Functional and anatomical differences between continent and incontinent men post radical prostatectomy on urodynamics and 3T MRI: a pilot study.

AIMS: There are competing hypotheses about the etiology of post prostatectomy incontinence (PPI). The purpose of this study was to determine the anatomical and functional differences between men with and without PPI. METHODS: Case-control study of continent and incontinent men after radical prostatectomy who underwent functional and anatomic studies with urodynamics and 3.0 Tesla MRI. All men were at least 12 months post prostatectomy and none had a history of pelvic radiation or any prior surgery for incontinence. RESULTS: Baseline demographics, surgical approach, and pathology were similar between incontinent (cases) (n = 14) and continent (controls) (n = 12) men. Among the cases, the average 24 hr pad weight was 400.0 ± 176.9 g with a mean of 2.4 ± 0.7 pads per day. Urethral pressure profiles at rest did not significantly differ between groups; however, with a Kegel maneuver the rise in urethral pressure was 2.6 fold higher in controls. On MRI, the urethral length was 31-35% shorter and the bladder neck was 28.9° more funneled in cases. There were no differences in levator ani muscle size between groups. There was distortion of the sphincter area in 85.7% of cases and in 16.7% of controls (P = 0.001). CONCLUSIONS: Men with PPI were not able to increase urethral pressure with a Kegel maneuver despite similar resting urethral pressure profiles. Additionally, incontinent men had shorter urethras and were more likely to have distortion of the sphincter area. All suggesting that the sphincter in men with PPI is both diminutive and poorly functional.

Dynamic MRI evaluation of urethral hypermobility post-radical prostatectomy.

AIMS: One postulated cause of post-prostatectomy incontinence is urethral and bladder neck hypermobility. The objective of this study was to determine the magnitude of anatomical differences of urethral and bladder neck position at rest and with valsalva in continent and incontinent men post-prostatectomy based on dynamic MRI. METHODS: All subjects underwent a dynamic MRI protocol with valsalva and non-valsalva images and a standard urodynamic evaluation. MRI measurements were taken at rest and with valsalva, including (1) bladder neck to sacrococcygeal inferior pubic point line (SCIPP), (2) urethra to pubis, and (3) bulbar urethra to SCIPP. Data were analyzed in SAS using two-tailed t tests. RESULTS: A total of 21 subjects (13 incontinent and 8 continent) had complete data and were included in the final analysis. The two groups had similar demographic characteristics. On MRI, there were no statistically significant differences in anatomic position of the bladder neck or urethra either at rest or with valsalva. The amount of hypermobility ranged from 0.8 to 2 mm in all measures. There were also no differences in the amount of hypermobility (position at rest minus position at valsalva) between groups. CONCLUSIONS: We found no statistically significant differences in bladder neck and urethral position or mobility on dynamic MRI evaluation between continent and incontinent men status post-radical prostatectomy. A more complex mechanism for post-prostatectomy incontinence needs to be modeled in order to better understand the continence mechanism in this select group of men.

Injectable Penile Enhancement Procedures: A Review of Agents, Risks, and Complications.

Penile dysmorphophobic disorder describes men who feel their normal penile size is inadequate. Penile fillers have been used to address penile size dissatisfaction. However, unpredictability of these procedures can yield unfavorable outcomes. Reactions to these foreign bodies are inherently uncertain, owing to an array of materials, concentrations, and biocompatibility. Management of complications also varies. As fillers are more commonly used in cosmetic procedures to augment facial features, most genitourinary surgeons are unfamiliar with these therapies. This review seeks to describe the available materials, techniques, and risk profiles of the various types of fillers used for penile augmentation.

Long-term durability of pubovaginal fascial slings in women who then become pregnant and deliver.

INTRODUCTION AND HYPOTHESIS: Pubovaginal fascial slings are commonly performed after childbearing is completed. Limited data is available regarding women who become pregnant following a sling procedure. METHODS: Three hundred forty-one women of childbearing age underwent pubovaginal sling surgery at our institution from July 1993 to December 2005. All patients were sent a questionnaire regarding their incontinence and health status. RESULTS: Nine women who delivered following surgery were identified (seven vaginal and two cesarean sections). Overall, five remained dry, three had no change in continence, and one noted worsening incontinence. Four women completed questionnaires (two vaginal and two caesarean sections). One patient who delivered vaginally reported high symptom scores and dissatisfaction while the remaining three reported low symptom scores and satisfaction. CONCLUSIONS: The pubovaginal fascial sling is a durable option for women with reproductive potential. Given our results, both vaginal delivery and cesarean section appear to be acceptable modes of delivery in this patient population.

Combination drug therapy improves compliance of the neurogenic bladder.

PURPOSE: Typical management of increased bladder storage pressures and decreased compliance related to neurogenic bladder dysfunction consists of antimuscarinic therapy with or without clean intermittent catheterization. However, these measures are often unsuccessful. In this patient group we commonly use combination therapy consisting of antimuscarinics combined with imipramine and/or an alpha-blocker. MATERIALS AND METHODS: A retrospective chart review was performed identifying all patients with neurogenic bladder dysfunction who were initially on no drug therapy or antimuscarinic therapy alone and were later switched to 2 or 3 drug therapy. RESULTS: In the group initially on no therapy and subsequently on 2 drugs (22) mean bladder pressure at capacity decreased 52% and mean compliance increased 5.0-fold. Similarly in the group starting without therapy but ending up on 3 drugs (28) bladder pressure decreased 67% and compliance increased 9.7-fold. In the group initially on an antimuscarinic agent alone (27) triple drug therapy decreased bladder pressure 60% and compliance increased 3.0-fold (all p <0.01). There were also improvements in incontinence, vesicoureteral reflux, detrusor overactivity and detrusor sphincter dyssynergia. CONCLUSIONS: In this highly selected group of patients with neurogenic bladder dysfunction and poor bladder compliance combination medical therapy with 2 or 3 drugs improved compliance, decreased bladder pressures at capacity and improved clinical outcomes. Combination therapy requires further study of the side effect profile but these results suggest that it should be considered for patients in whom antimuscarinic agents alone fail.

Long-term durability and functional outcomes among patients with artificial urinary sphincters: a 10-year retrospective review from the University of Michigan.

PURPOSE: The artificial urinary sphincter continues to be one of the most effective and commonly used surgical treatments for severe urinary incontinence. The long-term durability and functional outcome remains unclear. This study sought to report the artificial urinary sphincter complication rates, associated risk factors with complications, and long-term quality of life and durability. MATERIALS AND METHODS: This single institution study reports the outcomes of 124 consecutive index cases of artificial urinary sphincter from 1996 to 2006 for complications (infection, erosion, and mechanical failure). Bivariate statistics and multivariable logistic models were used to identify patient and artificial urinary sphincter characteristics associated with complications. Functional outcomes and long-term durability were assessed using a cross sectional analysis of a validated health related quality of life survey and a product limit estimates, respectively. RESULTS: Among the 124 male patients median followup was 6.8 years. The overall complication rate for patients undergoing an artificial urinary sphincter was 37.0%, with mechanical failure the most common cause (29), followed by erosion (10) and then infection (7). Significant differences between complications and specific patient and artificial urinary sphincter characteristics risk factors were not found. Functional outcomes appeared stable with similar mild-moderate urinary incontinence severity and 0 to 1 daily pad use at intervals of 0 to 4 years, 4 to 8 years and more than 8 years. Long-term durability was notable with 36% having complications (requiring surgical revision or removal) within 10 years and most events occurring within the first 48 months. CONCLUSIONS: Long-term durability and functional outcomes are achievable for the AMS 800, but there are appreciable complication rates for erosion, mechanical failure and infection in the first 48 months from implantation.

SIU/ICUD Consultation On Urethral Strictures: Epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, strictures, and pelvic fracture urethral disruption injuries.

This committee reviewed and evaluated published data, and recommended standardized terminology relating to the epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, urethral strictures, and pelvic fracture urethral disruption injuries, as well as their surgical management. A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), Embase, online acronym databases, and abstracts from scientific meetings was performed from 1980-2010. Articles were evaluated using the Levels of Evidence adapted by the International Consultation on Urological Diseases (ICUD) from the Oxford Centre for Evidence-Based Medicine. Recommendations were based on the level of evidence and discussed among the committee to reach a consensus. There is expert opinion to support standards regarding the epidemiology, anatomy, and nomenclature of urethral stenoses, urethral strictures, and pelvic fracture urethral disruption injuries. There is level 3 evidence regarding the epidemiology and etiology of urethral stenoses, urethral strictures, and pelvic fracture urethral injuries. The literature regarding the epidemiology, anatomy, and nomenclature of urethral stenoses, urethral strictures, and pelvic fracture urethral disruption injuries are sparse and generally of a low level of evidence. The proposed ICUD system does not readily apply to these areas. Further research is needed so that stronger levels of evidence can be developed leading to recommendations regarding the accuracy of the data. To improve future research and promote effective scientific progress and communication, a standardized nomenclature and anatomy regarding the urethra and urethral surgery is detailed herein.

Urethrocutaneous fistula after use of Tegress bulking agent: Case report and review of the literature.

We report a case of a 68-year-old man who presented with a urethrocutaneous fistula after off-label use of Tegress (C. R. Bard, Inc., Murray Hill, NJ) Urethral Implant for post-prostatectomy incontinence. He was treated for prostate cancer with an open radical retropubic prostatectomy and adjuvant external beam radiation therapy. He was treated unsuccessfully for stress incontinence with a Tegress Urethral Implant and presented to our clinic initially with extrusion of the material urethrally. Four years later he re-presented with a large bullous skin lesion on his suprapubic area. Contrast-enhanced magnetic resonance imaging and retrograde urethral cystogram demonstrated a urethrocutaneous fistula. Subsequent cystoscopy revealed the calcified extruded material in the same location as the site of Tegress injection. The patient underwent simple cystectomy with ileal diversion. He recovered well postoperatively. This appears to be the first reported case of urethrocutaneous fistula after use of a Tegress Urethral Implant for post-prostatectomy stress urinary incontinence.

Long-term outcomes after primary failures of artificial urinary sphincter implantation.

OBJECTIVES: To assess our institutional outcomes after primary artificial urinary sphincter (AUS) failures. METHODS: From 1985 to 2010, a total of 149 patients underwent 318 primary and additional AUS procedures. We classified additional procedures as revisions, replacements, or explantations. RESULTS: At a median of 52 months (range, 6-250 months), 53% of patients had required at least 1 additional procedure beyond their initial implantation. These included 106 (63%) revisions, 42 (24.9%) explantations, and 21 (12.4%) replacements. The most common revision was reservoir upsizing (37/106). Reasons for first revision included recurrent incontinence (56.7%), mechanical malfunction (22%), and infection or erosion (18.6%). Explantations were performed primarily for infection and erosion (64.3%). Median time to first revision was 20.1 months (range, 0.1-173 months) after implantation, with a median of 9.5 months (range, 1-102 months) between revisions. Explantation occurred at a median of 22 months (range, 1-221 months) after implant, and subsequent replacement at a median of 33.6 months (range, 2-138 months). At 5 years, 28/83 (33.7%) patients had undergone no additional procedures. Patients with previous radiation were more likely to experience infection (P = .03; OR 3.99; 95% CI 1.03-15.42). Patients with previous myocardial infarction were more likely to experience erosion (P = .04; OR 2.29; 95% CI 1.05-5.02), and obese patients were more likely to experience mechanical malfunction (P = .04; OR 2.62; 95% CI 1.07-6.4). CONCLUSIONS: More than half of patients with an AUS will require additional procedures, most likely revision. Radiation, previous myocardial infarction, and obesity are linked to complications. Median time to first revision or explantation is slightly less than 2 years, indicating that long-term follow-up is required after initial implantation.

Risk factors and quality of life for post-prostatectomy vesicourethral anastomotic stenoses.

OBJECTIVE: To evaluate the difference in vesicourethral anastomotic stenosis (VUAS) rates after open radical retropubic prostatectomy (RRP) vs robot-assisted radical prostatectomy (RARP), and to analyze associated factors and effect on quality of life. METHODS: From 2001 to 2009, a total of 1038 patients underwent RARP and 707 patients underwent open RRP. Perioperative factors and Expanded Prostate Cancer Index Composite (EPIC) quality of life scores were compared between patients who did and did not develop a VUAS. Independent significant predictors of VUAS development were identified using multivariable modeling. RESULTS: The incidence of VUAS in open RRP cases was higher (53/707, 7.5%) than for RARP (22/1038, 2.1%) (P<.0001). Intervention consisted of dilation in 34 of 75 cases (45.3%), internal urethrotomy in 8 of 75 (10.7%), and multiple procedures in 30 of 75 (40%). Open technique (P<.0001, odds ratio [OR]=3.0, 95% confidence interval [CI]=1.8-5.2), prostate-specific antigen (PSA) recurrence (P=.02, OR=2.2, 95% CI=1.2-4.1), postoperative hematuria (P=.02, OR=3.7, 95% CI=1.2-11.3), urinary leak (P=.002, OR=6.0, 95% CI=1.9-19.2), and urinary retention (P=.004, OR=3.5, 95% CI=1.5-8.7) were significant independent predictors of VUAS development. EPIC incontinence scores were similar between VUAS and non-VUAS patients, whereas irritative voiding scores were worse initially with VUAS but became similar by 12 months. CONCLUSION: There is a higher rate of VUAS after open RRP vs RARP. Most cases of VUAS require endoscopic intervention. Predictors include open surgery, PSA recurrence, and postoperative hematuria, urinary leak, and retention. There is no diminution of quality of life scores at 12 months.

Pharmacotherapy of overactive bladder: epidemiology and pathophysiology of overactive bladder.

INTRODUCTION: Overactive bladder (OAB) describes complex symptoms, comprising of urinary urgency, with or without urinary incontinence, often with increased daytime frequency and nocturia in the absence of infection or other obvious etiology. OAB is highly prevalent and affects physical and mental health, activities of daily life and the quality of life of millions of adults. The pathophysiology of OAB and detrusor overactivity is still not completely known, but is most probably multifactorial. AREAS COVERED: The epidemiology and pathophysiology of OAB is reviewed. A literature search using PubMed from 2000 to 2010 was undertaken for this review with pertinent older papers referenced as needed to gain a clearer understanding of the epidemiology of OAB and related bladder pathophysiology, which it is hoped will lead to more effective and better-tolerated treatments for OAB. EXPERT OPINION: With recent advances in our understanding of the basic science of OAB, it is becoming clear that the control of bladder function is far more complex than previously believed. Recent research has highlighted several potential targets for the treatment of OAB, particularly within the mechanosensory pathways.

The impact of urethroplasty on voiding symptoms and sexual function.

OBJECTIVE: To determine the effect of urethroplasty for urethral stricture disease on both voiding symptoms and sexual function through the use of validated patient questionnaires. METHODS: Pre- and post-operative scores for the American Urological Association Symptom Index (AUASI), Incontinence Symptom Index (ISI), and Sexual Health Inventory for Men (SHIM) were obtained and compared for adult male patients undergoing urethroplasty. Score differences were then stratified by age. Relevant clinical and demographic characteristics were also examined. RESULTS: Over the 15-year study period, 183 patients underwent 222 urethroplasties. Median age at the time of surgery was 45 years. Urethroplasties were performed for 207 anterior and 15 posterior urethral strictures. The most common approaches were primary anastomotic (36.5%), staged (23.9%), and buccal graft augmented (21.6%). Overall, 63% of men had a clinically meaningful (≥4 point) improvement in AUASI total score and 69% had improvement in their quality of life (QOL) score after urethroplasty. In aggregate, AUASI total scores improved by 7 points (P<.001), and QOL scores improved by 2 points (P<.001). There was no significant difference in ISI or SHIM scores before and after urethroplasty. AUASI total scores improved more dramatically in younger patients. Half of patients with improved AUASI QOL scores did not have a corollary improvement in their total score. CONCLUSIONS: As measured by validated questionnaires, patients of all ages can expect a meaningful improvement in bothersome voiding symptoms after urethroplasty for urethral stricture disease, with minimal impact on continence or erectile function.

Bone-anchored sling for male stress urinary incontinence: assessment of complications.

OBJECTIVES: To evaluate the complications associated with the male bone-anchored sling (BAS) to determine the appropriate preoperative counseling for men considering surgery. The BAS is a surgical option for the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency. METHODS: We retrospectively reviewed 119 men who had undergone 140 BAS procedures for SUI from May 2000 to May 2009 at our institution. All complications were recorded during the follow-up visits. Pad test and questionnaire results were recorded, as available. RESULTS: BAS was performed in 140 cases for 119 men with SUI. Mean patient age was 65.8 years (range 23-89). Main etiologies for SUI included previous treatment of prostate cancer (82.4%), neurologic dysfunction (12.6%), and previous transurethral resection of the prostate (3.6%). Recurrent SUI, de novo urge incontinence, and wound infection were the most frequent complications encountered (25.2%, 17.6%, and 16%, respectively). The 3 most common reasons for reoperation included bulking agent injection for recurrent SUI (5.9%), sling revision for bone screw dislodgement (5.9%), and sling revision for recurrent SUI (5.0%). Overall complication and reoperation rate for the index cases was 58.8% and 26.9%, respectively. CONCLUSIONS: The incidence of complications after male BAS placement might be greater than previously reported. Patient counseling before surgery regarding the potential complications is important. Men treated for prostate cancer should be informed of the risk of recurrent SUI. In appropriately selected patients, we believe the BAS is a reasonable surgical option; however, the risk of postoperative complication is not equivocal.

Simple cystectomy: outcomes of a new operative technique.

OBJECTIVE: To present an efficient technique for simple cystectomy. Urinary diversion for benign indications is a relatively rare procedure. However, diversion alone without accompanying cystectomy results in a significant risk of complications, such as pyocystis, hematuria, pain, and secondary carcinoma. METHODS: We retrospectively reviewed our institutional experience with this simple cystectomy technique, which included 23 patients from 2007-2010 performed by 3 surgeons. There were 14 females and 9 males. All patients had exhausted all other possible conservative therapies. Indication for the procedure included neurogenic bladder and resulting complications in 9 patients, complications from prostate radiation therapy in 5 patients, refractory interstitial cystitis in 5 patients, and refractory incontinence in 4 patients. RESULTS: The average patient was 63.3 years old and had undergone 2.7 prior abdominal or pelvic surgeries and 3.6 prior urinary operations. The average operative time was 27.5 minutes for the simple cystectomy portion of the case (recorded in 19 cases) and average blood loss was 46.7 mL (recorded in 12 cases). For the entire procedure, including diversion with bowel segment, the average blood loss was 231.5 mL. The mean entire operative time was 318.5 minutes. There were no complications noted intraoperatively or postoperatively specifically attributed to the cystectomy portion. All pathology specimens revealed no evidence of malignancy. Mean follow-up was 8 months (range 1-33). CONCLUSION: This simple cystectomy technique, in most cases of urinary diversion for benign indications, can be performed quickly with minimal blood loss and complications.