New Enhancements of the Scrotal One-Incision Technique for Placement of Artificial Urinary Sphincter Allow Proximal Cuff Placement

[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.

Pain Management Strategies in Contemporary Penile Implant Recipients

PURPOSE OF REVIEW

To review the most recent literature citing opioid-sparing multimodal analgesic strategies used to manage perioperative pain in patients who underwent inflatable penile prosthesis (IPP) surgery and to provide the penile implant surgeon a variety of non-opioid-based pain management strategies for IPP management.

RECENT FINDINGS

Interventions performed in the pre-operative, intraoperative, and post-operative arenas have all been shown to effectively lower pain scores and reduce opioid consumption. Certain surgical techniques performed during IPP surgery have helped with post-operative discomfort patients may feel after surgery. Multimodal analgesia (MMA) protocols adopted from other surgical fields and other urologic subspecialties that are implemented in IPP surgery have promising results with regard to post-operative pain control and opioid consumption. Protocols that implement a combination of refined surgical technique and multimodal analgesia offer substantial benefit to patients undergoing IPP surgery. Further work is needed to assess long-term pain control and opioid use in patients that undergo IPP surgery using these innovative strategies.

[REPARATIVE SURGERY OF PRESSURE-REGULATING BALLOON HERNIA AFTER ARTIFICIAL URINARY SPHINCTER REPLACEMENT: A CASE REPORT]

A 74-year-old male with post-prostatectomy incontinence underwent artificial urinary sphincter replacement due to device malfunction. Three months after the replacement surgery, he presented for a consultation due to a bulging area in his lower abdomen. Computed tomography revealed a hernia of the pressure-regulating balloon (PRB), while the device was working well. In the reparative surgery, reopening the lower abdominal incision, the PRB was carefully restored to its previous position after creating a sufficient submuscular space. As the rectus abdominis fascia showed an adequate strength, the fascia was tightly sutured without using a prosthetic mesh. Thereafter, the patient has been free from incontinence for two and a half years without hernia recurrence. Given the mechanical nature of the device, replacement surgery is sometimes required over time. Tissue fragility due to repetitive surgeries and increasing ambient pressure due to space reduction derived from the PRB deflation could cause PRB hernia. Such cases can be treated under careful manipulation without damaging the device. Considering the future potential need for repeated surgery, it would be preferable not to use prosthetic mesh, as it can cause dense adhesion.

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.

Synchronous surgery for the combined treatment of post-radical prostatectomy erectile dysfunction and stress urinary incontinence: a lucrative evolution or an unnecessary complexity?

Aim of this review is to summarize and evaluate the current literature addressing the synchronous combined surgical treatment approach for co-existent post-radical prostatectomy erectile dysfunction and stress urinary incontinence. Severity of stress urinary incontinence is the basic element that defines which option of combined surgery will be offered to a patient. So, for cases of severe erectile dysfunction and severe stress urinary incontinence (>4 pads/day) the only available option is synchronous inflatable penile prosthesis plus artificial urinary sphincter dual implantation. When severe erectile dysfunction coexist with mild to moderate stress urinary incontinence synchronous inflatable penile prosthesis plus male sling or ProAct (Uromedica, Plymouth, MN, USA) device are the current available treatment options. Finally, when severe erectile dysfunction along with mild stress urinary incontinence and with or without climacturia are present, a new surgical technique of simultaneous inflatable penile prosthesis plus urethral mini-sling, named "Andrianne mini-jupette", implantation has been recently proposed. Synchronous combined surgery for post-radical prostatectomy erectile dysfunction and stress urinary incontinence seems to offer similar efficacy and safety results compared with two-stage implantation but in a more cost- and time effective approach. Thus, synchronous surgery, in the hands of experienced prosthetic surgeons, could be potentially a valuable alternative for the management of co-existent post-radical prostatectomy erectile dysfunction and stress urinary incontinence. Nevertheless, in order to acquire robust scientific data further prospective comparative studies on larger numbers of patients are surely needed.

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.

Four-year follow-up on a Zephyr Surgical Implants 375 artificial urinary sphincter for male urinary incontinence from one urological centre in Poland

Introduction

The treatment of choice for patients who have iatrogenic urinary incontinence is the implantation of an artificial urinary sphincter. We performed a prospective study on the outcomes of men undergoing artificial urinary sphincter (AUS) implantation (ZSI 375; Zephyr Surgical Implants, Geneva, Switzerland).

Material and methods

Patients with moderate-to-severe stress incontinence urinary were included. The ZSI 375 device is a one-piece device with a cuff and a pump unit. Patients underwent a perineal incision for cuff insertion and an inguinal incision for the pump unit to be placed in the scrotum. Complications and number of pads used to manage incontinence were recorded. Perioperative complications were categorized according to the Clavien-Dindo classification. Pain connected with implantation of AUS was assessed with the visual analogue scale (VAS).

Results

Between July 2013 and June 2017, 50 patients underwent ZSI 375 device insertion in the Department of Urology and Urological Oncology in Puławy, Poland. The follow-up stopped at the end of September 2017. The median (range) follow-up was 21.04 (1-50) months. No patient experienced bladder hyperactivity. Complications leading to a revision or permanent device removal arose in 12 patients (erosion = 9, infection = 0, mechanical failure = 3). Social continence (0 or 1 pad/day) was achieved in 29/50 patients (58%). An improvement (50% less pads/day) was achieved in 15/50 patients (30%). A failure was seen in 6/50 patients (12%). Perioperatively, all patients were classified as grade I in the Clavien-Dindo classification. Mean value of pain intensity in VAS was 0.82.

Conclusions

The ZSI 375 device is safe, effective and the follow-up period was long enough to identify all potential complications.

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™.

Management of end-stage erectile dysfunction and stress urinary incontinence after radical prostatectomy by simultaneous dual implantation using a single trans-scrotal incision: surgical technique and outcomes

Stress urinary incontinence (SUI) and end-stage erectile dysfunction (ED) after radical prostatectomy (RP) can decrease a patient's quality of life (QoL). We describe a surgical technique involving scrotal incision for simultaneous dual implantation of an artificial urinary sphincter (AUS) and an inflatable penile prosthesis (IPP). Patients with moderate to severe SUI (>3 pads per day) and end-stage ED following RP were selected for dual implantation. An upper transverse scrotal incision was made, followed by bulbar urethra dissection and AUS cuff placement. Through the same incision, the corpora cavernosa was exposed, and an IPP positioned. Followed by extraperitoneal reservoirs placement and pumps introduced in the scrotum. Short-term, intra- and post-operative complications; continence status and erectile function; and patient satisfaction and QoL were recorded. A total of 32 patients underwent dual implantation. Early AUS-related complications were: AUS reservoir migration and urethral erosion. One case of distal corporal extrusion occurred. No prosthetic infection was reported. Over 96% of patients were socially the continent (≤1 pad per day) and > 95% had sufficient erections for intercourse. Limitations of the study were the small number of patients, the lack of the control group using a perineal approach for AUS placement and only a 12 months follow-up. IPP and AUS dual implantation using a single scrotal incision technique is a safe and effective option in patients with SUI and ED after RP. Further studies on larger numbers of patients are warranted.

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.

Simultaneous penile prosthesis and male sling/artificial urinary sphincter

Erectile dysfunction (ED) and stress urinary incontinence (SUI) from urethral sphincteric deficiency is not an uncommon problem. The commonest etiology is intervention for localized prostate cancer and/or radical cystoprostatectomy for muscle invasive bladder cancer. Despite advances in surgical technology with robotic assisted laparoscopic prostatectomy and nerve sparing techniques, the rates of ED and SUI remain relatively unchanged. They both impact greatly on quality of life domains and have been associated with poor performance outcomes. Both the artificial urinary sphincter and penile prosthesis are gold standard treatments with proven efficacy, satisfaction and durability for end-stage SUI and ED respectively. Simultaneous prosthesis implantation for concurrent conditions has been well described, mostly in small retrospective series. The uptake of combination surgery has been slow due in part to technical demands of the surgery and to an extent, a heightened anxiety over potential complications. This paper aims to discuss the technical aspect of concurrent surgery for both disease entity and the current published outcomes of the various surgical techniques with this approach.

ZSI 375 artificial urinary sphincter for male urinary incontinence: a preliminary study

OBJECTIVE

To assess retrospectively the safety and efficacy of an artificial urinary sphincter, the ZSI 375 device (Zephyr Surgical Implants, Geneva, Switzerland), in male patients with moderate-to-severe stress urinary incontinence after a prostate or bladder intervention.

PATIENTS AND METHODS

The ZSI 375 device is a one-piece device consisting of an adjustable cuff, moulded to fit around the urethra, which is connected by a tube to a pump and a pressure-regulating tank. It has no abdominal reservoir. Patients underwent a perineal incision for cuff placement and an inguinal incision for pump and tank scrotal placement. Complications and pads used to manage incontinence were recorded.

RESULTS

Between May 2009 and April 2011, 36 patients underwent ZSI 375 device placement. The median (range) follow-up was 15.4 (6-28) months. No patient experienced bladder overactivity, chronic urinary retention, or any other adverse effect after device activation. Complications leading to device removal arose in four patients (one case of erosion, three cases of infection). Social continence (0 or 1 pad/day) was achieved in 28/36 patients (78%) at 3 months and 26/36 patients (73%) at 6 months after device activation. In 12/14 patients for a sphincter closure pressure range of 60-70 cm H2O, in 3/3 patients for a range of 70-80 cm H2O and in 2/11 for a range of 90-100 cm, H2O social continence was achieved only after increasing the pressure of the cuff by trans-scrotal injection of saline.

CONCLUSIONS

The ZSI 375 device is safe and effective but our follow-up may not have been long enough to identify all potential complications. Further research is needed to confirm these results and extend our investigation, for instance, to the peno-scrotal approach.

Dual implantation of artificial urinary sphincter and inflatable penile prostheses for concurrent male urinary incontinence and erectile dysfunction

Erectile dysfunction and urinary incontinence secondary to sphincter dysfunction are common conditions affecting many men worldwide with a negative effect on quality of life. They are encountered in a number of etiologies most commonly following radical prostatectomy in which they coexist in the same patient. Implantations of an artificial urinary sphincter and inflatable penile prosthesis have proven to be effective in the treatment of both conditions should conservative and minimally invasive measures fail. The recent literature has shown that dual implantation of these devices is feasible and safe with a durable clinical outcome. Once indicated, this can be done in a synchronous or nonsynchronous manner; however, the emerging of the single transverse scrotal incision as well as advancement in the prostheses has made synchronous dual implantation more favourable and appealing option. It provides time and cost savings with an evidence of high patient satisfaction. Synchronous dual implantation should be offered initially when indicated. This paper discusses the surgical techniques of artificial urinary sphincter and inflatable penile prosthesis dual implantation in the management of concurrent moderate-to-severe urinary incontinence and medically refractive erectile dysfunction, in addition to highlighting the existing literature pertaining to this approach.