Inflatable penile prosthesis placement after prior transcorporal artificial urinary sphincter placement: A case report

Stress urinary incontinence and erectile dysfunction often coexist in men surgically treated for prostate cancer. Despite many men having both an artificial urinary sphincter and inflatable penile prosthesis to treat these conditions, there is limited information in the literature to guide surgeons when it comes to placing both devices. We recommend obtaining direct exposure of proximal crura to allow for complete dilation of corporal spaces for proper prosthetic placement. Further dissection via penoscrotal incision or perineal counter-incision can be utilized. Surgeons should consider dorsal lithotomy position at time of IPP placement to allow for perineal exposure.

Female LUTS adaptations to COVID era: Lessons learned from the ICS TURNOVER (Transition of fUnctional uRology to New COVID ERa)

Introduction

The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients' quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS.

Methods

The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0-10. Consensus achievement was defined as attaining ≥ 70% agreement.

Results

98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or β 3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities' guidance.

Conclusions

During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

Autologous versus synthetic slings in female stress urinary incontinence: A retrospective study

Objective

To evaluate and compare the clinical (patient’s morbidity, quality of life [QoL]) and economic impact of autologous vs synthetic slings in female stress urinary incontinence (SUI), as over the last decade, the introduction of synthetic vaginal tapes for managing SUI has gained wide acceptance being quicker with low morbidity. Synthetic vaginal tapes have been progressively replacing the use of autologous rectus fascia. However, the high cost of these synthetic tapes is almost always an obstacle for most patients of limited socio-economic resources in the Egyptian community.

Patients and methods

This retrospective study included 126 women with SUI. Data for patients that matched the study inclusion criteria were collected from the Urology Department of Ain-Shams University Hospitals from March 2011 to May 2013. Patients were categorised into two groups: Group I included 62 patients who underwent an autologous sling procedure using rectus sheath; and Group II included 64 patients that had a synthetic sling, using transobturator tape (TOT). The following variables were compared: operative time, postoperative pain scores, duration of indwelling urethral catheter, hospital stay, cost including the price of the synthetic tape when used, return to normal activity, and QoL assessment (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form [ICIQ-UI-SF]) before and after discharge from hospital.

Results

Patients amongst the two groups were normally distributed with no statistically significant differences in patient’s demographic data and comorbidities. The mean hospital stay was longer and the return to normal activity was delayed in Group I compared to Group II. The highest mean postoperative pain score was recorded in Group I. The overall morbidity was 12.9% and 4.68% in groups I and II, respectively. The mean (SD) overall cost was 2571.65 (254.8) and 3502.34 (196.9) Egyptian pounds (local currency) in groups I and II, respectively, being insignificantly lower in Group I when compared to Group II (P > 0.05). There were statistically significant differences between groups I and II for operative time, hospital stay, and postoperative pain scores. However, the differences in hospital cost amongst Group I and Group II were in favour of Group I. Post-surgical outcome was categorised into either complete cure (dry) or improved or failed with no significant differences in success rate and QoL amongst the study groups. The mean (SD) change in the QoL score was 10.95 (4.19) and 12.32 (4.1) in groups I and II, respectively. The higher success rate (complete cure) was in Group II, at 93.75%. Also, a statistically significant improvement of >70% of mean ICIQ-UI-SF score was shown in all groups when compared to baseline on both the 1- and 6-month follow-up visits.

Conclusion

Autologous grafts should be considered as a repair option in females with SUI in countries were health insurance policies do not cover the cost of synthetic materials in many instances. The cost-effectiveness of synthetic TOT slings, as a minimally invasive procedure with lower overall morbidity, has yet to be confirmed in larger scale studies with longer periods of follow-up, to confirm the durability of its successful outcomes and be considered as the primary treatment of choice in female SUI.

Use of surgeon-tailored polypropylene mesh as a needle-less single-incision sling for treating female stress urinary incontinence: Preliminary results

OBJECTIVE

To evaluate the safety and efficacy of a procedure using surgeon-tailored polypropylene mesh (STM) through a needle-less single-incision technique for treating stress urinary incontinence (SUI), aiming to decrease the cost of treatment, which is important in developing countries.

PATIENTS AND METHODS

In all, 43 women diagnosed using a cough stress test were treated from January 2011 to June 2013 at the Urology and Gynaecology Departments (dual-centre), Cairo University Hospitals. Previous surgery was not a contra-indication. Patients with a postvoid residual urine volume of >100 mL, a bladder capacity of <300 mL, impaired compliance or neurological lesions were excluded. The Stress and Urge incontinence Quality of life Questionnaire (SUIQQ) and urodynamic variables were compared before and after surgery. The variables were compared between the baseline and postoperative follow-up values using a paired t-test, a Wilcoxon signed-rank test or McNemar's test.

RESULTS

The mean age was 42.7 years and 20 (47%) patients had associated urgency UI (UUI), whilst 21 (49%) had intrinsic sphincter deficiency. The median (range) operative duration was 14 (5-35) min. There were no complications during surgery. The mean (SD, range) follow-up was 28.1 (5.1, 18-36) months. Postoperative complications were vaginal discharge (5%), failure of wound healing (5%), dyspareunia (5%) and UTI (5%). The sling was removed in one case. SUI, UUI and quality-of-life indices improved significantly after surgery. There were no significant differences in pressure-flow studies before and after surgery. In all, 38 (88%) patients were cured, four (9%) improved and in one only the treatment failed (2%).

CONCLUSION

This technique is simple, safe, effective, reproducible and economical for treating SUI. The STM was easy to insert in a short operation.

3-year results of transvaginal cystocele repair with transobturator four-arm mesh: A prospective study of 105 patients

OBJECTIVES

To evaluate the long-term efficacy and safety of transobturator four-arm mesh for treating cystoceles.

PATIENTS AND METHODS

In this prospective study, 105 patients had a cystocele corrected between January 2004 and December 2008. All patients had a symptomatic cystocele of stage ⩾2 according to the Baden-Walker halfway stratification. We used only the transobturator four-arm mesh kit (Surgimesh®, Aspide Medical, France). All surgical procedures were carried out by the same experienced surgeon. The patients' characteristics and surgical variables were recorded prospectively. The anatomical outcome, as measured by a physical examination and postoperative stratification of prolapse, and functional outcome, as assessed by a questionnaire derived from the French equivalents of the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire and the Pelvic Organ Prolapse-Urinary Incontinence-Sexual Questionnaire, were considered as the primary outcome measures. Peri- and postoperative complications constituted the secondary outcome measures.

RESULTS

At 36 months after surgery the anatomical success rate (stage 0 or 1) was 93%. On a functional level, all the scores of quality of life and sexuality were improved. The overall satisfaction score (visual analogue scale) was 71.4%. There were no perioperative adverse events. Mesh erosion was reported in 7.6% and mesh retraction in 5.7% of the patients.

CONCLUSIONS

If the guidelines and precautions are followed, vaginal prosthetic surgery for genitourinary prolapse has shown long-term benefits. It provides excellent results both anatomically and functionally. However, complications are not negligible and some are specific to prosthetic surgery.

The first Iraqi experience with the rectus fascia sling and transobturator tape for female stress incontinence: A randomised trial

Objectives

To present the first experience in Iraq of autologous rectus fascia sling (RFS) procedures and transobturator tape (TOT) for treating female stress urinary incontinence (SUI), and to review the validity of the RFS in the era of synthetic tapes.

Patients and methods

From December 2004 to July 2012, 80 female patients with SUI were enrolled in the study, and randomly assigned into two types of surgery, with 40 treated by RFS (retropubic route) and 40 by TOT. The surgical results were compared between the groups and with those from previous studies.

Results

The mean operative duration was 80 min for RFS vs. 20 min for TOT. The early cure rate was 98% for RFS (with one failure due to prolonged urinary retention) and 95% for TOT (with two failures due to persistent incontinence). The early complications were mainly abdominal wound problems (20%) for RFS, and groin and upper thigh pain (13%) for TOT. The late complications were the development of postvoid residual urine (8% in RFS vs. 5% in TOT) and de novo detrusor overactivity (5% in each group). There were no vaginal or urethral erosions up to the end of the study.

Conclusions

RFS and TOT have comparable efficacy and safety in treating SUI. Nevertheless RFS, with its more invasive nature and long operative duration, should only be used when synthetic tapes are not available or not preferable.

Male incontinence and the transobturator approach: An analysis of current outcomes

Objectives

To provide an analysis of the outcomes in patients who have a suburethral sling placed using the transobturator approach for the treatment of stress urinary incontinence after radical prostatectomy, because data in this specific area remain limited, and recent changes in male sling surgery might improve the efficacy in men with moderate or mild incontinence.

Methods

We evaluated the results of transobturator non-adjustable and re-adjustable sling systems after reviewing previous reports identified using the Medline and PubMed databases for original articles, from 2002 to 2012, using the terms ‘postoperative male incontinence’, ‘transobturator’ and ‘male sling’. Of a total of 31 articles, we reviewed the 22 related to the outcomes of the suburethral sling with positioning by the transobturator approach.

Results

Currently the only results of the transobturator approach are those relating to the AdVance™ device (American Medical Systems, Minnetonka, MN, USA), for which the cure rate is ≈ 60% at 20 months. The remaining devices, although innovative, were assessed in studies for which the follow-up was too short to make a judgement.

Conclusions

It would be advisable to reserve the transobturator approach for patients with mild and moderate incontinence, and refer those with severe incontinence, with or without adjuvant radiotherapy after radical prostatectomy, for treatment with an artificial urinary sphincter. More results and a long-term follow-up are needed to evaluate the effectiveness of these devices.

Different urodynamic patterns in female bladder outlet obstruction: Can urodynamics alone reach the diagnosis?

Objective

To define the different urodynamic patterns in female bladder outlet obstruction (BOO) and to assess whether urodynamics alone can be relied on for the diagnosis.

Patients and methods

This prospective study included 60 clinically obstructed women and 27 with stress urinary incontinence as a control group. All patients had pressure-flow studies and were divided into four groups. Group A (control group, 27 patients) and group B (22) had a maximum urinary flow rate (Q_max) of >15 mL/s and a detrusor pressure at Q_max (P_detQ_max) of <30 or >30 cm H₂O, respectively. Group C (20 patients) and group D (18) had a Q_max of <15 mL/s and a P_detQ_max of >30 or <30 cm H₂O, respectively.

Results

The mean Q_max for groups A, B, C, and D were 21.8, 21.9, 10.8 and 9.9 mL/s, respectively, while the mean P_detQ_max was 20.8, 40.4, 48.7, and 18.7 cm H₂O, respectively. The residual urine volume was <100 mL in groups A and B but >100 mL in groups C and D. When compared with group A, groups B–D had a significant difference in vesical pressure, groups B and C had a significant difference in P_detQ_max, while Q_max, the maximum voided volume and residual urine volume were significantly different in groups C and D. Group A was obviously unobstructed, group B might have early obstruction, group C had compensated obstruction, while group D can be considered to have late de-compensated obstruction.

Conclusions

BOO in females has three different urodynamic patterns, i.e. early, compensated and late obstruction. However, urodynamics should be combined with the clinical presentation and residual urine volume for an accurate diagnosis.

The fate of synthetic mid-urethral slings in 2013: A turning point

INTRODUCTION

Since the introduction of the first retropubic tension-free synthetic sling to treat stress urinary incontinence (SUI), newer approaches, different techniques and new devices have been created. Transobturator and single-incision sling (SIS) techniquespara-were developed with the goal of diminishing the rate of complications andspeeding the recovery phase.

METHODS

For this review we searched Medline for relevant papers, with an emphasis on meta-analysis and randomised controlled trials (RCTs). Specially selected reports were identified to address both 'index patients' (defined as those with genuine SUI and no previous anti-incontinence procedure or other genitourinary sign or symptom that might affect her SUI) and, briefly, non-index patients. Two authors independently reviewed papers for eligibility.

RESULTS

Level 1 evidence from a Cochrane review and two meta-analyses indicated that subjective outcomes with the mid-urethral sling (MUS) were similar to those from colposuspension. However, the MUS was better than colposuspension when assessing objective outcomes (Level 1). MUS are equally effective as autologous pubovaginal slings (Level1). Two meta-analyses suggest that retropubic MUS (RMUS) might be better than transobturator MUS when assessing objective outcomes. Five more recent RCTs with longer term outcomes showed high success rates and only one reported a significant advantage for the RMUS in women with intrinsic sphincteric deficiency. One meta-analysis addressing the SIS showed inferior outcomes to the MUS (Level 1). New and improved SIS techniques have been used, but long-term outcomes are limited and results are still controversial when compared to the MUS.

CONCLUSION

MUS are still the standard to treat the index patient as previously stated by the American and European Associations of Urology. Currently data are lacking to define which sling and what approach works best. Complications are significantly different between sling types and are dependent on technique.

Transobturator vaginal tape (inside-out) for stress urinary incontinence after radical cystectomy and orthotopic reconstruction in women

Objectives

To evaluate the safety and clinical efficacy of the transobturator vaginal tape ‘inside-out’ (TVT-O) procedure for managing new-onset stress urinary incontinence (SUI) after radical cystectomy (RC) and orthotopic W-neobladder construction in women.

Patients and methods

Between January 2004 and June 2010, 57 women were treated with RC and orthotopic ileal neobladder reconstruction. Six of these patients (median age 44 years, range 39–62; grade 2 muscle-invasive squamous cell carcinoma in four and transitional cell carcinoma in two) developed de novo SUI that was moderate in four and severe in two. The median (range) duration of SUI was 11 (9–18) months. All six patients underwent TVT-O for control of their SUI.

Results

Four patients were completely dry day and night (three of them can initiate voiding and one cannot, and uses intermittent catheterization). One patient improved, as assessed by using fewer pads (from 5–7 pads to 1 pad/day and night). She can initiate voiding but has minimal leakage only on moderate exertion. One patient who had severe SUI showed no improvement. Patients were followed for a mean (range) of 18 (17–32) months, with no deterioration in the continence status.

Conclusion

These encouraging results confirm the safety and clinical efficacy of TVT-O for managing new-onset SUI after RC and ileal neobladder construction, although a larger survey and a longer follow-up are needed.

Evaluation of transvaginal slings using different materials in the management of female stress urinary incontinence

PURPOSE

To evaluate tailored polypropylene (prolene) mesh, anterior rectus sheath, and vaginal wall slings positioned under the mid-urethra, to treat stress urinary incontinence (SUI) in women, as SUI is a common pathological condition causing considerable distress and compromising social, physical, psychological, and sexual health, and for which surgical treatment remains controversial.

PATIENTS AND METHODS

This prospective randomised study included 32 patients with SUI, evaluated by SEAPI (Stress, Emptying, Anatomy, Protection, and Instability) symptom score and urodynamics. According to sling material, 12 patients had tailored prolene mesh, 12 had anterior rectus sheath and eight had anterior vaginal wall slings. Operative variables (intraoperative bleeding, duration, complications and hospital stay) were documented, and postoperative complications and continence status were assessed. The follow-up was 12-18 months.

RESULTS

Patients who received tailored prolene mesh slings had a lower operative duration and hospital stay, and less intraoperative bleeding. Postoperative complications, e.g. urinary retention and urgency, were <12%, with no significant differences. There was no significant difference among the three studied groups in the success rate (75%, 67% and 75%).

CONCLUSIONS

Tailored prolene mesh, anterior rectus sheath and the vaginal wall sling are good alternatives to treat SUI in women, with comparable results in a short-term follow up. The surgeon's experience and the patient's clinical circumstances should be considered when choosing a sling material, as success rates are comparable, being slightly better for the prolene sling in operative duration, bleeding and hospital stay.