Primary implantation of an artificial urinary sphincter using the perineal and penoscrotal approaches: Functional results and assessment of reoperative procedures.

INTRODUCTION: Artificial urinary sphincter (AUS) is the standard treatment for severe stress urinary incontinence in men. While the perineal access is considered the gold standard, some authors have proposed penoscrotal AUS in order to facilitate the procedure. The main objective of our study was to evaluate the duration of survival without revision surgery (SSRC) according to the surgical approach for primary implantation. MATERIAL AND METHODS: Data from 1179 patients implanted in France between 1991 and 2020 with an AMS 800 AUS were retrospectively analyzed. A total of 762 men were implanted perineally (VP) and 417 penoscrotally (VPS). RESULTS: Median follow-up was 20 vs. 25months respectively. The groups were equivalent overall, apart from the use of anticoagulants (11% VP vs. 6.3% VPS P=0.014). In our population, 54% patients were considered as "dry" in the case of VPS vs. 42% for VP. There was no significant difference in terms of survival time without reoperation, revision, replacement or explantation. In univariate and multivariate analysis, age over 70years was predictive of more reinterventions, whereas the use of a 4.5cm cuff was protective, with hazard ratios of 1.42 (P=0.001) and 0.78 (P=0.04), respectively. CONCLUSION: The penoscrotal approach does not appear to be associated with more complications, has good functional results and no significant difference in reoperation-free survival. A prospective multicenter non-inferiority study could be of interest to confirm our findings.

Which revision strategy is the best for non-mechanical failure of male artificial urinary sphincter?

PURPOSE: Persistence or recurrence of stress urinary incontinence (prSUI) after artificial urinary sphincter (AUS) implantation may be secondary to non-mechanical failure (NOMECA). It have for long been assumed to result from urethral atrophy. Its existence is now debated. As the pathophysiology of NOMECA is not elucidated, the most appropriate management remains unclear. We aimed to compare the several revision techniques for NOMECA of AUS in men. METHODS: NOMECA was defined as prSUI, with normally functioning device, no erosion, infection or fluid loss. Exclusion criteria were neurogenic SUI, revision or explantation for other causes. From 1991 to 2022, 143 AUS revisions for NOMECA, including 99 cuff DOWNSIZING, 10 cuff repositioning (RELOC), 13 TANDEM-CUFF placement, 18 cuff changing (CHANGE), three increasing balloon pressure (BALLOON-UP), were performed in 10 centers. BALLOON-UP patients weren't included in comparative analysis due to small sample size. All components could be changed during the revision. Patients were also categorized in COMPLETE-CHANGE vs. PARTIAL-CHANGE of the device. RESULTS: The three-months complete continence rate was 70.8% with a significant difference between RELOC and DOWNSIZING groups (p = 0.04). COMPLETE CHANGE was significantly associated with complete continence status at three months in multivariate analysis (83.3% vs. 63.3%, OR = 2.7; CI 95% [1.1-7.1], p = 0.03). Estimated five-year reoperation-free and explantation-free survival were respectively 63.4% and 75.9% (p = 0.16; p = 0.30). Those were significantly longer in COMPLETE-CHANGE vs PARTIAL-CHANGE (82.2% vs. 69.6%, p = 0.03); (71.2% vs. 58.2%, p = 0.047). CONCLUSIONS: AUS revision for prSUI due to NOMECA yields satisfactory outcomes regardless of the technique used. We observed better functional outcomes when repositioning the new cuff. COMPLETE-CHANGE may improve functional outcomes, explantation-free and reoperation-free survivals.

Efficacy, Safety, and Reoperation-free Survival of Artificial Urinary Sphincter in Non-neurological Male Patients over 75 Years of Age.

Background: Artificial urinary sphincter (AUS) is a gold standard treatment in male stress urinary incontinence but remains poorly used in elderly patients. Objective: To assess the efficacy, safety, and reoperation-free survival of AUS implantation in male patients over 75 yr of age. Design setting and participants: We retrospectively reviewed the charts of all 1233 non-neurological male AUS implantations between 2005 and 2020 at 13 French centers. We compared 330 patients ≥75 yr old (GROUP75+) with 903 patients <75 yr old (GROUP75-) at the time of AUS implantation. Outcome measurements and statistical analysis: Our primary endpoint was social continence at 3 mo defined as the use of one or fewer pad daily. We used Kaplan-Meier analyses to assess reoperation-free survival. We sought factors of erosion using logistic regression. Results and limitations: Early postoperative continence was comparable in both groups (74.4% vs 80.1%, p = 0.114). We observed a higher rate of postoperative complications in GROUP75+ (18.8% vs 12.6%, p = 0.014), but the complications were more frequently of low grade in GROUP75+ (p = 0.025). The overall reoperation-free survival was similar (p = 0.076) after a median follow-up of 2 yr. However, patients in GROUP75+ had poorer explantation-free survival (p < 0.0001). A history of radiotherapy was a predictive factor of erosion (odds ratio [OR] = 5.31, p < 0.01), but age was not (OR = 1.08, p = 0.87). Unfortunately, our dataset did not include a systematic geriatric evaluation. Conclusions: AUS in elderly patients appears to be an effective option to treat stress urinary incontinence. However, we observed more postoperative complications and explantations, although age was not associated with the onset of erosion. A prospective study is required to determine whether a geriatric evaluation would be an effective strategy to select patients before surgery. Patient summary: In this study, we looked at outcomes of artificial urinary sphincter in elderly men in a large population. We found satisfying efficacy but slightly more postoperative complications and device infections.

Evaluation of continuous wound infusion with local analgesics in postoperative renal transplantation patients: A retrospective study.

Objectives: The objective is to evaluate the efficacy of the continuous wound infusion (CWI) with Ropivacaine (naropeine 2 mg/ml) on postoperative pain, analgesics consumption, and bowel function in renal transplantation patients. Materials and Methods: A retrospective study trial including 79 patients who underwent renal transplantation. Patients were separated into two groups (catheter or without catheter). We identified 52 (65.8%) patients who received catheter wound infusion during the first 48 h postoperatively. On the other hand, 27 (34.1%) patients received standard without catheter anesthetic technique. Catheter wound infusion was achieved through a 12 cm catheter, inserted subcutaneously after abdominal closure. The catheter was placed above the external oblique aponeurosis. All postoperative data were examined to evaluate the first postoperative 48 h. This study aims to assess three variables: postoperative pain analysis through a visual analog scale, analgesics consumption, and bowel function. Results: The overall score of the three variables was studied. Regarding pain assessment, we have determined that the group of patients with catheter scored better than patients without catheter with borderline significance (66.3 vs. 61.2 consecutively; P = 0.0843). An early bowel function was noted in patients with catheters on the 2nd postoperative day (P = 0.0209). Moreover, patients without catheter consumed more painkillers with nonsignificant difference (P = 0.2499). Conclusion: Patients with catheter showed earlier bowel function than the noncatheter group on the 2nd postoperative day. The catheter group had better pain evaluation.

Robot-assisted vesicovaginal fistula repair: comparison of the extravesical and transvesical techniques.

INTRODUCTION AND OBJECTIVES: Almost two decades after the description of robotic vesicovaginal fistula repair (R-VVF), the literature remains limited. The aims of this study are to report the outcomes of R-VVF and to compare the transvesical versus extravesical techniques. METHODS: We performed an observational, retrospective, multicenter study, including all patients who underwent R-VVF from March 2017 to September 2021 at four academic institutions. All abdominal VVF repair over the study period were performed using a robotic approach. The success of R-VVF was defined as the absence of clinical recurrence. The outcomes of the extravesical versus transvesical techniques were compared. RESULTS: Twenty-two patients were included. The median age was 43 years old (IQR 38-50). Fistulas were supratrigonal and trigonal in 18 and 4 cases respectively. Five patients had undergone previous attempts of fistula repair (22.7%). The fistulous tract was systematically excised, and an interposition flap was used in all but two cases (90.9%). The transvesical and extravesical techniques were used in 13 and 9 cases respectively. There were four postoperative complications, three minor and one major. None of the patients had vesicovaginal fistula recurrence after a median follow-up of 15 months. CONCLUSIONS: The present series, one of the largest R-VVF reported to date, is consistent with the few series already published with a 100% cure rate. Systematic excision of the fistulous tract and the high rate of flap interposition may explain the high success rate. The transvesical and extravesical approaches yielded similar outcomes.

Minimally Invasive and Open Donor Nephrectomy: Lessons Learned From a French Multicenter Experience.

BACKGROUND: We evaluated different techniques of donor nephrectomy. METHODS: Outcomes of 4 surgical approaches (open surgery [OS], standard laparoscopy [SL], hand-assisted laparoscopy [HAL], and robot-assisted la`paroscopy [RAL]) were compared. RESULTS: A total of 264 nephrectomies were performed: 65 in the OS group, 65 in the SL group, 65 in the HAL group, and 69 in RAL group. Operative time was longer for the RAL group (P < .001) with a mean time of 202 minutes (RAL), 182 minutes (OS), 173 minutes (SL), and 157 minutes (HAL). Complications (P = .002) and consumption of morphine derivates (P = .31) were lower for the RAL group (P = .0002). The visual analog scale pain scores (P = .002), hospital stay (P = .023), and time to return to full activities (P = .79) were higher for OS. CONCLUSIONS: The 4 different nephrectomy surgical approaches had similar favorable results. The robot-assisted technique presented as an alternative option, with low incidence of complications, less pain, and results comparable to the other techniques.

Early Efficacy and Safety Outcomes of Artificial Urinary Sphincter for Stress Urinary Incontinence Following Radical Prostatectomy or Benign Prostatic Obstruction Surgery: Results of a Large Multicentric Study.

BACKGROUND: Artificial urinary sphincter (AUS) is the gold standard for the management of moderate to severe stress urinary incontinence (SUI) in the male population. While outcomes of this device in postprostatectomy incontinence (PPI) are widely described, those obtained for incontinence after benign prostatic obstruction (BPO) surgery remains poorly explored. OBJECTIVE: To compare continence outcomes after AUS implantation in a PPI population with those obtained in men incontinent after BPO surgery. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of all cases of AUS implantation between 2005 and 2020 in 16 different French centers was conducted. Only patients with primary implantation whose indication was moderate to severe SUI after prostatectomy or BPO surgery were included (excluding those with a history of radiation therapy, brachytherapy, cystectomy, high-intensity focused ultrasound therapy, or neurogenic disease). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was the rate of social continence (zero or one pad per day) at 3 mo. Complications were also noted within 90 d of implantation. RESULTS AND LIMITATIONS: A total of 417 patients were included in the PPI group and 50 in the BPO surgery group. Social continence rates at 3 mo were similar between the groups (79% vs 72%, p = 0.701). Complication rate was significantly higher in the BPO group (8% vs 18%, p = 0.044). The same was found for the Clavien-Dindo type 2 complication rate (20.6% vs 44.4%, p = 0.026). The retrospective nature and lack of precise definition of incontinence are the main limitations of this study. CONCLUSIONS: This multicentric study strengthens the position of AUS as gold standard for SUI after radical prostatectomy. Comparable efficacy results were found for incontinence after BPO surgery, with nevertheless a higher rate of complications. PATIENT SUMMARY: Artificial urinary sphincter represents the gold standard for the treatment of moderate to severe stress urinary incontinence. Efficacy results are comparable between postprostatectomy incontinence and incontinence after benign prostatic obstruction surgery.

Impact of radiation therapy on artificial urinary sphincter implantation in male patients: A multicenter study.

AIMS: To evaluate the impact of an history of radiation therapy on the outcomes of artificial urinary sphincter (AUS) implantation in male patients. METHODS: The charts of all patients who underwent AUS implantation for stress urinary incontinence (SUI) after prostate surgery in thirteen centers between 2004 and 2020 were retrospectively reviewed. We excluded patients with neurogenic SUI. Continence rates and incidence of complications, revision and cuff erosion were evaluated. The outcomes in irradiated men were compared to those of non irradiated men. RESULTS: A total of 1277 patients who had an AUS met the inclusion criteria with a median age of 70 years, of which 437 had an history of prior radiotherapy. There was no difference in comorbidities. In irradiated patients, postoperative social continence, urethral atrophy and infection rates were respectively 75.6%, 2.4% and 9.5% and 76.8%, 5.4%, and 5.8% in nonirradiated men (respectively, p = 0.799, p = 0.128, p = 0.148). There were more urethral erosion in irradiated male patients. After a mean follow up of 36.8 months, the explantation free survival was poorer in irradiated patients (p = 0.001). CONCLUSION: These data suggest that pelvic radiotherapy before AUS adversely affect device survival with and increased greater occurrence of infection-erosion and therefore of explantation.

Transcorporal vs. bulbar artificial urinary sphincter implantation in male patients with fragile urethra.

PURPOSE: To compare transcorporal vs bulbar artificial urinary sphincter (AUS) implantation in men with fragile urethra and to investigate the risk factors of AUS explantation in this population. METHODS: The charts of all male patients who had an AUS implantation between 2004 and 2020 in 16 centers were reviewed retrospectively. The primary endpoint was device explantation-free survival. Only patients with a fragile urethra were included in the present analysis. Fragile urethra was defined as a urethra carrying a high risk of cuff erosion because of prior radiotherapy and/or history of AUS explantation and/or history of urethral stricture surgery. The patients were divided in two groups according to the implantation site: bulbar vs transcorporal. RESULTS: 464 patients were included for analysis. 88 patients underwent a transcorporal AUS implantation and 376 underwent a bulbar AUS implantation. Explantation-free survival was similar in both groups (estimated 5-year explantation free survival rates 55.3% vs. 58.4%; p=0.98). In the subgroup of patients with a history of previous AUS explantation, transcorporal approach tended to bring longer explantation-free survival (2-year explantation-free survival: 61.9% vs. 58.2%; p=0.096). In multivariate analysis, the only risk factor of shorter explantation-free survival was the history of previous AUS explantation (HR=2.65; p=0.01). CONCLUSIONS: Transcorporal AUS implantation was not associated with longer explantation-free survival. History of previous AUS explantation was the only risk factor associated with shorter explantation-free survival and this subgroup of patients may be the only one to draw benefits of transcorporal AUS implantation.

Prevalence and Risk Factors of Artificial Urinary Sphincter Revision in Nonneurological Male Patients.

PURPOSE: The main objective of this study was to assess the prevalence and risk factors of male artificial urinary sphincter (AUS) mechanical failures and nonmechanical failures. MATERIALS AND METHODS: The charts of all male patients who underwent AUS implantation between 2004 and 2020 in 16 centers were retrospectively reviewed. Patients with neurogenic stress urinary incontinence (SUI) were excluded as well as revisions/explantations due to infections and/or erosions. The causes of revision were divided into mechanical failures (fluid loss or malfunction from any components of the AUS), nonmechanical failures (urethral atrophy, recurrence/persistence of SUI despite normally functioning device) and other (pump malposition, balloon herniation, hematoma, pain). Failure-free survival analysis was performed both for general and specific causes of revision. Predictors of mechanical and nonmechanical failures were determined by Cox proportional hazards model. RESULTS: A total of 1,020 patients met the inclusion criteria. After a median followup of 20 months, the estimated 5-year and 10-year overall revision-free survival was 60% and 40%, respectively. There were 214 AUS revisions: 59 (27.6%) for mechanical failures, 121 (56.5%) for nonmechanical failures and 34 (15.9%) other causes of revision. In multivariable Cox regression analysis, larger cuff size was the only predictor of overall revisions (HR=1.04 [1.01-1.07]; p=0.01) and revision for nonmechanical failure (HR=1.05 [1.02-1.09]; p=0.004). CONCLUSIONS: Half of the male AUS patients underwent device revision within the first 10 years after implantation. Nonmechanical failures are the primary cause of AUS revision in nonneurological men. Larger cuff size appears to be the main determinant of AUS revision risk.

Robot-Assisted Cystectomy and Ileal Conduit for Neurogenic Bladder: Comparison of Extracorporeal vs Intracorporeal Urinary Diversion.

Objectives: The aim of the present study was to compare the perioperative outcomes of extracorporeal (EXTRA) vs intracorporeal (INTRA) urinary diversion in patients undergoing robotic cystectomy and ileal conduit for neurogenic bladder. Methods: All consecutive patients who underwent robot-assisted cystectomy and ileal conduit for neurogenic bladder in six centers between 2011 and 2020 were included in a retrospective study. Four centers performed exclusively INTRA urinary diversion all over the study period, one center performed exclusively EXTRA urinary diversion, and the last center performed EXTRA urinary diversion during a first period and INTRA during the subsequent period. Results: Ninety-seven patients were included: 66 in the EXTRA group and 31 in the INTRA group. There were 11 major (Clavien grade ≥3) postoperative complications in the overall population (11.3%) with no statistically significant difference between both groups (EXTRA = 12.1% vs INTRA = 9.7%; p = 0.99). The mean length of stay did not differ significantly between INTRA and EXTRA (13.1 vs 14.1 days; p = 0.44). The mean times to oral feeding and to return of bowel function were similar in the two groups (3.9 vs 3.5 days; p = 0.28 and 4.1 vs 4.1 days; p = 0.51, respectively). There was no incisional hernia in the INTRA group vs five in the EXTRA group (0% vs 7.6%; p = 0.17). Conclusion: The perioperative morbidity of robotic cystectomy and ileal conduit for neurogenic bladder appears to be relatively limited compared with the historical open series. Possibly due to the relatively small sample size, no difference was found between INTRA and EXTRA urinary diversion in terms of perioperative outcomes.

Robot-assisted continent urinary diversion according to the Mitrofanoff principle: results of a bicentric study.

PURPOSE: To assess the outcomes of continent urinary diversion according to the Mitrofanoff principle by robot-assisted laparoscopic surgery in terms of continence, catheterization and repeat surgery. METHODS: All adult patients who underwent procedures for continent urinary diversion via a robot-assisted laparoscopic route between October 2014 and November 2018 were enrolled retrospectively. Abdominal continence and clean intermittent catheterization ability were noted, as well as patient characteristics, details of the technique, intra- and perioperative parameters, and complications. RESULTS: Ten patients were included. Bladder-sphincter disorders were due to neurological causes in nine patients, and one patient had idiopathic bladder sphincter dyssynergia. A continent catheterizable channel was created using the appendix in six cases and the ileum in four cases. The median operative duration was 245 min (IQR 228-370). Two patients had a Clavien 3 complication requiring laparoscopy to separately drain a haematoma and a pelvic abscess. The median follow-up was 21 months (IQR 17-27). Abdominal continence without further intervention was obtained in 6/10 patients (60%). Two patients needed an open revision of the continent urinary diversion, one required injection of Deflux® and one an intradetrusorian injection of botulinum toxin type A (Botox®). Further surgery was needed for two patients to improve urethral continence. At the end of follow-up, all patients were continent and clean intermittent catheterization was possible. CONCLUSION: Continent urinary diversion performed according to the Mitrofanoff principle is possible via a robot-assisted laparoscopic route and yields good outcomes on abdominal continence in the short term in patients with clean intermittent catheterization ability.

Testicular microlithiasis and testicular tumor: a review of the literature.

INTRODUCTION: There are numerous scientific publications on testicular microlithiasis (TML) detected during ultrasound (US) examination. We wished to update the data. METHODS: PubMed was used to identify original articles published between 1998 and May 2017 describing the association between TML and testicular tumor. Studies were only included if TML was diagnosed by US. Studies were then classified into subgroups according to the following criteria: asymptomatic, symptomatic, infertility, cryptorchidism, family or personal history of testicular cancer, and "no given reason for US". A Z-Test was used to identify differences within these subgroups. In addition, we identified prospective cohorts of TML patients. Numbers, duration of follow-up, and occurrence of the "testicular tumor" event were recorded for each of them. RESULTS: One hundred and seventy-five articles were identified, 40 of which were included. Our review has not showed a clear evidence that cryptorchidism associated with TML is a risk factor for testicular tumor. However, there seems to be a correlation between infertility associated with TML and a higher tumor risk. There were not enough studies to confirm a relationship between family or personal history associated with TML and the tumor risk. There was also a correlation with a higher tumor risk for symptomatic associated with TML and "no given reason for US" plus TML groups. However, these groups are assumed to contain bias and caution must be taken regarding conclusions. Regarding the prospective cohort studies, 16 testicular tumors appeared in the follow-up of patients with TML, 13 patients had risk factors. CONCLUSION: In cases of TML incidental finding by US with the presence of risk factors (personal history of testicular cancer, testicular atrophy, infertility, cryptorchidism) a consultation with a specialist should be considered. In the absence of risk factors, the occurrence of testicular cancer in patients with TML is similar to the risk of the general population.

INTRODUCTION: Il existe de nombreux articles sur les microlithiases testiculaires découvertes au cours d'une échographie. Nous voulions mettre à jour les données. MÉTHODES: Pubmed a été utilisé pour identifier des articles originaux traitant de l'association entre les microlithiases testiculaires et les tumeurs testiculaires, de 1998 à mai 2017. Les études ont été incluses si les microlithiases étaient diagnostiquées par échographie. Les études ont été classées en sous-groupes selon certains critères (asymptomatiques, symptomatiques, infertilité, cryptorchidie, antécédents familiaux ou personnels de cancer des testicules, et « absence de motif pour la réalisation de l'échographie ¼). Nous avons utilisé un Z-test pour indiquer les différences au sein de ces groupes. De plus, nous avons identifié des cohortes prospectives de patients atteints de microlithiases testiculaires. Le nombre, la durée du suivi et la survenue de l'événement « tumeur testiculaire ¼ ont été enregistrés pour chacun d'entre eux. RÉSULTATS: Cent soixante-quinze articles ont été identifiés, dont 40 ont été inclus. Dans notre revue, il n'y a pas de lien évident pour que les microlithiases associées à la cryptorchidie soient un facteur de risque de tumeur testiculaire. Il semble y avoir une corrélation entre l'infertilité et les microlithiases avec un risque tumoral plus élevé. Il n'y avait pas assez d'études pour confirmer une relation entre les antécédents personnels ou familiaux associés aux microlithiases et le risque de tumeur. Il y avait aussi une corrélation avec un risque tumoral plus élevé pour les microlithiases dans le groupe symptomatique et le groupe « sans motif de réalisation de l'échographie ¼. Cependant, ces groupes sont supposés contenir des biais et des précautions doivent être prises en ce qui concerne les conclusions. En ce qui concerne les études de cohorte prospective, 16 tumeurs testiculaires sont apparues dans le suivi des patients atteints de microlithiases. Treize patients avaient des facteurs de risque. CONCLUSION: En cas de découverte fortuite de microlithiases testiculaires à l'échographie associées à la présence de facteurs de risque (antécédents personnels de cancer des testicules, atrophie testiculaire, infertilité, cryptorchidie), une consultation avec un spécialiste doit être envisagée. En l'absence de facteurs de risque, la survenue d'un cancer du testicule chez les patients atteints de microlithiases est. similaire au risque pour la population générale. MOTS-CLÉS: microlithiases testiculaires, tumeur testiculaire, cancer testiculaire, tumeur germinale, infertilité, échographie.