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.

Continence and Complication Rates of Artificial Urinary Sphincter Devices (AMS 800) for Parkinson and Stroke Patients with Incontinence after Prostate Surgery: Retrospective Analysis of a Prospective Database

OBJECTIVES

The artificial urinary sphincter (AUS) is the gold standard treatment for severe stress urinary incontinence (SUI). According to the literature, patients suffering from Parkinson's disease (PD) or stroke (ST) show adverse continence outcomes after prostate surgery and, therefore, constitute a challenging cohort for continence surgery. However, little is known with respect to the results of AUS surgery in these patients. A retrospective analysis of our institutional, prospectively maintained AUS database aims to address this aspect with a focus on surgical and functional outcomes.

METHODS AND PATIENTS

All data of patients with an AUS implantation were prospectively collected in our database since 2009. The AUS was implanted according to a standardized protocol and activated at 6 weeks postoperatively at our institution. Further follow-up (FU) consisted of pad-test, uroflowmetry, residual urine, and radiography as well as a standardized questionnaire including the Incontinence Quality of Life questionnaire (I-Quol) and International Consultation on Incontinence questionnaire (ICIQ-SF) and is scheduled at 6 and 24 months and every 2 years thereafter. Patients received a preoperative urodynamic evaluation (UD). Patients with normal voiding and storage function were considered for AUS implantation. All patients performed a preoperative test for manual dexterity. Patients with a history of ST or PD were grouped and compared to nonneurological patients. Primary/secondary endpoints of the study were complications/continence.

RESULTS

234 patients were available for analysis. The median FU was 24 months (interquartile range 7-36). Twenty-four patients (10%) had a neurological history (PD and ST). Neurological patients showed significantly worse outcomes regarding continence (objective/subjective/social continence; p = 0.04/p = 0.02/p = 0.1). Significant differences concerning explantation rates were not observed (p = 1). Kaplan-Meier analysis showed no significant difference regarding explantation-free survival (log-rank p = 0.53).

CONCLUSION

AUS implantation shows significantly worse continence rates for neurological patients, despite the fact that all patients showed normal UD results and sufficient manual dexterity. Although neurological patients showed worse outcomes for continence, AUS implantation seems to be a safe and viable treatment for patients with a history of neurological disease.

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).

Conclusions

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.

Comparative study of urodynamic tests after AMS 800 and ZSI 375 insertion

STUDY DESIGN

Retrospective, non-randomised, single-centre study.

OBJECTIVES

Comparative study of urodynamic tests in patients presenting social continence after AMS 800 or ZSI 375 insertion.

MATERIALS AND METHODS

Study was open to patients with social continence, implanted with AMS 800 or ZSI 375. Vesical pressure (VP), urethral functional length (FL), maximal urethral pressure (MUP), maximal urethral closure pressure (MUCP), maximal urinary flow rate (Q_max) were registered with standard urodynamic equipment.

RESULTS

From March 2012 to September 2014, 27 male patients with AMS 800 and 28 with ZSI 375 were recruited. In the AMS 800 group mean VP was 25.03 cmH₂O (range 13-47), mean FL 31.96 mm (range 20-52), mean MUCP 88.29 cmH₂O (range 32-160), mean MUP 119.55 cmH₂O (range 77-180), mean Q_max 22.86 mL/s (range 5.6-54.6). In the ZSI 375 group, mean VP was 24.89 cmH₂O (range 6-40), mean FL 30.53 mm (range 12-87), mean MUCP 70.11 cmH₂O (range 38-108), mean MUP 99.89 cm H2O (range 63-134), and mean Q_max 19.25 mL/s range (7.3-39.6).

DISCUSSION

Results of urodynamic tests are similar for both artificial urinary sphincters. AMS 800 cuff pressure over 70 cmH₂O could be explained by the pelvis pressure and the difference of altitude between the pressure-regulating balloon (PRB) and the cuff. ZSI 375 pressure-regulating tank (PRT) is not influenced by these factors. Very high MUP could be explained with too tightened cuffs.

CONCLUSIONS

AMS 800 and ZSI 375 urodynamic tests are similar. Pressure of the pelvis and difference of altitude between the AMS balloon and the cuff can lead to high MUP.