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1.
Urology ; 135: 154-158, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31585200

RESUMO

OBJECTIVE: To identify patient and component specific factors that predispose patients to device-related complications when undergoing pressure-regulating balloon (PRB) exchange in men with an artificial urinary sphincter (AUS). METHOD: From 2009 to 2018, 55 patients underwent AUS revision with placement of a higher pressure 71-80 cm H2O PRB to treat recurrent stress incontinence. Patient demographics, perioperative data, and postoperative outcomes were examined and multivariable logistic regression analyses performed to identify predictors of erosion and mechanical failure. RESULT: After a median follow-up of 26.4 months (range: 6-103.7 months), 21 of 55 (38.1%) patients developed a device-related complication that required operative repair or removal of the AUS. Four (7.3%) patients developed erosion after the PRB pressure increase and 5 patients showed evidence of impending erosion on follow-up and underwent successful revision surgery. Twelve patients developed mechanical failure (cuff leak, n = 7; pump malfunction, n =4; unidentified fluid loss, n = 1). Multivariable logistic regression analysis found that increasing body mass index was a predictor of mechanical failure. Hypertension and lower body mass index were found to increase the risk of cuff erosion whereas radiotherapy was not. CONCLUSION: In the carefully selected patient, PRB exchange can be performed to treat recurrent incontinence in patients with an AUS, including those treated with pelvic radiotherapy. Our data suggest that this technique is susceptible to a high rate of revision surgery. As such, when revising a functional AUS system, meticulous preoperative screening, comprehensive informed consent, and follow-up protocols are essential in minimizing adverse events.


Assuntos
Falha de Prótese , Reoperação/instrumentação , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Pressão , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
6.
Urology ; 133: 234-239, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31352019

RESUMO

OBJECTIVE: To analyze functional outcomes and complication rates of distal double cuffs (DC) or transcorporal cuffs (TC) as salvage approaches in high-risk patients, since there is an ongoing debate about optimal cuff-placement in a salvage setting (SV). Existing studies analyzing DC or TC are controversial with respect to functional outcomes and complication rates. Studies directly comparing both approaches in SV are scarce. METHODS AND PATIENTS: Prospective data collection was performed since 2009. DC/TC were applied according to a standardized protocol in SV. Salvage DC was chosen in case of a membranous single cuff explantation due to erosion or infection. TC were implanted after bulbar urethroplasty or DC explantation. Activation was performed 6 weeks postoperatively. Further follow-up was scheduled 6/24 months postoperatively and every 2 years thereafter. Primary/secondary endpoints were continence/complication rates. RESULTS: In total, 71 high-risk patients were available for analysis (58 DC, 13 TC). Median age was 70 years. Median follow-up was 24 months. Objective/social continence were 88%/94% in the DC and 72%/100% in the TC cohort, respectively (P = .37/P = 1). Overall, there were no significant differences with respect to infections, erosions, mechanical failure, and explantation rates. The times of explantation-free survival were similar in Kaplan-Meier analysis (Log-rank 0.399). CONCLUSION: Complication and continence rates were not significantly different between both cohorts. Hence, a DC in SV can be considered as equally safe and effective. A sequential implantation (first DC, second TC) may be a viable approach to extend overall AUS incontinence therapy.


Assuntos
Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial , Idoso , Humanos , Masculino , Estudos Prospectivos , Implantação de Prótese/métodos , Terapia de Salvação/métodos , Procedimentos Cirúrgicos Urológicos Masculinos/métodos
12.
Urologe A ; 58(6): 640-650, 2019 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-31089755

RESUMO

The differentiated surgical treatment of male urinary incontinence is a very interesting and sometimes also emotional topic, in which evidence is increasingly maturing. Nowadays, the most common surgical procedures are fixed sling and adjustable incontinence systems as well as the artificial urinary sphincter. The evidence for the procedures varies and there is currently a lack of prospective, comparative studies. The challenging question is: Which operation is the best for which patient? The following article is intended to give an overview of the surgical options and a constructive attempt to differentiate the indication.


Assuntos
Próteses e Implantes , Slings Suburetrais , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial , Procedimentos Cirúrgicos Urológicos/métodos , Humanos , Intenção , Masculino , Complicações Pós-Operatórias/cirurgia , Prostatectomia , Resultado do Tratamento , Incontinência Urinária por Estresse/diagnóstico , Incontinência Urinária por Estresse/etiologia , Procedimentos Cirúrgicos Urológicos Masculinos
13.
Urology ; 129: 210-216, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31005655

RESUMO

OBJECTIVE: To determine whether frailty is associated with increased odds of 30-day surgical complications among men undergoing both artificial urinary sphincter (AUS) placement and removal procedures and to determine whether frailty was associated with increased odds of having an AUS removal procedure. METHODS: This is a retrospective cohort study of men undergoing AUS placement and removal procedures using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2006 to 2013. Frailty was quantified using the NSQIP-FI (frailty index) and was applied to logistic regression models predicting 30-day complications (overall, major, and minor) and the odds of having an AUS removal procedure (over an AUS placement procedure). RESULTS: We identified a total of 624 and 147 men undergoing AUS placement and removal procedures, respectively. NSQIP-FI of ≥0.27, but not age, was associated with major complications (aOR 3.5, 95% confidence interval 1.2-9.9), while age ≥85 years, but not NSQIP-FI, was associated with minor complications (aOR 7.9, 95% confidence interval 1.4-45.6). Men undergoing AUS removal procedures tended to be more frail compared to men undergoing AUS placement procedures (12.9% vs 6.1% had NSQIP-FI of ≥0.27, P<.01). CONCLUSION: Men undergoing AUS removal procedures are, on average, more frail compared to men undergoing AUS placement procedures. Frailty is associated with increased odds of major complications and with having an AUS removal procedure. These findings highlight the importance of incorporating measures of frailty, instead of age alone, into the perioperative decision-making process for adults considering these types of procedures.


Assuntos
Remoção de Dispositivo/métodos , Fragilidade/complicações , Complicações Pós-Operatórias/epidemiologia , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial/efeitos adversos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Incontinência Urinária por Estresse/complicações
15.
Andrologia ; 51(7): e13295, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30995702

RESUMO

Artificial urinary sphincter (AUS) implantation is the gold standard treatment in total stress urinary incontinence (SIU). Our aim is to evaluate the effect of AUS implantation on erectile function and sexual satisfaction (SS). Fourteen patients aged 58-73 years (mean: 66.92 ± 4.51 years) who underwent AUS implantation by a perineal approach between May 2015 and April 2018 were included in our study. Patients with neurogenic disease or very low or no erectile function and those who underwent non-nerve-sparing radical prostatectomy were excluded. Erectile function and intercourse satisfaction were evaluated pre-operatively and post-operatively at 6-month follow-up using international index of erectile function (IIEF) questionnaires. After AUS implantation; eight patients were totally dry, four achieved social continence (less than one pad/day), and two still had SUI (two or more pads/day). Mean pre- and post-operative IIEF values of the patients were 16.14 ± 3.18 and 17.42 ± 4.43 respectively. Mean pre- and post-operative SS values were 8.57 ± 1.78 and 8.71 ± 2.19 respectively. There was no statistically significant difference between pre- and post-operative IIEF-5 and intercourse satisfaction scores (p > 0.05). Although we did not see a significant effect of AUS implantation in our study, in SIU patients, coital incontinence or unpleasant odour during intercourse can lead to sexual avoidance and reduced SS, and AUS implantation may improve SS.


Assuntos
Orgasmo/fisiologia , Ereção Peniana/fisiologia , Implantação de Prótese , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial , Idoso , Disfunção Erétil/etiologia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Prostatectomia/efeitos adversos , Resultado do Tratamento , Incontinência Urinária por Estresse/etiologia
17.
J Urol ; 201(6): 1152-1157, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30707131

RESUMO

PURPOSE: We evaluated the rate of bacterial colonization in artificial urinary sphincters during revision surgery for noninfectious etiologies. MATERIALS AND METHODS: We evaluated bacterial culture swab data on all explanted artificial urinary sphincter components (cuff, pump and reservoir) in patients who underwent revision surgery between February 2016 and July 2018. Those treated with revision for infection or erosion were excluded from study. Patient demographic variables were assessed to identify factors associated with colonization. RESULTS: Cultures were obtained from 200 components, including 86 cuffs, 56 pumps and 58 reservoirs among the total of 80 patients. The etiology of revision included urethral atrophy in 31 cases (39%) and mechanical failure in 49 (52%). Median time after prior artificial urinary sphincter placement was 4.3 years (IQR 2-9). Median operative time was 37.5 minutes (IQR 32-46). All components were explanted and replaced in 55 patients (69%) and a single component was replaced in 23 (28%). Positive culture swabs were identified in 37 of the 200 components (19%), including 25 of 86 cuffs (29%), 7 of 56 pumps (13%) and 5 of 58 reservoirs (9%). Of the 80 patients 31 (39%) had at least 1 positive component culture and were more likely to have a history of radiation (65% vs 33%, p = 0.006). Identified organisms included Staphylococcus species in 57% of cases, Propionibacterium in 10% and Aerococcus in 5%. CONCLUSIONS: Positive artificial urinary sphincter component bacterial swab cultures were found in 39% of patients undergoing artificial urinary sphincter revision in the absence of clinical infection. Those with positive cultures were more likely to have a history of pelvic radiation. These results suggest that bacterial colonization of organisms with low virulence may not lead to device infection.


Assuntos
Bactérias/isolamento & purificação , Contaminação de Equipamentos/estatística & dados numéricos , Esfíncter Urinário Artificial/microbiologia , Idoso , Idoso de 80 Anos ou mais , Humanos , Período Intraoperatório , Masculino , Estudos Prospectivos , Reoperação
18.
Int Braz J Urol ; 45(2): 354-360, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30735337

RESUMO

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 preoperative 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.


Assuntos
Esfíncter Esofágico Inferior/fisiologia , Prostatectomia/efeitos adversos , Slings Suburetrais/efeitos adversos , Incontinência Urinária por Estresse/etiologia , Esfíncter Urinário Artificial/efeitos adversos , Idoso , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Incontinência Urinária por Estresse/cirurgia
19.
Urology ; 124: 264-270, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30786981

RESUMO

OBJECTIVE: To determine the impact of concurrent inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) implantation on perioperative complications and long-term device survival, among men with postprostatectomy erectile dysfunction and urinary incontinence. METHODS: We identified men older than 65 treated with radical prostatectomy in the Surveillance, Epidemiology, and End Results Medicare database between 2002 and 2016. IPP or AUS placement was determined by current procedural terminology (CPT) code, with dual implantation (DI) defined as IPP and AUS placement on the same date. Device survival was assessed using CPT codes for device removal, replacement, and/or repair. Complications were assessed within 90 days using ICD-9 codes. Statistical analysis was performed using SAS v9.3 (Cary, NC). RESULTS: A total of 37,599 men underwent radical prostatectomy, with AUS placed in 793 (2.1%), IPP placed in 644 (1.7%), and DI in 62 (0.2%). Relative to AUS placement alone, men undergoing DI were younger (68.8 vs 70.2 years, P = 0.03), but had equivalent Charlson comorbidity index, tumor grades, and rates of prior radiotherapy. Relative to IPP placement alone, men were more likely to undergo DI if treated with adjuvant or salvage radiotherapy. The incidence of complications within 30 and 90 days of prosthetic implantation did not differ between groups. Long-term device survival on Kaplan-Meier analysis was not impacted by DI relative to single device implantation with median follow-up of 61 months. CONCLUSION: Combined AUS and IPP placement does not adversely affect perioperative complications or device survival relative to placement of either device alone.


Assuntos
Prótese de Pênis , Complicações Pós-Operatórias/epidemiologia , Prostatectomia , Falha de Prótese , Esfíncter Urinário Artificial , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Implante Peniano , Implantação de Prótese/métodos , Medição de Risco , Fatores de Tempo
20.
Actas urol. esp ; 43(1): 44-50, ene.-feb. 2019. ilus
Artigo em Espanhol | IBECS | ID: ibc-182185

RESUMO

Introducción: El esfínter urinario artificial (EUA) no está extendido en el tratamiento de la incontinencia urinaria de esfuerzo (IUE) femenina debido a la baja reproducibilidad de las técnicas empleadas. Describimos un nuevo abordaje de implante laparoscópico, cuyo paso fundamental consiste en disecar el espacio vesicovaginal. Esto permite una aproximación bajo visión directa a la cara posterior del cuello vesical. Material y métodos: Presentamos dos casos realizados con esta aproximación. Se realiza un abordaje transperitoneal en posición de Trendelenburg. Los principales pasos son: creación del espacio vesicovaginal hasta identificar el cuello, creación de dos espacios laterovesicales, comunicación de los mismos con el espacio vesicovaginal y disección de la cara anterior del cuello intentando preservar el ligamento pubovesical. El manguito y reservorio se introducen a través del trocar infraumbilical de 12 mm. Por una incisión suprapúbica izquierda se externalizan las conexiones y se crea un túnel subcutáneo hasta el labio mayor, donde se coloca la bomba de activación. Finaliza el procedimiento con el cierre del peritoneo. Es fundamental la utilización de una valva vaginal para facilitar la disección. Resultados: Tiempo quirúrgico: 140 y 135 min, sin complicaciones intraoperatorias. Tras la retirada de la sonda vesical una paciente presentó residuo posmiccional elevado que se manejó de forma conservadora. Estancia hospitalaria: 72 h. A los 3 y 9 meses, las pacientes presentaron continencia total. Conclusiones: Presentamos resultados preliminares de implante laparoscópico de EUA mediante la aproximación vesicovaginal a la cara posterior del cuello, que podría disminuir las potenciales complicaciones observadas con las técnicas habituales


Introduction: The artificial urinary sphincter (AUS) is not used extensively in the treatment of female urinary stress incontinence (USI) due to the poor reproducibility of the techniques used. We describe a new approach to laparascopic implantation, of which dissection of the vesicovaginal space is an essential step. This enables an approach under direct vision to the posterior surface of the bladder neck. Material and methods: We present two cases where this approach was used. A transperitoneal approach was made in the Trendelenburg position. The main steps were: creating the vesicovaginal space until identifying the bladder neck, creating two laterovesical spaces, communicating these with the vesicovaginal space, and dissecting the anterior surface of the bladder neck, attempting to preserve the pubovesical ligament. The cuff and reservoir were inserted through the 12 mm infraumbilical trocar. The connections were externalised through a left suprapubic incision and a subcutaneous tunnel created up to the labia majora where the activation pump was placed. The procedure was completed with closure of the peritoneum. It is essential to use a vaginal valve to facilitate dissection. Results: Surgery time: 140 and 135 minutes, with no intraoperative complications. After removing the urinary catheter, one patient had elevated postvoid residual urine volume, which was managed conservatively. Hospital stay: 72 h. At 3 and 9 months the patients were fully continent. Conclusions: We present the preliminary results of laparoscopic implantation of an AUS through a vesicovaginal approach to the posterior surface of the bladder neck, which might reduce potential complications that have been observed after the routine techniques


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial , Resultado do Tratamento , Laparoscopia
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