Artificial Urinary Sphincter Cuff Size Predicts Outcome in Male Patients Treated for Stress Incontinence: Results of a Large Central European Multicenter Cohort Study

Fabian Queissert,Tanja Huesch,Alexander Kretschmer,Ralf Anding,Martin Kurosch,Ruth Kirschner-Hermanns,Tobias Pottek,Roberto Olianas,Alexander Friedl,Jesco Pfitzenmaier,Carsten M. Naumann,Carola Wotzka 대한배뇨장애요실금학회 2019 International Neurourology Journal Vol.23 No.3

Purpose: The aim was to study the correlation between cuff size and outcome after implantation of an AMS 800 artificial urinary sphincter. Methods: A total of 473 male patients with an AMS 800 sphincter implanted between 2012 and 2014 were analyzed in a retrospective multicenter cohort study performed as part of the Central European Debates on Male Incontinence (DOMINO) Project. Results: Single cuffs were implanted in 54.5% and double cuffs in 45.5% of the patients. The cuffs used had a median circumference of 4.5 cm. Within a median follow of 18 months, urethral erosion occurred in 12.8% of the cases and was associated significantly more often with small cuff sizes (P<0.001). Multivariate analysis showed that, apart from cuff size (P=0.03), prior irradiation (P<0.001) and the penoscrotal approach (P=0.036) were associated with an increased erosion rate. Continence rate tended to be highest with median cuff sizes (4–5.5 cm). Conclusions: Apart from irradiation and the penoscrotal approach, small cuff size is a risk factor for urethral erosion. Results are best with cuff sizes of 4.5–5.5 cm.

Targeting Moderate and Severe Male Stress Urinary Incontinence With Adjustable Male Slings and the Perineal Artificial Urinary Sphincter: Focus on Perioperative Complications and Device Explantations

Alexander Kretschmer,Tanja Hüsch,Frauke Thomsen,Dominik Kronlachner,Alice Obaje,Ralf Anding,Tobias Pottek,Achim Rose,Roberto Olianas,Alexander Friedl,Wilhelm Hübner,Roland Homberg,Jesco Pfitzenmaier,F 대한배뇨장애요실금학회 2017 International Neurourology Journal Vol.21 No.2

Purpose: To analyze perioperative complications and postoperative explantation rates for selected readjustable male sling systems and the perineal single-cuff artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. Methods: Two hundred eighty-two male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in the study (n=127 adjustable male sling [n=95 Argus classic, n=32 Argus T], n=155 AUS). Perioperative characteristics and postoperative complications were analyzed. The explantation rates of the respective devices were assessed using the Fisher exact test and the Mann-Whitney U-test. A Kaplan-Meier curve was generated. Potential features associated with device explantation were analyzed using a multiple logistic regression model (P<0.05). Results: We found significantly increased intraoperative complication rates after adjustable male sling implantation (15.9% [adjustable male sling] vs. 4.2% [AUS], P=0.003). The most frequent intraoperative complication was bladder perforation (n=17). Postoperative infection rates did not vary significantly between the respective devices (P=0.378). Device explantation rates were significantly higher after AUS implantation (9.7% [adjustable male sling] vs. 21.5% [AUS], P=0.030). In multivariate analysis, postoperative infection was a strong independent predictor of decreased device survival (odds ratio, 6.556; P=0.001). Conclusions: Complication profiles vary between adjustable male slings and AUS. Explantation rates are lower after adjustable male sling implantation. Any kind of postoperative infections are independent predictors of decreased device survival. There is no significant effect of the experience of the implanting institution on device survival.

The artificial urinary sphincter and male sling for postprostatectomy incontinence: Which patient should get which procedure?

Craig V. Comiter,Amy D. Dobberfuhl 대한비뇨의학회 2016 Investigative and Clinical Urology Vol.57 No.1

Surgery is the most efficacious treatment for postprostatectomy incontinence. The ideal surgical approach depends on a variety of patient factors including history of prior incontinence surgery or radiation treatment, bladder contractility, severity of leakage, and patient expectations. Most patients choose to avoid a mechanical device, opting for the male sling over the artificial urinary sphincter. The modern male sling has continued to evolve with respect to device design and surgical technique. Various types of slings address sphincteric incompetence via different mechanisms of action. The recommended surgery, however, must be individualized to the patient based on degree of incontinence, detrusor contractility, and urethral compliance. A thorough urodynamic evaluation is indicated for the majority of patients, and the recommendation for an artificial urinary sphincter, a transobturator sling, or a quadratic sling will depend on urodynamic findings and the patient's particular preference. As advancements in this field evolve, and our understanding of the pathophysiology of incontinence and mechanisms of various devices improves, we expect to see continued evolution in device design.

전립선 수술 후 발생한 복압성요실금에서 인공 요도괄약근 수술의 효과 및 안전성

양진백,이영숙,한덕현,이규성 대한비뇨의학회 2009 Investigative and Clinical Urology Vol.50 No.9

Purpose: To evaluate the efficacy and safety of artificial urinary sphincter (AUS) for the treatment of stress urinary incontinence (UI) after prostate surgery. Materials and Methods: We performed a retrospective chart review of 19 patients who underwent AUS implantation from July 2003 to November 2008. Efficacy was evaluated in terms of the postoperative changes in daily pad use, incontinence visual analogue scale (I-VAS), International Continence Society male-Short Form questionnaire (ICS-male SF), Incontinence Quality of Life questionnaire (I-QoL), and patients’ satisfaction postoperatively. No pad use was defined as cure, and use of 1 pad or fewer per day as improvement. Cure and improvement were regarded as success. Complications and durability of the AUS were evaluated. Results: The median age of the patients was 70.0 years (range, 47-76 years). With a median follow-up period of 11.8 months (range, 6.2-48.1 months), the success rate was 68.4% (13/19; cure in 12 and improvement in 1). I-VAS, subscale scores of ICS-male SF (incontinence and QoL), and total and subscale scores of I-QoL (psychosocial impact, social embarrassment, avoidance, and limiting behaviors) were significantly improved. Fifteen (78.9%) patients reported being satisfied. Six (31.5%) patients required revision: volume adjustment for 2, second cuff implantation for 2, pump reposition for 1, and pump reposition, volume adjustment, and second cuff implantation for 1. One of the patients who had a second cuff implantation had the sphincter explanted for infection. Conclusions: Despite the high rate of revision, the satisfaction rate was high and the quality of life was significantly improved after AUS implantation for urinary incontinence after prostate surgery. Purpose: To evaluate the efficacy and safety of artificial urinary sphincter (AUS) for the treatment of stress urinary incontinence (UI) after prostate surgery. Materials and Methods: We performed a retrospective chart review of 19 patients who underwent AUS implantation from July 2003 to November 2008. Efficacy was evaluated in terms of the postoperative changes in daily pad use, incontinence visual analogue scale (I-VAS), International Continence Society male-Short Form questionnaire (ICS-male SF), Incontinence Quality of Life questionnaire (I-QoL), and patients’ satisfaction postoperatively. No pad use was defined as cure, and use of 1 pad or fewer per day as improvement. Cure and improvement were regarded as success. Complications and durability of the AUS were evaluated. Results: The median age of the patients was 70.0 years (range, 47-76 years). With a median follow-up period of 11.8 months (range, 6.2-48.1 months), the success rate was 68.4% (13/19; cure in 12 and improvement in 1). I-VAS, subscale scores of ICS-male SF (incontinence and QoL), and total and subscale scores of I-QoL (psychosocial impact, social embarrassment, avoidance, and limiting behaviors) were significantly improved. Fifteen (78.9%) patients reported being satisfied. Six (31.5%) patients required revision: volume adjustment for 2, second cuff implantation for 2, pump reposition for 1, and pump reposition, volume adjustment, and second cuff implantation for 1. One of the patients who had a second cuff implantation had the sphincter explanted for infection. Conclusions: Despite the high rate of revision, the satisfaction rate was high and the quality of life was significantly improved after AUS implantation for urinary incontinence after prostate surgery.

인공요도괄약근 시술의 20년 경험

오철영,이승환,정현진,임영재,마상열 대한비뇨의학회 2008 Investigative and Clinical Urology Vol.49 No.6

Purpose: The efficacy of the artificial urinary sphincter(AUS) in treating sphincteric incontinence has been clearly demonstrated. We report on 20 years of experience using artificial sphincter implantation at a single institute. Materials and Methods: The follow-up data for 37 patients who received AUS(AMS 800TM) implantation between 1987 and 2006 at Yonsei University were available for this study. We investigated various components of the medical records, such as the number of pads used per day, results of pre-operative urodynamic studies, operative and post-operative complications, and revision rate. Results: Mean patient age was 35.6 years(range 15-64 years), and mean follow-up duration was 12.4 years(range 1.4-19.8 years). Of the 37 patients, 21 had neurogenic bladder, and 9 had traumatic injury. Other causes of incontinence included post-operative complications(4 patients) and congenital anomalies(3 patients). The cuffs were placed were in the bladder necks of 21 patients and in the bulbous urethrae of 16 patients. The average number of pads used daily decreased significantly from 6.2 to 1.2 after the operation, and 27 patients(72.9%) were able to maintain 'dry-up status' (number of pads used≤1). A total of 32 artificial sphincters remained in place(86.4% survival rate), with 8 revisions(21.6%) required secondary to infection, mechanical failure, or urethral stone. Conclusions: AUS implantation is a safe and durable treatment for urinary incontinence in patients with intrinsic sphincter deficiency from various underlying diseases. (Korean J Urol 2008;49:520-525) Purpose: The efficacy of the artificial urinary sphincter(AUS) in treating sphincteric incontinence has been clearly demonstrated. We report on 20 years of experience using artificial sphincter implantation at a single institute. Materials and Methods: The follow-up data for 37 patients who received AUS(AMS 800TM) implantation between 1987 and 2006 at Yonsei University were available for this study. We investigated various components of the medical records, such as the number of pads used per day, results of pre-operative urodynamic studies, operative and post-operative complications, and revision rate. Results: Mean patient age was 35.6 years(range 15-64 years), and mean follow-up duration was 12.4 years(range 1.4-19.8 years). Of the 37 patients, 21 had neurogenic bladder, and 9 had traumatic injury. Other causes of incontinence included post-operative complications(4 patients) and congenital anomalies(3 patients). The cuffs were placed were in the bladder necks of 21 patients and in the bulbous urethrae of 16 patients. The average number of pads used daily decreased significantly from 6.2 to 1.2 after the operation, and 27 patients(72.9%) were able to maintain 'dry-up status' (number of pads used≤1). A total of 32 artificial sphincters remained in place(86.4% survival rate), with 8 revisions(21.6%) required secondary to infection, mechanical failure, or urethral stone. Conclusions: AUS implantation is a safe and durable treatment for urinary incontinence in patients with intrinsic sphincter deficiency from various underlying diseases. (Korean J Urol 2008;49:520-525)

Artificial Urinary Sphincter for Postradical Prostatectomy Urinary Incontinence — Is It the Best Option?

Yun-Sok Ha,Eun Sang Yoo 대한배뇨장애요실금학회 2019 International Neurourology Journal Vol.23 No.4

Male stress urinary incontinence (SUI) can undoubtedly reduce quality of life and promote personal distress and psychosocial alienation. The frequency of postprostatectomy urinary incontinence (PPI) counts on the characterization of urinary incontinence and the periods of patient follow-up. Operational therapeutics, for instance, urethral male slings and artificial urinary sphincters, are well-chosen as adequate and secure surgeries for male SUI in men with continual PPI when conservative treatment is ineffective. Over the former 2 decades, surgery has progressed regarding both operative approach and sling architecture. However, there are no guidelines about when surgery should be carried out and which is the most appropriate surgical option. In this review, we summarize recent advances in implantable devices for PPI and also discuss traditional surgical care. When we are planning the male PPI surgery, careful preoperative work-up should be performed and surgical method should be chosen according to the severity of the disease. Male sling is preferred in mild and moderate symptomatic patients with normal detrusor pressure and it is recommended to select traditional artificial urinary sphincter device in those with severe symptoms. It is expected that effective devices without adverse events will be developed with technical advances in near future.

Functional Outcomes and Long-term Durability of Artificial Urinary Sphincter Application: Review of 56 Patients With Long-term Follow-up

Ömer Gülpınar,Evren Süer,Mehmet İlker Gökce,Ahmet Hakan Haliloğlu,Erdem Öztürk,Nihat Arıkan 대한비뇨의학회 2013 Investigative and Clinical Urology Vol.54 No.6

Purpose: To evaluate the long-term outcomes of artificial urinary sphincter (AUS) implantation and to report the complication rates, including mechanical failure, erosion,and infection. Materials and Methods: From June 1990 to May 2011, AUS (AMS 800) implantations were performed in 56 adult males by one surgeon. Various demographic and preoperative variables, surgical variables, and postoperative outcomes, including success and complication rates with a median follow-up of 96 months, were recorded retrospectively. Results: The mean age of the patients at the time of AUS implantation was 61.8 (±14.2)years. During the follow-up period, the total complication rate was 41.1% (23 patients). The incidence of complications was significantly lower during the follow-up period after 48 months (p<0.05). Kaplan-Meier analysis revealed that 5- and 10-year failure-free rates were 50.3% and 45.2%, respectively. Conclusions: Long-term durability and functional outcomes are achievable for the AMS 800, but there are appreciable complication rates for erosion, mechanical failure, and infection of up to 30%.

Risk Factors for Revision After Artificial Urinary Sphincter Implantation in Male Patients With Stress Urinary Incontinence: A 10-Year Retrospective Study

Celeste Manfredi,Pramod Krishnappa,Esaú Fernández-Pascual,Elena García Criado,Diego Rengifo,David Vázquez Alba,Joaquín Carballido,Davide Arcaniolo,Juan Ignacio Martínez-Salamanca 대한배뇨장애요실금학회 2022 International Neurourology Journal Vol.26 No.2

Purpose: To evaluate the preoperative and intraoperative risk factors for revision after artificial urinary sphincter (AUS) implantation in male patients with stress urinary incontinence (SUI). Methods: A retrospective analysis from a prospectively maintained database was performed. Male patients, with moderate-tosevere SUI, undergoing AUS implantation were included. All patients underwent placement of AMS 800. Cause of revision, type of revision, and time to revision were recorded. Multivariable analyzes were performed using a logistic regression to investigate the risk factors. Competing risk analysis according to Fine-Gray model was used to study time to event data. Results: A total of 70 patients were included. Revision surgery was performed in 22 of 70 patients (31.4%), after a median (interquartile range) time of 26.5 months (6.5–39.3 months). Overall, 19 of 22 repairs (86.4%) and 3 of 22 explants (13.6%) were recorded. Mechanical dysfunction, urethral erosion, urethral atrophy, and device infection were the causes of revision in 11 of 22 (50.0%), 6 of 22 (27.3%), 3 of 22 (13.6%), and 2 of 22 patients (9.1%). Vesicourethral anastomosis stenosis (P=0.02), urethral cuff size of 3.5 cm (P=0.029), and dual implantation (P=0.048) were independent predictors for revision. Vesicourethral anastomosis stenosis (P=0.01) and urethral cuff size of 3.5 cm (P=0.029) predicted a lower survival of the AUS. Conclusions: The vesicourethral anastomosis stenosis, urethral cuff size of 3.5 cm, and dual implantation are independent predictors for revision after AUS implantation. However, only the vesicourethral anastomosis stenosis and urethral cuff size of 3.5 cm predict a lower survival of AUS.

The impact of incontinence etiology on artificial urinary sphincter outcomes

Adam R. Miller,Brian J. Linder,Laureano J. Rangel,David Y. Yang,Daniel S. Elliott 대한비뇨의학회 2017 Investigative and Clinical Urology Vol.58 No.4

Purpose: To evaluate the impact of incontinence etiology on artificial urinary sphincter (AUS) device outcomes. Materials and Methods: We identified 925 patients who underwent primary AUS placement from 1983 to 2011. The etiology of incontinence was categorized as radical prostatectomy alone, radical prostatectomy with radiation, benign prostate resection, and those with cryotherapy as a salvage prostate cancer treatment. Hazard regression and competing risk analyses were used to determine the association of the etiology of incontinence with device outcomes. Results: The distribution of the 4 etiologies of incontinence included: 598 patients (64.6%) treated with prostatectomy alone, 206 (22.2%) with prostatectomy and pelvic radiation therapy, 104 (11.2%) with benign prostate resection, and 17 (1.8%) with prior cryotherapy. With a median follow-up of 4.9 years (interquartile range, 1.2–8.8 years), there was significant difference in the cumulative incidence of device infection/urethral erosion events between the four etiologies (p=0.003). On multivariable analysis, prior cryotherapy (reference prostatectomy alone; hazard ratio [HR], 3.44; p=0.01), older age (HR, 1.07; p=0.0009) and history of a transient ischemic attack (HR, 2.57; p=0.04) were associated with an increased risk of device infection or erosion. Notably, pelvic radiation therapy with prostatectomy was not associated with an increased risk of device infection or erosion (reference prostatectomy alone, p=0.30). Conclusions: Compared to prostatectomy alone, prior treatment with salvage cryotherapy for recurrent prostate cancer was associated with an increased risk of AUS infection/erosion, whereas radiation (in addition to prostatectomy) was not.

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

Amy Marcia Pearlman,Alison Marie Rasper,Ryan Patrick Terlecki 대한비뇨의학회 2018 Investigative and Clinical Urology Vol.59 No.4

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.