Association between Previous Pelvic Radiation and All-Cause and Cause-Specific Failure of Replacement Artificial Urinary Sphincters.

PURPOSE: In order to accurately characterize how a history of radiation therapy affects the lifespan of replacement artificial urinary sphincters (AUSs), all possible sources of device failure must be considered. We assessed the competing risks of device failure based on radiation history in men with replacement AUSs. MATERIALS AND METHODS: We identified men who had a replacement AUS in a single institutional, retrospective database. To assess survival from all-cause device failure based on radiation history and other factors, we conducted Kaplan-Meier, Cox proportional-hazards and competing risks analyses. RESULTS: Among 247 men who had a first replacement AUS, men with a history of radiation had shorter time to all-cause device failure (median 1.4 vs 3.5 years for men with radiation vs without radiation history, p=0.02). On multivariable Cox-proportional hazards analysis, previous radiation was associated with increased risk of all-cause device failure (HR: 2.12, 95% CI: 1.30-3.43, p=0.002). On multivariable cause-specific hazards analysis, prior radiation was associated with a higher risk of erosion/infection (HR: 7.57, 95% CI: 2.27-25.2, p <0.001), but was not associated with risk of urethral atrophy (p=0.5) or mechanical failure (p=0.15). CONCLUSIONS: Among men with a replacement AUS, a history of pelvic radiation was associated with shorter time to device failure of any cause. Radiation was also specifically associated with a sevenfold increase in the risk of erosion or infection of replacement AUS, but not with urethral atrophy or mechanical failure. Patients with a replacement AUS should be appropriately counseled on how radiation history may impact outcomes of future revisions.

Spinal anesthesia does not impact prostate cancer recurrence in a cohort of men undergoing radical prostatectomy: an observational study.

BACKGROUND AND OBJECTIVES: Prior studies suggest a possible association between the use of neuraxial-general anesthesia and a decrease in prostate cancer recurrence after radical prostatectomy. We examine the correlation of a spinal anesthesia-only technique on prostate cancer recurrence. METHODS: Charts from consecutive radical prostatectomy patients of 3 experienced urologists from January 1999 to December 2005 were reviewed. In addition to the usual clinical and pathologic predictors of disease recurrence, patient records were queried for the type of anesthesia (general vs spinal) performed. A Cox proportional hazards model was used to determine the statistical significance of predictors of biochemical recurrence. RESULTS: A total of 1964 patients-1166 and 798 receiving spinal with sedation or general anesthesia, respectively-had complete preoperative and follow-up data. In univariate proportional hazards analysis, the use of general anesthesia was associated with a trend toward an increased risk of biochemical recurrence when compared with the use of spinal anesthesia (hazard ratio, 1.29; 95% confidence interval, 0.99-1.66; P = 0.053). In multivariable analysis, the effect size (hazard ratio, 1.10; 95% confidence interval, 0.85-1.42; P = 0.458) was diminished by clinical and pathologic variables. CONCLUSIONS: This was a retrospective study of patients with prostate cancer who have undergone radical prostatectomy during a time period when the practice of anesthesia for prostatectomy at our institution was transitioned from spinal to general anesthesia. In our study, when controlling for other predictors of advanced prostate cancer, the type of anesthetic given during prostatectomy had no effect on the risk of biochemical recurrence.

Combined inflatable penile prosthesis-artificial urinary sphincter implantation: no increased risk of adverse events compared to single or staged device implantation.

PURPOSE: Little data exist on the outcome of combined inflatable penile prosthesis and artificial urinary sphincter insertion for erectile dysfunction and stress urinary incontinence. We assessed patient outcomes for combined vs single device implantation at a single institution. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent inflatable penile prosthesis and artificial urinary sphincter insertion at our hospital from January 2000 to December 2011. A total of 55 combined procedures were performed compared to the single insertion of 336 inflatable penile prostheses and 279 artificial urinary sphincters. RESULTS: The surgical approach consisted of penoscrotal incisions for inflatable penile prostheses and transperineal incisions for artificial urinary sphincter cuff placement with a secondary lower abdominal incision for reservoir placement. Men treated with combined implantation had greater mean age and were at greater risk for prostate cancer diagnosis and treatment, and at lesser risk for Peyronie disease than men who received an inflatable penile prosthesis alone (each p<0.05). Although operative time was significantly longer for the combined procedure than for the inflatable penile prosthesis alone and the AUS alone (mean 218.1 vs 145.9 and 114.7 minutes, respectively, p<0.0001), the rate of device infection, erosion or malfunction was not increased irrespective of combined or staged procedures (p>0.05). CONCLUSIONS: Combined inflatable penile prosthesis-artificial urinary sphincter implantation and staged prosthesis implantation are feasible without an increased risk of adverse outcomes compared to implantation of a single prosthesis. Patients with concomitant erectile dysfunction and stress urinary incontinence should be counseled about the possible advantages of this surgical option, which include a single anesthesia event and faster resumption of sexual activity and urinary control.

Evaluation of the female urethra with intraurethral magnetic resonance imaging.

The purpose of this study was to demonstrate feasibility of intraurethral magnetic resonance imaging (MRI) for in vivo assessment of the female urethra and to determine the anatomy of the urethra and periurethral attachments as depicted using an endourethral MR coil. Twenty-three continent volunteers were studied with a 14F endourethral MR coil. Intraurethral MRI allowed detailed visualization and measurements of the muscular layers of the urethral sphincter and permitted the evaluation of supporting ligaments. This technique may become useful in the evaluation of anatomical defects associated with female urethral sphincter deficiency.

Pathophysiology: the varieties of bladder overactivity.

Overactive bladder (OAB) is the most common term currently used in clinical medicine to describe a complex of lower urinary tract symptoms (LUTS) with or without incontinence. The symptoms usually include urgency, frequency, nocturia, troublesome or incomplete emptying, and, occasionally, pain. Causes of bladder overactivity include neurologic illness or injury, bladder outlet obstruction, urethral weakness, detrusor hyperactivity and impaired contractility in elderly patients, emergence of new voiding reflexes, and so-called idiopathic bladder overactivity. Most clinicians agree that effective treatment for OAB symptoms should be guided by a basic assessment of patients for these contributing factors. However, it is not at all certain that outcomes are significantly improved by diagnostic precision. This is in part because of the ubiquity of LUTS in the setting of the various common lower urinary tract disorders: stress incontinence, outlet obstruction, and neurologic illness or injury. The ubiquity of LUTS would imply that they are caused by common mechanisms and, theoretically at least, would be amenable to a single form of effective therapy. Conversely, the limited kinds and number of LUTS and the limited representation of lower urinary tract structures in the central nervous system may mean that several different causes produce similar symptoms, but these are not amenable to a single form of effective therapy. Future research directions should keep each possible explanation in mind as new knowledge about lower urinary tract function and possible intervention continues to emerge.