Is the penoscrotal approach inferior to the perineal approach for artificial sphincter implantation in male urinary incontinence? A preliminary experience

[Comparison of penoscrotal and perineal approaches for implantation of an artificial urinary sphincter in man]

INTRODUCTION

Artificial urinary sphincter is considered the gold standard of treatment for male urinary incontinence because of intrinsic sphincter deficiency. The objective of our study was to compare the functional results and complications of the penoscrotal and perineal incision for the implantation of artificial urinary sphincter.

MATERIAL AND METHODS

A retrospective, monocentric study comparing the perioperative and long-term results of primary implantation of an artificial urinary sphincter in men, performed by the penoscrotal or the perineal incision, was conducted in a French university hospital.

RESULTS

Between April 2004 and February 2019, 175 patients were implanted (118 by penoscrotal incision and 57 by perineal incision) by 19 surgeons. Cuff placement approach depended on surgeon preference. The average follow-up was 34.2 ± 35.6 months. Cuff size was smaller in the penoscrotal group (4 [4;5] vs 4.5[4;5] p<0.001). At the end of follow-up, the rates of complete continence, social continence, reintervention for any reason, explantation, and revision was similar between the two groups.

CONCLUSION

Long-term outcomes of penoscrotal and perineal artificial sphincter implantation were similar between the two groups. Prospective multicenter studies are needed to confirm these results.

Twenty years later: is the scrotal one-incision AUS of value?

The artificial urinary sphincter, known as AMS 800, has been the gold standard for treating moderate to severe stress urinary incontinence in males for 40 years. Yet, the number of sphincters done globally is quite small and the majority of urologists doing them are infrequent implanters. Estimates for 2019 showed half of implanters did only one implant that year and worldwide only around 13,000 implantations were performed. The traditional two-incision technique of perineal exposure for cuff placement and abdominal incision for pump and pressure regulating balloon persists as the most common technique to surgically place an artificial urinary sphincter. Present estimates are that upwards of 80% are done via the perineal approach and that approach is the highly favored incision of large volume centers. The scrotal one-incision approach was invented by Wilson 20 years ago and was aimed at making the implantation of a sphincter quicker, easier and safer for the occasional implanter. These physicians perform 1-2 devices per year, comprise 60% of implanters who perform the surgery yearly, and implant 22% of all implanted devices. Our article targets these infrequent inserters discussing the history of the two techniques and what the authors have learned about the advantages and hazards of the one scrotal incision procedure over the last two decades.

Revisiting the penoscrotal approach to artificial urinary sphincter surgery: how does it compare to a perineal incision for initial implantation?

PURPOSE

Artificial urinary sphincters (AUS) remain the gold standard to treat male stress urinary incontinence. AUS implantation can be performed through a penoscrotal or perineal incision depending on surgeon preference.

METHODS

The present study compares initial AUS implantation through two surgical approaches focusing on outcomes of continence and revision. All AUS implanted at an academic medical center between 2000 and 2018 were retrospectively reviewed.

RESULTS

A total of 225 AUS implantations were identified, of which, 114 patients who underwent virgin AUS placement were included in the study with a mean follow-up of 28.5 months. A total of 68 patients (59.6%) had AUS placement through penoscrotal incision; while, 46 (40.4%) had a perineal incision. While operative time was significantly shorter for penoscrotal placement (98.6 min vs. 136.3 min, p = 0.001), there were no significant differences in continence rates between either surgical approach with 76.5% socially continent defined as using zero to less than 1 pad per day (safety pad). The overall rate of device erosion or infection was not significantly different between groups. However, the rate of revision or replacement was significantly higher in the perineal group (26.1% v. 8.8%; p = 0.01). On multivariate analysis, the penoscrotal incision predicted a lower rate of device revision (p = 0.01).

CONCLUSIONS

The penoscrotal approach of AUS placement is associated with shorter operative time. While we observed a lower revision rate compared to the perineal approach, there were equivalent continence outcomes.

Risk factors for artificial urinary sphincter failure

PURPOSE

To analyze revision rates and risk factors for artificial urinary sphincter failure.

METHODS

Eighty-four patients underwent implantation of an artificial urinary sphincter in one reference center. Continence rates were defined by daily pad usage. Influence of predefined risk factors for device explantation, revision, differences in preoperative pad usage, and device survival was analyzed using Chi-squared test, Wilcoxon signed-rank test, and Kaplan-Meier analysis. A multivariate analysis was performed using a logistic regression model. A p value below 0.05 was considered statistically significant.

RESULTS

After a mean follow-up of 39.7 months, the device was still in situ in 64 patients. In univariate analysis, perioperative need of anticoagulation led to a significant increase in urethral erosion (6 vs. 30 %; p = 0.002) and explantation rate (15 vs. 34 %; p = 0.047). Pelvic irradiation increased postoperative infection rates significantly (0 vs. 10 %; p = 0.018). Penoscrotal approach led to significant increase in urethral erosion rate (0 vs. 21 %; p = 0.015). Implantation of a double cuff led to a significant increase in explantation rate (58 vs. 24 %; p = 0.014), revision rate (75 vs. 38 %; p = 0.017), and infection rate (17 vs. 1 %; p = 0.008). When using cuff size of 3.5 cm, revision rate (20 vs. 50 %; p = 0.026) as well as incontinence rates (40 vs. 82 %; p = 0.014) was significantly lower. In multivariate analysis, only perioperative anticoagulation and double-cuff placement were independent predictors of artificial urinary sphincter failure.

CONCLUSIONS

Our findings highlight the influence of perioperative anticoagulative therapy. In addition, the current study provides further evidence that double-cuff implantation should be performed only with caution during primary implantation.

Does Pressure Regulating Balloon Location Make a Difference in Functional Outcomes of Artificial Urinary Sphincter?

PURPOSE

We compared functional outcomes in patients who received an artificial urinary sphincter in the space of Retzius vs the same device placed at a high submuscular location.

MATERIALS AND METHODS

We reviewed a prospectively maintained database of patients who received an artificial urinary sphincter between July 2007 and December 2014. After cuff placement was completed via a perineal incision, a 61 to 70 cm H2O pressure regulating balloon was placed through a separate high scrotal incision in the space of Retzius or in a high submuscular tunnel. Demographics, perioperative comorbidities and functional outcomes were compared between the groups.

RESULTS

A total of 294 consecutive patients underwent artificial urinary sphincter placement. Mean followup was 23 months. Space of Retzius and high submuscular placement was performed in 140 (48%) and 154 patients (52%), respectively. Functional outcomes were similar between the groups, including the continence rate (defined as 0 or 1 pad daily) in 81% vs 88% (p = 0.11), the erosion rate in 9% vs 8% (p = 0.66) and the explantation rate in 10% vs 11% (p = 0.62). Artificial urinary sphincter revision for persistent incontinence was required in a similar proportion of the 2 groups (13% vs 8%, p = 0.16) with a comparable mean followup (24 vs 23 months, p = 0.30). Kaplan-Meier analysis revealed no difference between the groups in the rate of explantation (p = 0.70) or revision (p = 0.06).

CONCLUSIONS

High submuscular placement of a pressure regulating balloon at artificial urinary sphincter surgery is a safe, effective alternative with functional outcomes equivalent to those of traditional placement in the space of Retzius.

Deep Venous Thrombosis as a Complication of Reservoir Placement in Post-Prostatectomy Erectile Dysfunction and Urinary Incontinence Prosthetic Surgery

INTRODUCTION

In 2014, most radical surgery for carcinoma of the prostate, and often the bladder, is done with the robotic-assisted laparoscopic approach. While proponents argue that nerve sparing, blood loss, and recovery times are improved with the robotic-assisted approach, changes in postoperative pelvic anatomy have made subsequent placement of inflatable devices for erectile dysfunction and incontinence more difficult. Because of the obliteration of the space of Retzius and opening of the peritoneum, the classic placement of the reservoirs of these devices is compromised.

AIM

Ectopic reservoir placement has attempted to alleviate these problems, but reservoir migration and problematic locations of these reservoirs persist.

METHOD

We report two cases of deep venous thrombosis after reservoir placement for inflatable prosthetic devices.

MAIN OUTCOME MEASURE AND RESULTS

Patients may manifest these placement problems with symptoms of vascular compromise postoperatively.

CONCLUSION

Early identification and reservoir relocation can eliminate the vascular issues and maintain inflatable device function. Selph JP, McKim SE, Langston JP, and Carson CC. Deep venous thrombosis as a complication of reservoir placement in post-prostatectomy erectile dysfunction and urinary incontinence prosthetic surgery. Sex Med Rev 2014;2:59-63.