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ObjectivesTo identify predictors of early artificial sphincter (AUS) erosion among a cohort of men with erosion, who underwent AUS placement by either university or community-based surgeons.MethodsThe records of all patients with AUS erosions, including men who underwent AUS placement at outside facilities, were retrospectively reviewed. A Cox proportional-hazards model for time to erosion was performed with the predictors being the components of a fragile urethra (history of radiation, prior AUS, prior urethroplasty), androgen deprivation therapy (ADT), trans-corporal (TC), and 3.5 cm cuff, controlling for other risk factors. Kaplan-Meier survival curves and log-rank test compared "fragile" urethras with "not fragile" urethras. All statistical analysis was done using R version 3.5.2.ResultsOf the 156 men included, 36% had undergone AUS placement in the community. Median time to erosion was 16.0 months (1.0-240.0 months), and 122 (78%) met at least one fragility criteria. Radiation (HR 2.36, 95% CI 1.52-3.64) and prior urethroplasty (HR 2.12, 95% CI 1.18-3.80) were independently associated with earlier time to erosion. The Kaplan-Meier estimates demonstrate 1- and 5-year survival rates of 76.5% and 50.0%, respectively, for "non-fragile" and 44.1% and 14.8% for "fragile" urethras (P < .0001).ConclusionIn a diverse cohort of men with AUS erosion, men with "fragile" urethras eroded sooner. Radiation and prior urethroplasty were independent risk factors for earlier time to erosion, but prior AUS, ADT, TC and 3.5 cm cuff were not.

To describe the novel gullwing technique for artificial urinary sphincter (AUS) placement. The transcorporal technique for AUS placement is beneficial in patients with 'fragile urethras' (previous failed AUS, urethroplasty or history of radiation) however limitations include insufficient lateral and ventral urethral support in addition to potential cinching during corporotomy closure which, in the absence of additional grafting may restrict our ability to conserve internal corporal capacity and limit options for future preservation of erectile function via penile prosthesis placement. The gullwing variation of the technique offers the potential to circumvent these disadvantages.This case describes the gullwing variation of transcorporal AUS placement in a complex patient with a history of abdominopelvic trauma and prior failed AUS placements secondary to urethral erosion.Transcorporal AUS placement in patients with prior urethral compromise has been shown to result in lower revision and erosion rates. The gullwing modification of the technique is a novel variation providing improved circumferential urethral protection and, with the addition of corporal grafting, aims to enable the preservation of the three-dimensional corporal volume necessary for ease of subsequent penile prosthesis implantation. However, studies assessing the long-term functional outcomes and durability of this technique are needed.

Male stress urinary incontinence most commonly presents secondary to prostate treatment of prostate cancer or benign prostatic hyperplasia, although it can be seen following trauma or secondary to neurologic dysfunction. Patient selection is supremely important when choosing the appropriate nonoperative or surgical treatment. Although most patients prefer the passive mechanism of adjustable balloon devices or slings, the artificial urinary sphincter provides the most efficacious and durable results with regard to patient satisfaction and continence. Changes in prostate treatment modalities and anti-incontinence device development will offer more surgical options for patients in the future.

Objectives To examine association between post-prostatectomy incontinence (PPI) severity and weight changes before and after restoration of continence via artificial urinary sphincter (AUS). Methods Single surgeon, retrospective review of urologic prosthetic surgery (UPS) after radical prostatectomy (RP). A cohort of post-RP inflatable penile prosthesis (IPP) patients served as a surgical control. Body Mass Index (BMI) and total body weight were assessed pre and post-UPS. Multivariable linear regression was utilized to assess BMI changes post-UPS. Results 187 AUS and 63 IPP patients met selection criteria. Greater PPI severity was associated with faster BMI gain after RP (coeff. 0.14 kg/m2, P = 0.03, per pad used) and magnitude of incontinence improvement (mean reduction in daily pad use) after AUS insertion was associated with greater BMI reduction at 12 months post-UPS (coeff. - 0.13 kg/m2, P = 0.04). On multivariable regression, AUS insertion was associated with a decrease in BMI by - 2.83 kg/m2 12 months post-UPS (P = 0.02). Twelve months post-UPS, men with AUS exhibited a mean BMI reduction of -1.0 kg/m2 compared to a mean BMI increase in the IPP cohort of 0.4 kg/m2 (P 5% body weight) at 12 months post-UPS (31.8% vs 8.3%, P Conclusion Severe PPI appears to be associated with weight gain and correction of PPI via AUS insertion with weight loss.

To characterize the safety and practice patterns of artificial urinary sphincter (AUS) placement on a population level. Increasingly AUS implantation has shifted to be an outpatient surgery; however, there is a lack of large-scale research evaluating factors associated with early (≤ 24 hours) versus late (24 hours) discharges and complications in men following AUS placement. We utilized the National Surgical Quality Improvement Program (NSQIP) database to identify and compare factors and outcomes associated with each approach.NSQIP database was queried for men undergoing AUS placement between 2007 and 2016. Patients were classified as either early discharge (ED ≤ 24 hours) and late discharge (LD24 hours). Baseline demographics, operating time, and complications were compared between the 2 groups. Multivariate logistic regression evaluated factors associated with discharge timing and 30-day complications.A total of 1176 patients were identified and were classified as ED in 232 and LD in 944 patients. Operative time was shorter in ED (83 minutes) compared to LD (95 minutes, P.001). Hypertension was more prevalent among LD patients (60.3% vs 69.1% for ED and LD respectively, P.001). The 30-day complication rate was similar in both groups (ED: 4.3% vs LD: 3.4%, P = .498). Multivariable analysis revealed that surgery after 2012 was associated with ED (OR = 3.66, P.001).At the national level, there are no differences in postoperative morbidity between early and late discharges. There is a trend toward more ED, specifically after 2012. A prospective study on the feasibility and safety of outpatient AUS is needed.

To assess whether a focused, simulation training course can improve trainee surgical knowledge and confidence in the treatment of male stress urinary incontinence.Urology residents participated in a prosthetic education course as part of the 2018 SUPS and SMSNA annual meeting. The course included didactic lectures and a hands-on cadaveric laboratory. Participants completed questionnaires before and after the lab (2 weeks and 6 months) to assess procedural knowledge and confidence. Analysis of lab responses was performed using the Wilcoxon signed rank test for matched pairs.Thirty-two residents (median age 29, range 27-34) participated in the course. The majority were postgraduate year 4 (63%) or postgraduate year 5 (20%). Most participants reported minimal AUS or sling experience with 50% and 94% reporting less than 5 cases, respectively. Overall score from the knowledge assessment improved significantly between the pre-lab versus 2-week post-lab (P = .02) and pre-lab versus 6-month post-lab (P = .01). Similarly, procedural confidence improved between pre-lab vs 2-week post-lab (P.001) and pre-lab versus 6-month post-lab (P.001). Knowledge and confidence assessments were not different between year of residency training or pre-lab experience.Simulation training improves knowledge and confidence in prosthetic surgery for male stress incontinence. In the current climate of reduced exposure and limited availability of prosthetic educators, simulation courses can provide much needed educational value.

Objectives To determine the role of slings and artificial urinary sphincters (AUS) in the management of mild and moderate stress urinary incontinence (SUI). Methods A retrospective review of our single-surgeon male SUI database was completed. Men having AUS or AdVance sling procedures between 2008 and 2019 were included in the analysis. Those with severe incontinence and/or incomplete pre- or postoperative data were excluded. All patients were evaluated by standing cough test and stratified according to the Male Stress Incontinence Grading Scale. Scores of 0-1 and 2-3 defined mild and moderate SUI, respectively. We performed 2 analyses: (a) sling outcomes were compared between mild vs moderate SUI patients, and (b) for men with moderate SUI, we compared outcomes between slings and AUS. Treatment failure was defined as >1 pad per day or need for subsequent incontinence procedure. Results Among 202 sling cases, those with mild SUI had significantly higher success rate (69/88, 78%) than those with moderate SUI (72/114, 63%; P = .02). Among the 179 men with moderate SUI, those who underwent AUS had significantly higher success rate (52/65, 80%) than those who underwent sling (72/114, 63%; P = .02). Conclusion Male slings are more effective for men with mild SUI than for men with moderate SUI. Men with moderate SUI have a higher success rate with AUS than with sling.

International audience; Analyzing concurrently data from the manufacturer and from a national comprehensive administrative claim database (PMSI)we found that, overall, the total number of AUS implanted (male+female) increased from 2012 to 2017 (+8.8%). This growth was driven by a strong increase in the number of female implants from 2015 to 2017 (+28.9%). Meanwhile, the number of AUS implanted in male patients remained roughly stable and the total number of anti-incontinence surgery in men (slings+AUS) decreased steadily over the period studied.

Objective To analyze functional outcomes and complication rates of distal double cuffs (DC) or transcorporal cuffs (TC) as salvage approaches in high-risk patients, since there is an ongoing debate about optimal cuff-placement in a salvage setting (SV). Existing studies analyzing DC or TC are controversial with respect to functional outcomes and complication rates. Studies directly comparing both approaches in SV are scarce. Methods and Patients Prospective data collection was performed since 2009. DC/TC were applied according to a standardized protocol in SV. Salvage DC was chosen in case of a membranous single cuff explantation due to erosion or infection. TC were implanted after bulbar urethroplasty or DC explantation. Activation was performed 6 weeks postoperatively. Further follow-up was scheduled 6/24 months postoperatively and every 2 years thereafter. Primary/secondary endpoints were continence/complication rates. Results In total, 71 high-risk patients were available for analysis (58 DC, 13 TC). Median age was 70 years. Median follow-up was 24 months. Objective/social continence were 88%/94% in the DC and 72%/100% in the TC cohort, respectively (P = .37/P = 1). Overall, there were no significant differences with respect to infections, erosions, mechanical failure, and explantation rates. The times of explantation-free survival were similar in Kaplan-Meier analysis (Log-rank 0.399). Conclusion Complication and continence rates were not significantly different between both cohorts. Hence, a DC in SV can be considered as equally safe and effective. A sequential implantation (first DC, second TC) may be a viable approach to extend overall AUS incontinence therapy.

Background Up to 50% of patients receiving an artificial urinary sphincter (AUS) require surgical revision after initial placement. However, the literature is heterogeneous regarding the leading causes of AUS failure and appropriate surgical management. Objective To inform a revision approach by tabulating the causes of AUS failure, assessing AUS component survival, and examining the single-component revision efficacy. Design, setting, and participants We retrospectively reviewed 168 patients receiving AUS placements carried out by a single surgeon from 2008 to 2016 at a high-volume academic institution. The median follow-up from initial placement was 2.7 yr, with 37.5% experiencing recurrent incontinence. The cuff size ranged from 4.0 to 5.5cm, with median size of 4.5cm. Intervention Patients without infection or erosion underwent systematic device interrogation and revision, starting with the pressure-regulating balloon (PRB) and then, if necessary, the urethral cuff. Device revision involved either PRB-only correction or cuff and PRB revision. Outcome measurements and statistical analysis We used bootstrapped intervals to estimate the mean time to failure for individual AUS components. Kaplan-Meier estimates were used to compare survival for individual components and for revised devices by revision technique. Results and limitations PRB malfunction most commonly caused device failure, while cuff or pump malfunction was rare. Among patients undergoing surgical revision, those with PRB-only correction had similar outcomes to those with more extensive device correction (cuff and PRB exchange; p =0.46). This study, while systematic and detailed, is limited by sample size, follow-up length, and its retrospective nature. Conclusions PRB malfunction most commonly caused AUS failure in our cohort. PRB-only correction may satisfactorily restore AUS function in select patients. Consequently, initial interrogation of the PRB may avoid a second incision and urethral exposure for many patients requiring AUS revision. Patient summary Artificial urinary sphincters remain prone to failure over time. In many instances, correcting only the pressure-regulating balloon may effectively restore device function, allowing for a less invasive revision.

Objectives To determine the impact of radical cystectomy and orthotopic neobladder (NB) diversion on device-related outcomes in patients who undergo subsequent placement of both, an artificial urinary sphincter (AUS) and 3-piece inflatable penile prosthesis. Materials and Methods Using an institutional prosthetic database, we identified 39 patients who underwent radical cystectomy and NB and subsequent implantation of both prosthetic devices from 2003 to 2017. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection, mechanical failure, revision surgery, and functional outcomes were examined and compared to an appropriate matched group of patients (n = 48, non-neobladder group). Results No intraoperative complications were observed. After median follow-up of 94 months (12-177 months), 1 patient developed an infection of their penile prosthesis and 4 patients developed an erosion of their AUS. In each case, the infection did not involve the other device. Two patients required revision surgery of their penile prosthesis due to mechanical failure (reservoir leak, n = 1; cylinder aneurysm, n = 1). Twenty-one patients underwent elective revision surgery to improve continence (cuff downsizing, n = 18; pressure-regulating balloon exchange, n = 3). There were 6 cases of AUS mechanical failure. No reservoir-related complications such as herniation or erosion were observed. Compared to the control group of non-neobladder patients, there were no significant differences in prosthetic infection, mechanical failure, and revision surgery. Conclusion The AUS and 3-piece inflatable penile prosthesis can coexist safely in patients with NB without an increased risk of device-related complications.

To assess the efficacy of exchanging the pressure regulating balloon (PRB) to 71-80 cm HPatients with SUI following AUS placement who underwent PRB replacement between 2011 and 2017 in the absence of urethral cuff malfunction, atrophy, stricture, or erosion were reviewed. Primary outcomes included changes in pad per day (PPD), Incontinence Symptom Index score, and Incontinence Quality of Life (I-QOL). Secondary outcomes included rates of device erosion and all-cause explant or revision. Differences were compared between patients with and without erosion, explant, or revision. Kaplan Meier device survival analysis was performed.Twenty two patients (67 ± 9 years, body mass index of 30 ± 5 kg/mPRB exchange can transiently alleviate persistent or recurrent post-AUS SUI in the absence of mechanical failure or urethral pathology. Caution is warranted in patients with prior radiation as this was a risk factor for urethral erosion. Although many patients may require device revision within 2 years, it can be a temporizing solution that avoids urethral manipulation and periprocedural device deactivation.

Objectives To report the prevalence of low serum testosterone (LST) in men undergoing artificial urinary sphincter (AUS) placement at a single high-volume institution. Methods We retrospectively reviewed all men undergoing AUS procedures by a single surgeon from January 2015 to January 2018 to identify men with pretreatment total serum testosterone levels. LST was defined as less than 280 ng/dL. Patients with only posttreatment testosterone levels were excluded. Demographic characteristics and clinical outcomes were compared between men with and without LST. Results Among 113 patients who underwent AUS with pretreatment serum testosterone levels drawn an average of 2.2 months before AUS surgery, 45.1% (51 of 113) met criteria for LST, including 18 patients on androgen deprivation therapy. The rate of primary LST was 34.7% (33 of 95). The median total serum testosterone level among men with LST was 118 ng/dL (interquartile range 6-211), and 413 mg/dL (interquartile range 333-550) in the normal serum testosterone group. There were no differences in patient age, history of radiation, erectile dysfunction, or other comorbidities between the groups. Body mass index was higher in the LST group compared to normal serum testosterone (30 vs 27 kg/m2, P = .001). Cuff size and rates of transcorporal cuff placement were similar between groups. Conclusion Nearly one-half of men with stress urinary incontinence undergoing AUS placement present with LST. While AUS cuff erosion appears to be more common in men with LST, further study is needed to determine if treating LST will reduce cuff erosion rates.

Objective To describe the dramatic and rapid unmasking of urinary-pubic symphysis fistula (UPF) and chronic osteomyelitis after artificial urinary sphincter (AUS) implantation. This has never been reported as UPF is usually an insidious sequelae of radiotherapy or energy ablation for prostate cancer. Methods We prospectively identified men who underwent rapid clinical decline due to UPF soon after AUS implantation at our institution in the previous 24 months. Chart and imaging was reviewed to assess preoperative and postoperative factors. Results Three patients were identified. All men had undergone radiation therapy for prostate cancer and all had undergone prior manipulation of the posterior urethra for complications of radiotherapy. Radiation cystitis was present and all had a low cystometric bladder capacity before surgery. All patients declined rapidly after surgery. UPF was diagnosed in 2 men after activation of AUS at 6-7 weeks postoperatively and 1 patient presented before activation at 3 weeks postoperatively. UPF tract was demonstrated with magnetic resonance imaging in the acute phase in all 3 cases. Two patients have undergone cystectomy and loop diversion with resolution of symptoms and one patient is awaiting definitive surgery. Conclusion Unmasking of occult UPF resulted in rapid clinical decline after AUS implantation. Increased intravesical filling pressure from increased urethral resistance likely resulted in opening of occult fistula tracts. UPF should be in the differential diagnosis if there is history of radiotherapy or urethral instrumentation. An underlying and undiagnosed UPF may lead to grave consequences after AUS implantation.

Objective To characterize the risk of delayed infectious complications from retained pressure-regulating balloons (PRBs) after artificial urinary sphincter (AUS) cuff erosion. Methods From our database of 530 AUS cases between 2007 and 2016, we identified 40 total AUS cuff erosions. Twenty-four (60%) presented without evidence of gross device infection and underwent explant of cuff and pump without removal of the PRB. Space of Retzius (SoR) and high submuscular (HSM) balloon locations were analyzed to assess for ease of removal. Presenting clinical features and retained balloon-related outcomes are reported. Results Of the 24 AUS cuff erosions with retained balloons, 6 (25%) men subsequently required PRB removal for infection during the median follow-up of 36 months (interquartile range 29-53). The median time to balloon infection after AUS erosion surgery was 4 months (interquartile range 4-16). Infection risk was reduced in those without concurrent inflatable penile prosthesis (20%) and in those who underwent “drain and retain” of the PRB (13%). The most common presenting clinical symptoms with retained PRB infection were pain and erythema near the site of the PRB (83%). No patient developed sepsis-related complications. The location of the PRB in this subcohort included 2 SoR and 4 HSM placements. The median operative time for balloon removal in the SoR was 3.5 times greater than that for HSM PRBs (133 minutes vs 38 minutes). Conclusion With extended follow-up, three-quarters of the men with retained PRBs after AUS cuff erosion experienced no infectious complications. Removal of infected SoR PRBs was associated with greater operative times and surgical complexity relative to HSM PRBs.

Summary Objectives To report our experience of inflating or changing pressure balloon to treat recurrent urinary incontinence after AMS800 ® implantation instead of changing all the devices. Patients and methods A retrospective study was conducted in a tertiary reference center between 2005 and 2015. All patients, treated by AMS800 ® implantation for post-prostatectomy urinary incontinence and whom balloon was subsequently changed or inflated, were included. Main clinical end point was the need for another surgery. Secondary end points were urethral erosion, infection, and efficacy on pad test and pad use. Results Thirty-one patients were included. All had had a 61–70 cm H 2 0 balloon implanted, with a single cuff (13 with transcorporeal placement). Twenty-one patients had their balloon changed for a 71–80 cm H 2 0 type, while 10 patients had their balloon refilled (median 3 mL [range 2–7]). Median follow-up was 23 months (range 1–129). Overall rate of another subsequent surgery was 48.3% ( n = 15). Erosion and atrophy occurred more frequently after balloon repressurizing than after balloon replacement (80% vs 33%, P = 0.024). At last follow-up, median pad use was higher in repressurizing group (2 vs 1, P = 0.033). Conclusion Balloon repressurizing is associated with a higher erosion and reoperation rate than changing pressure balloon. Continence results seem better when PRB is changed. It could be an alternative instead of changing all devices in patients with frail urethra. Level of evidence 4.

Objective To determine the trend in surgical management of male stress urinary incontinence (SUI) in the context of the rate of radical prostatectomy (RP) as reported by a national database. Traditionally, the artificial urinary sphincter (AUS) has been the gold standard, but the male sling represents a newer and popular alternative. Refinements in prostate surgery may reduce the incidence and degree of subsequent SUI. Materials and Methods A retrospective cross-sectional analysis was performed using the National Inpatient Survey database, which captures discharge data from inpatient and overnight admissions. Cases were identified by their International Classification of Diseases, Ninth Revision procedure codes. We queried the codes 58.93 (implantation of AUS), 59.4 (suprapubic sling operation), 59.5 (retropubic urethral suspension), and 59.6 (paraurethral suspension). We also queried 60.5 (RP) for comparison. Data were collected from January 2000 to December 2012 and weighted to a national average using National Inpatient Survey guidelines. Results A total of 32,416 anti-incontinence operations (20,790 AUS and 11,625 sling procedures) were performed over the study period. There was a significant downward trend in the total number of incontinence procedures (F(1,11) = 6.15, P = .03). However, when stratifying the data by procedure type, only AUS placement demonstrated a significant decline (F(1,11) = 21.70, P P .01). There was no significant change in the annual incidence of RP. Conclusion Inpatient surgery for male SUI is decreasing overall. Placement of the AUS declined significantly, whereas sling placement became more common. Future study will determine the etiology of these trends.

Context Radical prostatectomy is the most common reason for male stress urinary incontinence. There is still insecurity about its therapeutic management. Objective To evaluate current evidence regarding therapy of postprostatectomy incontinence (PPI). Evidence acquisition In October 2017, a nonsystematic review of the literature published within the last 2 yr was performed using the PubMed/Medline database. In total, 58 articles were included in the current analysis. Evidence synthesis Regarding invasive management of moderate-to-severe PPI, artificial urinary sphincter (AUS) is still the treatment of choice. Recent studies focused on efficacy, but also a plethora of potential predictive features for treatment success has been investigated. Owing to inconsistent results, there still is no consensus about valid risk factors of AUS treatment success to date. There are increasing efficacy data about the use of adjustable slings, and long-term follow-up results are now available for the AdVanceXP male sling. Evidence addressing the use of the quadratic Virtue male sling needs further evaluation. To date, there is no randomized controlled trial investigating the outcome of one specific surgical treatment or comparing the outcome of different surgical treatment options. Limitations include the nonsystematic approach. Conclusions Level of evidence addressing the surgical management of PPI is increasing but still unsatisfying. Patient summary In this review article, we look at current research regarding surgical management of stress urinary incontinence following radical prostatectomy. Many studies focus on how to predict treatment failure and outcomes after artificial urinary sphincter implantation. In addition, more information on the long-term results after male sling implantation is now available.

Objective To evaluate the success of urethroplasty for urethral strictures arising after erosion of an artificial urinary sphincter (AUS) and rates of subsequent AUS replacement. Patients and Methods From 2009-2016, we identified patients from the Trauma and Urologic Reconstruction Network of Surgeons and several other centers. We included patients with urethral strictures arising from AUS erosion undergoing urethroplasty with or without subsequent AUS replacement. We retrospectively reviewed patient demographics, history, stricture characteristics, and outcomes. Variables in patients with and without complications after AUS replacement were compared using chi-square test, independent samples t test, and Mann-Whitney U test when appropriate. Results Thirty-one men were identified with the inclusion criteria. Radical prostatectomy was the etiology of incontinence in 87% of the patients, and 29% had radiation therapy. Anastomotic (28) and buccal graft substitution (3) urethroplasty were performed. Follow-up cystoscopy was done in 28 patients (median 4.5 months, interquartile range [IQR]: 3-8) showing no urethral stricture recurrences. Median overall follow-up was 22.0 months (IQR: 15-38). In 27 men (87%), AUS was replaced at median of 6.0 months (IQR: 4-7) after urethroplasty. In 25 patients with >3 months of follow-up after AUS replacement, urethral complications requiring AUS revision or removal occurred in 9 patients (36%) and included subcuff atrophy (3) and erosion (6). Mean length of stricture was higher in patients who developed a complication after urethroplasty and AUS replacement (2.2 vs. 1.5 cm, P = .04). Conclusion In patients with urethral stricture after AUS erosion, urethroplasty is successful. However, AUS replacement after urethroplasty has a high erosion rate even in the short-term.

Objective To report our experience with permanent urethral ligation for severe incontinence among men with end-stage urethra. Materials and Methods From our institutional artificial urinary sphincter database of 512 patients from 2010 to 2016, 10 men underwent permanent urethral ligation with concurrent suprapubic tube diversion following recurrent artificial urinary sphincter cuff erosion. Clinical characteristics and outcomes were evaluated. Quality of life was assessed using the Michigan Incontinence Symptom Index and the Patient Global Index of Improvement. Results Urethral ligation resulted in resolution of incontinence in 8 men (80%), including 7 (70%) after 1 surgery and in 1 (10%) after a single revision. The average American Society of Anesthesiologists physical status rating was 2.7 (range 2-3). Seven patients (70%) experienced postoperative complications (4 Clavien-Dindo grade II complications [1 Clostridium difficile infection, 3 refractory bladder spasms) and 5 grade III complications (2 abscesses, 2 urethrocutaneous fistula, and 1 bladder stone formation]). Overall, satisfactory Michigan Incontinence Symptom Index urinary scores were reported in 8 (80%) men. On the Patient Global Index of Improvement, 6 (60%) men reported improvement in overall condition following surgery. All men (10/10) stated that they would recommend this procedure to others. Conclusion For debilitated men with end-stage urethra and severe refractory stress urinary incontinence, permanent urethral ligation with chronic suprapubic tube drainage can restore continence and improve quality of life without the need for more invasive formal urinary diversion, though with a high risk of complication.

Objective To evaluate the influence of both repair type and degree of cuff erosion on postoperative urethral stricture rate. Sparse literature exists regarding patient outcomes after artificial urinary sphincter (AUS) cuff erosion. Surgeons from 6 high-volume male continence centers compiled a comprehensive database of post-erosion patients to examine outcomes. Materials and Methods This retrospective multi-institution study included 80 patients treated for AUS cuff erosions. Seventy-eight patients had specific information regarding post-cuff erosion urethral strictures. Erosion patients were categorized into 1 of 3 repair types at the time of explant surgery: catheter only, single-layer capsule-to-capsule repair (urethrorrhaphy), and formal urethroplasty. Operative notes and available medical records were extensively reviewed to collect study data. Results Twenty-five of 78 patients manifested a urethral stricture after AUS cuff erosion (32%). More strictures occurred among patients who underwent urethrorrhaphy (40% vs 29% for catheter only and 14% for urethroplasty). Stricture rates did not vary significantly by repair type ( P = .2). Strictures occurred significantly more frequently in patients with complete cuff erosions (58%) as compared to partial erosions (25%, P = .037). A trend was detected regarding increased percentage of erosion correlating with increased stricture rate, but this did not reach statistical significance ( P = .057). Partially eroded patients were more likely to undergo urethrorrhaphy repair (60%, P = .002). Conclusion Urethral stricture was more likely to occur after complete cuff erosion as opposed to partial erosion in this multicenter retrospective population. Repair type, whether catheter only, urethrorrhaphy, or formal urethroplasty, did not appear to influence postoperative stricture rate.

To analyze a series of clinical risk factors associated with pretreatment urethral atrophy.We retrospectively reviewed 301 patients who underwent artificial urinary sphincter (AUS) placement between September 2009 and November 2015; of these, 60 (19.9%) transcorporal cuff patients were excluded. Patients were stratified into 2 groups based on intraoperative spongiosal circumference measurements. Men with urethral atrophy (3.5 cm cuff size) were compared to controls (≥4 cm cuff size). Chi-square test, Mann-Whitney U test, and logistic regression analyses were performed to determine risk factors for urethral atrophy.Among 241 AUS patients analyzed, urethral atrophy was present in 151 patients (62.7%) compared to 90 patients (37.3%) who received larger cuffs (range 4-5.5 cm). Patients with urethral atrophy were older (71.1years vs 68.3 years; P .02), more likely to have received radiation (52.9% vs. 33.3%; P .007), and had a longer time interval between prostate cancer treatment and AUS surgery (8.9 years vs. 6.6 years; P .033). On multivariable analysis, radiation therapy was independently associated with risk of urethral atrophy (odds ratio 1.77, 95% confidence interval: 1.01-3.13; P = .046), whereas greater time between cancer therapy and incontinence surgery approached clinical significance (odds ratio 1.05, 95% confidence interval 1.00-1.09; P = .05).History of radiation therapy and increasing length of time from prostate cancer treatment are associated with urethral atrophy before AUS placement.

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

Despite the emergence of different devices in the treatment of postprostatectomy urinary incontinence, the AMS 800 (American Medical Systems, Minnetonka, MN) remains the gold standard for the treatment of stress urinary incontinence in men. We reviewed the current literature regarding the indications, surgical principles, outcomes, and complications of artificial urinary sphincter placement for stress urinary incontinence after prostatectomy. Despite all the available information, heterogeneous data, different success definitions, and the lack of high-quality prospective studies with long-term follow-up, it is difficult to compare outcomes between studies. In spite of these, the perineal implantation of a single cuff artificial urinary sphincter has withstood the test of time.

Several devices exist for treating postprostatectomy incontinence. In specific cases, male slings can offer good results instead of an artificial urinary sphincter. This short consultation guide aims to help in offering the right surgery to the right patient.

Objective To compare the results of various single-component artificial urinary sphincter (AUS) revision techniques for continued/recurrent stress urinary incontinence (SUI). Although AUS placement for male SUI has a high rate of success, revisions may be performed for mechanical failure of an isolated component or continued/recurrent SUI. Materials and Methods From 1993 to 2012, 90 AUS revisions including urethral cuff downsizing (19), pressure-regulating balloon replacement (18), cuff repositioning (11), or tandem cuff placement (42) were performed at 2 institutions. End points included reoperation, incontinence failure, and urethral erosion. The Kruskal-Wallis test was used to compare continuous variables, and the log-rank test was used to compare Kaplan-Meier curves. Results Mean age was 70.2 years, and median follow-up was 33.6 months. Median time to revision was 28.9 months. Tandem cuff placement was associated with a lower rate of incontinence failure (P = .02), whereas cuff repositioning was associated with a higher rate of incontinence failure (P = .02). An increased rate of mechanical failure was observed with cuff downsizing (P = .01). Among options for revision (1) cuff downsizing is associated with a higher rate of mechanical failure, and (2) cuff repositioning with the same size is associated with a higher rate of incontinence failure, whereas (3) tandem cuff placement is associated with a lower rate of recurrent SUI compared to other types of AUS revision. Conclusion Cuff repositioning is associated with an increased rate of persistent incontinence after AUS revision whereas tandem cuff placement is associated with a lower rate of recurrent or persistent incontinence.

Objective To review our experience with artificial urinary sphincter (AUS) and to consider the role of nonsurgical management of sterile AUS cuff erosion. Methods We retrospectively reviewed our 10-year experience with AUS implantation, including complication rates. We focus on the outcomes of eroded sphincters including 2 unique patients who were managed nonsurgically for sterile cuff erosion. Results Between 2002 and 2012, 126 AUS units were implanted in 79 adult male patients by single surgeon (A.K.S.). Twenty-five patients (31.6%) required at least 1 additional procedure because of urethral atrophy (22.8%) or erosion or infection (8.9%). In addition, 2 patients with congenital anomalies underwent AUS implantation at bladder neck and were followed up nonsurgically for several years after cuff erosion. Both refused surgical management and have since remained continent and infection-free despite chronic erosion for 15 years' duration in 1 patient and for 5 years' duration in the other. Of note, the patient with the longer duration of erosion developed bladder stones requiring surgical removal. Conclusion Our AUS complication rates are consistent with those of prior series. Our unique experience with 2 patients suggests that immediate removal of AUS after sterile cuff erosion may occasionally be instituted only in difficult cases where repeat AUS implantation is not possible. To our knowledge, this is the first report of nonsurgical management of eroded AUS cuff in the literature. Larger prospective series concerning patient selection for salvaging eroded AUS may be warranted.

Objective To investigate the feasibility, safety, and functional results of robotic-assisted artificial urinary sphincter (R-AUS) laparoscopic implantation in women with stress urinary incontinence due to intrinsic sphincter deficiency. Patients and Methods Six women underwent an R-AUS implantation between 2012 and 2013. The mean age was 65 ± 9.6 years. Five patients had previous surgery for incontinence. The mean duration of follow-up was 14.3 months. A transperitoneal approach with a lateral positioning of the robotic arms was performed. The cuff implantation, positioning of the reservoir, and the pump were carried out similarly to the laparoscopic technique. Operative time, intraoperative occurrence of injuries of the bladder or vagina, postoperative complications, and continence (pad per day) were assessed. Results The R-AUS implantation was feasible in all cases without intraoperative injury and 1 grade 1 postoperative complication. Mean operative time, postoperative bladder catheterization, and hospitalization time were 210 ± 32 minutes, 7 days, and 6 days, respectively. At the end of the follow-up, 83% of cases were fully continent. Conclusion R-AUS implantation in incontinent women with intrinsic sphincter deficiency was feasible and safe with good functional results. More data are needed before concluding to the superiority of this new technique compared with open or laparoscopic approaches.

Objective To present our experience with 2-stage management for recalcitrant refractory bladder neck contracture (BNC) after radical prostatectomy. Methods A 15-year retrospective medical record review was performed for patients referred for BNC using current procedural terminology code or by International Classification of Diseases - Ninth Revision code for bladder neck incision (BNI). Treatment consisted of deep cold-knife BNI, followed by cystoscopy at 3-4 months. If stable and healed, an artificial urethral sphincter (AUS) or male sling was placed depending on continence level. Recurrent BNC at 3 months was treated with a second BNI. Results Sixty-three patients were referred with median (range) age of 66 (41-82) years, body mass index 30.1 (21.9-64.8) kg/m2, and follow-up of 11 (1-144) months. Seventeen (27%) underwent adjuvant radiation therapy. Of the 46 who had successful management of the BNC, 91.3% were satisfied with level of continence after BNI alone or with a single additional operation. Of the 33 who underwent AUS or sling, only 2 failures occurred: 1 ultimately required cystectomy after multiple urethral erosions, and 1 with mild incontinence was satisfied with a secondary sling procedure. Four patients progressed to permanent urinary diversion. Together, either BNI (n = 4) or the secondary incontinence procedure (n = 1) was not successful in a total of 5 patients and required permanent urinary diversion. Nine had concurrent severe membranous strictures with no coaptation of the external urethral sphincter and were treated with direct vision internal urethrotomy and AUS and were continent. Conclusion This represents the largest known experience with BNC after radical prostatectomy. Patients can be managed with cold-knife incision, followed by AUS or sling, with 66% achieving continence.

Objective To evaluate our 5-year experience with deep lateral transurethral incisions of bladder neck contracture (TUIBNC), identify risk factors associated with failure of procedure, and assess outcomes of men subsequently treated for concomitant or de novo stress urinary incontinence (SUI). Materials and Methods We reviewed 50 consecutive patients who underwent TUIBNC between June 2007 and January 2012. TUIBNC was standardized to include initial dilation followed by deep transurethral incisions. All patients were evaluated cystoscopically after a 2-month interval; those with recurrent bladder neck contracture (RBNC) underwent a second TUIBNC. For patients with concomitant SUI, we assessed the timing between TUIBNC and subsequent artificial urinary sphincter (AUS) placement and its outcome. Perioperative characteristics were reviewed to identify factors associated with failure. Results Of the 50 patients analyzed, most were refractory, 78% having failed previous TUIBNC. After TUIBNC, 72% required no further surgery for obstruction at a mean follow-up of 12.9 months. Of the 14 who failed initial TUIBNC, 7 underwent repeat TUIBNC with success, representing an overall success rate of 86% after 2 procedures. Significant factors associated with treatment failure were >10 pack/year smoking history (P = .039) and ≥2 previous endoscopic BNC procedures (P = .03). Of 39 men (78%) with concomitant SUI, two-thirds underwent AUS placement after an average of 2.9 months after TUIBNC. Only 2 of 26 (8%) patients required repeat transurethral procedures after AUS placement for RBNC. Conclusion Deep lateral TUIBNC alone is a highly effective treatment modality for RBNC. Smokers and those having 2 or more previous transurethral procedures appear to have greater risk for failure. Subsequent AUS placement can be safely performed with >90% long-term urethral patency.

To evaluate the relative risk of prolonged urethral catheterization (PC),48 hours, on artificial urinary sphincter (AUS) cuff erosion in a tertiary referral population.All men who had undergone AUS implantation or revision by multiple surgeons at our institution from 2000 to 2010 with ≥6 months of follow-up were reviewed for urethral erosion, catheterization after AUS placement, and comorbid conditions.Of the 258 AUS patients reviewed, 200 met the inclusion criteria, with an average follow-up of 24 months. AUS cuff erosions were noted in 24 men (12%) and were diagnosed at a mean of 16.9 months (range 0.8-87.1). PC was identified in 44 of the 200 men (22%)-of these men, erosions occurred in 17 (39%, P .001). The indication for PC was most often major nongenitourinary surgery (36%) or urinary retention (32%). Univariate analysis identified an increased risk of erosion associated with hypertension, diabetes, coronary artery disease, PC, previous radiotherapy, and secondary AUS placement (P .05). On multivariate analysis, only PC, radiotherapy, and revision surgery were significant (P .05), but cuff size and concomitant inflatable penile prosthesis were not associated with AUS cuff erosion.PC is an independent risk factor for AUS cuff erosion.

Objective Patients with persistent and/or recurrent stress urinary incontinence (SUI) after multiple artificial urinary sphincter (AUS) revisions for erosion and infection represent a very challenging treatment population. Available management options are limited, with poor overall outcomes. We assess another treatment option. Methods A retrospective analysis was performed of 8 patients presenting with severe, recurrent incontinence after multiple prior failed AUS procedures. All patients were treated with small intestinal submucosa (SIS) "urethral wrap" with subsequent AUS cuff placement to provide additional urethral bulk and serve as a "buffer" between the cuff and urethra. Results Eight patients (median age 76 years, range 55-81) presented with near-total (4-5 pads) to total urinary incontinence, having previously undergone a combined 19 AUS procedures with 6 tandem cuffs and 8 prior urethral erosions. At a median follow-up of 12.4 months, 38% (3/8) of patients were dry, requiring no pads. Three patients underwent AUS explantation for sphincter erosion (n = 2) and infection (n = 1). Two patients had recurrent incontinence, with one occurring after wrap revision for urinary retention. Patients with prior radiation accounted for 80% (4/5) of procedure failures. All patients had temporary postoperative urinary retention. Conclusion SIS urethral wrap with AUS placement for severe SUI after multiple previous AUS placements and erosion/infection is a viable treatment option in appropriately selected patients for this very complicated issue. However, because of the complexity of the underlying problem, patients should be counseled about the expected risks and outcomes of surgery.

Background The artificial urinary sphincter (AUS) is a well-established treatment for male stress urinary incontinence. Objective We aimed to characterize the surgical learning curve for reoperation rates after AUS implantation. Design, setting, and participants The study cohort consisted of 65 602 adult males who received an AUS between 1988 and 2008, constituting close to 90% of all operations conducted during that time. Data on reoperations were obtained from the manufacturer, which requires documentation for warranty coverage. Measurements Surgeon experience was calculated as the number of original AUS implants performed prior to the index patient's surgery. Multivariable logistic regression models were used to examine the association between experience and reoperative rates, adjusted for case mix. Results and limitations There was a slow but steady decrease in reoperative rates with increasing surgeon experience ( p =0.020), showing no plateau through 200 procedures. The risk of reoperation for a surgeon with five prior cases was 24.0%, which decreased to 18.1% for a surgeon with 100 prior implants (absolute risk difference [ARD]: 5.9%; 95% confidence interval [CI], 1.3–10.1%) and to 13.2% for a surgeon with 200 prior implants (ARD: 10.7%; 95% CI, 2.6–16.6%). Two-thirds of contemporary patients (having AUS procedure between years 2000 and 2008) saw a surgeon who had done ≤25 prior AUS implants; only 9% saw a surgeon with ≥100 prior procedures. Conclusions The learning curve for AUS surgery appears to be very long and without an obvious plateau. This is in contrast to typical surgeon experience, suggesting a considerable burden of avoidable reoperations. Efforts to flatten the learning are urgently needed.

Context: In recent years, despite improvement in the surgical technique, the prevalence of postprostatectomy incontinence has increased due to a rise in the number of radical prostatectomies performed annually. Objective: The aim of this review is to evaluate contemporary noninvasive and invasive treatment options for postprostatectomy incontinence. Evidence acquisition: In August 2010, a review of the literature was performed using the Medline database. Evidence synthesis: All articles concerning noninvasive and invasive treatment for postprostatectomy incontinence were included. Conclusions: No randomised controlled trials exist to compare currently used noninvasive and invasive treatments for postprostatectomy incontinence. Pelvic floor muscle training is recommended for the initial treatment of stress urinary incontinence (SUI). Additionally, antimuscarinic therapy should be applied for urgency or urge incontinence. For decades, the artificial urinary sphincter was the reference standard for persistent SUI. Nowadays, male slings are an alternative for men with mild to moderate postprostatectomy SUI.

The female urethra is relatively short compared with its male counterpart and is generally between 2 and 4 cm in length. It is made up of an inner layer of mucosal epithelium with numerous infoldings that create an effective seal against the passive loss of urine. Beneath the mucosa lies a rich, vascular network of elastic tissue that is much like the corpus spongiosum. Surrounding the spongy vascular tube is a collagen-rich fibromuscular envelope comprising the periurethral fascia. These three components of a normal urethra are crucial in maintaining continence and enabling dynamic function during increases in abdominal pressure and during normal micturition. Two fascial attachments suport the urethra: the pubourethral and urethropelvic ligaments. The pubourethral ligaments are a band of fascial support located superiorly between the urethra and pubic symphysis. These ligaments often serve as a point of anatomic division between the proximal and distal urethra. The urethropelvic ligaments are comprised of two layers of fascial condensation, the endopelvic fascia and the pubocervical fascia, whichprovide lateral attachment to the arcus tendineus. Themidurethra is believed to be the center of continence where the striated sphincter complex maintains active and passive tone. A basic understanding of female urethral anatomy is necessary to approach urethral reconstruction from an anatomic standpoint. This article reviews the techniques of female urethral reconstruction based on these anatomic divisions: proximal and bladder neck, midurethra, and distal urethra.

Since its introduction in 1973 (American Medical Systems [AMS] model 721), the artificial urinary sphincter (AUS) has become a widely accepted therapy, particularly for male urinary incontinence. Over the years, improvements in product design, surgical techniques, and patient selection have led to increased reliability with durable success. The current American Medical Systems model 800 (AMS 800) AUS was introduced in 1983 and has a 20-year history of use. This device has become the gold-standard treatment for incontinence of many causes, including prostatectomy, radiation therapy, neuropathy, and as a part of reconstructive procedures. Outcomes with the device are excellent, and most patients are pleased with the results, an outcome that persists in the long term [1–3]. The authors review their experience with more than 600 AUS devices and discuss practical points concerning surgery and revisions. They describe their routine surgical approach as a means of reporting on technical lessons learned. Preoperative evaluation Evaluation of patients for treatment with an AUS starts with a comprehensive office visit, including taking a history and performing a physical examination, urinalysis, and urine culture. Each patient completes a 72-hour voiding diary and a 24-hour urinary pad weight test that is brought to the office visit. The pad-weight study is an invaluable objective measure of the magnitude of the incontinence. During the office visit, videourodynamics are performed. This step, along with the voiding diary and patient history, helps confirm the factors contributing to the incontinence and identifies factors that may mitigate against a good outcome. Some investigators have suggested that urodynamic study is superfluous to the selection of the patient for implantation, but the authors disagree. Cystoscopy is performed in all patients to evaluate the urethra for a healthy placement site and to exclude urethral strictures and anastomotic contracture.

Objectives We report on the use of the AdVance male sling to treat men who had an artificial urinary sphincter placed and subsequently developed recurrent urinary incontinence. Methods Nineteen men who had undergone placement of an artificial urinary sphincter for post prostatectomy urinary incontinence, and who had developed recurrent incontinence, were treated by placing an AdVance sling. Self-reported pad use preoperatively was 2-5 pads per day. Results All 19 patients (100%) reported improvement in their incontinence as documented by decreased pad use. Of these men, 15 (79%) became dry, using no further pads, and four (21%) decreased pad use to 1 pad per day. Of the 15 dry patients, 8 remained dry without reactivation of the artificial sphincter (53%); the other 7 maintained complete continence with a combination of the sling and an activated artificial sphincter. Conclusions Men who suffer from recurrent urinary incontinence secondary to cuff compression atrophy can be made continent by the placement of a male sling. The technique of sling placement requires no special modification in these patients. By not revising the artificial urinary sphincter the capsule surrounding the device is not violated, which may decrease the risk of postoperative infection. In addition, the patient may not need to rely upon the use of his artificial sphincter to maintain continence.

We evaluated the perioperative and long-term functional outcomes of bladder neck and peribulbar cuff placement of an artificial urinary sphincter in a population of adult male patients with spinal dysraphism.We retrospectively analyzed the French spina bifida network database. Patients who underwent implantation of an artificial urinary sphincter from January 1985 to November 2015 were selected and stratified into 2 groups according to cuff location, that is bladder neck vs bulbar urethra. Explantation-free and revision-free device survival was estimated by the Kaplan-Meier method and compared with the log rank test. Cox regression models were created to assess prognostic factors of artificial urinary sphincter device failure.A total of 65 patients were included in study. Most patients were not wheelchair bound. The cuff was implanted around the bulbar urethra at 46 procedures (59%) and around the bladder neck in 32 (41%). In the peribulbar and bladder neck groups median revision-free device survival was 11.7 and 14.3 years, respectively (p = 0.73). Median explantation-free device survival was 18.5 and 24.5 years, respectively (p = 0.08). On multivariate analysis clean intermittent catheterization was the only predictor of artificial urinary sphincter device failure. Cuff location had no influence. At the last followup satisfactory continence was similar in the 2 groups (83% vs 75%, p = 0.75).In male patients with spinal dysraphism morbidity and functional outcomes were similar for bladder neck and bulbar urethra cuff placement but with a trend toward longer survival without explantation in the bladder neck group. Clean intermittent catheterization was the only predictor of shorter device survival on multivariate analysis.

Background Treatment for stress urinary incontinence (SUI) after radical prostatectomy (RP) with the male Adjustable Continence Therapy (ProACT) system, implanted using fluoroscopy for guidance, has been described with promising clinical results. Objective This retrospective study aims to describe the surgical technique in detail and to evaluate the continence recovery and complication rate of a cohort of male patients with SUI after RP. All patients were treated with a modified technique that uses transrectal ultrasound (TRUS) for guidance and that may be performed under local anaesthesia. Design, setting, and participants Between June 2005 and March 2009, we operated on 79 consecutive patients with post-RP urodynamic intrinsic sphincter deficiency. Surgical procedure ProACT system implantation was performed with TRUS guidance under general or local anaesthesia. Measurements Perioperative data and adverse events were recorded in all patients. Outcome data (24-h pad test, number of pads per day (PPD) used by patients, a validated incontinence quality of life questionnaire) were analysed in the 62 of 79 patients who completed the postoperative system adjustments. In this group of patients, the mean follow-up is 25 mo. Results and limitations According to the 24-h pad test and the mean number of PPD used, 41 patients were dry (66.1%), 16 patients improved (25.8%), and 5 patients failed treatment (8%). The dry rate in previously irradiated patients was 35.7%. Complications included intraoperative bladder perforations (2 of 79; 2.5%), transient urinary retention (1 of 79; 1.2%), migrations (3 of 79; 3.8%), and erosions (2 of 79; 2.5%). According to the degree of incontinence, the dry rate in patients with mild, moderate, and severe incontinence was, respectively, 85%, 63.6%, and 33.3%. Conclusions TRUS guidance for ProACT implantation results in success and complication rates that compare favourably with published data using fluoroscopy for guidance. Previous radiotherapy and severe incontinence seem to be a relative contraindication. Larger series and longer follow-up are progressing to establish long-term efficacy.

Background The artificial sphincter is the method of choice in patients with stress urinary incontinence due to neurogenic bladder dysfunction. However, long-term studies reveal a high revision rate. Objective To determine the success and revision rates of a modified implant. Design, Setting, and Participants In a retrospective analysis, the results of 51 consecutive patients presenting at a private paraplegic center with neurogenic bladder dysfunction (meningomyelocele: n =8; spinal cord injury: n =37; others: n =6) who underwent implantation of an artificial sphincter at the bladder neck using a port instead of a pump were evaluated. Measurements Subjective and objective cure rates were assessed by video-urodynamics and a standardized interview. Results and Limitations After a mean follow up of 95.9 mo, 70.6% of the patients were objectively and subjectively cured; 90.2% were completely continent in everyday life. Mean bladder capacity (465ml) and compliance (41.7ml/cm H 2 O) were normal. Sixteen patients underwent 18 revisions (35.3%). One implant had to be permanently removed. This is a single-centre study; thus, the results have to be confirmed. Conclusions With a long follow up of 8 yr, the modification presented by our group proved to be highly successful, reliable, safe, and even cost-effective. Therefore, it seems to be a valuable tool for the treatment of this group of patients.

We have evaluated prospectively the long-term efficacy of the artificial urinary sphincter (AUS) AMS 800 for the treatment postradical prostatectomy urinary incontinence (PRPUI) patients. We also evaluated the correlation between preoperative urodynamic findings and surgical outcomes.From May 1997 to April 2003, 40 consecutive patients with PRPUI caused by intrinsic sphincter deficiency (ISD) were treated with the AMS 800. Mean age was 68.3 +/- 6.3 years. Continence status was evaluated on the basis of pad count, impact of urinary incontinence on the quality of life, complications, and surgical revisions. Preoperative urodynamic findings were correlated with surgical outcomes.Follow-up ranged from 27 to 132 months (mean = 53.4 +/- 21.4 months). There was a significant reduction in pad count from 4.0 +/- 0.9 to 0.62 +/- 1.07 diapers per day (P0.001) leading to continence in 90%. There was a significant reduction on the impact of incontinence decreasing from 5.0 +/- 0.7 to 1.4 +/- 0.93 (P0.001) in a visual analogue scale (VAS). Surgical revision rate was 20%. Preoperative urodynamics was useful to identify sphincter deficiency. Except by a tendency of worse results in patients with reduced bladder compliance (RBC), other urodynamic parameters did not correlate with a worse surgical outcome.The AMS 800 offers good long-term continence to most PRPUI patients. Preoperative findings like detrusor hyperactivity (DH), impaired detrusor contraction (IDC), low Valsalva leak point pressure, bladder outlet obstruction (BOO), and mild RBC were not associated with worse surgical outcomes.

Objectives: To compare the effectiveness of macroplastique injection with artificial urinary sphincter implantation (AUS) for treatment of postprostatectomy incontinence (PPI). Methods: A prospective randomized clinical trial including 45 patients with PPI was performed secondary to radical retropubic prostatectomy (RRP), transvesical prostatectomy (TVP), transurethral prostatectomy (TURP), and TURP with TVP, in 12, 16, 16, 1 patients respectively. Patients were divided into two groups as minimal (group I) and total incontinence (group II) according to the severity of incontinence. Respectively, Group I ( n = 21) and group II ( n = 24) patients were randomized as AUS implantation ( n = 11, n = 11) and macroplastique injection ( n = 10, n = 13). Follow-up period was 48 (6–84) months in patients with macroplastique injection and 60 (8–120) months in AUS implantation. The success of the treatment was evaluated by calculating the average number of pads used by the patient per day, the weight of the pads and score of quality of life survey scale for each group both in the preoperative and in the postoperative period. Results: There were statistically significant differences between preoperative and postoperative average pad weight, average number of pads and quality of life scores, both in patients with minimal and total incontinence. In group I there was no statistically significant difference between the two techniques. However, in group II there was a significant difference favoring AUS implantation. Conclusions: Endourethral injection should be the treatment of choice for patients with minimal incontinence, whereas AUS implantation as the first choice for patients with total incontinence.

Objective: The long-term outcome of artificial urinary sphincter (AUS) is unpredictable because of, among others, the risk of breakdown of one of its components. Our objective was to define a strategy for an accurate diagnosis and an appropriate management of these problems. Patients and Methods: From 1985 to 2000, 298 AUS (AMS 800) have been implanted in 288 patients aged 53±21 years (8 to 87 years). There were 130 women with urinary stress incontinence, 84 with neurological disorders, 76 following prostatic surgery and 8 for other reasons. Diagnosis was often done following the recurrence of urinary incontinence. The pump was systematically checked and all patients underwent radiographic and urodynamic studies. We have systematically looked for the defective component in order to avoid replacing the entire sphincter. Results: Fifty-five patients (19%) have been re-operated on after a median follow-up of 23 months (11 days–10 years): Thirty-two only once, 20 twice and 3 patients 4 times. There were 55 depressurizations, 18 device dysfunctions without depressurization and 11 removals of the sphincter. Among the 55 depressurizations, 30 were related to a perforation of one component, 24 to a functional but insufficient sphincter and 1 to tubing disconnection. In forty cases, only one component of the AUS was replaced while 2 components were replaced in 10 cases, the entire AUS in 4 cases and no component in one case. Conclusion: The longer the follow-up the greater is the probability of a dysfunction. We systematically continue to look for the defective component and just to replace it instead of the entire sphincter.

Urinary incontinence is a debilitating problem that requires careful evaluation. Causes of incontinence in children are numerous, and once the mechanism of incontinence has been identified, management can be planned carefully. The management and outcome in children born with the exstrophy-epispadias complex, posterior urethral valves, and children who have an infrasphincteric ureteric orifice are discussed in this article.