Ambulatory peri-bulbar implantation, revision and replacement of Artificial Urinary Sphincter in neurogenic and non-neurogenic male patients: A preliminary feasibility study over a one-year experience.

INTRODUCTION: Our goal was to determine the rate of complications, early revision and removal after full ambulatory implantation of bulbar AUS in men; secondly, to describe satisfaction and short-term continence rate. MATERIAL AND METHODS: Between April 2018 and April 2019, 28 consecutive patients underwent AUS implantation in a newly organised ambulatory setting. A prospective database of all included patients was established with comprehensive data collected on medical history, aetiology and severity of SUI, surgical procedures, postoperative complications and patient satisfaction. RESULTS: Twenty-eight patients were included (30 consecutive procedures: 22 primary AUS placement, 6 complete revisions, 2 partial revisions), with a mean follow up of 223±220.5 days. Fourteen patients had prior radiotherapy. Readmission rate was 6.7% in the first 30 days after surgery. Both revision and removal rates were 6.7%. Complications were reported in 26.7% of procedures, mainly Clavien-Dindo I. Patient satisfaction of ambulatory surgery organisation and experience was high (87/5% satisfied or very satisfied). Full continence & social continence were achieved for, respectively, 55.6% and 88.9% of procedures. CONCLUSION: Ambulatory placement of AUS is safe and can be performed successfully. Larger patient cohorts and randomised trials are crucial to improve knowledge on non-indications for full ambulatory AUS implantation in men.

Neurogenic stress urinary incontinence management. From past to recent techniques: What have we learnt?

Urinary prostheses for the treatment of male stress urinary incontinence ranged from simple to adjustable bulbourethral compressing devices to complex artificial urinary sphincter. Those devices have remarkably evolved since the 1950s. In this article, we review the story of a patient who experienced this device evolution. His history provides us with the opportunity to retrieve the historical transformation of the incontinence prostheses around time. Moreover, this patient story challenges us on those devices past and present limitations.

[Artificial urinary sphincter in patients with urinary incontinence after High Intensity Focused ultrasound]. / Sphincter urinaire artificiel chez les patients présentant une incontinence urinaire après High Intensivity Focused Ultrasound Therapy.

INTRODUCTION: Urinary incontinence after High Intensity Focused ultrasound (HIFU) is a poorly documented issue. To our knowledge, no study has evaluated the outcomes of artificial urinary sphincter (AUS) after HIFU. The aim of this study was to evaluate the functional outcomes of AUS for post-HIFU urinary incontinence. METHODS: The charts of all male patients who underwent an AUS implantation between 2004 and 2020 in 13 centers were reviewed retrospectively. Only men with a history of HIFU were included. The primary endpoint was social continence at 3 months defined as wearing 0 to 1 pad per day. RESULTS: Out of 1318 procedures, nine men were implanted with an AUS after HIFU including four men with an history of pelvic irradiation: 3 pelvic radiation therapy and 1 prostatic brachytherapy. The patients were divided into two groups, 5 in the HIFU group without a history of pelvic irradiation, 4 patients in the HIRX group with a history of pelvic irradiation. The median age was 74 years (IQR 71-76). There was no perioperative complication. The median follow-up was 47.5 (IQR 25-85.5) months. Social continence at 3 months was 75% in the total cohort: 80% in the HIFU group and 67% in the HIRX group. CONCLUSION: AUS implantation may provide satisfactory long-term functional outcomes in the treatment of stress urinary incontinence resulting from HIFU. Larger series are needed to confirm these findings. LEVEL OF EVIDENCE: 4.

[Comparison of penoscrotal and perineal approaches for implantation of an artificial urinary sphincter in man]. / Comparaison des voies d'abords peno-scrotales et perineales pour l'implantation d'un sphincter urinaire artificiel chez l'homme.

INTRODUCTION: Artificial urinary sphincter is considered the gold standard of treatment for male urinary incontinence because of intrinsic sphincter deficiency. The objective of our study was to compare the functional results and complications of the penoscrotal and perineal incision for the implantation of artificial urinary sphincter. MATERIAL AND METHODS: A retrospective, monocentric study comparing the perioperative and long-term results of primary implantation of an artificial urinary sphincter in men, performed by the penoscrotal or the perineal incision, was conducted in a French university hospital. RESULTS: Between April 2004 and February 2019, 175 patients were implanted (118 by penoscrotal incision and 57 by perineal incision) by 19 surgeons. Cuff placement approach depended on surgeon preference. The average follow-up was 34.2 ± 35.6 months. Cuff size was smaller in the penoscrotal group (4 [4;5] vs 4.5[4;5] p<0.001). At the end of follow-up, the rates of complete continence, social continence, reintervention for any reason, explantation, and revision was similar between the two groups. CONCLUSION: Long-term outcomes of penoscrotal and perineal artificial sphincter implantation were similar between the two groups. Prospective multicenter studies are needed to confirm these results.

[Influence of urethral self-dilatation on the morbidity of the artificial urinary sphincter after endoscopic treatment of recurrent stenosis of the vesicourethral anastomosis]. / Impact des autodilatations urétrales sur la morbidité du sphincter urinaire artificiel, après le traitement endoscopique de la récidive de sténose de l'anastomose vesico-uretrale.

OBJECTIVE: To analyze the morbidity of the practice of daily self-dilatation (SD) in patients undergoing total prostatectomy, who have had artificial urinary sphincter (AUS) for urinary incontinence (UI) and who have had a recurrence of endoscopically treated vesicourethral anastomosis (VUS) stenosis. MATERIALS AND METHOD: One hundred and thirty-eight patients with SUA for urinary incontinence (UI) fitted between 1998 and 2007 were divided into two groups. Thirty-five patients have had used self-dilatation (SD) for recurrent anastomotic stenosis (SD group) and 103 patients did not perform SD (non-SD group). These two groups were compared for explantation rate (erosion-infection), revision rate (urethral atrophy and mechanical failure) and 2-year functional results. The uni- and multivariate statistical analysis taken into consideration confounding factors such as age and radiotherapy history. The functional assessment was done by the validated IQoL, Ditrovie and MHU tests. RESULTS: Patients in both groups were comparable except for the importance of urinary incontinence assessed by PAD test and questionnaires. The explantation rate was significantly higher in the "SD" group (28.5% vs 7.77%) and (OR=4.68, 95% CI [1.490-15.257], P=0.006). There was no significant difference between the two groups in the surgical revision rate (32% vs 20%, OR=0.44, P=0.09). The functional results at two years did not show any significant difference. CONCLUSIONS: The use of self-dilation for recurrence of stenosis of vesicourethral anastomosis after prostatectomy exposes patients fitted with an SUA to a higher explantation rate. LEVEL OF EVIDENCE: 3.

[Robotic-assisted laparoscopic implantation of artificial urinary sphincter AMS 800® in woman: Single center experience]. / Implantation du sphincter artificiel AMS 800® chez la femme par cœlioscopie robot-assistée : expérience monocentrique.

INTRODUCTION: Artificial urinary sphincter (AUS) is the treatment of last resort of stress urinary incontinence (UI) due to intrinsic sphincter deficiency (IS). The implantation procedure has been described by open surgery and laparoscopy with a significative rate of complication by Lucas et al. (2012) and Costa et al. (2001). We report our experience of implantation of SUA by robotic-assisted laparoscopy (R-SUA) in 17 patients among 3 revisions. MATERIAL AND METHODS: Between 2012 and 2017, 17 patients have been consecutively included. The surgical technique was described by Fournier et al. The continence was defined by the absence of urine leakage. RESULTS: The median age at implantation was 66,8±7 years, in the primo-implantation (PI) group, one patient had a neurological acontractile bladder, and bladder was open in 11 patients (78,6%) to ensure the bladder neck dissection. In the revision group (R) 3 patients had a complete replacement of SUA for mechanical failure. One vaginal bound was reported, but did not compromise the implantation, and the survival of SUA. Duration of intervention, size of cuff, postoperative catheterization and hospitalization time were respectively 205±34 and 112±8min; 7,7±0.9 and 5.2±0.8cm; 5.9±2.1 and 4.3±4 days; 6.6±1.5 and 7±3.6 days for PI and R groups. At the end of a mean follow-up of 24.6±18.4 and 59±5 months, continence was respectively 86% and 100%, for the PI and R groups. CONCLUSION: The implantation of R-SUA was feasible and safe with encouraging results. Other studies must evaluate the place of R-SUA among the different enabled surgical techniques. LEVEL OF EVIDENCE: 4.

[Laparoscopic robot-assisted artificial urinary sphincter in women: First approach]. / Sphincter urinaire artificiel robot chez la femme : début d'expérience.

OBJECTIVE OF THE STUDY: To analyze the medium-term results and complications of the artificial urinary sphincter (AUS) AMS 800 implanted using laparoscopic robot surgery in women with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective cohort study, which included all procedures done in the CHU of Nîmes from July 2015 to January 2017. Patients with SUI by ISD needing an AUS or patients with a malfunctioning AUS needing to be changed were included. We collected data on intraoperative complications, length of hospitalization, postoperative complications, continence rate at twelve months and satisfaction of patients. RESULTS: Nineteen patients were included, 10 for primo-implantation and 9 for AUS revision. There were 4 postoperative bladder injuries, of which 2 led to laparoconversions. The mean length of hospitalization was 4.1days. Three patients had postoperative complications, which needed an intervention without AUS removal. One patient with persisting SUI due to bladder weakness preferred AUS ablation rather than having a cuff change. There was a median follow-up of 22months (12 to 33months). Sixteen patients out of 19 were completely continent and were satisfied of their intervention and the improvement of their quality of life. CONCLUSION: The laparoscopic robot surgery for AUS implantation is safe and reproducible with good medium-term results. LEVEL OF EVIDENCE: 4.

[Male neurogenic stress urinary incontinence treated by artificial urinary sphincter AMS 800™ (Boston Scientific, Boston, USA): Very long-term results (>25 years)]. / Traitement de l'incontinence urinaire masculine neurologique par le sphincter urinaire artificiel AMS 800™ (Boston Scientific, Boston, États-Unis) : résultats à très long terme (>25 ans).

OBJECTIVE: The aim of the study was to report the very long-term functional outcomes of artificial urinary sphincter (AUS) in male neurological patients. MATERIAL AND METHODS: Male neurological patients diagnosed with stress urinary incontinence due to sphincter deficiency and undergoing AUS (AMS 800®) implantation between 1985 and 1992 were enrolled. Continence, defined by no pad/condom usage, explantation and revision rates were reported. RESULTS: Fourteen patients with a median age of 27.3 years (IQR: 27.3-40.8) were included: four had a spinal cord injury and ten a spina bifida. Prior continence surgery was reported by 6 patients (42.9 %). Artificial urinary sphincter was implanted in a peribulbar (n=4) or periprostatic position (n=10). Median follow-up was 18.3 years (IQR: 10.1-20.3). At last follow-up, all patients were alive. Three native devices were still in place, eight were revised (four of them were secondarily explanted) and three were explanted due to erosion or infection. The 5-, 10-, 15-, 20-year explantation-free survival rates were respectively 85.7, 62.3, 52.0, 39.0 %. The 5-, 10-, 15-, 20-year revision-free survival rates were respectively 78.6, 42.9, 28.6, 7.1 %. At last follow-up, 50 % patients were continent. CONCLUSION: In the very long run, AUS provided a 50 % continence rate in male neurological patients but the revision rates were important. LEVEL OF EVIDENCE: 4.

[Impact of anastomotic strictures on treatment of post-prostatectomy stress incontinence by artificial urinary sphincter]. / Impact des sténoses anastomotiques sur le traitement de l'incontinence urinaire post-prostatectomie par sphincter artificiel.

INTRODUCTION: Stress urinary incontinence (SUI) is a degradation of the quality of life factor in the consequences of radical prostatectomy. Artificial urinary sphincter (AUS) is the standard treatment. Screening and preoperative treatment of anastomotic strictures (AS) is an essential step for the success of the intervention. The objective of the study was to assess the impact of AS on the results of AUA. METHODS: We retrospectively studied 147 AUS settlements from 2005 to 2013 in the urology department of the Centre Hospitalier Lyon by three operators. The demographic characteristics, the irradiation history, the severity of incontinence, the complications of AUS, the continence rate and the postoperative satisfaction were collected. Wilcoxon statistical tests and Fischer and a Kaplan-Meier curve were used to compare the two control groups and AS. Logistic regression analysis looked for predictors of surgical reintervention. RESULTS: Of the 147 patients included, 24 (16.3%) had a history of AS. Of these, 21 (87.5%) were treated with endoscopic urethrotomy. Patients in the AS group had more severe incontinence (P<0.05) than in the control group. Explantation rates, recurrence of incontinence and reoperation was 12.5%, 8.3% and 33.3% in the AS group against 4.9%, 15.4% and 27.6% in the control group. In logistic regression, history of AS has not been found as reoperation risk factor. Continents and satisfied patients rate were 77.8% and 76.5%, respectively in the AS group against 91.1% and 81.1% in the control group. CONCLUSION: The history of AS does not appear to be predictive of poor outcome after implementation of a AUS. Larger cohort studies are needed to confirm these results. LEVEL OF EVIDENCE: 4.

[Functional results and treatment of functional dysfunctions after radical prostatectomy]. / Résultats fonctionnels et prise en charge des troubles fonctionnels après prostatectomie totale.

OBJECTIVE: To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer. MATERIAL AND METHOD: Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta. RESULTS: Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9-16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach. CONCLUSION: Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.

[Intrinsic sphincter deficiency and female urinary incontinence]. / Insuffisance sphinctérienne et incontinence urinaire de la femme.

OBJECTIVE: Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article. MATERIAL AND METHODS: This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association. RESULTS: Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary. CONCLUSION: Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.

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.

[Last resort surgical management of postradiation urinary cystitis after external beam radiation for prostate cancer: a monocentric analysis]. / Traitement chirurgical de dernier recours en cas de cystite radique après radiothérapie externe du cancer de la prostate : analyse monocentrique.

PURPOSE: To assess functional outcomes obtained after surgical management of post-radiation urinary incontinence after prostate cancer. PATIENTS AND METHOD: A retrospective review of the data from patients treated in our centre between September 2004 and February 2012 by surgery for vesicosphincteric injuries after prostatic external beam radiation therapy was performed. RESULTS: A total of seven men with a median age of 70 years ± 4.1 were included. Mean follow-up was 32.3 months ± 29 (3-86). All patients underwent a partial cystectomy and augmentation enterocystoplasty. The vesicocutaneous fistula rate was 33% occurring within a mean time of 18.5 days ± 2.1 (17-20). The mean length of urinary catheter and hospital stay were respectively 16 days ± 8.4 (12-35) and 18 days ± 7.8 (13-37). Five patients underwent asynchronous insertion of artificial urinary sphincter. The success rate of partial cystectomy and augmentation enterocystoplasty with asynchronous implantation of artificial urinary sphincter to treat post-radiation urinary incontinence was 71.5%. The median time between partial cystectomy and augmentation enterocystoplasty and artificial urinary sphincter implantation was 27.6months ± 26.4 (7-72). CONCLUSION: Surgical management of post-radiation urinary cystitis offers good functional outcomes albeit its morbidity is not negligible. It should be proposed only in expert surgical centres.