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Bernard C, Bentellis I, El-Akri M, Durand M, Guérin O, Cornu JN, Cousin T, Gaillard V, Dupuis H, Tricard T, Hermieu N, Lecoanet P, Bruyère F, Capon G, Biardeau X, Karam E, Saussine C, Hermieu JF, Peyronnet B, Game X, Brierre T. Primary implantation of an artificial urinary sphincter using the perineal and penoscrotal approaches: Functional results and assessment of reoperative procedures. THE FRENCH JOURNAL OF UROLOGY 2024; 34:102604. [PMID: 38417628 DOI: 10.1016/j.fjurol.2024.102604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/18/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
INTRODUCTION Artificial urinary sphincter (AUS) is the standard treatment for severe stress urinary incontinence in men. While the perineal access is considered the gold standard, some authors have proposed penoscrotal AUS in order to facilitate the procedure. The main objective of our study was to evaluate the duration of survival without revision surgery (SSRC) according to the surgical approach for primary implantation. MATERIAL AND METHODS Data from 1179 patients implanted in France between 1991 and 2020 with an AMS 800 AUS were retrospectively analyzed. A total of 762 men were implanted perineally (VP) and 417 penoscrotally (VPS). RESULTS Median follow-up was 20 vs. 25months respectively. The groups were equivalent overall, apart from the use of anticoagulants (11% VP vs. 6.3% VPS P=0.014). In our population, 54% patients were considered as "dry" in the case of VPS vs. 42% for VP. There was no significant difference in terms of survival time without reoperation, revision, replacement or explantation. In univariate and multivariate analysis, age over 70years was predictive of more reinterventions, whereas the use of a 4.5cm cuff was protective, with hazard ratios of 1.42 (P=0.001) and 0.78 (P=0.04), respectively. CONCLUSION The penoscrotal approach does not appear to be associated with more complications, has good functional results and no significant difference in reoperation-free survival. A prospective multicenter non-inferiority study could be of interest to confirm our findings. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Clémence Bernard
- Department of Urology, Renal Transplantation and Andrology, CHU Rangueil, TSA 50032, 31059 Toulouse, France.
| | - Imad Bentellis
- Urology Department, Nice University Hospital, Nice, France
| | - Mehdi El-Akri
- Urology Department, Rennes University Hospital, Rennes, France
| | | | - Olivier Guérin
- Urology Department, Nice University Hospital, Nice, France
| | | | - Tiffany Cousin
- Urology Department, Bordeaux University Hospital, Bordeaux, France
| | | | - Hugo Dupuis
- Urology Department, CHU de Rouen, Rouen, France
| | | | | | - Pierre Lecoanet
- Urology Department, Nancy University Hospital, Nancy, France
| | | | - Grégoire Capon
- Urology Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Biardeau
- Urology Department, Lille University Hospital, Lille, France
| | - Elias Karam
- Visceral Surgery and Liver Transplant Unit, CHU de Tours, Tours, France
| | | | | | | | - Xavier Game
- Department of Urology, Renal Transplantation and Andrology, CHU Rangueil, TSA 50032, 31059 Toulouse, France
| | - Thibaut Brierre
- Department of Urology, Renal Transplantation and Andrology, CHU Rangueil, TSA 50032, 31059 Toulouse, France
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Girard C, El-Akri M, Durand M, Guérin O, Cornu JN, Brierre T, Cousin T, Gaillard V, Dupuis H, Tricard T, Hermieu N, Leon P, Chevallier D, Bruyere F, Biardeau X, Hermieu JF, Lecoanet P, Capon G, Game X, Saussine C, Rambaud C, Peyronnet B, Bentellis I. Efficacy, Safety, and Reoperation-free Survival of Artificial Urinary Sphincter in Non-neurological Male Patients over 75 Years of Age. EUR UROL SUPPL 2023; 53:23-30. [PMID: 37441348 PMCID: PMC10334236 DOI: 10.1016/j.euros.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 07/15/2023] Open
Abstract
Background Artificial urinary sphincter (AUS) is a gold standard treatment in male stress urinary incontinence but remains poorly used in elderly patients. Objective To assess the efficacy, safety, and reoperation-free survival of AUS implantation in male patients over 75 yr of age. Design setting and participants We retrospectively reviewed the charts of all 1233 non-neurological male AUS implantations between 2005 and 2020 at 13 French centers. We compared 330 patients ≥75 yr old (GROUP75+) with 903 patients <75 yr old (GROUP75-) at the time of AUS implantation. Outcome measurements and statistical analysis Our primary endpoint was social continence at 3 mo defined as the use of one or fewer pad daily. We used Kaplan-Meier analyses to assess reoperation-free survival. We sought factors of erosion using logistic regression. Results and limitations Early postoperative continence was comparable in both groups (74.4% vs 80.1%, p = 0.114). We observed a higher rate of postoperative complications in GROUP75+ (18.8% vs 12.6%, p = 0.014), but the complications were more frequently of low grade in GROUP75+ (p = 0.025). The overall reoperation-free survival was similar (p = 0.076) after a median follow-up of 2 yr. However, patients in GROUP75+ had poorer explantation-free survival (p < 0.0001). A history of radiotherapy was a predictive factor of erosion (odds ratio [OR] = 5.31, p < 0.01), but age was not (OR = 1.08, p = 0.87). Unfortunately, our dataset did not include a systematic geriatric evaluation. Conclusions AUS in elderly patients appears to be an effective option to treat stress urinary incontinence. However, we observed more postoperative complications and explantations, although age was not associated with the onset of erosion. A prospective study is required to determine whether a geriatric evaluation would be an effective strategy to select patients before surgery. Patient summary In this study, we looked at outcomes of artificial urinary sphincter in elderly men in a large population. We found satisfying efficacy but slightly more postoperative complications and device infections.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Xavier Game
- University Hospital of Toulouse, Toulouse, France
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Queissert F, Huesch T, Kretschmer A, Kirschner-Hermanns R, Pottek T, Olianas R, Friedl A, Homberg R, Pfitzenmaier J, Naumann CM, Nyarangi-Dix J, Hofmann T, Rose A, Weidemann C, Wotzka C, Hübner W, Loertzer H, Abdunnur R, Grabbert M, Anding R, Bauer RM, Haferkamp A, Schrader AJ. Is the Standard Artificial Urinary Sphincter AMS 800 Still a Treatment Option for the Irradiated Male Patient Presenting with a Devastated Bladder Outlet? J Clin Med 2023; 12:4002. [PMID: 37373698 DOI: 10.3390/jcm12124002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
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.
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Affiliation(s)
- Fabian Queissert
- Department of Urology and Pediatric Urology, University Hospital Münster, 48149 Münster, Germany
| | - Tanja Huesch
- Department of Urology, University Medical Center of Johannes Gutenberg University, 55131 Mainz, Germany
| | - Alexander Kretschmer
- Department of Urology, Ludwig-Maximilians University, Campus Großhadern, 80539 Munich, Germany
| | | | - Tobias Pottek
- Department of Urology, Vivantes Hospital Am Urban, 10117 Berlin, Germany
| | - Roberto Olianas
- Department of Urology, Hospital Lüneburg, 21339 Lüneburg, Germany
| | - Alexander Friedl
- Department of Urology, Göttlicher Heiland Vienna, 1170 Vienna, Austria
| | - Roland Homberg
- Department of Urology and Pediatric Urology, St. Barbara Hospital Hamm, 59075 Hamm, Germany
| | - Jesco Pfitzenmaier
- Department of Urology, Evangelic Hospital Bethel, 42240 Bielefeld, Germany
| | - Carsten M Naumann
- Department of Urology and Pediatric Urology, St. Elisabeth Hospital, 56564 Neuwied, Germany
| | - Joanne Nyarangi-Dix
- Department of Urology and Pediatric Urology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Torben Hofmann
- Department of Urology, Diakonie Hospital Schwaebisch Hall, 74523 Schwaebisch Hall, Germany
| | - Achim Rose
- Department of Urology and Pediatric Urology, Helios Hospital Duisburg, 47166 Duisburg, Germany
| | - Christian Weidemann
- Department of Urology and Pediatric Urology, Catholic Hospital St. Johann Nepomuk, 99097 Erfurt, Germany
| | - Carola Wotzka
- Department of Urology, Diakonie Hospital Stuttgart, 70176 Stuttgart, Germany
| | - Wilhelm Hübner
- Department of Urology, Hospital Weinviertel Korneuburg, 2100 Korneuburg, Austria
| | - Hagen Loertzer
- Department of Urology and Pediatric Urology, Westpfalz Medical Center, 67655 Kaiserslautern, Germany
| | - Rudi Abdunnur
- Department of Urology, Helios Hospital Schwelm, 58332 Schwelm, Germany
| | - Markus Grabbert
- Department of Urology, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Ralf Anding
- Department of Urology, University Hospital Basel, 4031 Basel, Switzerland
| | - Ricarda M Bauer
- Department of Urology, Ludwig-Maximilians University, Campus Großhadern, 80539 Munich, Germany
| | - Axel Haferkamp
- Department of Urology, University Medical Center of Johannes Gutenberg University, 55131 Mainz, Germany
| | - Andres J Schrader
- Department of Urology and Pediatric Urology, University Hospital Münster, 48149 Münster, Germany
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Kurtzman JT, Kerr P, Blum R, Han DS, Baas W, Argade S, Brandes SB. The role of transcorporal cuff placement in high-risk and ultra-high-risk patients: are they actually helpful? World J Urol 2023; 41:879-884. [PMID: 36749394 DOI: 10.1007/s00345-023-04284-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/02/2023] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To assess the incidence of artificial urinary sphincter (AUS) explant in high-risk patients and to evaluate the relationship between transcorporal cuff (TCC) placement and explant risk in this population. METHODS We retrospectively reviewed all AUS insertions performed on high-risk patients by a single surgeon from 2010 to 2020. "High-risk" was defined as having ≥ 1 urethral risk factor: pelvic radiation, urethroplasty, recalcitrant urethral/bladder neck stenosis, urethral stenting, or previous AUS erosion/infection. Patients with ≥ 2 factors were "ultra-high-risk." Time-to-event analyses were used to assess all-cause-, infection/erosion-related-, and mechanical failure-related explant-free survival. Subgroup analyses were performed for patients with a history of radiation and urethral dissection. RESULTS The final cohort included 68 men, mean age of 67 years (SD 11), and 77 AUS cuffs. Mean follow-up was 32 months (IQR 6-50). 29% of cuffs (n = 22) were transcorporal. 32 cuffs (42%) were explanted. All-cause explant-free survival was 64% at 1 year and 52% at 2 years. Classification as "ultra-high-risk" was not associated with explant risk (all p-values > 0.05). TCC placement was associated with an increased risk of explant for infection/erosion across all patients (HR 2.74, p = 0.03) and in radiated patients (n = 50; HR 4.1, p = 0.04), but not in patients with prior urethral dissection (n = 52; HR 1.98, p = 0.21). CONCLUSION High-risk patients have a high rate of AUS explant and TCC placement may not be protective in this population. TCC placement was associated with an increased risk of infection/erosion in radiated patients, but not in those with a history of open urethral surgery.
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Affiliation(s)
- Jane T Kurtzman
- Department of Urology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 11th Floor, New York, NY, 10032, USA
| | - Preston Kerr
- Department of Urology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 11th Floor, New York, NY, 10032, USA
| | - Ruth Blum
- Department of Urology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 11th Floor, New York, NY, 10032, USA
| | - David S Han
- Department of Urology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 11th Floor, New York, NY, 10032, USA
| | - Wesley Baas
- Division of Urology, Washington University, St. Louis, MO, USA
| | - Shilpa Argade
- Division of Urology, Washington University, St. Louis, MO, USA
| | - Steven B Brandes
- Department of Urology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, 11th Floor, New York, NY, 10032, USA.
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ATOMS (Adjustable Trans-Obturator Male System) in Patients with Post-Prostatectomy Incontinence and Previously Treated Urethral Stricture or Bladder Neck Contracture. J Clin Med 2022; 11:jcm11164882. [PMID: 36013121 PMCID: PMC9410097 DOI: 10.3390/jcm11164882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/22/2022] Open
Abstract
(1) Background: Male stress incontinence in patients with previously treated urethral or bladder neck stricture is a therapeutic challenge. The efficacy and safety of the adjustable trans-obturator male system (ATOMS) in these patients is unknown. (2) Methods: All patients with primary ATOMS implants in our institution between 2014 and 2021 were included. The outcomes of patients with previously treated urethral or bladder neck stricture (≥6 months before ATOMS implant) and stable 16Ch urethral caliber were compared to those without a history of stricture. The primary endpoint was the dry patient rate, defined as the pad test ≤ 20 mL/day, and complication rate, including device removal. The secondary variable was self-perceived satisfaction using the Patient Global Impression of Improvement (PGI-I) scale. Wilcoxon rank sum test, Fisher’s exact test and logistic regression were performed. (3) Results: One hundred and forty-nine consecutive patients were included, twenty-one (14%) previously treated for urethral or bladder neck stricture (seven urethroplasty, nine internal urethrotomy and five bladder neck incision). After ATOMS adjustment, 38% of the patients with treated stricture were continent compared to 83% of those without (p < 0.0001). After weighted matched observations using propensity score pairing, the proportion of continent patients without a previous stricture was 56% (p = 0.236). Complications occurred in 29% of the patients with stricture and in 20% of those without (p = 0.34). The severity of the complications was distributed evenly among the groups (p = 0.42). Regarding self-perceived satisfaction with the implant, 90% of the patients with stricture perceived the results satisfactorily (PGI-I 1−3) compared to 97% of the rest (p = 0.167). Stricture was associated with radiotherapy (p < 0.0001) and time from prostatectomy to implantation (p = 0.012). There was a moderate correlation between previous stricture and the severity of incontinence, both evaluated according to the 24-h pad test (Rho = 0.378; p < 0.0001) and the ICIQ-SF questionnaire (Rho = 0.351; p < 0.0001). Multivariate analysis for the factors predictive of failure after ATOMS adjustment revealed previous stricture (OR 4.66; 95% CI 1.2−18.87), baseline 24-h pad test (per 100 mL, OR 1.28; 95% CI 1.09−1.52) and final cushion volume (per mL, OR 1.34; 95% CI 1.19−1.55). This model predicted dryness with an AUC of 92%. After the PSMATCH procedure using a propensity score, the model remained unchanged, with the previous stricture (OR 8.05; 95% CI 1.08−110.83), baseline 24-h pad test (per 100 mL, OR 1.53; 95% CI 1.15−2.26) and final cushion volume (per mL, OR 1.45; 95% CI 1.17−2) being independent predictors and an AUC of 93%. (4) Conclusions: ATOMS can be used to treat male stress incontinence in patients with a history of stricture, although the effectiveness of the device is reduced. On the other hand, the security and perceived satisfaction were equivalent for both groups.
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Koch GE, Kaufman MR. Male Stress Urinary Incontinence. Urol Clin North Am 2022; 49:403-418. [DOI: 10.1016/j.ucl.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Maurer V, Dahlem R, Howaldt M, Riechardt S, Fisch M, Ludwig T, Engel O. Transcroporal Artificial Urinary Sphincter Placement With Closure of Corporal Bodies—A Long-Term Analysis of Functional Outcomes. Front Surg 2022; 9:918011. [PMID: 35722536 PMCID: PMC9198723 DOI: 10.3389/fsurg.2022.918011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives An artificial urinary sphincter (AUS) is the gold standard for postoperative stress urinary incontinence (SUI). The transcorporal AUS (TC) placement constitutes the main salvage option in high-risk patients suffering from SUI with fragile urethras. The literature analyzing long-term outcomes with respect to explantation rates, continence, and erectile function is scarce. Methods and Patients Retrospective data collection was performed in 2011. TC was applied according to a standardized protocol. TC was implanted after bulbar urethroplasty or double-cuff (DC) explantation. After TC placement, the tunica albuginea was closed in order to minimize the risk of postoperative bleedings and erectile dysfunction. Activation was performed 6 weeks postoperatively. Further follow-up (FU) was scheduled 6/24 months postoperatively and every 2 years thereafter. Primary/secondary endpoints were explantation/objective, subjective, and social continence rates. Objective or social continence was defined as the use of 0 pads/day or <2 pads/day, respectively. Thereupon, postoperative bleedings and erectile function were analyzed. Results A total of 39 high-risk patients were available for analysis. The median age was 72 years. In total, 84.6%, 10.3%, and 2.6% had a history of radical prostatectomy, TURP, and radical cystectomy, respectively. In total, 61.5% had a history of radiation therapy of the prostate, 41% had a history of urethral surgery, and 95% had a history of double cuff explantation. The median FU was 27 months. Objective, subjective, and social continence were 54.5%, 69.7%, and 78.8%, respectively. The median pad usage was 1 pad/day [1–2.5]. Only one patient suffered from a postoperative hematoma. In total, 15.4% of the patients were able to have an erection preoperatively, compared to 7.7% after TC placement. The estimated mean explantation-free survival of the TC was 83 months in the Kaplan–Meier analysis. Conclusions TC AUS implantation constitutes a viable salvage approach in high-risk SUI patients with a mean device survival of almost 7 years and high social continence rates of almost 80%. An intraoperative closure of the tunica albuginea after TC placement allows for very low rates of postoperative hematoma and supports postoperative erectile rigidity.
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Affiliation(s)
- Valentin Maurer
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Asklepios Medical Center Hamburg-Harburg, Hamburg, Germany
- Correspondence: Valentin Maurer
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marian Howaldt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Asklepios Medical Center Hamburg-Harburg, Hamburg, Germany
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim A. Ludwig
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Engel
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Asklepios Medical Center Hamburg-Harburg, Hamburg, Germany
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