Is the Standard Artificial Urinary Sphincter AMS 800 Still a Treatment Option for the Irradiated Male Patient Presenting with a Devastated Bladder Outlet?

BACKGROUND: Circular urethral compression with an artificial sphincter allows control of voiding, even in patients with severe stress urinary incontinence, but it heightens the risk of urethral atrophy and erosion. This study of one of the largest populations of patients treated with radiotherapy investigates the additive effect of the post-radiogenic stricture of the membranous urethra/bladder neck on AMS 800 artificial urinary sphincter outcomes. METHODS: In a retrospective multicenter cohort study, we analyzed patients fitted with an AMS 800, comparing those who had received radiotherapy with patients presenting a devastated bladder outlet (stricture of the membranous urethra/bladder neck). We determined the correlation between these groups of patients using both univariate and stepwise adjusted multivariate regression. The revision-free interval was estimated by a Kaplan-Meier plot and compared by applying the log-rank test. A p value below 0.05 was considered statistically significant. RESULTS: Of the 123 irradiated patients we identified, 62 (50.4%) had undergone at least one prior desobstruction for bladder-neck/urethra stenosis. After a mean follow-up of 21 months, the latter tended to achieve social continence less frequently (25.7% vs. 35%; p = 0.08). Revision was required significantly more often for this group (43.1% vs. 26.3%; p = 0.05) due to urethral erosion in 18 of 25 cases. A stenosis recurred in five cases; desobstruction was performed in two cases, leading to erosion in both. Multivariate analysis revealed a significantly higher risk of revision when recurrent stenosis necessitated at least two prior desobstructions (HR 2.8; p = 0.003). CONCLUSIONS: A devastated bladder outlet is associated with a lower proportion of men with social continence and a significantly higher need for revision compared with irradiated patients without a history of urethral stenosis. Alternative surgical procedures should be discussed beforehand, especially in cases of recurrent urethral stenosis.

Mesh Graft Urethroplasty-Still a Safe and Promising Technique in Mostly Unpromising Complex Urethral Strictures.

Long urethral strictures or even recurrent urethral strictures, mostly with scar tissue showing insufficient healing tendencies, are defined as complex and represent a big challenge in modern reconstructive urology. Initially, the treatment of complicated urethral strictures was associated with a high failure rate (20-40%) due to the growth of hair in the neourethra and a lack of sufficient suitable epithelium when scrotal skin was used. Although much effort was put into tissue engineering recently, harvesting and transplanting autologous tissue represent the standard of care for urethral substitution or augmentation. Since 1977, two-staged urethroplasty with the usage of free foreskin or 0.1 mm thick meshed skin from the upper leg was performed in complicated cases and was initially described in 1984 and 1989 by Schreiter and Schreiter and Noll, respectively. In stage 1, the graft is harvested by cutting the skin thinly above the hair follicles and transplanted as a plate around the opened urethra. In stage 2, after 8-12 weeks, the neourethra is formed. Success rates of up to 84% are described. Considering the complexity of the strictures in which mesh graft urethroplasty is usually performed, the reachable success rates are outstanding, especially considering that this surgery is most likely the last opportunity to prevent perineostomy or even urinary diversion. This article describes the surgical technique and embeds the mesh graft urethroplasty in today's literature to underline its importance in the surgical management of complex urethral strictures.

Fixed or adjustable sling in the treatment of male stress urinary incontinence: results from a large cohort study.

BACKGROUND: Fixed and adjustable male slings for the treatment of male urinary stress incontinence became increasingly popular during the last decade. Although fixed slings are recommended for the treatment of mild to moderate stress urinary incontinence, there is still a lack of evidence regarding the precise indication for an adjustable male sling. Furthermore, there is still no evidence that one type of male sling is superior to another. However, both, adjustable and fixed slings, are commonly utilized in daily clinical practice. This current investigation aims to evaluate the differences between fixed and adjustable male slings regarding indications, complication rates and functional outcome in the treatment of male stress urinary incontinence in current clinical practice. METHODS: A total of 294 patients with a fixed and 176 patients with an adjustable male sling were evaluated in a multicenter single arm cohort trial. Data collection was performed retrospectively according the medical record. Functional outcome was prospectively analyzed by standardized, validated questionnaires. Descriptive statistics was performed to present patient characteristics, complication rates and functional outcome. A chi2-test for categorical and independent t-test for continuous variables was performed to identify heterogeneity between the groups and to correlate preoperative characteristics with the outcome. A P value <0.05 was considered statistically significant. RESULTS: Patients with higher degree of urinary incontinence (P<0.001) and risk factors such as history of pelvic irradiation (P<0.001) or prior surgery for urethral stricture (P=0.032) were more likely to receive an adjustable MS. Complication rates were comparable except for infection (P=0.009, 0 vs. 2.3%) and pain (P=0.001, 1.7% vs. 11.3%) which occurred more frequently in adjustable slings. Functional outcome according validated questionnaires demonstrated no differences between fixed and adjustable male slings. CONCLUSIONS: Adjustable male slings are more frequently utilized in patients with higher degree of incontinence and risk factors compared to fixed slings. No differences could be identified between functional outcome which may imply an advantage for adjustability. However, pain and infection rates were significantly higher in adjustable MS and should be considered in the decision process for sling type.

High/low-volume center experience predicts outcome of AMS 800 in male stress incontinence: Results of a large middle European multicenter case series.

AIM: To analyze the influence of implantation volume of artificial sphincters (AMS 800) on outcome in a large central European multicenter cohort study. METHODS: As part of the DOMINO (Debates on Male Incontinence) project, the surgical procedures and outcomes were retrospectively analyzed in a total of 473 patients who received an artificial sphincter (AMS 800) between 2010 and 2012. Clinics that implanted at least 10 AMS 800 per year were defined as high-volume centers. RESULTS: Sixteen centers had a mean rate of 9.54 AMS 800/y of which five clinics were identified as high-volume centers. They implanted significantly more double cuffs (55% vs 12.1%; P < .001), used the perineal approach significantly more often (78% vs 67.7%; P = .003) and chose larger mean cuff sizes (4.63 cm vs 4.42 cm; P = .002). With a mean follow-up of 18 months, the revision rate was significantly higher at low-volume centers (38.5% vs 26.7%; P = .037), urethral erosion being the main reason for revision. Social continence (0-1 pads/24 h) was achieved significantly more often in high-volume centers (45.5% vs 24.2%; P = .002). CONCLUSIONS: Our study showed significantly better continence results and lower revision rates at high-volume centers, confirming earlier results that are still true in this decade. We, therefore, recommend surgery for male incontinence at qualified centers.

Impact of previous urethroplasty on the outcome after artificial urinary sphincter implantation: a prospective evaluation.

PURPOSE: To evaluate the impact of previous urethroplasty on complication rates and postoperative continence after primary artificial urinary sphincter (AUS) implantation in male patients with severe stress urinary incontinence. PATIENTS AND METHODS: A prospective evaluation of patients undergoing primary AUS implantation was conducted. Patients with previous radiotherapy, AUS implantation or urethral stent placement were excluded. Main endpoints were postoperative continence and complication rates including necessity of AUS explantation. Kaplan-Meier analysis evaluated explantation-free survival. Logistic regression analyses were performed to identify potential predictors for AUS explantation. RESULTS: 105 patients were included with a mean follow-up of 76.6 months (SD 15.9). 30 of these patients had a history of urethroplasty. Postoperatively, 96.2% of all patients were objectively continent (≤ 1 pad/day). No differences in postoperative continence and early complication rates were observed. Concerning long-term complications, infection, mechanical implant failure, and tissue atrophy were also comparable. Overall sphincter erosion rate was 12.3%, but significantly higher in urethroplasty patients (23.3% vs. 8.0%, p = 0.038) and sphincter explantation rate was threefold higher (p = 0.016) in the urethroplasty group. Furthermore, explantation-free survival was reduced compared to the non-urethroplasty group (p = 0.044). On logistic regression analysis, the previous urethroplasty was the only significant predictor for AUS explantation (p = 0.016). CONCLUSION: AUS implantation in patients with former urethroplasty can provide satisfying results. Compared to patients without the previous urethroplasty, the higher risk of cuff erosion and AUS explantation has to be addressed during preoperative consultation. Patients with the previous urethroplasty with grafting, long strictures and previous visual internal urethrotomy might be at highest risk.

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

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). CONCLUSION: 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.

The outcome of Y-V plasty as a final option in patients with recurrent bladder neck sclerosis following failed endoscopic treatment.

INTRODUCTION: Bladder neck sclerosis is a rare late complication of transurethral resection of the prostate (TURP). Endoscopic resection or incision of the bladder neck is usually successful in the management of such cases. In some cases, even repeated endoscopic management always followed with recurrent sclerosis. In these cases, the Y-V plasty of the bladder neck provides a final option of treatment. MATERIAL AND METHODS: Retrospective evaluation of 24 patients who underwent Y-V plasty of the bladder neck from 2007 to 2014 was performed. All patients had TURP once and presented after at least 2 failed attempts of endoscopic management. The principle of this technique is to insert a V-shaped part of the bladder wall into the fibrosed bladder neck. The patient evaluation included measuring Q max, residual urine volume and asking about their satisfaction. All patients were operated in the same center by the same surgeon. RESULTS: The mean age of patients at surgery was 66.8 years (range 56-74 years). All patients presented preoperatively with obstructive micturition with mean Qmax 2.2 ml/s (SD ±1.9) and mean residual urine volume of 381 ±169 ml. After a mean follow-up of 46 months (SD ±22), the mean Qmax reached 16.4 ml/s (SD 3.3) while the mean residual urine volume was 18 ml (SD ±6). Recurrent sclerosis occurred in three patients (12.5%). A total of 94.1% of patients reported satisfactory micturition with significant improvement in the quality of life. CONCLUSIONS: The Y-V plasty can provide a final option with a high success rate for patients with bladder neck sclerosis after failed endoscopic treatment.

The AdVance and AdVanceXP male sling in urinary incontinence: is there a difference?

PURPOSE: To compare the efficacy and perioperative complications of the AdVanceXP with the original AdVance male sling. METHODS: We retrospectively enrolled 109 patients with an AdVance and 185 patients with an AdVanceXP male sling. The baseline characteristics and complication rates were analyzed retrospectively. Functional outcome and quality of life were evaluated prospectively by standardized, validated questionnaires. The Chi2-test for categorical and Mann-Whitney U test for continuous variables were performed to identify heterogeneity between the groups. RESULTS: Regarding operation time, there was no significant difference between the slings (p = 0.146). The complication rates were comparable in both groups except for postoperative urinary retention. This occurred significantly more often in patients with the AdVanceXP (p = 0.042). During follow-up, no differences could be identified regarding ICIQ-SF, PGI or I-QoL or number of pad usage. CONCLUSIONS: The AdVance and AdVanceXP are safe and effective treatment options for male stress urinary incontinence. However, the innovations of the AdVanceXP sling did not demonstrate a superiority over the original AdVance sling regarding functional outcome.

Anterior Urethroplasty Using a New Tissue Engineered Oral Mucosa Graft: Surgical Techniques and Outcomes.

PURPOSE: We investigated whether tissue engineered material may be adopted using standard techniques for anterior urethroplasty. MATERIALS AND METHODS: We performed a retrospective multicenter study in patients with recurrent strictures, excluding those with failed hypospadias, lichen sclerosus, traumatic and posterior strictures. A 0.5 cm2 oral mucosa biopsy was taken from the patient cheek and sent to the laboratory to manufacture the graft. After 3 weeks the tissue engineered oral mucosal MukoCell® graft was sent to the hospital for urethroplasty. Four techniques were used, including ventral onlay, dorsal onlay, dorsal inlay and a combined technique. Cystourethrography was performed 1 month postoperatively. Patients underwent clinical evaluation, uroflowmetry and post-void residual urine measurement every 6 months. When the patient showed obstructive symptoms, defined as maximum urine flow less than 12 ml per second, the urethrography was repeated. Patients who underwent further treatment for recurrent stricture were classified as having treatment failure. RESULTS: Of the 38 patients with a median age of 57 years who were included in study the strictures were penile in 3 (7.9%), bulbar in 29 (76.3%) and penobulbar in 6 (15.8%). Median stricture length was 5 cm and median followup was 55 months. Treatment succeeded in 32 of the 38 patients (84.2%) and failed in 15.8%. Success was achieved in 85.7% of ventral onlay, 83.3% of dorsal onlay, 80% of dorsal inlay and 100% of combined technique cases. No local or systemic adverse reactions due to the engineered material were noted. CONCLUSIONS: Our findings show that a tissue engineered oral mucosa graft can be implanted using the same techniques suggested for anterior urethroplasty and native oral mucosa, and guaranteeing a similar success rate.

The TiLOOP® Male Sling: Did We Forejudge.

INTRODUCTION: To evaluate the safety and efficacy of the TiLOOP® male sling (pfm medical, Cologne, Germany) used in the treatment for male stress urinary incontinence (SUI). MATERIAL AND METHODS: We retrospectively evaluated a total of 34 patients with a TiLOOP® male sling. Perioperative complication rates were assessed and validated questionnaires were prospectively evaluated to assess quality of life and satisfaction rate. Outcome and complication rates were analysed by using descriptive statistics. Correlation of continence outcome and risk factors was performed with the chi-square test. A p value below 0.05 was considered statistically significant. RESULTS: The majority of patients (70.6%) were diagnosed with mild or moderate male SUI. During surgery, one instance (2.9%) of intraoperative urethral injury was observed. There were no immediate postoperative complications. The mean follow-up time was 44.6 months. An improvement of male SUI was reported by 61.9% of the patients and 38.1% reported no change according the Patient Global Impression of Improvement. The mean perineal pain score was 0.5 according to the international index of pain. CONCLUSIONS: The TiLOOP® is a safe treatment option for male SUI in our cohort with a low complication rate. However, the functional outcome of the TiLOOP® was inferior when compared to the outcome of the AdVance® male sling.

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.

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.

Antibiotic Coating of the Artificial Urinary Sphincter (AMS 800): Is it Worthwhile?

OBJECTIVE: To investigate the impact of the antibiotic coating InhibiZone on the infection and explantation rates of the AMS 800 in comparison to the AMS 800 without InhibiZone. MATERIALS AND METHODS: We retrospectively identified 305 patients with an AMS 800 in a multicenter cohort study. Patients were subsequently divided into InhibiZone and without InhibiZone-coated groups. Infection and explantation rates were analyzed by univariate and consecutively by multivariate logistic regression adjusted to variable risk factors. The infection-free interval was estimated by Kaplan-Meier plot and compared by the log-rank test. A P value below .05 was considered statistically significant. RESULTS: We identified 47 patients with InhibiZone and 258 without InhibiZone coating. In univariate analysis, we could not identify a significant difference in infection (P = .932) or explantation (P = .715) rates between the groups. In multivariate analysis, impaired wound healing (P = .008) and urethral erosion (P < .001) were independent predictors for infection. The InhibiZone coating neither demonstrated significant influence on the infection rate (P = .534) nor on the explantation rate (P = .214). There was no significant difference in estimated infection-free survival between the groups (P = .265). CONCLUSION: The antibiotic coating of the AMS 800 had no significant impact on infection or explantation rates in our cohort.

Risk Factors for Failure of Male Slings and Artificial Urinary Sphincters: Results from a Large Middle European Cohort Study.

INTRODUCTION: We analysed the impact of predefined risk factors: age, diabetes, history of pelvic irradiation, prior surgery for stress urinary incontinence (SUI), prior urethral stricture, additional procedure during SUI surgery, duration of incontinence, ASA-classification and cause for incontinence on failure and complications in male SUI surgery. MATERIALS AND METHODS: We retrospectively identified 506 patients with an artificial urinary sphincter (AUS) and 513 patients with a male sling (MS) in a multicenter cohort study. Complication rates were correlated to the risk factors in univariate analysis. Subsequently, a multivariate logistic regression adjusted to the risk factors was performed. A p value <0.05 was considered statistically significant. RESULTS: A history of pelvic irradiation was an independent risk factor for explantation in AUS (p < 0.001) and MS (p = 0.018). Moreover, prior urethral stricture (p = 0.036) and higher ASA-classification (p = 0.039) were positively correlated with explantation in univariate analysis for AUS. Urethral erosion was correlated with prior urethral stricture (p < 0.001) and a history of pelvic irradiation (p < 0.001) in AUS. Furthermore, infection was correlated with additional procedures during SUI surgery in univariate analysis (p = 0.037) in MS. CONCLUSIONS: We first identified the correlation of higher ASA-classification and explantation in AUS. Nevertheless, only a few novel risk factors had a significant influence on the failure of MS or AUS.

Complications and Short-Term Explantation Rate Following Artificial Urinary Sphincter Implantation: Results from a Large Middle European Multi-Institutional Case Series.

UNLABELLED: Background/Aims/Objectives: To analyze perioperative complication and short-term explantation rates after perineal or penoscrotal single-cuff and double-cuff artificial urinary sphincter (AUS) implantation in a large middle European multi-institutional patient cohort. METHODS: 467 male patients with stress urinary incontinence underwent implantation of a perineal single-cuff (n = 152), penoscrotal single-cuff (n = 99), or perineal double-cuff (n = 216) AUS between 2010 and 2012. Postoperative complications and 6-month explantation rates were assessed. For statistical analysis, Fisher's exact test and Kruskal-Wallis rank sum test, and a multiple logistic regression model were used (p < 0.05). RESULTS: Compared to perineal single-cuff AUS, penoscrotal single-cuff implantation led to significantly increased short-term explantation rates (8.6% (perineal) vs. 19.2% (penoscrotal), p = 0.019). The postoperative infection rate was significantly higher after double-cuff compared to single-cuff implantation (6.0% (single-cuff) vs. 13.9% (double-cuff), p = 0.019). The short-term explantation rate after primary double-cuff placement was 6.5% (p = 0.543 vs. perineal single-cuff). In multivariate analysis, the penoscrotal approach (p = 0.004), intraoperative complications (p = 0.005), postoperative bleeding (p = 0.011), and perioperative infection (p < 0.001) were independent risk factors for short-term explantation. CONCLUSIONS: Providing data from a large contemporary multi-institutional patient cohort from high-volume and low-volume institutions, our results reflect the current standard of care in middle Europe. We indicate that the penoscrotal approach is an independent risk factor for increased short-term explantation rates.

Efficacy and safety of the ZSI375 artificial urinary sphincter for male stress urinary incontinence: lessons learned.

PURPOSE: To analyze efficacy and safety for the ZSI375 artificial urinary sphincter in a multicenter case series. METHODS: Thirteen male patients with stress urinary incontinence underwent implantation of a ZSI375 artificial urinary sphincter device between 2010 and 2012 in three international continence reference centers. Perioperative characteristics and postoperative complications were analyzed using the Clavien-Dindo scale. Re-hospitalization and explantation rates, and functional outcome were assessed. Inner-group and between-group differences were analyzed using Wilcoxon, Mann-Whitney U, and Fisher's exact test whenever indicated. Kaplan-Meier analysis was performed to assess device survival. A p value below 0.05 was considered statistically significant. RESULTS: There were no intraoperative complications. Median follow-up was 13.5 months. In this period, four device defects (30.8 %) could be observed, being the main cause for device explantation, followed by device infection (15.4 %), non-resolvable pain (7.7 %), and urethral erosion (7.7 %). There were no Clavien IV or Clavien V complications. Overall explantation rate was 61.5 %. Mean time-to-explantation was 279 ± 308 days. There was no significant influence of previous irradiation and previous invasive incontinence therapy (p = 0.587 and p = 0.685, respectively). Mean daily pad usage decreased from 5.8 ± 1.5 to 2.4 ± 2.1 (p = 0.066). One patient (7.7 %) did not use any pads. Social continence (0-1 pads) was achieved in 15.4 % of the patients. CONCLUSION: This is the most current study that is investigating the outcome after ZSI375 implantation in a multicenter case series. Based on our results, explantation rates after ZSI375 implantation are high and efficacy rates seem lower than previously described. Addressing this high failure rate, the system has undergone a two-step modification in the meantime.

Artificial urinary sphincter (AMS 800) implantation for women with intrinsic sphincter deficiency: a technique for insiders?

Artificial urinary sphincter (AUS) implantation is one of several surgical options for the treatment of female stress urinary incontinence. It is indicated for women with both clinically and urodynamically defined intrinsic sphincter deficiency that significantly affects quality of life. The erosion/revision risk increases after several previous surgical interventions. Therefore, women believed to be candidates for AUS implantation should be rapidly (after the failure of a maximum of two previous surgical procedures) referred to specialized centres, where the knowledge and experience concerning the diagnosis, surgery and management of female stress urinary incontinence is concentrated. To refer correctly, non-academic urologists/gynaecologists should also be well informed about AUS implantation. Only in this way can the patient weigh the high long-term success rate and high quality of life improvement of AUS implantation against the greater complication/revision risk and take a well-considered decision.

Penile implantation in Europe: successes and complications with 253 implants in Italy and Germany.

INTRODUCTION: Results for prosthesis implantation from everyday clinical practice within Europe are few. This report provides data on the most commonly used penile prostheses (the American Medical Systems [AMS] series). AIM: The study aimed to assess, retrospectively, complications and patient satisfaction with AMS penile implants in 253 consecutive patients with erectile dysfunction from three European centers. METHODS: Pre, intra- and postoperative data were obtained from chart review, with a mean follow-up of 60 months; 200 patients were available for evaluation. Patient satisfaction data were collected using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire. MAIN OUTCOME MEASURE: Complications and patient satisfaction were assessed. Patient satisfaction was evaluated using a standardized assessment tool (the modified EDITS questionnaire). RESULTS: Major postoperative complications occurred in 40 (20%) patients, including 9 (22.5%) prosthesis infections, 18 (45%) mechanical failures, and 13 (32.5%) erosions. Patient satisfaction with the AMS 700CX, AMS Ambicor, and AMS 600-650 was 97%, 81%, and 75%, respectively; dissatisfaction was 0%, 5%, and 6%, respectively. Partner satisfaction with the AMS 700CX, AMS Ambicor, and AMS 600-650 was 91%, 91%, and 75%, respectively; dissatisfaction was 0%, 5%, and 6%, respectively. Erections were more natural (harder) than before with the AMS 700CX, AMS Ambicor, and AMS 600-650 in 91%, 85%, and 88%, respectively; hardness was the same as before in 9%, 15%, and 13%, respectively; no erections were less hard than before. CONCLUSIONS: Postoperative complications differed from those reported in the literature, while patient satisfaction rates were roughly similar. The reporting of specific data for different implant types, plus the use of standardized assessment tools for patient satisfaction is significant as in the future, it will allow comparison of data between centers performing penile prosthesis implants using these devices.

The dorsal lamina of the rectus sheath: a suitable grafting material for the penile tunica albuginea in Peyronie's disease?

OBJECTIVE: To estimate the morphological suitability of human connective tissue structures from different regions as graft material in Peyronie's disease, and to present preliminary results from 12 patients with grafting of corporal bodies using autologous rectus sheath. PATIENTS AND METHODS: In five male cadavers the penile tunica albuginea was compared with the dorsal lamina of the rectus sheath, the palmar aponeurosis, the iliotibial tract and the Achilles tendon by using histological sections stained with haematoxylin and eosin, Crossmon's trichrome stain and resorcin-fuchsin. Surgical results and complication rates were investigated in 12 patients with Peyronie's disease after grafting the corporal bodies with autologous rectus sheath to correct their penile curvature. RESULTS: On histology, the penile tunica albuginea showed a three-dimensional meshwork of collagenous and elastic fibres. The dorsal lamina of the rectus sheath had a remarkably similar fibre structure. The other tissues had a different histology, with long collagenous fibres in parallel orientation and elastic fibres restricted to the loose connective tissue around blood vessels and nerves. Clinically, the penile deviation was successfully corrected in 10 patients; there were two residual deviations (15 degrees and 35 degrees ). There were minor complications after surgery in six patients, not requiring surgery. CONCLUSIONS: The dorsal lamina of the rectus sheath has similar morphological characteristics to the tunica albuginea, and therefore represents an ideal autologous graft; the first clinical results are promising.

Long-term results of surgery for urethral stricture: a statistical analysis.

PURPOSE: We assessed the long-term results of surgery for urethral stricture by statistical methods using guidelines for survival analysis. MATERIALS AND METHODS: Of the 267 patients who underwent surgery for urethral strictures between March 1993 and December 1999, 238 (89%) were followed prospectively. The primary end point was success rate of urethroplasty. Secondary end points were variables that might influence success rates. Survival data were analyzed by the Kaplan-Meier method and Cox regression using guidelines for survival analysis. RESULTS: The success rate of all urethroplasties was 82% (95% CI 66 to 89) at 7.5 years. A 6.5-year success rate of 86% (95% CI 70 to 95) was achieved by flap, of 86% (95% CI 66 to 100) by anastomotic, of 79% (95% CI 64 to 94) by mesh graft and of 56% (95% CI 20 to 100) by graft urethroplasty. No significant difference was found among the surgical procedures using the log rank (p = 0.269) or Gehan-Wilcoxon (p = 0.259) test. Multivariate analysis showed an increased risk of failed urethroplasty in patients previously treated with urethral stents (HR 3.69, 95% CI 1.27 to 10.8) and by 2 or more urethrotomies (HR 2.25, 95% CI 1.05 to 4.8). CONCLUSIONS: Using standardized success criteria and statistical methods that applied guidelines for survival analysis conclusions were drawn. Excellent results are achievable by all forms of urethroplasty, justifying a more liberal indication for urethral reconstruction.

Patient satisfaction with the outcome of surgery for urethral stricture.

PURPOSE: We assessed patient satisfaction with the outcome of surgery for urethral strictures and compared it with objective clinical data. MATERIALS AND METHODS: A total of 267 consecutive patients who underwent surgery for urethral stricture between March 1993 and December 1999 were questioned regarding satisfaction. Mailed questionnaires or a telephone interview, if questionnaires were not returned, provided information on the urinary tract, voiding, sexual function, overall satisfaction and miscellaneous impairments after surgery for urethral strictures. The response rate was 87% (233 of 267 patients). Subjective data were compared with objective clinical findings. RESULTS: Of the 203 patients who underwent successful urethroplasty 159 (78%) and 24 of the 30 (80%) in whom urethroplasty was considered a failure from the physician viewpoint were satisfied or very satisfied with the outcome of urethral surgery. Patients who underwent re-intervention for complications other than re-stricture and those who complained of a weak or very weak urinary stream were considerably less satisfied. Factors influencing sexual function also had an important impact on patient satisfaction. Patients with marked or severe penile curvature, penile shortening, erection deterioration and a markedly or severely impaired sexual life were especially dissatisfied. CONCLUSIONS: Patients consider the outcome of surgery for urethral strictures differently than physicians. The outcome of urethroplasty should be assessed not only by objective, but also by subjective criteria. Patients need appropriate preoperative counseling. With realistic expectations most men are satisfied with surgery for urethral stricture.