Long-term device survival and quality of life outcomes following artificial urinary sphincter placement

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.

A new adjustable artificial urinary sphincter for male stress urinary incontinence (VictoTM): preliminary clinical results

Background

Artificial urinary sphinkter (AUS) are still the gold standard for treatment of male stress urinary incontinence with good clinical outcomes and high patient's reported satisfaction rate. However, more than half of the patients with an AUS will require additional procedures, most likely revisions. To introduce a novel adjustable AUS for treatment of male stress urinary incontinence and perform a preliminary clinical investigation to determine the safety and efficacy of the device.

Methods

Men with urodynamically proven SUI following radical prostatectomy (RP), transurethral resection of prostate (TURP) and pelvic injuries were implanted with the Victo-AUS. Patients with three or more previous incontinence surgeries were excluded from the series. Patients were monitored over a mean follow up of 29 months (range, 13.7-47.9 months). The device was tested for efficacy by using objective measurements of urinary leakage and continence. We used validated questionnaires at baseline and clinical follow-ups. The key outcomes were overall improvement, patients reported satisfaction and complication rate.

Results

A total of 88 patients between December 2016 and December 2019 have been enrolled in this trial. Improvement was defined as a reduction in pad usage per day (p/d) over 50% compared to baseline. In total, 70 (88%) patients were reported to be improved. Treatment success according to the definition of 0-1 p/d was accomplished in 56 (70%) patients. Urethral erosion, infection or mechanical failure occurred in 4 (5%), 4 (5%) and 1 (1.3%) patient respectively. Explantation of the device was mandatory in 6 patients due to erosion, infection or mechanical failure.

Conclusions

In this series, a continence rate of 70% was achieved with an acceptable complication-rate. These results together with a high satisfaction rate demonstrate effectiveness and safety of the Victo system in mid-term follow-up for the treatment of male SUI.

Narrative patent review of penile clamp, artificial urinary sphincter, and sling innovation in the management of male stress urinary incontinence

Background and Objective

Stress urinary incontinence (SUI) is the involuntary loss of urine affecting 1-3% of the male population. To manage leakage, patients may try a plethora of penile clamps. and may even consider artificial urinary sphincters (AUS) or sling implantation. We aimed to synthesize the evolution of the modern clamp, AUS, and sling through a comprehensive patent search.

Methods

Patents were found through the databases of United States Patent and Trademark Office (USPTO), GooglePatents, and the World Intellectual Property Office Patentscope, covering patents published through January 6, 2024.

Key Content and Findings

We found 30 different patents (10 clamps, 13 AUS, and 7 slings), including the patents pertaining to the functionalities and design of five commercially available penile clamps, the American Medical System 800 (AMS 800), the InVance, AdVance, AdVance XP, and Virtue Slings. The clamps, spanning back to 1938 with Bard Cunningham's clamp, have undergone significant refinements. For example, inventors such as Edson S. Outwin and Juan F. V. Wiesner, have modified the location of the primary pressure point. Accessibility has also improved with inventors, such as Gerald French and John W. Timmons, fastening the clamps with Velcro®, as opposed to the screw and ratchet catch closing mechanism, as in Cunningham's clamp. Similarly, the AUS has greatly evolved since Foley's 1947 "Artificial Sphincter and Method", which was the primary AUS precedent to Mark Polyak's AUS invention, which covered the essential elements and functionalities, such as the incorporation of a balloon reservoir, for the AMS 800. In addressing AUS limitations, inventors such as David W. Anderson and Louisa Thomas have created non-hydraulic AUSs. Likewise, the male sling has seen an evolution in the method of securement, from the use of fixed bone anchors in the InVance sling to the transobturator route used in the AdVance XP, avoiding bone complications. Additionally, innovation in sling adjustment of urethral compression allows for adjustable urethral elevation and distal compression respectively. Recent patents have claimed technological integration for clamps, AUS, and slings, especially concerning automation.

Conclusions

Overall, patents have built upon the limitations of previous devices. However, there is still a need to innovate for increased clamp comfort and reduced reoperation rates for the AUS and sling.

Inguinal hernia repair in patients with artificial urinary sphincter after radical prostatectomy

PURPOSE

Stress urinary incontinence (UI) often develops after radical prostatectomy for prostate cancer, and in those patients with moderate-to-severe stress UI an artificial urinary sphincter (AUS) is implanted. Inguinal hernias (IHs) often occur after radical prostatectomy. As the prevalence of AUS implantation increases, it is possible to encounter patients with IHs undergoing AUS implantation (IHA). This study investigated our treatment and discussed an appropriate approach for IHAs.

METHODS

We retrospectively investigated patients who underwent IH repair with AUS implantation at our hospital from January 2018 to March 2023. We classified IHAs into Types A-D based on the positions of the IHs and AUS devices (the positions of the control pump, pressure-regulating balloon, and connecting tube). The hernia and control pump were ipsilateral in Types A and B, whereas the hernia and pressure-regulating balloon were ipsilateral in Types A and C.

RESULTS

This study included 12 IHs of 11 patients. The median patient age was 77 years. We conducted open repair in nine patients with all types and laparoscopic repair in two patients with Type B. The median operation times for unilateral and bilateral repairs were 96 and 182 min, respectively. There were no complications with AUS or hernia surgeries.

CONCLUSION

IHA has its own characteristics, and multidisciplinary knowledge thereof will help surgeons safely perform IH surgery.

ProACT™ (Uromedica, Plymouth, USA) balloons for male urinary incontinence: A fourteen-year-old cohort

BACKGROUND

Male urinary incontinence is attributed to SUI consecutive to benign prostate hypertrophy surgery, trauma, neurological diseases, or injury. Medical devices are developed to treat male urinary incontinence among them proACT® balloons. This technique was chosen in our center to achieve continence. Our study aims to evaluate safety and efficacy of proACT® balloons implanted in our center by measuring the rate of efficacy.

METHODS

We performed a retrospective and single centre study. A single expert surgeon performed all surgeries. Seventy-one balloons were implanted in 57 male patients between 2007 and 2020. Primary endpoint was the efficacy time lapse of the balloons after surgery. The analysis was performed using Kaplan-Meier method. Factors, which could affect the efficacy of the balloons, were analysed using a Cox regression analysis.

RESULTS

In all, 45 balloons successfully cured stress urinary incontinence among the 57 men implanted resulting in a 63.38% success rate. Twenty-six balloons failed to treat stress urinary incontinence and were retrieved out of the 71 implanted. Ten balloons failed to treat urinary stress incontinence without organic cause, 6 balloons deflated, 5 balloons migrated out of the initial implantation site, 2 eroded, and 3 ended up infected. Fifty percent of the balloons were successful for a median time of 95 months. Univariate analysis did not reveal any predictive factor of failure.

CONCLUSIONS

Our study showed 50% success rate at 95 months follow-up, therefore allowing a life expectancy of 7.9 years for the balloons. This safe mini-invasive technique ensured stress urinary incontinence in men.

LEVEL OF EVIDENCE: 4

Natural History of Artificial Urinary Sphincter Erosion: Long-term Lower Urinary Tract Outcomes and Incontinence Management

OBJECTIVE

To describe long-term lower urinary tract outcomes and incontinence management after AUS erosion, including risk factors associated with each outcome.

METHODS

We retrospectively reviewed our prospectively maintained AUS database for men undergoing device explantation for urethral erosion from January 1, 1986 to October 10, 2023. Outcomes included development of urethral stricture and management of post-explant incontinence (eg, pads/clamp, catheter, salvage AUS, supravesical diversion). Risk factors were tested for association with stricture formation and repeat AUS erosion using logistic regression.

RESULTS

Around 1943 unique patients underwent AUS implantation during the study period, and 217 (11%) had a device explantation for urethral erosion. Of these, 194 had complete records available and were included for analysis. Median follow-up from implantation was 7.5 years (IQR 2.7-13.7) and median time to erosion was 2 yrs (IQR 0-6). Ninety-six patients (49%) underwent salvage AUS placement. Of those, 38/96 (40%) were explanted for subsequent erosion. On multivariable analysis, no factors were significantly associated with risk of salvage AUS erosion. On multivariable model, pelvic radiation (OR 2.7; 95% CI 1.0-7.4) and urethral reapproximation during explant for erosion (OR 4.2; 95% CI 1.5-11.2) were significantly associated with increased risk of urethral stricture (P <.05). At the time of last follow-up, 69/194 (36%) patients had a functioning salvage AUS, including both initial and subsequent salvage implants.

CONCLUSION

Following AUS erosion, radiation history and urethral reapproximation at explantation were risk factors for development of urethral stricture. Salvage AUS replacement can be performed, but has a higher rate of repeat urethral erosion.

Artificial Urinary Sphincter Complications: A Narrative Review

Stress urinary incontinence is a financially burdensome and socially isolating problem and can be experienced by men as a result of radical prostatectomy, radiation therapy, or other urologic surgery. Artificial urinary sphincter (AUS) placement for stress urinary incontinence is considered the 'gold standard' for male stress urinary incontinence. While initially only placed by specialized prosthetic surgeons, changes in urologic training have made implantation of the device by general urologists more widespread. Additionally, even though a minority of urologists place the majority of implants, many urologists may find themselves caring for patients with these devices even if they have never placed them themselves. For this reason, it is paramount that the urologic surgeon implanting the device and those caring for patients with prostheses are familiar with the various perioperative and postoperative complications of AUS implantation. This review discusses the most commonly reported complications of AUS implantation as well as those that are rarely described. Knowledge of these potential complications is necessary in order to care for patients with urologic implants.

A modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for male stress urinary incontinence: a pilot study

OBJECTIVES

The aim of this study was to demonstrate the feasibility of a modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for the treatment of male urinary incontinence and to preliminarily evaluate the short-term clinical efficacy of this technique.

PATIENTS AND METHODS

The clinical data of patients treated with the modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique using a Pelvimesh pelvic floor repair patch as a sling were collected. The primary evaluation criteria were surgery-related indicators and daily urinal pad usage before and after treatment, and the secondary evaluation criteria were the corresponding incontinence scores and the results of surgery-related questionnaires.

RESULTS

After 1-12 months of follow-up, seven patients were clinically cured. Follow-up 1 month after surgery showed that one patient (14.3%) used one pad daily, and six patients (85.7%) did not need pads. The incontinence quality of life questionnaire (I-QOL) scores at 3 days and 1 month postoperatively were 89.4 ± 2.5 and 88.1 ± 6.7, respectively, which were significantly higher than the preoperative scores (31.5 ± 18.9) (P < 0.05). The scores of the International Continence Control Association Incontinence Questionnaire Short Form (ICI-Q-SF) at 3 days and 1 month postoperatively were 3.2 ± 0.9 and 4.2 ± 1.7, respectively, which were significantly lower than the preoperative scores of 19.4 ± 5.0 (P < 0.05). In addition, the results of the surgery-related questionnaires were positive. No serious complications occurred in any of the patients.

CONCLUSION

The modified sling mid-urethral suspension + subcutaneous tunnel-double point fixation technique for the treatment of male urinary incontinence patients is safe, effective, minimally invasive, and has few complications. However, further validation in large sample, randomized, comparative, and longer-term follow-up studies is still needed.

Modified Sling Midurethral Suspension+Hemolock Fixation Technique for Male Urinary Incontinence: A Pilot Study

OBJECTIVE

To demonstrate the feasibility of a modified midurethral sling+hemolock fixation technique for treating male urinary incontinence. This study aims to provide a preliminary assessment of the short-term clinical efficacy of this technique.

METHODS

We collected the clinical data of patients treated with modified sling midurethral suspension+ hemolock fixation technique. The primary evaluation criteria were surgery-related indicators and daily urinal pad usage by patients before and after treatment, and the secondary evaluation criteria were the corresponding incontinence scores and the results of surgery-related questionnaires.

RESULTS

Follow-up 1-7months, eight patients achieved a clinical cure. Follow-up 1month after surgery showed that two patients (25.0%) used one pad daily and six patients (75.0%) did not need pads. The incontinence quality of life questionnaire (I-QOL) scores were (86.0 ± 7.0) and (89.0 ± 3.0) at three postoperative days and one postoperative month, respectively, which were significantly higher than the preoperative scores (26.0 ± 6.0) (P <.05). The scores of the International Continence Control Association Incontinence Questionnaire Short Form (ICI-Q-SF) at three postoperative days and one postoperative month were (4.0 ± 2.0) and (4.0 ± 1.0), respectively, which were significantly lower than the preoperative scores of (18.0 ± 1.0) (P <.05). Besides, the results of the surgery-related questionnaires were positive.

CONCLUSION

The short-term efficacy of the modified sling midurethral suspension+ hemolock fixation technique for the treatment of male urinary incontinence patients is safe, effective, minimally invasive, and has few complications. However, further validation in large samples, randomized, comparative, and longer-term follow-up studies is still needed.

Management of urologic prosthetic reservoirs at the time of inguinal or pelvic surgery

INTRODUCTION

The artificial urinary sphincter and 3-piece inflatable penile prosthesis each require a fluid storage component and thus have components in the inguinal and pelvic regions. Because of this, patients with urologic prosthetics sometimes present challenges during future nonprosthetic operations. Presently, there is no established guideline for device management with ensuing inguinal or pelvic surgery.

AIMS

This article outlines concerns during pelvic and inguinal surgery for patients with an artificial urinary sphincter and/or inflatable penile prosthesis and proposes an algorithm for preoperative surgical planning and decision making.

METHODS

We conducted a narrative review of the literature on operative management of these prosthetic devices. Publications were identified by searching electronic databases. Only peer-reviewed publications available in English were considered for this review.

RESULTS

We review the important considerations as well as available options for operative management of these prosthetic devices during subsequent nonprosthetic surgery and highlight the advantages and disadvantages of each. Finally, we suggest a framework for helping surgeons determine which management strategy is most appropriate for their individual patients.

CONCLUSION

The best management strategy will differ depending on patient values, the planned surgery, and patient-specific factors. Surgeons should understand and counsel patients on all available options and encourage informed, shared decision making to determine the best individualized approach.

Does Medicaid cover artificial urinary sphincter and male urethral sling surgery?-a state-by-state analysis

Background

Information regarding the Medicaid coverage of artificial urinary sphincter (AUS) and male suburethral slings (MS) placement in the United States (US) is not readily available. In this manuscript, we seek to elucidate the state-by-state Medicaid coverage of these two procedures in the US.

Methods

State Medicaid websites were utilized to access publicly available physician fee schedules for the calendar year 2020. Fee schedules were searched for current procedural terminology (CPT) codes. CPT codes representing insertion of tandem cuff, insertion of AUS, removal of AUS, removal and replacement AUS, sling operation for correction of male stress urinary incontinence (SUI), and removal or revision of sling for male SUI were utilized. Data were recorded by the procedure for each device, including the coverage status and physician fees.

Results

Of the 50 US states analyzed, 49 publish publicly accessible physician fee schedules. All 49 of these states reported coverage for removal with and without revision of the AUS, and 48 states reported coverage for insertion of an AUS, and insertion of a tandem cuff. The median reimbursement for each AUS related procedure was $624.00 ($181.84-$10,960.90) for tandem cuff, $665.54 ($199.89-$11,949.86) for AUS insertion, $528.03 ($146.90-$1,893.12) for AUS removal, and $630.29 ($208.55-$11,586.74) for AUS revision. All 49 states reported coverage for placement of MS, and 48 states reported coverage for removal or revision of MS. The median reimbursement was $652.57 ($198.00-$5,237.35) for MS placement and $554.47 ($104.27-$2,288.93) for MS revision.

Conclusions

AUS and MS procedures in the Medicaid population are covered by nearly all states. Therefore, surgical treatment of SUI may be offered to Medicaid patients in most states without reimbursement concerns.

Simultaneous bladder augmentation and artificial urinary sphincter placement in children with neuropathic urinary incontinence. Is it safe to perform? Long-term results

INTRODUCTION

Simultaneous performance of artificial urinary sphincter (AUS) placement and bladder augmentation (BA) in patients with neuropathic bladder is currently controversial.

OBJECTIVE

The aim of this study is to describe our very long-term results after a median follow-up of 17 years.

STUDY DESIGN

A retrospective single-center case-control study was performed in patients with neuropathic bladder treated in our institution between 1994 and 2020, in whom AUS placement and BA were performed simultaneously (SIM group) or sequentially at different times (SEQ group). Demographic variables, hospital length of stay (LOS), long-term outcomes and postoperative complications were compared between both groups.

RESULTS

A total of 39 patients (21 males, 18 females) were included, with a median age of 14.3 years. BA and AUS were performed simultaneously at the same intervention in 27 patients, and sequentially in different interventions in 12 cases, with a median of 18 months between both surgeries. No demographics differences were observed. SIM group had a shorter median LOS when compared to SEQ group, considering the two sequential procedures (10 vs. 15 days; p = 0.032). Median follow-up was 17.2 years (interquartile range 10.3-23.9). Four postoperative complications were reported, 3 patients in SIM group and 1 case in SEQ group, with no statistically significant differences between them (p = 0.758). Adequate urinary continence was achieved in more than 90% of patients in both groups.

DISCUSSION

There are scarce recent studies comparing the combined performance of simultaneous or sequential AUS and BA in children with neuropathic bladder. The results of our study show a much lower postoperative infection rate than previously reported in the literature. It is a single-center analysis with a relatively small sample of patients although it is among the largest series published so far, and presents the longest long-term follow-up with more than 17 years of median follow-up time.

CONCLUSION

Simultaneous BA and AUS placement appears safe and efficacious in children with neuropathic bladder, with shorter LOS and no differences in postoperative complications or long-term outcomes when compared to performing the two procedures sequentially at different times.

Performance of the artificial urinary sphincter implantation in men with urinary incontinence: Results from a contemporary long-term real-world nationwide analysis

PURPOSE

The artificial urinary sphincter (AUS) is one of the most effective surgical treatments for male urinary incontinence regardless of its severity. Current knowledge comes from high-volume centers, but little is known about the performance of this surgery from community practices. This study aims to report contemporary AUS performance in a nationwide observational study in Colombia.

METHODS

Male patients who underwent AUS surgery with AMS 800™ between 2000 and 2020 in more than 17 centers and four cities were identified. Pre, intra, and postoperative characteristics were evaluated, mainly addressing patient reported outcomes measurements in the postoperative period. Retrospective and prospective data collection and descriptive analysis were completed. Kaplan-Meier analysis was used to determine AUS survival rate.

RESULTS

Out of an initial 667 cases, a total of 215 patients met inclusion and exclusion criteria and were included. Mean age was 67 ± 9.4 years, and mean follow-up was 6.0 ± 4.4 years with maximum range of 14 years. The etiology of urinary incontinence was prostate cancer surgery in 141 (81%) of the cases. The rest of the cases were related to benign prostatic disease or spinal cord injury. It is noteworthy that out of 115 patients, only 59 (51.3%) reported previous formal pelvic floor rehabilitation. Subjective severity of urinary incontinence determined by a visual analog scale showed a decrease in 4.5 points after sphincter implantation. Sphincter removal was required in 50 (23.2%) cases. The main reasons for implant removal were urethral erosion and infection. The sphincter survival rate at 2, 5, 8, 10, and 14 years was 76%, 70%, 60%, 57%, and 17%, respectively. Of the subjects at the last follow-up with the device still in place, 80.7% defined their urinary condition as "does not cause or causes minor discomfort," and 99% would recommend the device to a friend or relative in the same condition.

CONCLUSIONS

This series from a community-based practice shows the lack of adherence to clinical practice guidelines and the lack of standardized data collection. In contrast, this study provides real-world data on explantation and revision rates, allows physicians to inform patients and to have clear metrics for a shared decision-making process before the procedure.

Artificial urinary sphincter in congenital neuropathic bladder: Very long-term outcomes

OBJECTIVE

Artificial urinary sphincter has been used to treat urinary incontinence in children with neuropathic bladder, although there are few studies reporting very long-term results. We assess our experience over the last 27 years in the management of artificial urinary sphincter.

METHODS

A retrospective study was performed in patients with neuropathic bladder in whom an artificial urinary sphincter was placed in our institution between 1994 and 2020. Demographic variables, pre- and post-artificial urinary sphincter implantation urodynamic studies, long-term outcomes, and postoperative complications were collected.

RESULTS

An artificial urinary sphincter was implanted in 71 patients (median age 14.5; interquartile range 12.8-15.9), with a median follow-up time of 17.2 years (interquartile range 9.8-23.9 years). Thirty-nine patients underwent enterocystoplasty combined with artificial urinary sphincter placement and 32 underwent artificial urinary sphincter implantation alone, of whom 12 patients (16.9%) eventually required an enterocystoplasty because of unexpected bladder behavior changes, usually within 3 years of artificial urinary sphincter implantation. Adequate urinary continence was reported in 90.1% of patients, nine void their bladders spontaneously, and 62 need clean intermittent catheterization. Eighteen mechanical malfunctions occurred in 15 patients (21.1%), with an average artificial urinary sphincter working life of 15.1 ± 1.3 years. In five patients artificial urinary sphincter was removed due to infection or erosion. In 12 patients (30.8%), a continent catheterizable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterization through the urethra.

CONCLUSION

The very long-term results of this study demonstrate that artificial urinary sphincter is an effective treatment for urinary incontinence in neuropathic bladder patients. Long-term follow-up is important to identify potential unexpected changes in bladder behavior in these patients.

Efficacy and safety of intradetrusor botulinum toxin injections for idiopathic overactive bladder syndrome in patients with an artificial urinary sphincter

PURPOSE

To assess the efficacy and safety of intradetrusor botulinum toxin type A injections (IBTI) for idiopathic overactive bladder (iOAB) in non-neurological adults with an artificial urinary sphincter (AUS).

MATERIALS AND METHODS

We retrospectively selected, in the 11 French centers, members of a collaborative network (GENULF (Groupe d'étude de neuro-urologie de langue francaise)), the patients who had had an artificial urinary sphincter implantation and who had subsequently developed iOAB requiring IBTI. This study was approved by the French association of urology ethics committee (no 2018012).

RESULTS

Between 2006 and 2020, 33 patients were included from 5 French centers. Mean follow-up after the first IBTI was 47 months. The average age of the studied population was 68 years, with 70% of females. A complete resolution of symptoms at optimal IBTI dose was experienced by 21 (64%) patients. Seven (21%) patients had partial improvement. Five non-responder patients (15%) had no improvement at all. Maximum cystometric bladder capacity was 240 ml pre-IBTI and 335 ml post IBTI. Discontinuation free survival at 60 months was 50%. Two erosions occurred during the 6 months following an IBTI both in male patients with a perineal implantation. There were four AUS balloon perforations that occurred during the 6 months following an IBTI, all of them in female patients.

CONCLUSIONS

IBTI has a good efficacy for the treatment of iOAB in patients with an AUS. However, both patients and practicians must be aware of the risk of rare and usually mild complications.

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.

Artificial urinary sphincter or a second adjustable transobturator male system offer equivalent outcomes in patients whom required revision on the initial ATOMS device: An international multi-institutional experience

AIM

To evaluate treatment options after surgical revision of adjustable transobturator male system (ATOMS) and the results of further incontinence implantation.

MATERIALS AND METHODS

A retrospective multicenter study evaluating patients with surgical revision of ATOMS in academic institutions. Causes and factors affecting revision-free interval were studied and also the frequency of device explant and placement of second ATOMS or artificial urinary sphincter (AUS) at surgeon discretion. Operative results, complications (Clavien-Dindo), and efficacy (postoperative pad-test, pad-count, patient satisfaction, and patient global impression of improvement [PGI-I scale]) of each treatment option were compared.

RESULTS

Seventy-eight out of 902 patients (8.65%) with ATOMS underwent surgical revision at 4.1 ± 2.4 years mean follow-up and 75 (8.3%) were explanted. The main causes for revision included persistence of incontinence (35.9%) and scrotal port erosion (34.6%). Independent risk factors of the shortened revision-free interval were previous anti-incontinence surgery (HR, 1.83; 95% CI, 1.06-3.16; p = 0.007) and port erosion (HR, 1.83; 95% CI, 1.06-3.16; p = 0.0027). Fifty-eight (6.4%) received a second implant: 31 repeated ATOMS and 27 AUS. Operative time was longer for AUS (p = .003). The visual analog scale of pain at hospital discharge (p = 0.837) and postoperative complications (p = 0.154) were equivalent. The predominant cuff size for AUS was 4.5 cm (59.3%). Mean follow-up after the second implant was 29.1 ± 25.8 months. Postoperative efficacy of secondary treatment results favored ATOMS based on pad-test (p = 0.016), pad-count (p = 0.029), patient satisfaction (p = 0.04), and PGI-I (p = 0.025).

CONCLUSIONS

ATOMS surgical revision due to different reasons generally leads to device explant. Rescue treatment is possible with ATOMS or AUS. No difference in postoperative complications was detected between secondary devices, but efficacy favors repeating ATOMS implantation.

[Survival analysis of adjustable continence therapy device (ACT®/proACT®): a new message for patients]

INTRODUCTION

The main purpose was to assess the failure free survival of adjustable continence therapy ACT®/proACT® after continence was obtained and to seek factors influencing it.

MATERIAL AND METHODS

Retrospective, single-center survival study of peri-urethral balloons implanted between 2007 and 2014. Efficacy was defined by the wearing of 0 or 1 safety pad per day. The primary end point was time to failure estimated from a survival curve (Kaplan-Meier). Factors that could influence failure free survival were: sex, age, radiotherapy, diabetes, number of pad before surgery, number of balloon inflation, early complications, mixed urinary incontinence and previous ACT®/proACT® placement. They were analyzed in a COX regression.

RESULTS

Of the 82 peri-urethral balloons placed, 41 were effective in 36 patients. The failure free survival was 50 % at 60 months. Radiotherapy, diabetes and previous peri-urethral balloon placement appeared to significantly decrease survival (P=0.031;P=0.025;P=0.029, respectively). Fifteen peri-urethral balloons were still effective at the last follow-up, one was lost to follow-up and 25 required re-intervention for loss of efficacy. The main cause of efficacy loss was system leakage. Fifty-two percent of peri-urethral balloons that became ineffective were replaced by new peri-urethral balloons and 28% by an artificial urinary sphincter.

CONCLUSION

Patients who became continent with adjustable continence therapy (ACT®/proACT®) had a 50 % new surgery probability at 5 years for a loss of efficacy. Radiotherapy seems to be the main risk factor of the efficacy loss.

LEVEL OF EVIDENCE

IV.

Artificial urinary sphincter significantly better than fixed sling for moderate post-prostatectomy stress urinary incontinence: a propensity score-matched study

OBJECTIVE

To compare the efficacy of artificial urinary sphincter (AUS) vs retrourethral transobturator sling (RTS) in men with moderate post-prostatectomy urinary incontinence (PPI) using propensity score-matching analysis to enhance the validity of the comparison (Canadian Task Force classification II-2).

PATIENTS AND METHODS

Consecutive men with moderate (3-5 pads/day) stress-prevalent PPI were included if implanted with a RTS (TiLOOP^® Male; pfm medical, Köln, Germany) or AUS (AMS800^® ; Boston Scientific, Boston, MA, USA) since July 2011 to December 2017 and with ≥12 months of follow-up. Preoperative assessment included 24-h pad usage, International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), urethrocystoscopy, and urodynamics if indicated. Propensity score-matching analysis was based on age, body mass index, Charlson Comorbidity Index, pad usage, previous radiotherapy, and urethrotomy. The primary outcome was at least 'much improved' response at 12-months according to the Patient Global Impression of Improvement questionnaire, without additional PPI surgery or prosthesis explantation.

RESULTS

Of 109 included patients, 70 patients were matched and the study groups were well balanced for the baseline matched variables. The median baseline 24-h pad usage was four in both groups (P = 0.10), and median follow-up was 51.2 months for AUS and 47.2 months (P = 0.5) for RTS patients. In the AUS and RTS cohorts, respectively, 33 (94.3%) and 24 (68.6%) patients achieved the primary outcome (P < 0.001), the 0-1 pad/day rates was 94.3% vs 68.6% (P = 0.012) at 12 months, and 91.4% vs 68.6% (P = 0.034) at last follow-up. At the last follow-up, the median 24-h leakage volumes, median ICIQ-SF scores and satisfaction rates were 0 vs 15 mL (P = 0.017), 4 vs 10 (P = 0.001), and 94.3% vs 68.6% (P = 0.012) in the AUS and RTS cohorts, respectively. There were no significant differences in overall rates of complications and re-interventions, although Clavien-Dindo Grade III complications (n = 3) occurred only in the AUS group. At sensitivity analysis, the study was reasonably robust to hidden bias.

CONCLUSION

We found that AUS implantation significantly outperformed RTS in patients with moderate PPI for both subjective and objective outcomes.

World record: Single AMS 800 artificial urinary sphincter functioning uninterrupted for 29 years in male paraplegic patient

Lapides has revolutionized the treatment of neurogenic patients by introducing routine intermittent catheterization in 1971. This drastically lowered mortality from urosepsis. Scott introduced the artificial urinary sphincter (AUS) in 1972. This gave a completely new perspective for incontinent patients by dramatically increasing the quality of life. In patients with neurogenic urinary incontinence, the principles of care are preserving renal function, maintaining a low-pressure reservoir, allowing unobstructed urine flow and providing continence. We describe a male patient that received an AUS with a bladder neck cuff that functioned without revision for 29 years. After 30 years, AUS exchange proved successful.