Proposal of a new way to evaluate the external sphincter function prior male sling surgey

ABSTRACT Objective: To propose a new way to objectively evaluate the external sphincter function prior to male sling surgery. Materials and Methods: We evaluated the pre-operative sphincter function throughout sphincter pressure at rest (SPAR) and sphincter pressure under contraction (SPUC) obtained throughout urethral profilometry profile (UPP) of 10 consecutive patients (age range, 54-79 years) treated with the retrourethral transobturator sling (RTS) for stress urinary incontinence (SUI) because of prostate surgery. The primary endpoint for surgery success rate was post-operative pad weight test. This was correlated to pre-operative pad test, RT, SPAR and SPUC. Post-operatively patients were classified as continent (no pad use) and those who still were incontinent. Results: Mean SPUC in the continent and incontinent group was respectively 188 + 8.8 (median 185.1, range 181 to 201) and 96.9 + 49.4 (median 109.9, range 35.6 to 163.6) (P = 0.008). Mean 24-hour pad test was 151 + 84.2gm (median 140, range 80 to 245) and 973 + 337.1gm (median 1940, range 550 to 1200) in post-operative continent and incontinent groups respectively (P = 0.008). The repositioning test (RT) was positive in all continent patients except one. The RT was also positive in three incontinence patients (false positive). In all post-operative continent patients SPUC was higher than 180cmH2O and pre-operative pad test was less than 245gm. Conclusions: SPUC seems to be a way for optimizing the sphincter evaluation as well to become a useful tool for patient selection prior to RTS surgery.

Salvage surgical procedure for artificial sphincter extrusion

ABSTRACT Case Hypothesis: Surgical removal is the standard treatment for artificial sphincter extrusion. However in some specific situations is possible to maintain the prosthesis with good results. Case report: We report a 60 years old patient presenting sphincter pump extrusion one month after artificial urinary sphincter (AUS) AMS 800™ placement for treating post-radical prostatectomy urinary incontinence (PRPUI). He also had a penile pros- thesis implant one year before that was replaced in the same surgery the sphincter was implanted. As patient refused sphincter removal and there were no signals of active infection he was treated by extensive surgical washing with antibiotics and antiseptics. Pump was repositioned in the opposite side of the scrotum. Patient had good evolution with sphincter activation 50 days later. After 10 months of follow up, patient is socially continent and having regular sexual intercourse. Savage surgery may be an option in select cases of artificial sphincter extrusion. Promising future implications: Like in some patients with penile prosthesis some pa- tients with artificial sphincter extrusion can be treated without removing the device. This may be a line of research about conservative treatment of artificial sphincter complications.

A new material to prevent urethral damage after implantation of artificial devices: an experimental study

ABSTRACT Objective To validate the application of the bacterial cellulose (BC) membrane as a protecting barrier to the urethra. Materials and Methods Forty female Wistar rats (four groups of 10): Group 1 (sham), the urethra was dissected as in previous groups and nothing applied around; Group 2, received a 0.7cm strip of the BC applied around the urethra just below the bladder neck; Group 3, received a silicon strip with the same dimensions as in group 2; Group 4, had a combination of 2 and 3 groups being the silicon strip applied over the cellulosic material. Half of the animals in each group were killed at 4 and 8 months. Bladder and urethra were fixed in formalin for histological analysis. Results Inflammatory infiltrates were more intense at 4 months at lymphonodes (80% Grade 2), statistically different in the group 2 compared with groups 1 (p=0.0044) and 3 (p=0.0154). At 8 months, all samples were classified as grade 1 indicating a less intense inflammatory reaction in all groups. In group 2, at 8 months, there was a reduction in epithelial thickness (30±1μm) when com-pared to groups 1 (p=0.0001) and 3 (p<0.0001). Angiogenesis was present in groups 2 and 4 and absent in group 3. In BC implant, at 4 and 8 months, it was significant when comparing groups 4 with 1 (p=0.0159). Conclusion BC membrane was well integrated to the urethral wall promoting tissue remodeling and strengthening based on morphometric and histological results and may be a future option to prevent urethral damage.

Case report of deep vein thrombosis caused by artificial urinary sphincter reservoir compressing right external iliac vein

Artificial urinary sphincters [AUSs] are commonly used after radical prostatectomy for those who are incontinent of urine. However, they are associated with complications, the most common being reservoir uprising or migration. We present a unique case of occlusive external iliac and femoral vein obstruction by the AUS reservoir causing thrombosis. Deflation of the reservoir and anticoagulation has, thus far, not been successful at decreasing thrombus burden. We present this case as a rare, but significant surgical complication; explore the risk factors that may have contributed, and other potential endovascular therapies to address this previously unreported AUS complication

Esfíncter urinário artificial na incontinência urinária masculina grave pós-prostatectomia / Artificial urinary sphincter in severe male urinary incontinence after prostatectomy

Demandante: American Medical System, INC - EUA. Tipo: Produto, dispositivo implantável cirurgicamente. Nome comercial: AMS 800. N° de registro na ANVISA: 80219980027. Validade do registro: 28/12/2014. Indicação de uso e finalidade do produto na ANVISA: incontinência urinária grave Indicação proposta: incontinência urinária grave pós-prostatectomia radical em pacientes com câncer de próstata. Descrição da Tecnologia: O esfíncter urinário é um dispositivo implantável de elastômero de silicone sólido, cheio de líquido, utilizado para tratar a incontinência urinária, restabelecendo o processo natural de controle urinário. O dispositivo simula a função esfincteriana normal ao abrir e fechar a uretra sob o controle do paciente. É composto por três componentes interligados: uma manga oclusora, uma bomba e um balão regulador da pressão. Os três componentes estão ligados por tubos resistentes a dobras. Considerações finais: A análise da evidência disponível sobre o implante de esfíncter urinário artificial e opções terapêuticas como slings e injeções, para o manejo de incontinência urinária moderada a grave, permitem uma abordagem indireta da efetividade comparativa dessas técnicas. Em relação ao uso de injeções de preenchimento, não parece ser uma terapia adequada para incontinência moderada a grave, pois praticamente não foi estudada e, no único estudo teve efetividade baixa. Com base nas informações disponíveis, o esfíncter artificial e os slings parecem ser terapias efetivas no manejo de incontinência urinária moderada a grave pós-prostatectomia radical para o tratamento do câncer de próstata. Em pacientes com sintomas moderados, ambas as estratégias parecem ter efetividade similar, tendo em vista a sobreposição dos intervalos de confiança das estimativas da meta-análise de cada terapia. Por outro lado, para casos com sintomas graves, o EA parece ter um benefício adicional em melhora dos sintomas e cura (intervalos de confiança não se cruzam). A análise econômica demonstrou que a alternativa de tratamento usual para incontinência urinária (medidas comportamentais e medicamentos) apresentou-se como a tecnologia menos custosa, mas também menos efetiva. Já a relação custo-efetividade das comparações entre as tecnologias esfíncter urinário e sling, parece estar relacionada ao grau de gravidade da incontinência urinária. Nos cenários de incontinência moderada e moderada/grave, o sling foi dominante, sendo mais efetivo e de menor custo do que o esfíncter artificial. Para o cenário de incontinência grave, não houve dominância, porém a RCEI do esfíncter quando comparado ao sling foi bastante alta. Diante do exposto, e por considerar a necessidade prévia de elaboração de um protocolo clínico e diretrizes terapêuticas (PCDT) para a linha de cuidado da incontinência urinária antes da incorporação isolada de tecnologias para essa condição, os membros da CONITEC, presentes na 12ª reunião ordinária do plenário dos dias 05 e 06/02/2013, recomendaram, por unanimidade, a não incorporação no SUS do esfíncter urinário artificial para tratamento da incontinência urinária masculina grave pós-prostatectomia. A Portaria nº 22, de 23 de maio de 2013 - Torna pública a decisão de não incorporar o esfíncter urinário artificial para o tratamento da incontinência urinária masculina grave pós-prostatectomia no Sistema Único de Saúde (SUS).

Periurethral constrictor: late results of the treatment of post prostatectomy urinary incontinence

OBJECTIVES: We evaluated retrospectively, the long-term outcome of patients with post-prostatectomy urinary incontinence (PPUI) after placement of the Periurethral Constrictor (PUC). MATERIALS AND METHODS: Fifty-six men with severe PPUI were studied, with a mean age of 68.5 years old. Fifty-one men had PPUI due to radical surgery having the device placed around the bulbous urethra, and five individuals with benign prostatic hypertrophy (BPH) had placement around the bladder neck. The mean follow-up was 82.2 months. RESULTS: Twenty-two patients (39.28 percent) became continent (0 to 1 pad a day) and 34 (60.72 percent) were incontinent. Complications were as follows: urethral erosion in 15 (26.78 percent); mechanical malfunction in 2 (3.5 percent); infection in 2 (3.5 percent); urinary fistula in 1 (1.7 percent); Urinary tract infection1 (1.7 percent). Twenty-three patients needed to have the device removed (41.07 percent). Success rate (continent me) was 30.35 percent. CONCLUSION: In the present series the PUC was not effective for the treatment of severe PPUI in the long-term follow-up.

Le sphincter artificiel urinaire chez l'homme à propos de 23 cas

Objectif Evaluer notre experience dans la mise en place des sphincters artificiels urinaires (SAU). Discuter; apres une revue de la litterature; les indications; les examens complementaires et le pronostic. Patients et methodes Il s'agit d'une etude retrospective; a partir de 23 cas de sphincters artificiels type AMS 800; poses a des patients de sexe masculin; dans le service d'urologie au Centre Hospitalo-Universitaire Dupuytren de Limoges; et colliges sur une periode de 10 ans; entre avril 1996 et avril 2005. L'age moyen de nos patients etait de 70.3 ans; avec des extremes de 47 et 77 ans. Huit de nos malades ont recu un traitement par radiotherapie pelvienne d'un cancer de la prostate. Les causes d'insuf-fisance sphincterienne etaient: une prostatectomie radicale dans 10 cas; une resection endoscopique d'un adenome de la prostate dans 5 cas; une adenomectomie transvesicale dans 4 cas; une sphincterotomie endoscopique avec un agrandissement vesical dans 2 cas; une radiotherapie externe curative pour adenocarcinome localise de la prostate stade T2a dans un cas; et une cysto-prostatectomie avec enterocystoplastie type Camey II dans un cas. Les examens complementaires demandes etaient une analyse des urines; un bilan biologique inflammatoire et infectieux; une uretro-cystoscopie et un bilan urodynamique. Une reeducation perineale a ete pratiquee dans tous les cas; tandisqu'une injection du materiel macroplastique n'a ete faite que dans 15 cas. Enfin un sphincter artificiel a ete mis en position periuretrale dans tous les cas. Resultats L'appreciation du resultat fonctionnel du sphincter artificiel est basee sur la clinique et la satisfaction du patient. On a evalue ces resultats 6 mois apres l'activa-tion du sphincter. Sur nos 23 patients; 18 se disent entierement satisfaits et les 5 autres signalent des fuites qui sont minimes et positionnelles ou liees a des efforts; dont un avec une diminution du jet. Les complications sont apparues plus tard; en effet sur nos 23 SAU; 9 ont ete greves de complications dont 3 cas ont ete facilement corriges. Il s'agit: d'une complication d'ordre technique avec une hyperpression dans le ballon; une fistule vesico-parietale a minima et une migration de la pompe ayant necessite de la repositionner. Dans les autres 6 cas; la complication etait une erosion de l'uretre par la manchette; survenue en moyenne dans un delai de 5 ans apres la mise en place. Conclusion L'efficacite du sphincter artificiel AMS 800 pour la prise en charge de l'incontinence urinaire par insuffisance sphincterienne chez l'homme est indiscutable comme en temoigne le taux de satisfaction des patients qui en sont porteurs. Neanmoins; il persiste encore un taux d'echec non negligeable ayant souvent des consequences graves puisqu'il se solde en general par l'ablation du materiel surtout s'il s'agissait d'une erosion uretrale. Pour ceci; un respect des indications; une selection stricte des candidats; et un bon suivi des patients est necessaire dans l'espoir de diminuer l'emergence de complications