Artificial urinary sphincter or a second adjustable transobturator male system offer equivalent outcomes in patients whom required revision on the initial ATOMS device: An international multi-institutional experience.

AIM: To evaluate treatment options after surgical revision of adjustable transobturator male system (ATOMS) and the results of further incontinence implantation. MATERIALS AND METHODS: A retrospective multicenter study evaluating patients with surgical revision of ATOMS in academic institutions. Causes and factors affecting revision-free interval were studied and also the frequency of device explant and placement of second ATOMS or artificial urinary sphincter (AUS) at surgeon discretion. Operative results, complications (Clavien-Dindo), and efficacy (postoperative pad-test, pad-count, patient satisfaction, and patient global impression of improvement [PGI-I scale]) of each treatment option were compared. RESULTS: Seventy-eight out of 902 patients (8.65%) with ATOMS underwent surgical revision at 4.1 ± 2.4 years mean follow-up and 75 (8.3%) were explanted. The main causes for revision included persistence of incontinence (35.9%) and scrotal port erosion (34.6%). Independent risk factors of the shortened revision-free interval were previous anti-incontinence surgery (HR, 1.83; 95% CI, 1.06-3.16; p = 0.007) and port erosion (HR, 1.83; 95% CI, 1.06-3.16; p = 0.0027). Fifty-eight (6.4%) received a second implant: 31 repeated ATOMS and 27 AUS. Operative time was longer for AUS (p = .003). The visual analog scale of pain at hospital discharge (p = 0.837) and postoperative complications (p = 0.154) were equivalent. The predominant cuff size for AUS was 4.5 cm (59.3%). Mean follow-up after the second implant was 29.1 ± 25.8 months. Postoperative efficacy of secondary treatment results favored ATOMS based on pad-test (p = 0.016), pad-count (p = 0.029), patient satisfaction (p = 0.04), and PGI-I (p = 0.025). CONCLUSIONS: ATOMS surgical revision due to different reasons generally leads to device explant. Rescue treatment is possible with ATOMS or AUS. No difference in postoperative complications was detected between secondary devices, but efficacy favors repeating ATOMS implantation.

Long-term outcomes of artificial urinary sphincter in female patients with spina bifida.

AIMS: To report the long-term functional outcomes of artificial urinary sphincter (AUS) implantation in female patients with spinal dysraphism and stress urinary incontinence (SUI) related to intrinsic sphincter deficiency (ISD). METHODS: The charts of all spina bifida female patients with SUI due to ISD who underwent AUS (AMS 800) implantation between 2005 and 2019 at three academic departments of urology were retrospectively reviewed. Reoperation was defined as either revision or explantation of the AUS device. Reoperation-free survival of the AUS device was estimated using the Kaplan-Meier method. Continence status as per patients' subjective assessment was categorized as follows: complete continence (no pads), improved continence, unchanged SUI or worsened SUI. RESULTS: Twenty-three patients were included, 69.6% were self-catheterizing. The median follow-up was 14 years. Median time to first reoperation was 10 years. Survival rates without reoperation were 85.9%, 41.8%, 34.6%, and 20.9% at 5, 10, 15, 20 years, respectively. Survival rates without AUS explantation were 90.7%, 66.3%, 55.2%, and 41.4% at 5, 10, 15, 20 years, respectively. None of the patients who underwent device explantation had a new AUS implanted. The only predictive factor of reoperation-free survival was the type of spinal dysraphism (hazards ratio = 3.60 for closed vs. open dysraphism; p = .04). At last follow-up, 17 of the 23 patients were fully continent (73.9%). CONCLUSION: AUS in female patients with spina bifida may be associated with satisfactory long-term functional outcomes and a high reoperation rate. The median time to first reoperation was similar to what is reported in the male AUS literature (10 years).

Surgical Treatment of Male Postprostatectomy Incontinence: Current Concepts.

CONTEXT: Radical prostatectomy is the most common reason for male stress urinary incontinence. There is still insecurity about its therapeutic management. OBJECTIVE: To evaluate current evidence regarding therapy of postprostatectomy incontinence (PPI). EVIDENCE ACQUISITION: In October 2017, a nonsystematic review of the literature published within the last 2 yr was performed using the PubMed/Medline database. In total, 58 articles were included in the current analysis. EVIDENCE SYNTHESIS: Regarding invasive management of moderate-to-severe PPI, artificial urinary sphincter (AUS) is still the treatment of choice. Recent studies focused on efficacy, but also a plethora of potential predictive features for treatment success has been investigated. Owing to inconsistent results, there still is no consensus about valid risk factors of AUS treatment success to date. There are increasing efficacy data about the use of adjustable slings, and long-term follow-up results are now available for the AdVanceXP male sling. Evidence addressing the use of the quadratic Virtue male sling needs further evaluation. To date, there is no randomized controlled trial investigating the outcome of one specific surgical treatment or comparing the outcome of different surgical treatment options. Limitations include the nonsystematic approach. CONCLUSIONS: Level of evidence addressing the surgical management of PPI is increasing but still unsatisfying. PATIENT SUMMARY: In this review article, we look at current research regarding surgical management of stress urinary incontinence following radical prostatectomy. Many studies focus on how to predict treatment failure and outcomes after artificial urinary sphincter implantation. In addition, more information on the long-term results after male sling implantation is now available.

Urethral lumen occlusion by artificial sphincteric devices: a computational biomechanics approach.

The action induced by artificial sphincteric devices to provide urinary continence is related to the problem of evaluating the interaction between the occlusive cuff and the urethral duct. The intensity and distribution of the force induced within the region of application determine a different occlusion process and potential degradation of the urethral tissue, mostly at the borders of the cuff. This problem is generally considered in the light of clinical and surgical operational experience, while a valid cooperation is established with biomechanical competences by means of experimental and numerical investigation. A three-dimensional model of the urethra is proposed aiming at a representation of the phases of the urethral occlusion through artificial sphincters. Different conformations of the cuff are considered, mimicking different loading conditions in terms of force intensity and distribution and consequent deformation caused in soft tissues. The action induced in the healthy urethra is investigated, as basis for an evaluation of the efficacy and reliability of the sphincteric devices. The problem is characterized by coupled nonlinear geometric and material problem and entails a complex constitutive formulation. A heavy computational procedure is developed by means of analyses that operate within an explicit finite element formulation. Results reported outline the overall response of the urethral duct during lumen occlusion, leading to an accurate description of the phenomenon in the different phases.

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)

Newer and novel artificial urinary sphincters (AUS): the development of alternatives to the current AUS device.

INTRODUCTION: The current artificial urinary sphincter (AUS), AMS 800 (American Medical Systems, Minnesota, MN, USA) is considered the standard of care for the treatment of urinary incontinence (UI). While the long-term effectiveness, safety, and durability of the current model of the AMS 800 are well documented, it is not without its limitations and complications. Over the last few years, improvements in design and innovative research into AUS devices have increased the treatment arsenal in male UI. METHODS: Articles from peer-reviewed journals, abstracts from scientific meetings and electronic literature searches formed the basis of this review. RESULTS: Newer AUS models, e.g. FlowSecure, Zephyr, Pro-ACT and other novel experimental AUS devices, are designed to simulate a healthy human sphincter and address the limitation of the existing AMS 800 device. CONCLUSIONS: Newer and novel AUS models are innovative and showed promising outcomes in short- to intermediate-term follow-up. However, there exists the need for prospective randomised clinical trials and complete reporting of adverse and long-term results before these AUS models can replace the existing AMS 800 device.

An adjustable continence therapy device for treating incontinence after prostatectomy: a minimum 2-year follow-up.

OBJECTIVE: To evaluate the efficacy and safety of the ProACT (Uromedica, Inc., MN, USA) balloon device, an alternative for the surgical management of incontinence after prostatectomy. PATIENTS AND METHODS: The initial patients who received this device at our institution were evaluated, using urodynamics at baseline and at 6 months. Perioperative variables were recorded and pad usage, volume adjustments, an estimate of Incontinence Quality of Life (I-QoL) and adverse events were recorded at baseline, and 1, 3, 6, 12 and 24 months after surgery. RESULTS: In all, 37 patients were treated on this protocol between November 2001 and March 2005. Of these, 30 had had radical prostatectomy and seven holmium laser enucleation of the prostate. The mean (range) pad usage decreased from 2.81 (1-12) at baseline to 0.7 (0-4) pads at 24 months, and the I-QOL increased from 49.7 (4.5-77) to 81.3 (13.6-100) over the same period. At 24 months, 62% of 34 men were pad-free and 81% required one pad or less. Bilateral explantation was required in three patients (11%) for infection (one) and balloon migration (two). All other adverse events were mild and transient. CONCLUSIONS: The ProACT balloon device is an acceptable therapy for the surgical management of incontinence after prostatectomy.

[Satisfactory long-term results with a sphincter prosthesis in patients with urinary incontinence due to an intrinsic urinary sphincter deficiency: evaluation of 86 patients]. / Bevredigende langetermijnresultaten van een sfincterprothese bij patiënten met urine-incontinentie door deficiëntie van de intrinsieke urethrasfincter: onderzoek bij 86 patiënten.

OBJECTIVE: Evaluation of the results of treatment with an artificial urinary sphincter in 86 patients with urinary incontinence due to intrinsic sphincter deficiency. DESIGN: Retrospective. METHODS: In the period 1982-1997 an artificial urinary sphincter (American Medical Systems, Minnetonka, Minnesota, USA) was inserted in the Academic Hospital Rotterdam-Dijkzigt, Department of Urology, the Netherlands, in 86 patients (15 women and 71 men) aged 8-84 years. All patients suffered from urinary incontinence due to intrinsic sphincter deficiency. A 'good' result was defined as being completely dry or using a maximum of one pad per day. During follow-up visits, the pad counts were registered and the pumping characteristics of the prosthesis were checked. In case of deterioration of the continence status a re-evaluation was started using imaging modalities and urodynamic studies. RESULTS: After an average follow-up of 41 months 76% of the patients were either completely dry or used a maximum of one incontinence pad per day. Urinary continence had markedly improved in another 7% of the patients. One or more reoperations due to mechanical or non-mechanical problems with the prosthesis had to be performed in 37 patients (43%). CONCLUSION: The artificial urinary sphincter can give excellent results as far as urinary continence is concerned, if the price of a relatively large number of revisions is accepted, in a population of patients to whom, in most cases, no other treatment options apply.

The artificial urinary sphincter in men incontinent after radical prostatectomy: 5 year actuarial adequate function rates.

OBJECTIVE: To determine the success (as both continence and revision rates) of the artificial urinary sphincter (AUS) in men incontinent after radical prostatectomy, and thus improve the preoperative counselling provided for these patients. PATIENTS AND METHODS: The AUS was implanted in 27 men incontinent after radical prostatectomy (mean age 69 years, range 59-75) at a mean (range) interval of 20 (4-60) months after surgery. The Kaplan-Meier method of survival analysis was used to determine the 'primary adequate function' (PAF) rate and the 'additional procedure-assisted adequate function' (APA-AF) rate. Adequate function was defined as satisfactory continence (use of at most one pad per 24 h) in combination with good AUS function. PAF was defined when no revisions of the AUS were required and APA-AF when one or more revisions of one or more parts of the AUS were required; a complete exchange or explantation of the AUS defined failure, i.e. the end of APA-AF. RESULTS: At a mean follow-up of 35 months, 81% of the patients had achieved satisfactory continence. However, the 5 year PAF and APA-AF rates, based on the Kaplan-Meier curves, were 49% and 71%, respectively. CONCLUSIONS: Implantation of an AUS can provide excellent continence rates in patients incontinent after radical prostatectomy, but only at the expense of a considerable re-operation rate. The outcome is best represented by Kaplan-Meier curves of the PAF and the APA-AF.

Laparoscopic approaches to the treatment of intrinsic urethral weakness (type III stress urinary incontinence).

The treatment of intrinsic urethral weakness (Type III stress urinary incontinence) has traditionally been accomplished by the performance of a sling cystourethropexy or the placement of an artificial urinary sphincter. As experience with operative laparoscopy continues to increase, the possibility of performing these procedures from a laparoscopic approach becomes realistic. We report our experience with the laparoscopic performance of a sling cystourethropexy and placement of an artificial urinary sphincter in the canine model. On the basis of initial results, we believe these techniques are feasible in human subjects.

[Treatment of male urinary incontinence with the AMS 800 sphincter prosthesis: 45 cases]. / Le traitement de l'incontinence d'urines chez l'homme par prothèse sphinctérienne AMS 800: à propos de 45 cas.

Urinary incontinence due to sphincter incompetence constitutes a major source of disability. The AMS 800 artificial urinary sphincter allows durable restoration of satisfactory continence in patients who are often unresponsive to any other forms of treatment. 45 men underwent implantation of a peribulbar urethral (40) or pericervical (5) artificial sphincter over a 5-year period. Incontinence was secondary to prostatic surgery in the majority of cases (33). The technique, which is now well defined, consisted of urinary drainage via a bladder catheter for 8 days and activation of the sphincter after 1 month. The mean follow-up is 30 months. 36 (80%) of the patients are continent, including 27 (60%) without revision and 9 (20%) underwent unsuccessful revision resulting in partial or complete removal or permanent inactivation of the prosthesis (sepsis, urethral erosion, defective prosthesis). Strict patient selection, a rigorous implantation technique and standardised management of any incidents are key elements in the success of this procedure.