New technique of robot-assisted laparoscopic artificial urinary sphincter implantation in female by a posterior approach with intraoperative cystoscopic monitoring

Open vs. Robot-Assisted Artificial Urinary Sphincter Implantation in Women with Stress Urinary Incontinence: A Multicenter Comparative Study

Background: The artificial urinary sphincter has been an effective treatment for stress urinary incontinence caused by intrinsic sphincter deficiency in women. However, the use of this device has been limited by the technical difficulties and risks associated with the open implantation procedure. Preliminary studies using robotic techniques have shown promising results, but only one small study has compared robotic to open procedures. This study aims to compare the outcomes of robotic and open artificial urinary sphincter implantation in women with stress urinary incontinence due to intrinsic sphincter deficiency in a large multicenter cohort. Methods: Data were collected retrospectively from female patients who underwent open or robot-assisted artificial urinary sphincter implantation from 2006 to 2020 at 12 urology departments. The primary outcome was the rate of complications within 30 days after surgery, graded using the Clavien-Dindo Classification. Perioperative and functional outcomes were compared between the two groups. Results: A total of 135 patients were included, with 71 in the robotic group and 64 in the open group. The open group had a higher rate of intraoperative complications (27.4% vs. 12.7%; p = 0.03) and postoperative complications (46.8% vs. 15.5%; p < 0.0001). More patients in the robotic group achieved full continence (83.3% vs. 62.3%; p = 0.01). The open group had higher explantation (27.4% vs. 1.4%; p < 0.0001) and revision rates (17.5% vs. 5.6%; p = 0.02). The estimated 1-year explantation-free survival rate was higher in the robotic group. (98.6% vs. 78.3%; p = 0.001). Conclusions: Robot-assisted implantation may reduce perioperative morbidity and improve functional outcomes compared to open implantation in women with stress urinary incontinence.

A systematic review and meta-analysis of complications of artificial urinary sphincters in female patients with urinary incontinence due to internal sphincter insufficiency

BACKGROUND

Urinary incontinence (UI) is a common worldwide rising health issue among women with a prevalence of 5 to 70%. Stress urinary incontinence (SUI) is the most common subtype of UI. There are different treatments for UI, including AUS (artificial urinary sphincter) implantation, as one of the surgical options for treating SUI. The aim of this study was to determine the complication rate of AUS, exclusively in female patients with SUI, which resulted from ISD (intrinsic sphincter deficiency). We also compared the complication rate between minimally invasive (laparoscopic or robotic surgery) and open approaches.

METHODS

Scopus, PubMed, Web of Science, Embase, and Google Scholar were searched for studies regarding complications in AUS implantation surgery, from the beginning of the project to March 2022. After screening and reviewing of full text, the general characteristics of the study and study population including follow-up time, type of surgery, and the number of complications that occurred such as necrosis, atrophy, erosion, infection, mechanical failure, revision, and leak, were extracted.

RESULTS

We found that atrophy occurred in 1 of 188 (0.53%) patients treated with minimally invasive surgery and in 1 of 669 (0.15%) patients treated with open surgery. None of the 17 included studies reported the occurrence of necrosis in the patients under study. Erosion occurred in 9 of 188 (4.78%) patients treated with minimally invasive surgery and in 41 of 669 (6.12%) patients treated with open surgery. Infection occurred in 12 of 188 (6.38%) patients treated with minimally invasive surgery and in 22 of 669 (3.2%) patients treated with open surgery. The mechanical failure occurred in 1 of 188 (0.53%) patients treated with minimally invasive surgery and in 55 of 669 (8.22%) patients treated with open surgery. Reconstructive surgery occurred in 7 of 188 (3.72%) patients treated with minimally invasive surgery and in 95 of 669 (14.2%) patients treated with open surgery. Leaks occurred in 4 of 188 (2.12%) patients treated with minimally invasive surgery and in 6 of 669 (0.89%) patients treated with open surgery. The type of surgery was associated with a statistically significant increase in mechanical failure (p-value = 0.067) and infection (p-value = 0.021), and reconstructive surgery (p-value = 0.049). Out of the 857 participats in the study,469 were studied for less than five years and 388 were studied for more than five years.21 of 469 (4.4%) (p-value = 0.08) patients and 81 of 388 (20.8%) (p-value = 0.001) patients required reconstructive surgery. Erosion occurred in 23 of 469 (4.9%) (p-value = 0.01)patients with following time less than five years and in 27 of 388 (6.9%) (p-value = 0.001) patients with following time more than five years.

CONCLUSION

The use of artificial urinary sphincters in the treatment of UI causes complications such as atrophy, erosion, and infection; the amount of which is influenced by the surgical method and the duration of using the artificial urinary sphincter. It seems that the use of new surgical methods, such as laparoscopic surgery, is useful in reducing the incidence of complications.

Long-term results of artificial urinary sphincter implantation for urinary incontinence due to intrinsic sphincter deficiency in children

PURPOSE

To report long-term results of artificial urinary sphincter implantation for urinary incontinence due to intrinsic sphincter deficiency in children.

MATERIALS AND METHODS

This retrospective monocentric study included all patients who underwent artificial urinary sphincter (AMS 800) implantation before 18 years of age between 1986 and October 2018 for intrinsic sphincter deficiency. The primary outcome was the continence rate at the last follow-up, defined by the daily use of 0 pads. The secondary outcome was the overall survival of the device, defined as the absence of any repeated surgery (revision or explantation) during follow-up. Reoperation-free, revision-free, and explantation-free device survival rates were estimated using the Kaplan-Meier method.

RESULTS

Thirty-six patients with a median age of 12 years (interquartile range [IQR]: 10-14) were included (15 females, 21 males). The median follow-up was 18.7 years (IQR: 9-26). The main underlying condition was spinal dysraphism (n = 24; 67%). The median time to the first reoperation was 9 years (IQR: 3.75-14.7). At the last follow-up, survival rates without revision were 84%, 71%, 55%, and 33% at 5, 10, 15, and 20 years, respectively. Survival rates without explantation were 91%, 84%, 80%, and 72% at 5, 10, 15, and 20 years, respectively. At the last follow-up, 29 patients had a functional device. The overall continence rate was 88%. All patients who had their device still in place were continent at the last follow-up.

CONCLUSION

The artificial urinary sphincter is an effective long-term treatment for urinary incontinence related to intrinsic sphincter deficiency in children, providing a high rate of continence, even if associated with a high rate of reoperation.

Efficacy and Safety of Robot-assisted AUS Implantation Surgery in Treating Severe Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the effectiveness and safety of robot-assisted artificial urinary sphincter (AUS) implantation surgery for female patients with severe stress urinary incontinences (SUI) by performing a systematic literature review.

METHODS

A comprehensive search was carried out across multiple databases, including PubMed, EMBASE, Web of Science Clarivate, Cochrane library, Medicine and clinicaltrials.gov between inception to March 2022. Studies were included if they met the inclusion criteria and were evaluated by different quality evaluation methods according to study types. P value and 95% confidence intervals (CI) of outcome measures mainly including continence rates, intraoperative and postoperative complication rates were pooled to present the efficacy and safety.

RESULTS

A total of 9 studies with 157 participants were finally included. Eight retrospective and 1 prospective study met the inclusion criteria with moderate and high evidence levels. The pooled results showed that patients with robot-assisted AUS implantation treatment, presented great continence rate (P = .83, 95%CI:0.76-0.89) but high complication rate (Intraoperation: 0.21 95%CI:0.11-0.34; Postoperation: 0.20 95%CI: 0.12-0.29). In addition, subgroup analysis of 2 approaches showed that compared with the posterior approach, the traditional surgical approach had better efficacy and safety.

CONCLUSION

The results of this study indicated that robot-assisted AUS implantation surgery improved SUI patients' urinary continence, but the complication rates were high, which mainly included intraoperative vaginal and bladder injury and postoperative acute urinary retention. More evidence from prospective studies is needed to provide guidance for clinical practice.