is healthy, a new cuff can be placed in the same position as the old cuff was removed from; however, if the urethra is unhealthy, the cuff can be implanted in a more proximal/distal position, or a transcorporal cuff implant may be chosen. This article reviews the literature on diagnostic and treatment strategies for recurrent SUI in male patients with AUS and proposes a flowchart for AUS revision.

[Urinary stress incontinence in men: diagnostic workup and modern surgical treatment]

Radical prostatectomy is the most common cause of urinary stress incontinence in male patients. The exact pathophysiology is not clearly defined but probably due multifactorial. Thorough preoperative diagnostic workup before surgical therapy appears to be crucial for good postoperative results. Various systems are available. The artificial urinary sphincter continues to be considered standard procedure with a high success rate, even in patients with more complex situations and severe urinary incontinence. However, there are also relevant complication and revision rates. Modern alternatives include various sling systems. The adjustable sling systems consist of a cushion that is placed against the urethral bulb and leads to a permanent increase in urethral resistance, which can be readjusted in different ways depending on the system implanted. The adjustable sling systems also seem to be an alternative in patients with a prior history of radiation therapy. The AdVance XP sling (Boston Scientific, Marlborough, MA, USA) is a fixed sling that corrects the postoperative hypermobility of the posterior urethra after radical prostatectomy and, thus, leads to a longer functional urethral length. Good long-term results after AdVance XP implantation are only possible in selected patients.

Using a stress reservoir to improve urine leakage after artificial urinary sphincter implantation

INTRODUCTION

Although the longest efficacy record, some patients report about urinary leakage during higher intra-abdominal pressure after Artificial Urinary Sphincter (AUS) implantation. To improve the continent results, we placed in addition to the occluding cuff and the pressure regulating balloon, in a second procedure a stress-relief reservoir in lower abdomen, for additional passive pressure transmission to the occluding cuff.

METHODS

In this retrospective monocentric data analysis between 2011 and 2018, 80 patients with persistence incontinence after AUS implantation were included. Stress-relief reservoir was indicated in 12 patients with involuntary leakage of urine, that occurred when intra-abdominal pressure raised.

RESULTS

In all 12 cases, the stress reservoir was easily implanted and there were no intraoperative complications. In a mean follow-up time of 53 months, the pad per day usage (p/d) improved from 3 (± 1.2) to 1.7 (± 1.5) (p = 0.001). Two patients with multiple previous abdominal surgeries used an equal number of pads after SRR; however, an improvement during physical exertion was reported. Continence situation was evaluated with a questionnaire and was rated as "excellent", "good", or "satisfactory" by 11 (92%) patients.

CONCLUSION

The persistence of urinary incontinence after AUS is a challenging topic. Implantation of a stress reservoir in carefully selected patients with urinary leakage during higher intra-abdominal pressure is minimally invasive and offers new options to improve the proven long-term record of AUS. Certainly, more investigations are needed to determine the clinical relevance of this approach.

Effectiveness of artificial urinary sphincter to treat stress incontinence after prostatectomy: A meta-analysis and systematic review

BACKGROUND

Artificial Urinary Sphincter (AUS) has always been considered the gold standard for surgical treatment of male non-neurogenic Stress Urinary Incontinence (SUI). The purpose of this meta-analysis was to evaluate AUS's effectiveness in treating male SUI, as described in the literature.

METHODS

Two independent reviewers used PubMed, EMBASE, Web of Science, CNKI, WanFang Data, and VIP databases, to find the efficacy of artificial urethral sphincter in treating SUI after male prostate surgery. We excluded studies on female urinary incontinence. The main purpose of this study was to evaluate the clinical efficacy based on the degree of dry rate after AUS AMS 800™: postoperative complete dry was defined as no pad use per day. Postoperative social dry was defined as 0-1 pad per day. The secondary goal was to analyze the use of AUS AMS 800™ to improve SUI and to calculate the degree of influence by analyzing the number of pads and postoperative quality of life. And methodologic quality of the overall body of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines.

RESULTS

The data in this paper are mostly based on prospective or retrospective cohort studies without control groups. Fortunately, most studies have the same criteria to assess effectiveness. The pooled data of 1271 patients from 19 studies (6 prospective cohort studies, 12 retrospective cohort studies, and 1 randomized controlled trial) showed that: the number of pads used (pads/ day) after AUS was significantly reduced by about 4 (P < 0.001) and the quality of life was improved (P < 0.001).In addition, data analysis showed a high degree of heterogeneity between studies. According to the severity of baseline SUI, subgroup analysis was performed on the postoperative dry rate and social dry rate. Although heterogeneity was reduced, I2 is still above 50%, considering that heterogeneity may not be related to the severity of SUI. The random effect model was used for data analysis: the dry rate was about 52% (P < 0.001), and the social dry rate was about 82% (P < 0.001). The evidence level of GRADE of dry rate is very low, the evidence level of social dry rate and Pads use (pads/day) is Moderate, and the evidence level of Quality of life is low.

CONCLUSION

Although the evidence in this paper is based on descriptive studies and limited follow-up, the results show that AUS is effective in treating urinary incontinence and can improve patients' quality of life.

Biomechanical study of the male lower urinary tract: Simulation of internal and external sphincters dyssynergia

Urethral sphincter dysfunction is an important cause of stress urinary incontinence (SUI). The most effective treatment is the insertion of an artificial urethral sphincter (AUS), which relies to a large extent on the surgeon's experience. However, there is no quantitative standard for cuff tightness, resulting in frequent postoperative complications. This study aimed to investigate the effect of internal and external sphincter dyssynergia on urodynamic parameters in the lower urinary tract. A geometric model of male lower urinary tract tissue was constructed from collodion slices, accounting for the active behavior of the internal and external sphincters. Normal and dyssynergic internal and external sphincters (active sphincter behavior was individually injured by 25%, 50%, 75%, or 100%) were simulated with fluid-structure interactions and changes in urethral stress, displacement, and urine flow rate were detected. We found that when the internal sphincter was injured by 25%, 50%, 75%, and 100%, urethral stress near the internal sphincter decreased by 8.3%, 15.6%, 24.3%, and 35.7%, respectively. Additionally, when the external sphincter was injured by 25%, 50%, 75%, and 100%, urethral stress near the external sphincter was reduced by 13.3%, 24.3%, 38.6%, and 46.6%, respectively. Internal sphincter injury primarily affects positions near the internal sphincter and prostate, while external sphincter injury affects the area between the prostate and urethral outlet. These data could facilitate the standardized evaluation of internal and external sphincter dysfunction and lead to novel methods of preoperative assessment for AUS surgery.

Transcroporal Artificial Urinary Sphincter Placement With Closure of Corporal Bodies—A Long-Term Analysis of Functional Outcomes

Objectives

An artificial urinary sphincter (AUS) is the gold standard for postoperative stress urinary incontinence (SUI). The transcorporal AUS (TC) placement constitutes the main salvage option in high-risk patients suffering from SUI with fragile urethras. The literature analyzing long-term outcomes with respect to explantation rates, continence, and erectile function is scarce.

Methods and Patients

Retrospective data collection was performed in 2011. TC was applied according to a standardized protocol. TC was implanted after bulbar urethroplasty or double-cuff (DC) explantation. After TC placement, the tunica albuginea was closed in order to minimize the risk of postoperative bleedings and erectile dysfunction. Activation was performed 6 weeks postoperatively. Further follow-up (FU) was scheduled 6/24 months postoperatively and every 2 years thereafter. Primary/secondary endpoints were explantation/objective, subjective, and social continence rates. Objective or social continence was defined as the use of 0 pads/day or <2 pads/day, respectively. Thereupon, postoperative bleedings and erectile function were analyzed.

Results

A total of 39 high-risk patients were available for analysis. The median age was 72 years. In total, 84.6%, 10.3%, and 2.6% had a history of radical prostatectomy, TURP, and radical cystectomy, respectively. In total, 61.5% had a history of radiation therapy of the prostate, 41% had a history of urethral surgery, and 95% had a history of double cuff explantation. The median FU was 27 months. Objective, subjective, and social continence were 54.5%, 69.7%, and 78.8%, respectively. The median pad usage was 1 pad/day [1–2.5]. Only one patient suffered from a postoperative hematoma. In total, 15.4% of the patients were able to have an erection preoperatively, compared to 7.7% after TC placement. The estimated mean explantation-free survival of the TC was 83 months in the Kaplan–Meier analysis.

Conclusions

TC AUS implantation constitutes a viable salvage approach in high-risk SUI patients with a mean device survival of almost 7 years and high social continence rates of almost 80%. An intraoperative closure of the tunica albuginea after TC placement allows for very low rates of postoperative hematoma and supports postoperative erectile rigidity.

Urethral Stricture Formation Following Cuff Erosion of AMS Artificial Urinary Sphincter Devices: Implication for a Less Invasive Explantation Approach

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.

Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review

The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.

Artificial Urinary Sphincter Complications: Risk Factors, Workup, and Clinical Approach

PURPOSE OF REVIEW

To review risk factors for AUS complications and present a systematic approach to their diagnosis and management.

RECENT FINDINGS

Established risk factors for AUS complications include catheterization, channel TURP, pelvic radiation, urethroplasty, anticoagulation, cardiovascular disease, diabetes mellitus, frailty index, hypertension, low albumin, and low testosterone. We present our algorithm for diagnosis and management of AUS complications. Despite being the gold standard of treatment for men with SUI, major and minor complications can occur at any point after AUS insertion. Careful consideration of the urologic, medical, and operative risk factors for each patient can help prevent complications. A systematic approach to early and late complications facilitates their identification and effective management. The evaluating urologist must have a thorough understanding of potential AUS complications in order to restore quality of life in men with bothersome SUI.

High/low-volume center experience predicts outcome of AMS 800 in male stress incontinence: Results of a large middle European multicenter case series

AIM

To analyze the influence of implantation volume of artificial sphincters (AMS 800) on outcome in a large central European multicenter cohort study.

METHODS

As part of the DOMINO (Debates on Male Incontinence) project, the surgical procedures and outcomes were retrospectively analyzed in a total of 473 patients who received an artificial sphincter (AMS 800) between 2010 and 2012. Clinics that implanted at least 10 AMS 800 per year were defined as high-volume centers.

RESULTS

Sixteen centers had a mean rate of 9.54 AMS 800/y of which five clinics were identified as high-volume centers. They implanted significantly more double cuffs (55% vs 12.1%; P < .001), used the perineal approach significantly more often (78% vs 67.7%; P = .003) and chose larger mean cuff sizes (4.63 cm vs 4.42 cm; P = .002). With a mean follow-up of 18 months, the revision rate was significantly higher at low-volume centers (38.5% vs 26.7%; P = .037), urethral erosion being the main reason for revision. Social continence (0-1 pads/24 h) was achieved significantly more often in high-volume centers (45.5% vs 24.2%; P = .002).

CONCLUSIONS

Our study showed significantly better continence results and lower revision rates at high-volume centers, confirming earlier results that are still true in this decade. We, therefore, recommend surgery for male incontinence at qualified centers.

Effectiveness of surgical management with an adjustable sling versus an artificial urinary sphincter in patients with severe urinary postprostatectomy incontinence: a systematic review and network meta-analysis

Background:

The purpose of this study was to determine the effectiveness of an adjustable sling compared with an artificial urinary sphincter (AUS) in patients with severe urinary incontinence (SUI) postprostatectomy (PP).

Methods:

This review was carried out following the Cochrane Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. We searched Medline, Embase, LILACS, and CENTRAL databases. Studies with patients older than 18 years of age with SUI PP who underwent sling or AUS intervention and had been monitored for longer than 12 months were included.

Results:

Seven studies were included, yielding a sample size of 420. Pads were reportedly dry or improved in 70% of the sling group compared with 74% in the AUS group. The Incontinence Impact Questionnaire, Short Form (IIQ-7) was the most frequently used scale and showed improvement, with a score of 82.8% in the AUS group compared with 86.1% in the sling group. When comparing interventions with nonintervention, relative risks (RRs) of 35.37 (95% confidence interval [CI]: 7.17–174.35) and 45.14 (95% CI: 11.09–183.70) were found for the adjustable sling and AUS, respectively, which were statistically significant. No significant differences were found when AUS versus adjustable sling were compared, with an RR of 0.78 (95% CI: 0.09–6.56). We found a low risk of bias in most studies.

Conclusions:

Both interventions can reduce incontinence and improve the quality of life of patients with SUI PP. The published literature is substantially limited as no randomized clinical trials are available, no consensus has been reached regarding the definition of severity of incontinence, and considerable heterogeneity exists across the outcome variables measured.

Artificial Urinary Sphincter Cuff Size Predicts Outcome in Male Patients Treated for Stress Incontinence: Results of a Large Central European Multicenter Cohort Study

PURPOSE

The aim was to study the correlation between cuff size and outcome after implantation of an AMS 800 artificial urinary sphincter.

METHODS

A total of 473 male patients with an AMS 800 sphincter implanted between 2012 and 2014 were analyzed in a retrospective multicenter cohort study performed as part of the Central European Debates on Male Incontinence (DOMINO) Project.

RESULTS

Single cuffs were implanted in 54.5% and double cuffs in 45.5% of the patients. The cuffs used had a median circumference of 4.5 cm. Within a median follow of 18 months, urethral erosion occurred in 12.8% of the cases and was associated significantly more often with small cuff sizes (P<0.001). Multivariate analysis showed that, apart from cuff size (P=0.03), prior irradiation (P<0.001) and the penoscrotal approach (P=0.036) were associated with an increased erosion rate. Continence rate tended to be highest with median cuff sizes (4-5.5 cm).

CONCLUSION

Apart from irradiation and the penoscrotal approach, small cuff size is a risk factor for urethral erosion. Results are best with cuff sizes of 4.5-5.5 cm.

Efficacy and safety of artificial urinary sphincter (AUS): Results of a large multi-institutional cohort of patients with mid-term follow-up

AIMS

To assess efficacy and safety as well as predictive factors of dry rate and freedom from surgical revision in patients underwent AUS placement. The artificial urinary sphincter (AUS) is still considered the standard for the treatment of moderate to severe post-prostatectomy stress urinary incontinence (SUI). However, data reporting efficacy and safety from large series are lacking.

METHODS

A multicenter, retrospective study was conducted in 16 centers in Europe and USA. Only primary cases of AUS implantation in non-neurogenic SUI after prostate surgery, with a follow-up of at least 1 year were included. Efficacy data (continence rate, based on pad usage) and safety data (revision rate in case of infection and erosion, as well as atrophy or mechanical failure) were collected. Multivariable analyses were performed in order to investigate possible predictors of the aforementioned outcomes.

RESULTS

Eight hundred ninety-two men had primary AUS implantation. At 32 months mean follow-up overall dry rate and surgical revision were 58% and 30.7%, respectively. Logistic regression analysis showed that patients without previous incontinence surgery had a higher probability to be dry after AUS implantation (OR: 0.51, P = 0.03). Moreover institutional case-load was positively associated with dry rate (OR: 1.18; P = 0.005) and freedom from revision (OR: 1.51; P = 0.00).

CONCLUSIONS

The results of this study showed that AUS is an effective option for the treatment of SUI after prostate surgery. Moreover previous incontinence surgery and low institutional case-load are negatively associated to efficacy and safety outcomes.

[Sphincter and corpus cavernosum prostheses as components of endoprosthetics in urology]

Artificial urinary sphincters and penile corpus cavernosum prostheses are effective for patients who are not adequately treated by conservative treatment or pharmacotherapy. Both of these devices show good results concerning functional outcome if used within the correct patient selection. Penile prostheses are meant to be the last line of treatment for severe erectile dysfunction after failure of conventional treatment. Artificial urinary sphincters are the treatment of choice for severe urinary stress incontinence. Although the surgical procedure is an easy one, only highly experienced centers should perform the implantation due to minimization of infections and loss of function. Because of the hydraulic working principle of both devices, check-ups on a regular basis are strongly recommended. In the case of a loss of function or infections, a rapid and targeted treatment is the key to make new implantations possible in the future.

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

OBJECTIVE

To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown.

MATERIALS AND METHODS

We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates.

RESULTS

We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation.

CONCLUSION

Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.