Transcorporal Artificial Urinary Sphincter Technique Video.

OBJECTIVE: The artificial urethral sphincter (AUS) is the gold standard treatment for male stress urinary incontinence which commonly results from prostatectomy or pelvic radiation for prostate cancer. Patients with prior pelvic radiation history experience increased risk of developing urethral erosion. Transcorporal AUS (TAUS) placement can be used as an alternative for compromised urethras to incorporate a small portion of the corporal bodies for additional support. The inclusion of an additional tissue barrier has been shown to improve outcomes. Patients who undergo this technique require device explanation and AUS revision less often than those with AUS devices placed in the standard fashion. Additionally, TAUS placement has been shown to improve functional urinary outcomes such as postoperative Internal prostate symptom score (IPSS), and postoperative IPSS Quality of Life (QoL) scores. MATERIALS AND METHODS: A 67-year-old male with a past medical history of prostate cancer treated with surgery and radiation underwent a TAUS placement which was filmed to demonstrate placement technique and tips. Informed consent was obtained prior to filming this video. RESULTS: This technique can serve as a successful primary or salvage AUS placement technique as seen in this video. CONCLUSION: This video is used to demonstrate the technique of TAUS placement.

Transperineal bulbovesical anastomosis for extensive posterior urethral stenoses after treatment of prostatic disease.

OBJECTIVES: We report our surgical experience of transperineal bulbovesical anastomosis (BVA) for extensive posterior urethral stenosis (PUS). METHODS: Six male patients who had extensive PUS extending from the bulbomembranous urethra to the bladder neck due to prostatic disease treatment and underwent transperineal BVA between 2014 and 2020 were retrospectively reviewed. BVA was performed according to the elaborate perineal approach for pelvic fracture urethral repair with minor modifications. After confirming the absence of recurrent stenosis 6 months postoperatively, the patients were offered artificial urinary sphincter (AUS) placement for subsequent urinary incontinence (UI). RESULTS: Median patient age was 68, and the etiology of PUS was radical prostatectomy for prostate cancer in four patients, brachytherapy for prostate cancer in one, and transurethral resection of the prostate for benign prostatic hyperplasia in one. All patients had been previously treated with multiple transurethral procedures such as urethrotomy and dilation. Median operative time and blood loss were 211 min and 154 ml, respectively. Five cases (83.3%) had no recurrent stenosis with a median follow-up of 45 months, but a single direct vision internal urethrotomy was performed in one (16.7%) due to restenosis. Four (66.7%) patients underwent AUS placement via transcorporal approach for subsequent UI, but two had it removed due to urethral erosion. CONCLUSION: Transperineal BVA could effectively manage extensive PUS after prostatic disease treatment. Staged AUS placement could be a viable option for subsequent UI, but the risk of urethral erosion seemed high.

Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT.

BACKGROUND: Stress urinary incontinence is common in men after prostate surgery and can be difficult to improve. Implantation of an artificial urinary sphincter is the most common surgical procedure for persistent stress urinary incontinence, but it requires specialist surgical skills, and revisions may be necessary. In addition, the sphincter is relatively expensive and its operation requires adequate patient dexterity. New surgical approaches include the male synthetic sling, which is emerging as a possible alternative. However, robust comparable data, derived from randomised controlled trials, on the relative safety and efficacy of the male synthetic sling and the artificial urinary sphincter are lacking. OBJECTIVE: We aimed to compare the clinical effectiveness and cost-effectiveness of the male synthetic sling with those of the artificial urinary sphincter surgery in men with persistent stress urinary incontinence after prostate surgery. DESIGN: This was a multicentre, non-inferiority randomised controlled trial, with a parallel non-randomised cohort and embedded qualitative component. Randomised controlled trial allocation was carried out by remote web-based randomisation (1 : 1), minimised on previous prostate surgery (radical prostatectomy or transurethral resection of the prostate), radiotherapy (or not, in relation to prostate surgery) and centre. Surgeons and participants were not blind to the treatment received. Non-randomised cohort allocation was participant and/or surgeon preference. SETTING: The trial was set in 28 UK urological centres in the NHS. PARTICIPANTS: Participants were men with urodynamic stress incontinence after prostate surgery for whom surgery was deemed appropriate. Exclusion criteria included previous sling or artificial urinary sphincter surgery, unresolved bladder neck contracture or urethral stricture after prostate surgery, and an inability to give informed consent or complete trial documentation. INTERVENTIONS: We compared male synthetic sling with artificial urinary sphincter. MAIN OUTCOME MEASURES: The clinical primary outcome measure was men's reports of continence (assessed from questions 3 and 4 of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) at 12 months post randomisation (with a non-inferiority margin of 15%). The primary economic outcome was cost-effectiveness (assessed as the incremental cost per quality-adjusted life-year at 24 months post randomisation). RESULTS: In total, 380 men were included in the randomised controlled trial (n = 190 in each group), and 99 out of 100 men were included in the non-randomised cohort. In terms of continence, the male sling was non-inferior to the artificial urinary sphincter (intention-to-treat estimated absolute risk difference -0.034, 95% confidence interval -0.117 to 0.048; non-inferiority p = 0.003), indicating a lower success rate in those randomised to receive a sling, but with a confidence interval excluding the non-inferiority margin of -15%. In both groups, treatment resulted in a reduction in incontinence symptoms (as measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form). Between baseline and 12 months' follow-up, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score fell from 16.1 to 8.7 in the male sling group and from 16.4 to 7.5 in the artificial urinary sphincter group (mean difference for the time point at 12 months 1.30, 95% confidence interval 0.11 to 2.49; p = 0.032). The number of serious adverse events was small (male sling group, n = 8; artificial urinary sphincter group, n = 15; one man in the artificial urinary sphincter group experienced three serious adverse events). Quality-of-life scores improved and satisfaction was high in both groups. Secondary outcomes that showed statistically significant differences favoured the artificial urinary sphincter over the male sling. Outcomes of the non-randomised cohort were similar. The male sling cost less than the artificial sphincter but was associated with a smaller quality-adjusted life-year gain. The incremental cost-effectiveness ratio for male slings compared with an artificial urinary sphincter suggests that there is a cost saving of £425,870 for each quality-adjusted life-year lost. The probability that slings would be cost-effective at a £30,000 willingness-to-pay threshold for a quality-adjusted life-year was 99%. LIMITATIONS: Follow-up beyond 24 months is not available. More specific surgical/device-related pain outcomes were not included. CONCLUSIONS: Continence rates improved from baseline, with the male sling non-inferior to the artificial urinary sphincter. Symptoms and quality of life significantly improved in both groups. Men were generally satisfied with both procedures. Overall, secondary and post hoc analyses favoured the artificial urinary sphincter over the male sling. FUTURE WORK: Participant reports of any further surgery, satisfaction and quality of life at 5-year follow-up will inform longer-term outcomes. Administration of an additional pain questionnaire would provide further information on pain levels after both surgeries. TRIAL REGISTRATION: This trial is registered as ISRCTN49212975. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 36. See the NIHR Journals Library website for further project information.

Leakage of urine associated with physical exertion (e.g. sporting activities, sneezing or coughing) is common in men who have undergone prostate surgery, but it is difficult to improve. Many men still leak urine 12 months after their prostate surgery and may continue to wear protective pads or sheaths. The most common operation to improve incontinence is implantation of an artificial urinary sphincter. An artificial urinary sphincter is an inflatable cuff that is placed around the urethra, the tube that drains urine from the bladder. The cuff is inflated and compresses the urethra to prevent leaking. When the man needs to pass urine, he must deflate the cuff by squeezing a pump placed in his scrotum, which releases the compression on the urethra and allows the bladder to empty. Recently, a new device, the male sling (made from non-absorbable plastic mesh), has been developed. The sling, which is surgically inserted under the urethra, supports the bladder, but, in contrast to the artificial sphincter, it does not need to be deactivated by a pump and, therefore, the patient does not need to do anything to operate it. A sling is also easier for the surgeon to insert than a sphincter. However, in some men, the sling does not provide enough improvement in incontinence symptoms and another operation, to place an artificial urinary sphincter, is needed. The aim of this study was to determine if the male sling was as effective as the artificial urinary sphincter in treating men with bothersome incontinence after prostate surgery. The study took the form of a randomised controlled trial (the gold standard and most reliable way to compare treatments) in which men were randomised (allocated at random to one of two groups using a computer) to either a male sling or an artificial urinary sphincter operation. We asked men how they got on in the first 2 years after their operation. Regardless of which operation they had, incontinence and quality of life significantly improved and complications were rare. A small number of men did require another operation to improve their incontinence, and it was more likely that an artificial urinary sphincter was needed, rather than another sling operation, if a male sling was not successful. Satisfaction was high in both groups, but it was significantly higher in the artificial urinary sphincter group than in the male sling group. Those who received a male sling were less likely than those who received an artificial urinary sphincter to say that they would recommend their surgery to a friend.

[Application of urethral pressure profilometry in artificial urinary sphincter implantation].

Objective: To investigate the changes of maximum urethral pressure (MUP) and maximum urethral closure pressure (MUCP) after artificial urethral sphincter (AUS) implantation and their prognostic value. Methods: The clinical data of patients who had undergone AUS implantation in multiple medical centers between March and July 2019 were retrospectively analyzed. Data of urethral pressure profilometry, pad usage, related scores and complications related to surgery were collected and compared. The primary endpoint was social continence (defined as 0-1 pad/d) 1 month after activation of the pump. Results: A total of five male patients were included in this study. Two underwent transurethral resection of the prostate for benign prostatic hyperplasia, two underwent radical prostatectomy for prostate cancer, and one underwent urethral reunion, urethral stricture dilatation and cystostomy due to trauma from traffic accident. All patients had different degrees of urinary incontinence. The results of preoperative urethral profilometry test showed that the MUP of five patients were 52, 53, 88, 32, and 66 cmH(2)O(1 cmH(2)O=0.098 kPa), respectively, and the MUCP were 17, 52, 62, 27, and 40 cmH(2)O, respectively. AUS implantation was performed. The intraoperative urethral pressure profilometry showed that the MUP were 53, 113, 50, 77, and 89 cmH(2)O in the inactivated state, and the MUCP were 50, 97, 31, 71, and 51 cmH(2)O, respectively. In the activated state, the MUP were 112, 174, 193, 121, and 120 cmH(2)O, and the MUCP were 109, 160, 175, 114, and 92 cmH(2)O, respectively. All patients met the social continence (0-1 pad/d) criterion. No complications were reported during the follow-up. Conclusions: The relationship between the range of intraoperative urethral pressure and the effect of urinary control can be gained by measuring the specific values of MUP and MUCP during AUS implantation and the post-operative effects, which provides as a data basis for standardizing AUS implantation.

Artificial urinary sphincter longevity following transurethral resection of the prostate in the setting of prostate cancer.

PURPOSE: Refractory urinary incontinence after channel transurethral resection of the prostate (cTURP) (TURP in the setting of prostate cancer) is a rare occurrence treated with artificial urinary sphincter (AUS). We sought to characterize those patients receiving AUS after cTURP and understand device longevity. MATERIALS AND METHODS: We identified patients who underwent cTURP and AUS placement in SEER-Medicare from 2002 to 2014. We analyzed factors affecting device longevity using multivariable Cox proportional hazard models. We performed propensity matching to accurately compare patients receiving AUS after cTURP to those receiving AUS after radical prostatectomy (RP). RESULTS: For patients undergoing cTURP, 201 out of 56,957 ultimately underwent AUS placement (< 0.5%). AUS after cTURP incurred a 48.4% rate of reoperation versus 30.9% after RP. Importantly, patients undergoing cTURP were significantly older than those undergoing RP [75 vs. 71 years of age (p < 0.01)]. At 3 years after insertion, 28.2% of patients after RP required reoperation compared to 37.8% of patients post-cTURP (p < 0.01). There were no detectable differences in revision rates for those patients who underwent traditional vs. laser cTURP. Patients with a history of radiation therapy had significantly shorter device survival. Even after propensity matching, patients receiving AUS after cTURP incurred more short-term complications compared to AUS after RP. Differences in device longevity were diminished after propensity match. CONCLUSIONS: In the SEER-Medicare population, AUS after cTURP remains rare. While there is an increased risk of infectious complications, AUS after cTURP fared similarly to AUS after RP in terms of device longevity. A history of radiation therapy leads to worse outcome for all patients.

Prospective analysis of artificial urinary sphincter AMS 800 implantation after buccal mucosa graft urethroplasty.

OBJECTIVES: To analyze functional outcomes and complication rates of artificial urinary sphincter (AUS) implantation in patients who had undergone buccal mucosa graft urethroplasty (BMGU) beforehand. PATIENTS AND METHODS: This prospectively maintained single-center database comprises data from 236 patients from 2009 to 2015 who underwent AUS implantation. A total of 17 patients after BMGU were available for analysis. Primary endpoints consisted of continence and complication rates. Continence was defined as no use of safety pads, social continence as < 2 pads per day. Stricture recurrence was defined as a decrease in uroflowmetry, a maximum flow rate < 10 ml/s or residual urine volume (> 100 ml). Kaplan-Meier analysis determined explantation-free survival. RESULTS: Median follow-up was 24 months (interquartile range [IQR] 6-31 months). Indication for AUS implantation was severe urinary incontinence with a history of radical prostatectomy (RRP) in 8 (47.1%), trauma in 1 (5.9%) and TUR-P in 8 (47.1%) patients. Pelvic irradiation was reported in 13 (76.5%) cases. The median length of buccal mucosa graft for urethroplasty was 4 cm (3-5 cm). A double cuff was implanted in 14 patients (82.4%), 3 patients received a single cuff. Complete and social continence was achieved in 76.5% and 100% of the patients, respectively. There was no significant difference in complications and explantation-free survival (log-rank, p = 0.191) between patients who had undergone BMGU before AUS compared to patients with no history of BMGU. CONCLUSIONS: According to the prospective follow-up data in a homogenous cohort, AUS implantation seems to be a viable, safe and effective therapeutic strategy for incontinence treatment despite previous BMGU.

A User's Guide for Surgery Involving the Artificial Urinary Sphincter.

INTRODUCTION: The artificial urinary sphincter (AUS) has long been regarded as the gold standard for surgical correction of male stress urinary incontinence (SUI). Despite impressive rates of initial success for restoration of continence, durability may wane to the point of considering revision surgery. AIM: To provide a review of existing data as well as personal experience regarding patient selection, surgical technique, and postoperative troubleshooting for the AUS. METHODS: A systematic review of the peer-reviewed literature was performed to identify relevant and contemporary articles regarding perioperative and long-term management of the AUS. Additional input is presented based on clinical experience of the senior author. MAIN OUTCOME MEASURE: The main outcome measures are durability, patient satisfaction, mechanical failure, and urethral erosion. RESULTS: In addition to a thorough history and examination, preoperative screening should include office cystoscopy to rule out bladder neck contracture in patients with a history of radical prostatectomy. Perineal cuff placement appears superior to alternative approaches. Prior radiation and use of the 3.5-cm cuff are risk factors for future erosion. Newer findings suggest that subsequent recurrence of SUI may be due to restrictive encapsulation, rather than true atrophy, with implications for revision surgery. CONCLUSION: The AUS remains an excellent option for surgical correction of moderate to severe male SUI. Detailed preoperative evaluation and patient selection are critical. The challenge of downstream recurrent SUI after AUS can be effectively managed for most patients with a structured approach. Chouhan JD, Terlecki RP. A User's Guide for Surgery Involving the Artificial Urinary Sphincter. Sex Med Rev 2019;7:167-177.

Técnica quirúrgica de la implantación de dispositivo ajustable transobsturador anti-incontinencia urinaria masculina tipo Atoms en una clínica de III nivel en Bogotá / Surgical Technique of the Implantation of Adjustable Masculine Transobsturador Anti-Incontinence Urinary Device Type Atoms in a Clinic of III Level in Bogotá

La prevalencia de incontinencia urinaria de esfuerzo (IUE) post-prostatectomía varía entre el 4% y el 50%, siendo más frecuente en pacientes que son llevados a prostatectomía radical. Es una condición que afecta la calidad de vida de los pacientes y presenta un impacto de grado variable de severidad. Existen diferentes opciones para el tratamiento de esa entidad, dentro de los cuales se encuentran: terapia de piso pélvico con biofeedback, fisioterapia, sistemas recolectores de orina, clamps peneanos, inyecciones periuretrales de materiales abultantes, esfínter urinario artificial (EUA) y cintas pubouretrales.[1] [2] El gold standard para la IUE es el EUA con tasa de éxito entre 50%­80%, no obstante, con una tasa de explante de hasta el 33%. Se han desarrollado otras alternativas con cintas pubouretrales las cuales han reportado una tasa de éxito hasta del 83%.[2] La principal limitante de esas alternativas en el manejo de la IUE, ha sido la necesidad de reajustar esos dispositivos con procedimientos quirúrgicos, exponiendo en repetidas ocasiones a los pacientes a los riesgos de anestesia y del procedimiento quirúrgico, situación que se ha tratado de mejorar con el dispositivo ATOMS®, introducido en Europa desde marzo del 2009, el cual ofrece la oportunidad de realizar tales ajustes en el consultorio.[3] La indicación para la colocación del ATOMS® es la IUE, sin tener claridad en su severidad, hasta en un 92,9% de las ocasiones, y usualmente son pacientes con antecedente de cirugías previas anti-incontinencia fallidas (34,3%). El tiempo quirúrgico promedio es de 47 minutos, entre 29 minutos a 112 minutos.[1]

Proof of concept: Exposing the myth of urethral atrophy after artificial urinary sphincter via assessment of circumferential recovery after capsulotomy and intraoperative pressure profiling of the pressure regulating balloon.

Purpose: Rate of continence after artificial urinary sphincter (AUS) placement appears to decline with time. After appropriate workup to exclude inadvertent device deactivation, development of urge or overflow incontinence, and fluid loss, many assume recurrent stress urinary incontinence (rSUI) to be secondary to nonmechanical failure, asserting urethral atrophy as the etiology. We aimed to characterize the extent of circumferential urethral recovery following capsulotomy and that of pressure regulating balloon (PRB) material fatigue in men undergoing AUS revision for rSUI. Materials and Methods: Retrospective review of a single surgeon database was performed. Cases of AUS removal/replacement for rSUI involving ventral subcuff capsulotomy and intraoperative PRB pressure profile assessments were identified. Results: The described operative approach involving capsulotomy was applied in 7 patients from November 2015 to September 2017. Mean patient age was 75 years. Mean time between AUS placement and revision was 103 months. Urethral circumference increased in all patients after capsulotomy (mean increase 1.1 cm; range 0.5-2.5 cm). Cuff size increased, remained the same, and decreased in 2, 3, and 2 patients, respectively. Six of 7 patients underwent PRB interrogation. Four of these 6 PRBs (66.7%) demonstrated pressures in a category below the reported range of the original manufacturer rating. Conclusions: Despite visual appearance to suggest urethral atrophy, subcuff capsulotomy results in increased urethral circumference in all patients. Furthermore, intraoperative PRB profiling demonstrates material fatigue. Future multicenter efforts are warranted to determine if capsulotomy, with or without PRB replacement, may simplify surgical management of rSUI with reductions in cost and/or morbidity.

Male synthetic sling versus artificial urinary sphincter trial for men with urodynamic stress incontinence after prostate surgery (MASTER): study protocol for a randomised controlled trial.

BACKGROUND: Stress urinary incontinence (SUI) is a frequent adverse effect for men undergoing prostate surgery. A large proportion (around 8% after radical prostatectomy and 2% after transurethral resection of prostate (TURP)) are left with severe disabling incontinence which adversely effects their quality of life and many are reliant on containment measures such as pads (27% and 6% respectively). Surgery is currently the only option for active management of the problem. The overwhelming majority of surgeries for persistent bothersome SUI involve artificial urinary sphincter (AUS) insertion. However, this is expensive, and necessitates manipulation of a pump to enable voiding. More recently, an alternative to AUS has been developed - a synthetic sling for men which elevates the urethra, thus treating SUI. This is thought, by some, to be less invasive, more acceptable and less expensive than AUS but clear evidence for this is lacking. The MASTER trial aims to determine whether the male synthetic sling is non-inferior to implantation of the AUS for men who have SUI after prostate surgery (for cancer or benign disease), judged primarily on clinical effectiveness but also considering relative harms and cost-effectiveness. METHODS/DESIGN: Men with urodynamic stress incontinence (USI) after prostate surgery, for whom surgery is judged appropriate, are the target population. We aim to recruit men from secondary care urological centres in the UK NHS who carry out surgery for post-prostatectomy incontinence. Outcomes will be assessed by participant-completed questionnaires and 3-day urinary bladder diaries at baseline, 6, 12 and 24 months. The 24-h urinary pad test will be used at baseline as an objective assessment of urine loss. Clinical data will be completed at the time of surgery to provide details of the operative procedures, complications and resource use in hospital. At 12 months, men will also have a clinical review to evaluate the results of surgery (including another 24-h pad test) and to identify problems or need for further treatment. DISCUSSION: A robust examination of the comparative effectiveness of the male synthetic sling will provide high-quality evidence to determine whether or not it should be adopted widely in the NHS. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Registry: Number ISRCTN49212975 . Registered on 22 July 2013. First patient randomised on 29 January 2014.

Management of Postradical Prostatectomy Urinary Incontinence: A Review.

Postprostatectomy urinary incontinence has a significant impact on the quality of life of patients who undergo radical prostatectomy. Stress and overflow incontinence may result from the procedure, with sphincteric incompetence and detrusor hypocontractility implicating their development, respectively. In many cases, treatment begins with conservative approaches, including pelvic floor muscle training or biofeedback. Pharmacotherapy can be used to treat overactive bladder. For stress incontinence, transurethral bulking agents are utilized in select patients; however, artificial urinary sphincter and male slings are the most efficacious options with good success rates. In this review, the various treatment modalities are critically discussed with special emphasis on safety and efficacy.

Robotic-assisted laparoscopic artificial urinary sphincter and MACE procedure on a pediatric patient.

OBJECTIVE: To describe robotic-assisted laparoscopic artificial urinary sphincter (RAL-AUS) placement and a Malone antegrade continent enema (MACE) procedure on a 6-year-old girl. PATIENTS AND RESULTS: Our patient is a 6-year-old girl with myelomeningocele. She was totally incontinent of urine and chronic constipated despite aggressive bowel regimen. Preoperative workup included renal and bladder ultrasound showing normal findings. Video-urodynamics was also obtained showing low leak point pressure (25 cm H2O) with no reflux. RAL-AUS was performed totally intra-corporally with no complications. The total operative time was 5 h 42 min. Estimated blood loss was minimal. The patient was discharged on postoperative day 4 with the AUS deactivated. Follow-up cystoscopy and activation of the AUS was done 6 weeks later. At 3-month follow-up, the patient was fully recovered and remained completely dry between voids. Also her bowel movements improved significantly with the MACE. Both patient and family appeared comfortable in using the AUS. CONCLUSION: To our knowledge, this is the first case described of RAL-AUS placement in the pediatric population. We believe this can be safely accomplished with good outcomes. The robotic approach provides an advantage in performing deep pelvic surgeries and facilitates concomitant intra-abdominal procedures.

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.

Transcorporal artificial urinary sphincter in radiated and non - radiated compromised urethra. Assessment with a minimum 2 year follow-up.

PURPOSE: to assess the efficacy of transcorporal artificial urinary sphincter (AUS) implantation on continence for male stress urinary incontinence in cases of prior surgical treatment or/and radiation failure, and as a first option in radiation patients. MATERIALS AND METHODS: From March 2007 to August 2012, 37 male patients were treated with transcorporal AUS AMS™ 800. Twelve patients had primary placement of transcorporal cuff, a surgical option due to a previous history of radiation and 25 patients had secondary procedure after failure of AUS or urinary incontinence surgery. Functional urinary outcomes were assessed by daily pad use, 24-hour Pad-test and ICIQ-SF questionnaire. Quality of life and satisfaction were assessed based on I-QoL and PGI-I questionnaires. RESULTS: After a median of 32 months, the continence rate (0 to 1 pad) was 69.7%. Median pad test was 17.5g (0-159), mean ICIQ-SF score was 7.3/21 (±5.4) and mean I-QoL score was 93.9/110. A total of 88% of the patients reported satisfaction with the AUS. The 5-year actuarial revision-free for AUS total device was 51%. Patients for primary implant for radiation were not more likely to experience revision than non-radiation patients. Preservation of erections was reported in half of the potent patients. CONCLUSIONS: Transcorporal AUS cuff placement is a useful alternative procedure option for severe male UI treatment, especially in patients with a compromised urethra after prior surgery or radiation. A high continence rate was reported and implantation as first option in radiation patients should be considered.

Transcorporal artificial urinary sphincter in radiated and non - radiated compromised urethra. Assessment with a minimum 2 year follow-up

ABSTRACT Purpose to assess the efficacy of transcorporal artificial urinary sphincter (AUS) implantation on continence for male stress urinary incontinence in cases of prior surgical treatment or/and radiation failure, and as a first option in radiation patients. Materials and Methods From March 2007 to August 2012, 37 male patients were treated with transcorporal AUS AMS™ 800. Twelve patients had primary placement of transcorporal cuff, a surgical option due to a previous history of radiation and 25 patients had secondary procedure after failure of AUS or urinary incontinence surgery. Functional urinary outcomes were assessed by daily pad use, 24-hour Pad-test and ICIQ-SF questionnaire. Quality of life and satisfaction were assessed based on I-QoL and PGI-I questionnaires. Results After a median of 32 months, the continence rate (0 to 1 pad) was 69.7%. Median pad test was 17.5g (0-159), mean ICIQ-SF score was 7.3/21 (±5.4) and mean I-QoL score was 93.9/110. A total of 88% of the patients reported satisfaction with the AUS. The 5-year actuarial revision-free for AUS total device was 51%. Patients for primary implant for radiation were not more likely to experience revision than non-radiation patients. Preservation of erections was reported in half of the potent patients. Conclusions Transcorporal AUS cuff placement is a useful alternative procedure option for severe male UI treatment, especially in patients with a compromised urethra after prior surgery or radiation. A high continence rate was reported and implantation as first option in radiation patients should be considered.

Instrumentación transuretral en portadores de esfínter urinario artificial. Presentación y discusión de tres casos clínicos / Transurethral instrumentation in patients with artificial urinary sphincter. Presentation and discussion of three clinical cases

El tratamiento para la incontinencia urinaria masculina de esfuerzo severa es la colocación de un esfínter urinario artificial (EUA). La etiología de la incontinencia con frecuencia es la cirugía prostática previa. Los resultados funcionales son buenos con una tasa aceptable de complicaciones. Las complicaciones son más frecuentes si existe radioterapia previa o se realizan procedimientos transuretrales sin tener en cuenta la presencia del manguito del EUA. Cuando es necesaria la cirugía transuretral, por ejemplo por tumor vesical, es necesario realizar el desabrochado del manguito esfinteriano. Los sondajes uretrales precisan también desactivar el manguito y manipular la uretra con sumo cuidado, evitando su manipulación siempre que sea posible. Se presentan tres casos muy complejos de pacientes portadores de EUA que han precisado diversas soluciones ante manipulación uretral y presencia de complicaciones como estenosis de uretra (AU)

Artificial urinary sphincter (AS) is the gold standard treatment for severe male urinary stress incontinence. The etiology of incontinence is often previous prostate surgery as a radical prostatectomy. Functional results are good with an acceptable rate of complications. If there is prior radiotherapy complications are more frequent. When transurethral surgery, for example for bladder tumor is needed, it is necessary unbuttoned the sleeve. Urethral soundings need also turn off the sleeve and manipulate the urethra carefully, avoiding handling whenever possible. We present three very complex cases of patients with US showing several solutions to urethral manipulation and to resolve complications such as urethral perforation and stricture (AU)

A pragmatic approach to the characterization and effective treatment of male patients with postprostatectomy incontinence.

PURPOSE OF REVIEW: To highlight the recent developments in the past 12 months in the field of postprostatectomy incontinence. RECENT FINDINGS: The evaluation of postprostatectomy incontinence is mainly based on clinical details and symptoms assessment. The situation in which urodynamics will change the management and influence clinical decision-making is still unknown. MRI may play a role in the future for postprostatectomy incontinence assessment. Artificial urinary sphincter is the most widely used treatment, and the literature is full of technical reports to improve the management of challenging cases and minimize the risk of complications. Advance male sling has been the subject of multiple reports that support its safety and efficacy. Many other innovative devices have been presented but not adequately tested. SUMMARY: Evaluation of postprostatectomy incontinence is based on clinical data, involving symptoms assessment, quality of life, and incontinence severity. Endoscopy is requested, and urodynamic study indications are debated. The treatment is mainly focused on surgical options, of which artificial urinary sphincter and transobturator male slings are the two leaders. The field is critically lacking of comparative studies.

Surgery for stress urinary incontinence due to presumed sphincter deficiency after prostate surgery.

BACKGROUND: Incontinence after prostatectomy for benign or malignant disease is a well-known and often a feared outcome. Although small degrees of incidental incontinence may go virtually unnoticed, larger degrees of incontinence can have a major impact on a man's quality of life.Conceptually, post-prostatectomy incontinence may be caused by sphincter malfunction or bladder dysfunction, or both. Most men with post-prostatectomy incontinence (60% to 100%) have stress urinary incontinence, which is involuntary urinary leakage on effort or exertion, or on sneezing or coughing. This may be due to intrinsic sphincter deficiency and may be treated with surgery for optimal management of incontinence. Detrusor dysfunction is more common after surgery for benign prostatic disease. OBJECTIVES: To determine the effects of surgical treatment for urinary incontinence related to presumed sphincter deficiency after prostate surgery for:- men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) - transurethral resection of prostate (TURP), photo vaporisation of the prostate, laser enucleation of the prostate or open prostatectomy - and- men with prostate cancer - radical prostatectomy (retropubic, perineal, laparoscopic, or robotic). SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, and handsearching of journals and conference proceedings (searched 31 March 2014); MEDLINE (January 1966 to April 2014); EMBASE (January 1988 to April 2014); and LILACS (January 1982 to April 2014). We handsearched the reference lists of relevant articles and conference proceedings. We contacted investigators to locate studies. SELECTION CRITERIA: Randomised or quasi-randomised trials that include surgical treatments of urinary incontinence after prostate surgery. DATA COLLECTION AND ANALYSIS: Two authors independently screened the trials identified, appraised quality of papers, and extracted data. MAIN RESULTS: Only one study with 45 participants met the inclusion criteria. Men were divided in two sub-groups (minimal or total incontinence) and each group was randomised to artificial urethral sphincter (AUS) implantation or Macroplastique injection. Follow-up ranged from six to 120 months. In the trial as a whole, the men treated with AUS were more likely to be dry (18/20, 82%) than those who had the injectable treatment (11/23, 46%) (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.28 to 25.10). However, this effect was only statistically significant for the men with more severe ('total') incontinence (OR 8.89, 95% CI 1.40 to 56.57) and the CIs were wide. There were more severe complications in the group undergoing AUS, and the costs were higher. AUS implantation was complicated in 5/22 (23%) men: the implant had to be removed from one man because of infection and in one man due to the erosion of the cuff, in one man the pump was changed due to mechanical failure, in one man there was migration to the intraperitoneal region, and one man experienced scrotal erosion. In the injectable group, 3/23 (13%) men had a complication: one man treated with Macroplastique injection had to be catheterised because of urinary retention and two men developed urinary tract infections. AUTHORS' CONCLUSIONS: The evidence available at present was of very low quality because we identified only one small randomised clinical trial. Although the result was favourable for the implantation of AUS in the group with severe incontinence, this result should be considered with caution due to the small sample size and uncertain methodological quality of the study found.

[Treatment of the urethral sphincter insufficiency]. / Prise en charge de l'insuffisance sphinctérienne urétrale.

The intrinsic sphincter insufficiency is a cause of stress urinary incontinence. Its definition is clinical and based on urodynamics. It is mostly met with women, in context of the post-obstetrical period or older women in a multifactorial context. For men, it occurs mainly as complication of the surgery of the cancer of prostate or bladder. An initial, clinical and paraclinical assessment allows to confirm the diagnosis of intrinsic sphincter insufficiency, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment. The perineal reeducation is the treatment of first intention in both sexes. At the menopausal woman, the local hormonotherapy is a useful additive. In case of failure or of incomplete efficiency, the treatment of the intrinsic sphincter insufficiency is surgical. Bulking agents, urethral slings, peri-urethral balloons and artificial sphincter are 4 therapeutic options to discuss according to history, the severity of the incontinence, the expectations of the patient.