Patient Selection in Surgical Centers of Expertise in the Treatment of Patients with Moderate to Severe Male Urinary Stress Incontinence.

OBJECTIVE: To analyze decision-making in patients with male urinary incontinence (SUI) in centers of expertise. The artificial urinary sphincter (AUS) remains the gold standard for male patients with moderate to severe SUI but adjustable male slings are a minimally invasive treatment option with good results, hence without a high level of evidence regarding the optimal patient selection. MATERIALS AND METHODS: In total, 220 patients (88 AUS; 132 adjustable slings) were investigated from the DOMINO database that underwent surgery between 2010 and 2012 in 5 urological departments that offer adjustable sling systems as well as AUS systems for patients with moderate to severe urinary incontinence. For statistical analysis, the Mann-Whitney U test was used to identify differences between both groups. RESULTS: Patients selected for an adjustable male sling were less likely to have a neurological disease (5.3 vs. 9.1%; p = 0.030), a prior urethral stricture (22.7 vs. 50.0%; p = 0.001), a prior incontinence surgery (24.4 vs. 45.5%; p = 0.01), or a prior radiation therapy (26.5 vs. 40.1%; p = 0.001). The severity of preoperative incontinence was higher in patients selected for an AUS with a mean pad usage per day of 7.60 versus 5.80 (p < 0.001). Mean postoperative pad usage and patients' subjective perception were comparable in both groups. CONCLUSION: In centers offering both options, the decision-making is mainly based upon presence of radiation therapy and previous failed incontinence surgery. Despite the more complex patient cohort selected for an AUS implantation with a possible impact on the postoperative outcome, the functional results seem to be comparable indicating a proper preoperative patient assessment and selection in this cohort.

Robotic-assisted Excision of Giant Prostatic Utricular Cysts: Technique, Outcomes and Follow-up.

BACKGROUND: Utricular cysts are usually the result of incomplete involution of the Müllerian ducts and may have no urethral connection. Treatment options for symptomatic utricular cysts include an open abdominal approach, trans-vesical excision, vasoligation without excision and laparoscopic/robotic-assisted excision. PATIENTS AND METHODS: Two patients (14 and 45 years old) with recurrent urinary tract infections associated with recurrent lower urinary tract irritative symptoms and recurrent perineal pains presented to our department. Clinical, radiological and MRI examinations showed 6x3 and 5x4cm utricular cysts, respectively. Both patients underwent robotic-assisted complete dissection of the cyst, including its neck. Separation of the cysts from surrounding tissues as well as the seminal vesicles while avoiding injury to the neurovascular bundles was followed by incision of the prostate base to dissect the cyst neck from the prostatic parenchyma up to its connection to the urethra. The cyst neck was secured with either one clip or 4/0 vicryl sutures. The field was reconstructed with 4/0 sutures. The patients were followed-up at 3, 6 and 12 months postoperatively. RESULTS: There were no intraoperative complications or injuries to the neighboring structures (seminal vesicles, vas deferens and urethra). The operative time was 95 and 80 minutes, respectively, with negligible blood loss. Both patients underwent an uneventful recovery from surgery, and were discharged on the 5th postoperative day. Both patients were asymptomatic throughout the entire follow-up period (15 months). MRI at 3 months showed no abnormalities. The postoperative IIEF score in the older patient showed no difference compared to his baseline findings. The life quality score showed high patient acceptance and both patients indicated that they would recommend the procedure. CONCLUSIONS: Symptomatic presentation of utricular cysts may be associated with recurrent urinary tract infections, orchitis-epididymitis and potential for malignancy. The present cases demonstrate that robotic-assisted surgical excision of symptomatic utricular cysts is a feasible and safe procedure. It seems to provide excellent visualization and access to these lesions. This procedure provides patients the advantages of minimally invasive surgery with outcomes comparable to those with other management techniques.