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Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018–February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08–1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED., Among hospitalized patients with ASB, the majority of urine testing and treatment was initiated by emergency medicine clinicians and often continued by inpatient clinicians. Antibiotic treatment was associated with Clostridioides difficile infection and longer duration of hospitalization.

In order to accurately characterize how a history of radiation therapy affects the lifespan of replacement artificial urinary sphincters (AUSs), all possible sources of device failure must be considered. We assessed the competing risks of device failure based on radiation history in men with replacement AUSs.We identified men who had a replacement AUS in a single institutional, retrospective database. To assess survival from all-cause device failure based on radiation history and other factors, we conducted Kaplan-Meier, Cox proportional-hazards and competing risks analyses.Among 247 men who had a first replacement AUS, men with a history of radiation had shorter time to all-cause device failure (median 1.4 vs 3.5 years for men with radiation vs without radiation history, p=0.02). On multivariable Cox-proportional hazards analysis, previous radiation was associated with increased risk of all-cause device failure (HR: 2.12, 95% CI: 1.30-3.43, p=0.002)Among men with a replacement AUS, a history of pelvic radiation was associated with shorter time to device failure of any cause. Radiation was also specifically associated with a sevenfold increase in the risk of erosion or infection of replacement AUS, but not with urethral atrophy or mechanical failure. Patients with a replacement AUS should be appropriately counseled on how radiation history may impact outcomes of future revisions.

Management of pregnancy and delivery in women with lower urinary tract reconstruction is challenging and the currently available literature is insufficient to guide clinical practice. We report pregnancy and delivery outcomes in this specific population.We conducted a national multicenter retrospective study (16 centers) including 68 women with 96 deliveries between 1998 and 2019. These women had at least 1 successful pregnancy and delivery after augmentation enterocystoplasty, catheterizable channel creation and/or artificial urinary sphincter implantation. Maternal and fetal complications during pregnancy and delivery were reported, as well as postpartum functional outcomes, according to the delivery mode. The chi-square test and Student's t-test were used to compare categorical and continuous variables, respectively.Overall 32% of reported pregnancies were complicated by febrile urinary tract infections, 13.5% by renal colic and 14.6% required upper urinary tract diversion. In addition, 10% of patients reported transient self-catheterization difficulties and 13.5% reported de novo or increased urinary incontinence. The preterm delivery rate was 35.3%. Elective C-section was performed in 61% of pregnancies. Twenty complications occurred during delivery (20%), including 19 during elective C-section. Urinary continence at 1 year was unchanged for 93.5% of deliveries. Delivery mode (p=0.293) and multiparity (p=0.572) had no impact on urinary continence.In this population C-section appeared to be associated with a high risk of complications. In the absence of any obstetric or neurological contraindications, vaginal delivery should be proposed as the first line option to the majority of these women.

We describe and compare artificial urinary sphincter cuff erosion sites and associated clinical implications.We retrospectively reviewed men who presented with artificial urinary sphincter erosion treated by a single surgeon between 2007 and 2019 at a tertiary medical center. Transcorporal indications included complications of prior anti-incontinence procedures and prior urethral reconstruction. Location of artificial urinary sphincter cuff erosion defects was assessed by cystoscopy prior to device explantation, and findings were stratified into patients who had transcorporal vs standard artificial urinary sphincter placement.Out of 723 artificial urinary sphincter cases in 611 patients we identified 54 (7.5%) cuff erosions. Erosion developed in 15 of 82 (18.3%) cases of transcorporal artificial urinary sphincter and 39 of 641 (6.1%) cases of standard artificial urinary sphincter (p0.05). Artificial urinary sphincter cuff erosions occurred predominantly ventrally in both groups (66.7% for transcorporal and 79.5% for standard artificial urinary sphincter, p=0.4) followed by lateral urethral location (33.3% transcorporal and 20.5% standard, p=0.3). Dorsal erosions were rare in both groups (20% transcorporal and 5.1% standard, p=0.1). History of artificial urinary sphincter and previous erosion were associated with transcorporal artificial urinary sphincter erosion. History of radiotherapy, prior urethroplasty, hypogonadism and urethral cuff size were similar between groups.Artificial urinary sphincter cuff erosions appear to occur ventrally and laterally in most patients regardless of cuff placement. Dorsal erosions were the least common in both groups. The protective effect of transcorporal artificial urinary sphincter could not be conclusively demonstrated.

Stress urinary incontinence following radical prostatectomy is common and potentially debilitating. Surgical therapy with a urethral sling or an artificial urinary sphincter is an effective option with high patient satisfaction in men in whom conservative measures fail to treat post-prostatectomy incontinence. We sought to characterize the contemporary utilization of surgical therapy of post-prostatectomy incontinence using an all payer database.We used the Healthcare Cost and Utilization Project databases for Florida from 2006 to 2015 and identified men who underwent radical prostatectomy between 2006 and 2012 using ICD procedure codes. Patients were tracked longitudinally for placement of an ambulatory or inpatient urethral sling, or an artificial urinary sphincter between 2006 and 2015. Patient and clinical data were extracted and analyzed with descriptive statistics. A multivariable logistic regression model was constructed to determine risk adjusted predictors of subsequent incontinence surgery.During the study period 29,287 men underwent radical prostatectomy, of whom 1,068 (3.6%) were treated with subsequent incontinence surgery a median of 23.5 months after prostatectomy. On multivariate analysis risk factors for incontinence surgery included age groups 61 to 70 years (OR 1.25, p=0.008) and 71 to 80 years (OR 1.34, p=0.022), Medicare insurance (OR 1.33, p0.005) and an increased Charlson Comorbidity Index (OR 1.13 per unit increase, p0.005).Of patients who underwent radical prostatectomy 3.6% subsequently underwent stress urinary incontinence surgery. Post-prostatectomy incontinence surgery is likely under performed and delayed in performance based on the previously reported prevalence of severe post-prostatectomy incontinence and the natural history of symptoms. Efforts to increase prompt repair of refractory or severe incontinence can greatly improve patient quality of life after radical prostatectomy.

Inflatable penile prostheses and artificial urinary sphincters are used to treat men with erectile dysfunction and stress urinary incontinence, respectively. After prostate cancer treatment men often experience erectile dysfunction and stress urinary incontinence. Dual prosthetic implantation can improve the quality of life of these men. We evaluated reoperation outcomes in men who underwent dual implantation compared to each device implanted individually.We queried the SPARCS (New York State Department of Health Statewide Planning and Research Cooperative) database for men who underwent inflatable penile prosthesis and/or artificial urinary sphincter insertion between 2000 and 2014. The primary outcomes were the inflatable penile prosthesis and artificial urinary sphincter reoperation rates (revision, replacement or removal). Multivariable regression analysis was performed to assess the association of dual implantation with reoperation. Adjusted time to event analysis was also performed.Median followup in the inflatable penile prosthesis cohort was 66 months (IQR 25-118) and in the artificial urinary sphincter cohort it was 69 months (IQR 27-121). Compared with men who received a penile prosthesis alone those with a penile prosthesis and an artificial urinary sphincter had a higher likelihood of undergoing inflatable penile prosthesis reoperation at 1 year (OR 2.08, 95% CI 1.32-3.27, p0.01) and 3 years (OR 2.60, 95% CI 1.69-3.99, p0.01). Compared with an artificial urinary sphincter alone patients with an inflatable penile prosthesis and an artificial urinary sphincter did not have a higher likelihood of undergoing artificial urinary sphincter reoperation at 1 year (p = 0.76) or 3 years (p = 0.73).Combined inflatable penile prosthesis and artificial urinary sphincter insertion portends a higher likelihood of inflatable penile prosthesis reoperation at 1 and 3 years. However, artificial urinary sphincter outcomes remain comparable. These findings should be used to better counsel patients about the risk of reoperation when undergoing dual implantation.

The AMS 800™ artificial urinary sphincter remains the gold standard for the surgical management of male stress urinary incontinence. We reviewed artificial urinary sphincter device survival after primary implantation.Retrospective data were collected from the AMS 800 patient information form database. Since 1972, 77,512 patient information forms for primary artificial urinary sphincter implantation have been completed in the United States. Following exclusion of procedures performed in children and females, and those labeled with an unknown surgical technique, 27,096 artificial urinary sphincter cases were included in the analysis. Collected variables included patient age, surgical approach, number of cuffs and surgeon volume. Measured outcomes included device explantation, device revision, component revision and time to each event.Artificial urinary sphincter insertion was performed by low volume implanters in 22,165 (82.6%) cases. The approach was perineal in 18,373 cases (67.8%) and a tandem cuff was used in 2,224 cases (8.2%). Overall 5,723 cases required revision or explantation (21.1%). Younger age and penoscrotal approach were associated with higher device explantation and revision rates, while the use of a tandem cuff was associated with higher explantation rates. On multivariate analysis younger age, penoscrotal approach and use of a tandem cuff but not surgeon volume were significant factors associated with device explantation and component revision.These data provide a general overview of artificial urinary sphincter device survival and may serve urologists when counseling patients. Younger age, penoscrotal approach and use of a tandem cuff may be associated with inferior outcomes.

We evaluate the characteristics of artificial urinary sphincter mechanical failures and compare outcomes based on the surgical revision strategy, replacing only the failed component or the entire device.A total of 1,802 male patients with stress urinary incontinence underwent artificial urinary sphincter procedures from 1983 to 2011 at our institution, of which 1,082 were primary placements. Of these patients 125 experienced mechanical device malfunction. Multiple clinical and surgical variables were evaluated for a potential association with device malfunction. In addition, we evaluated for predictors of failure of the revised device, including time from primary artificial urinary sphincter to revision surgery and surgical revision strategy (single component vs entire device), with failure defined as any tertiary surgery.At a median followup of 4.2 years (IQR 0.8, 7.9) 125 patients experienced device malfunction. The urethral cuff was the most common component failure (46.1%), followed by abdominal reservoir (22.6%), tubing (21.7%) and pump (9.6%). There was no association of time from primary surgery to revision for mechanical failure (HR 0.89, p=0.33) or revision strategy (HR 0.47, p=0.15) with the risk of tertiary surgery. Additionally, as there was no significant interaction between these variables (HR 1.11, p=0.39), no cutoff could be identified at which one revision technique produced significantly improved device survival compared to another. However, there was a trend toward improved 3-year device survival after replacement of the entire device vs a single component (76% vs 60%, p=0.11).No cutoff in time to mechanical failure could be identified to guide decision making in the management of mechanical artificial urinary sphincter failure. Likewise, it is unclear if replacing the entire device, rather than the single malfunctioning component, alters device survival. As such, further studies are needed. However, given the current trend toward improved overall device survival, the limited additional risk and the lack of adequate clinical predictors for tertiary surgery, we would advocate for replacement of the entire device when possible.

We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling.We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis.A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31).In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

Recalcitrant posterior urethral stenosis is a challenging disease. When combined with a defunctionalized bladder, cutaneous urinary diversion is the most common surgical option. We present a novel technique of total lower urinary tract reconstruction, combining salvage cystectomy, ileal neobladder formation and urethral pull-through, as an orthotopic alternative in patients with a defunctionalized bladder and recalcitrant posterior urethral stenosis.We completed a retrospective review of 8 patients who underwent salvage cystectomy, orthotopic ileal neobladder formation and urethral pull-through. Artificial urinary sphincter placement was performed in a staged fashion. Six patients received prostate cancer treatment including radiation therapy, 1 had urethral disruption after robotic radical prostatectomy, and 1 experienced bladder rupture and urethral distraction injury during a motorcycle accident. Patient demographics, operative variables and postoperative outcomes were examined.No high grade complications were observed after salvage cystectomy, orthotopic neobladder formation and urethral pull-through. After staged artificial urinary sphincter placement, a median of 2 revision surgeries (range 0 to 4) was required to establish social continence. All patients maintained functional urinary storage, urethral patency and social continence at a median followup of 58 months. No patient had complications related to orthotopic neobladder formation, including ureteroileal anastomotic stricture or pyelonephritis, and no patient required cutaneous diversion.Total lower urinary tract reconstruction with cystectomy, ileal neobladder formation and urethral pull-through offers an orthotopic alternative for patients with recalcitrant posterior urethral stenosis and defunctionalized bladders. Although it requires staged placement of an artificial urinary sphincter, this approach can offer functional urinary storage, durable urethral patency and avoidance of cutaneous urinary diversion.

Some patients fitted with an AMS 800™ type artificial urinary sphincter report urinary leaks in the sitting position whose mechanism remains unclear. In this experimental study we explain these residual leaks by characterizing fluid transfer and pressure variations in the device during cuff compression.Two complete sets of AMS 800 devices were tested on an original test bench. A qualitative study using methylene blue dye was performed to assess fluid transfer within the device during manual cuff compression. After estimating the pressures exerted on the perineal floor in the sitting position, pressure variations in the AMS 800 components were measured in real time using the pressure sensors of a urodynamic workstation.When the AMS 800 cuff was compressed between 2 fingers, reflux of the blue dye into the balloon through the pump resistor was observed. After the cuff was compressed for 5, 10, 15 and 20 seconds at a pressure of 150 cm H2O, the minimal pressure measurements in the cuff were 37, 25, 14 and 12 cm H2O, respectively. Furthermore, the time required for cuff re-pressurization was 68, 87, 101 and 117 seconds, respectively.Urinary leaks reported in sitting position by patients fitted with an AMS 800 may be explained by compression of the urethral cuff between the pelvic floor and the chair, which causes emptying of the cuff into the balloon. Patients should be reassured that there is no implant dysfunction and may adopt simple lifestyle strategies to circumvent these leaks.

We compare stricture outcomes in patients with artificial urinary sphincter cuff erosion managed with and without synchronous urethral repair.Records of patients who underwent artificial urinary sphincter removal for cuff erosion from 2007 to 2013 were retrospectively reviewed. Two cohorts of patients were evaluated, with those in group 1 treated with in situ urethroplasty and those in group 2 treated with a Foley catheter only. We compared demographic, clinical and radiological data to assess resultant stricture disease, and compared operative times between the cohorts.Of the 26 artificial urinary sphincter cuff erosion cases identified 13 underwent in situ urethroplasty while 13 did not. Mean patient age was 73 years (range 61 to 83) with a mean followup of 24 months (range 8 to 69). The rate of urethral stricture formation after artificial urinary sphincter explantation was significantly reduced among patients treated with in situ urethroplasty (5 of 13, 38%) compared to those treated with Foley catheter only (11 of 13, 85%; p=0.047). Mean operative times were similar at 78 minutes (50 to 133) for the in situ urethroplasty group vs 70 minutes (51 to 92) for the Foley catheter only group (p=0.39). Those treated with in situ urethroplasty underwent significantly fewer procedures per patient before artificial urinary sphincter replacement (0.4 vs 1.1, p=0.004) and had a much higher rate of eventually undergoing secondary artificial urinary sphincter implantation (7 of 13, 54% vs 2 of 13, 15%, p=0.04) compared to those with cuff erosion treated with Foley catheter only.Urethral repair at the time of artificial urinary sphincter explantation for cuff erosion appears to prevent stricture development, thus facilitating successful artificial urinary sphincter replacement.

We review our experience with artificial urinary sphincter and augmentation cystoplasty in patients with neurogenic bladder. This is the largest known series to specifically evaluate cuff only artificial urinary sphincter at augmentation cystoplasty.A total of 18 males underwent simultaneous artificial urinary sphincter and augmentation cystoplasty at our institution between 1982 and 2012, of whom 13 (72%) underwent cuff only artificial urinary sphincter. Outcomes included urinary continence, emptying modality, artificial urinary sphincter status, complications and additional procedures.Of the patients undergoing augmentation cystoplasty and cuff only artificial urinary sphincter 10 (77%) were initially continent. Average time of continence was 52.9 months. Four patients (31%) required no additional procedures and remained continent. Urinary incontinence developed in 3 patients (23%) immediately postoperatively and in 6 (46%) subsequently. Ultimately 9 patients (69%) required conversion to complete artificial urinary sphincter at a mean of 36.9 months postoperatively. Overall 12 patients (92%) were continent at followup. There were no artificial sphincter specific complications in patients undergoing the cuff only procedure with conversion to complete artificial urinary sphincter. After conversion to complete artificial urinary sphincter 3 patients (23%) experienced artificial sphincter specific complications. Reoperation was performed in 10 patients (77%), for 13 total procedures (1.3 per patient). There were no complications with cuff only artificial urinary sphincter and 6 complications with complete artificial urinary sphincter (p = 0.025). Finally, patients undergoing cuff only artificial urinary sphincter requiring revision were younger than those not requiring revision (15.6 vs 30.8 years, p = 0.026).Simultaneous cuff only artificial urinary sphincter and augmentation cystoplasty appears safe and efficacious in patients with neurogenic bladder, with fewer complications than complete artificial urinary sphincter, and may provide definitive urinary continence in up to a third of patients. This procedure is technically easy, allows for outpatient revision, provides time for the child to mature and may be cost effective in avoiding placement of additional components in this select patient population.

Little data exist on the outcome of combined inflatable penile prosthesis and artificial urinary sphincter insertion for erectile dysfunction and stress urinary incontinence. We assessed patient outcomes for combined vs single device implantation at a single institution.We retrospectively reviewed the records of all patients who underwent inflatable penile prosthesis and artificial urinary sphincter insertion at our hospital from January 2000 to December 2011. A total of 55 combined procedures were performed compared to the single insertion of 336 inflatable penile prostheses and 279 artificial urinary sphincters.The surgical approach consisted of penoscrotal incisions for inflatable penile prostheses and transperineal incisions for artificial urinary sphincter cuff placement with a secondary lower abdominal incision for reservoir placement. Men treated with combined implantation had greater mean age and were at greater risk for prostate cancer diagnosis and treatment, and at lesser risk for Peyronie disease than men who received an inflatable penile prosthesis alone (each p0.05). Although operative time was significantly longer for the combined procedure than for the inflatable penile prosthesis alone and the AUS alone (mean 218.1 vs 145.9 and 114.7 minutes, respectively, p0.0001), the rate of device infection, erosion or malfunction was not increased irrespective of combined or staged procedures (p0.05).Combined inflatable penile prosthesis-artificial urinary sphincter implantation and staged prosthesis implantation are feasible without an increased risk of adverse outcomes compared to implantation of a single prosthesis. Patients with concomitant erectile dysfunction and stress urinary incontinence should be counseled about the possible advantages of this surgical option, which include a single anesthesia event and faster resumption of sexual activity and urinary control.

In April 2008 InhibiZone® antibiotic coated artificial urinary sphincters were introduced. The antibiotic coating significantly increased the cost of the device by an average of $1,300 per artificial urinary sphincter. To our knowledge, no clinical data to date support the theory that this antibiotic coating decreases the risk of artificial urinary sphincter infection. Therefore, we compared infection rates in our cases before and after the introduction of InhibiZone coated artificial urinary sphincters to determine whether the coating decreased the device infection rate.We retrospectively reviewed the records of 426 consecutive patients in whom an artificial urinary sphincter was implanted by a single surgeon from January 2005 to June 2012. Patients were divided equally into 213 consecutive males who received an artificial urinary sphincter without the antibiotic coating from January 2005 to March 2008 and 213 consecutive males implanted with the antibiotic coated artificial urinary sphincter from April 2008 to June 2012. Demographics and infection rates were compared.Patient mean age, associated comorbidities and complexity were almost identical in the groups with and without the antibiotic coating, and infection rates were identical at 7 patients (3.3%) per group (p = 0.99). In the more complex patient subgroup with revision the antibiotic coating did not impact the infection rate. Infection developed in 2 of 50 patients (5%) with the antibiotic coated device and in 3 of 38 (6%) with the uncoated device (p = 0.42).The InhibiZone coating of the artificial urinary sphincters did not alter the infection rate in our study. The added cost of the antibiotic coated artificial urinary sphincters (total of approximately $276,000 more for all 213 coated devices) was of no benefit in our series. Based on this assessment, we will transition to using artificial urinary sphincters without InhibiZone in our practice.

We investigated patient satisfaction with the artificial urinary sphincter and established criteria for a successful outcome by inquiring about patient perceived satisfaction, continence achieved and comparison with the surgeon office records.During 9 years 65 patients with post-prostatectomy incontinence underwent placement of the AMS800 artificial urinary sphincter. Review of charts and a telephone questionnaire were conducted to determine patient perceived satisfaction.A total of 50 patients participated in the survey. Median followup was 23.4 months. Preoperative incontinence was severe. Of the patients 90% reported continuous leakage, and 70% wore an average of 6 diapers and 24% wore an average of 7.4 pads daily. The long-term complete continence rate was 20%. Of the patients with wetness 55% had leakage of a few drops daily and 22% had leakage of less than a teaspoon. Of all patients 50% had leakage daily, 24% had leakage 1 or more times a week and wore an average of 1.5 pads per day, and 6% reported changing clothes due to wetness. A total of 90% of the patients reported satisfaction with the artificial urinary sphincter and 96% stated that they would recommend or had recommended the artificial urinary sphincter to a friend. In retrospect, 92% of the patients would have the artificial urinary sphincter placed again, 90% of those undergoing revision reported no change in satisfaction and 14% reported improved sexual activity.Patient satisfaction with the artificial urinary sphincter for post-prostatectomy incontinence is uniformly high. Although postoperative continence was not 100%, relative improvement in continence was the most significant factor affecting patient perceived outcome. Using these parameters criteria for a successful outcome can be established, and patient concerns regarding the artificial urinary sphincter can be dispelled.

To assess the efficacy of the artificial urinary sphincter survival and continence were first evaluated 5 years ago. We now evaluated the effects of the artificial urinary sphincter more than a decade after implantation.Before 1985 an artificial urinary sphincter was implanted in 22 male and 14 female consecutive patients 4 to 30 years old (median age 12). In addition, between 1985 and 1990, 18 other children underwent artificial urinary sphincter implantation. Results of both series were compared.Of the 25 sphincters in the original series that were functioning after 5 years 1 was removed and 2 patients were lost to followup, resulting in 22 functioning implants (61% of the patients). Mean survival time of the prostheses was 12.1 years and average followup for functioning sphincters was 13.7 years. There was no statistically significant difference in artificial urinary sphincter survival between the original group at 5 years and the second group treated after 1985. Of the patients in both groups with sphincters in place 32 of 39 (82%) were dry. Augmentation cystoplasty was performed in 9 of 18 patients (50%) in the second series (5 preoperatively and 4 postoperatively) compared to 10 of 36 (28%) in the original series at 5 years (3 preoperatively and 7 postoperatively). Renal failure developed in 6 patients from both series.The artificial urinary sphincter is a durable long-term solution for children with intractable incontinence. Long-term surveillance of the urinary tract is mandatory because of the potential for renal failure in patients who have bladder hypertonicity after placement of the device.

We examined urodynamic findings and treatment outcomes in a large population of men with post-prostatectomy incontinence.A total of 215 men was referred for evaluation and treatment of significant post-prostatectomy incontinence. Urodynamic evaluation consisted of provocation multichannel medium fill cystometry with vigorous attempts to demonstrate incontinence. Treatment was directed by the results of the urodynamic study. A pad scoring system was used to gauge the severity of incontinence before and after treatment.Based on the results of urodynamic studies 40% of the men had genuine stress incontinence alone and approximately 60% had a major component of bladder dysfunction contributing to incontinence. Treatment results of 135 men demonstrated a significant decrease in pad score (p0.001) for those treated with anticholinergics, those undergoing artificial sphincter insertion and those treated pharmacologically before sphincter placement.In our large series most men with prostatectomy incontinence did not have genuine stress incontinence alone. Thus, urodynamic studies are critical, not only to define cause of incontinence but to direct effective therapy.

We investigated the surgical learning curve of artificial urinary sphincter implantation using a large, consecutive, single surgeon series.We retrospectively reviewed the results of the first 150 consecutive, virgin artificial urinary sphincter implantations performed by a single surgeon between 1992 and 2003 for post-prostatectomy male stress urinary incontinence. Complication and reoperation rates, and continence outcomes (daily pad use and number of patients with a functional artificial urinary sphincter at last followup) were analyzed as a function of consecutive implant cases.There was a significant decrease in the number of patients with complications (12 vs 3, relative risk 4.0, p = 0.012) and the number with reoperation (11 vs 3, relative risk 3.7, p = 0.026) when the first 25 patients who underwent artificial urinary sphincter implantation were compared to the second 25. No further decrease was noted beyond the first 25 cases. Despite significantly higher complication and reoperation rates in the first 25 cases, equivalent functional outcomes (same postoperative daily pad use and number of patients with a functional artificial urinary sphincter at last followup) were still achieved after artificial urinary sphincter revision.The surgical learning curve of placing a virgin artificial urinary sphincter was about 25 cases, as measured by complication and reoperation rates. This case number was high compared to typical exposure during residency and clinical practice. There is an urgent need to improve urological prosthetic training and emphasize the referral of artificial urinary sphincter cases to regional centers of excellence or to high volume, artificial urinary sphincter implanters to improve the surgical outcome.

We defined the relevant skin flora during genitourinary prosthetic surgery, evaluated the safety of chlorhexidine-alcohol for use on the male genitalia and compared chlorhexidine-alcohol to povidone-iodine in decreasing the rate of positive bacterial skin cultures at the surgical skin site before prosthetic device implantation.In this single institution, prospective, randomized, controlled study we evaluated 100 consecutive patients undergoing initial genitourinary prosthetic implantation. Patients were randomized to a standard skin preparation with povidone-iodine or chlorhexidine-alcohol. Skin cultures were obtained from the surgical site before and after skin preparation.A total of 100 patients were randomized, with 50 in each arm. Pre-preparation cultures were positive in 79% of the patients. Post-preparation cultures were positive in 8% in the chlorhexidine-alcohol group compared to 32% in the povidone-iodine group (p = 0.0091). Coagulase-negative staphylococci were the most commonly isolated organisms in post-preparation cultures in the povidone-iodine group (13 of 16 patients) as opposed to propionibacterium in the chlorhexidine-alcohol group (3 of 4 patients). Clinical complications requiring additional operations or device removal occurred in 6 patients (6%) with no significant difference between the 2 groups. No urethral or genital skin complications occurred in either group.Chlorhexidine-alcohol was superior to povidone-iodine in eradicating skin flora at the surgical skin site before genitourinary prosthetic implantation. There does not appear to be any increased risk of urethral or genital skin irritation with the use of chlorhexidine compared to povidone-iodine. Chlorhexidine-alcohol appears to be the optimal agent for skin preparation before genitourinary prosthetic procedures.

We compared cuff sites and assessed anatomical and manometric differences between the transscrotal and perineal approaches to artificial urinary sphincter placement in fresh male cadavers.Artificial urinary sphincter implantation using perineal and transscrotal incisions was performed in 15 fresh male cadavers. The artificial urinary sphincter cuffs were placed as proximal as possible using each approach. After measuring urethral circumference at each cuff site, an appropriately sized cuff was placed at each location. The 61 to 70 cm H(2)O pressure reservoir and control pump were then connected to the cuffs. Retrograde leak point pressure was assessed sequentially across each cuff. The paired t test was used to compare urethral circumference and retrograde leak point pressure between the 2 approaches.Mean urethral circumference using the perineal and transscrotal approaches was 5.38 (range 3.2 to 7.5) and 3.81 cm (range 3 to 4.5), respectively (p0.0001, 95% CI of difference 0.99-2.13). Mean retrograde leak point pressure using the perineal and transscrotal approaches was 90.1 and 64.9 cm H(2)O, respectively (p = 0.0002, 95% CI of difference 13.7-33.5). On visual inspection of cuff sites, the perineal approach was more proximal on the urethra than the transscrotal approach.While the transscrotal approach to artificial urinary sphincter placement has the advantage of technical ease, the anatomical and manometric findings of this cadaver study suggest that the perineal approach offers a more proximal cuff location, more robust urethral size and more effective urethral coaptation than the transscrotal approach.

Urinary incontinence can be a significant complication of radical prostatectomy. It can be treated with post-prostatectomy surgical procedures. The long-term rate of patients who undergo these surgeries, including artificial urinary sphincter or urethral sling insertion, is not well described. We examined the long-term rate of post-prostatectomy incontinence surgery and factors influencing it.We performed a population based study of 25,346 men who underwent radical prostatectomy for prostate cancer in Ontario, Canada between 1993 and 2006. We used hospital and cancer registry administrative data to identify patients from this cohort who were later treated with surgery for urinary incontinence.Of the 25,346 patients 703 (2.8%) underwent artificial urinary sphincter insertion and 282 (1.1%) underwent urethral sling placement a median of 2.9 years after prostatectomy. The probability of an artificial urinary sphincter/sling procedure increased with time from prostatectomy. Cumulative 5, 10 and 15-year Kaplan-Meier rates of an artificial urinary sphincter/sling procedure were 2.6% (95% CI 2.4-2.8), 3.8% (95% CI 3.6-4.1) and 4.8% (95% CI 4.4-5.3), respectively. Factors predicting surgery for incontinence were patient age at radical prostatectomy (HR 1.24 per decade, 95% CI 1.11-1.38, p = 0.0002), radiotherapy after surgery (HR 1.61, 95% CI 1.36-1.90, p0.0001) and surgeon volume (49 or greater prostatectomies per year) (HR 0.59, 95% CI 0.46-0.77, p0.0001).Of patients who undergo radical prostatectomy 5% are expected to be treated with surgery for urinary incontinence during a 15-year period. Increasing patient age, radiation treatment and low surgeon volume are associated with significantly higher risk.

Several options exist for the surgical correction of male stress urinary incontinence including periurethral bulking agents, artificial urinary sphincters and the recently introduced male urethral slings. We investigated contemporary trends in the use of these treatments.Annualized case log data for incontinence surgeries from certifying and recertifying urologists were obtained from the ABU (American Board of Urology), ranging from 2004 to 2010. Chi-square tests and logistic regression models were used to evaluate the association between surgeon characteristics (type of certification, annual volume, practice type and practice location) and the use of incontinence procedures.Among the 2,036 nonpediatric case logs examined the number of incontinence treatments reported for certification has steadily increased over time from 1,936 to 3,366 treatments per year from 2004 to 2010 (p = 0.008). Nearly a fifth of urologists reported placing at least 1 sling. The proportion of endoscopic procedures decreased from 80% of all incontinence procedures in 2004 to 60% in 2010, but they remained the exclusive incontinence procedure performed by 49% of urologists. A urologist's increased use of endoscopic treatments was associated with a decreased likelihood of performing a sling procedure (OR 0.5, p0.0005). Artificial urinary sphincter use remained stable, accounting for 12% of procedures.Incontinence procedures are on the rise. Urethral slings have been widely adopted and account for the largest increase among treatment modalities. Endoscopic treatments continue to be commonly performed and may represent overuse in the face of improved techniques. Further research is required to validate these trends.

We report our initial clinical experience with the new 3.5 cm artificial urinary sphincter cuff.We reviewed the records of all men who underwent artificial urinary sphincter placement done by a single surgeon since September 2009. A perineal approach was used to ensure cuff placement around the most proximal corpus spongiosum after precise spongiosal measurement with a redesigned measuring tape. Clinical factors and cuff sizes were analyzed.During the 14-month study period 45 of 67 patients (67%) with an artificial urinary sphincter received the 3.5 cm cuff with no difference between primary and revision surgery (73% vs 58%, p = 0.29). Transcorporal cuff placement was reserved for 8 select patients (12%) after prior artificial urinary sphincter cuff erosion or complex urethroplasty. A tandem cuff artificial urinary sphincter was not used. Erectile dysfunction (89% vs 77%, p = 0.28) and prior radiation (47% vs 27%, p = 0.12) were more common in men who received a 3.5 vs a 4.0 cm or greater cuff. A similar proportion of men with a 3.5 cm vs a larger cuff (4 of 45 or 9% vs 2 of 22 or 9%) required explantation for infection and/or erosion.At our center the 3.5 cm cuff has become the predominant size used for primary and revision artificial urinary sphincter placement. Liberal use of the 3.5 cm cuff has simplified and improved artificial urinary sphincter placement without additional morbidity.

The long-term success and efficacy of the artificial urinary sphincter for the management of neurogenic incontinence have been well documented. We evaluated if long-term results were affected by patient age at the time of sphincter placement.A retrospective review of the medical records of patients who underwent artificial urinary sphincter placement and had minimum of 10 years of followup was conducted. All patients with an intact sphincter were interviewed to assess current results. Patients were stratified into groups 1 and 2 if the sphincter was implanted before or after age 11 years, respectively, and the results were compared statistically.An artificial urinary sphincter was placed in 45 children at Children's Hospital of Michigan between October 1978 and August 1986, and medical records and followup were available for 32. Mean followup was 15.4 years. Of the 21 group 1 patients 12 (57%) have an intact sphincter after 26 revisions, and all are dry and 9 (75%) require intermittent catheterization. Of the 11 group 2 patients 7 (64%) have an intact sphincter, and 6 (86%) are dry, 3 (43%) perform intermittent catheterization and 6 required 8 revisions. There was no statistically significant difference in the number of artificial urinary sphincter removals, continence, revision rate, bladder augmentations, complications or upper tract changes.The artificial urinary sphincter is a successful and durable option for the surgical management of neurogenic incontinence. The long-term results appear independent of patient age at the time of sphincter placement.