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Objective: To determine clinical, surgical and urodynamic attributes associated with earlier AUS reintervention. The artificial urinary sphincter (AUS) is the gold standard treatment for postprostatectomy stress urinary incontinence. Factors impacting long-term device survival have not been investigated., Materials and Methods: We identified men with post-prostatectomy incontinence who underwent AUS reintervention from 2011 to 2021 at a single center. Urodynamic study, pad weights and voiding diaries are routinely assessed prior to AUS placement. Relationships between clinical, urodynamic and surgical variables and AUS reintervention were assessed using cox regression. Multiple imputation of chained equations was used to handle missing data elements, with truncated linear regression for continuous variables and logistic regression for binary variables., Results: A total of 524 records were reviewed and 92 met inclusion. Median time to AUS reintervention was 5.7 years (2.3, 9.4). Indications were mechanical failure (38; 41.3%), sub-cuff atrophy (37; 40.2%), erosion/infection (11; 11.9%) and other (6; 6.5%). On univariable testing, earlier intervention was associated with pad weight (P < .01), nocturnal voids (P = .01), bladder capacity (P = .01), bladder volume at strong sensation (P = .03), detrusor overactivity (P < .01) and maximum voiding pressure (P = .02). On multivariable analysis, earlier surgical intervention was associated with detrusor overactivity (HR 1.95, P < .01 CI 1.22-3.1) and pad weight (HR 1.0006, P = .02, CI 1.000-1.001)., Conclusions: Detrusor overactivity is associated with significantly shorter time to AUS failure. This information may allow for more individualized counseling., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The management of artificial urinary sphincter sub-cuff atrophy remains controversial, and clinical outcomes are underreported. We intend to examine the impact of cuff downsizing in cases of isolated sub-cuff atrophy., Materials and Methods: We reviewed our prospectively collected, institutionally approved quality improvement database for this study from 2011 to 2022. Institutional Review Board approval was obtained for the analysis. Sub-cuff atrophy in patients with post-prostatectomy incontinence was diagnosed with a clinical presentation of recurrent urinary leakage, serial pelvic films, cystoscopy, and patient evaluation. Outcomes were assessed with pad use, subjective measures, and American Urological Association Symptom Score scores., Results: During the study interval, 871 encounters for artificial urinary sphincter placement were identified, 229 for revision or replacement, of which cuff downsizing for isolated cases of sub-cuff atrophy occurred in 34. Downsizing took place after a median of 6.5 years after initial artificial urinary sphincter placement. Of the patients, 97% reported subjective improvement and 93% experienced a decrease in daily incontinence pad use, with a mean±SD decrease of 2.2±1.45 pads ( P < .01). American Urological Association Symptom Score bother scores decreased from pre-downsizing values by a mean±SD of 1.5±1.4 ( P = .01). After a median follow-up of 1.8 years after downsizing, 24 (70.6%) of downsized cuffs remained in place, 2 (5.9%) were further downsized, 2 (5.9%) required replacement for mechanical failure, 4 (11.8%) underwent removal for erosion, and 2 (5.9%) underwent replacement for a herniated pressure regulating balloon., Conclusions: When diagnosed using objective criteria, cuff downsizing improves continence and patient satisfaction in cases of sub-cuff atrophy.

Introduction and Objectives: Urodynamic studies are often performed in the evaluation of post-prostatectomy urinary incontinence (PPUI). The male transobturator sling (TOS) is a minimally invasive treatment for PPUI. Others have reported their results with a specific Valsalva leak point pressure (VLPP) that predicts a good outcome with the male TOS. Our objective was to determine the relationship of the pre-operative VLPP on the success rate of the male TOS in a high-volume, single center. We hypothesized that a higher pre-operative VLPP better predicts successful outcomes., Methods: We reviewed patients undergoing a male TOS placement from 2006 to 2012 at our institution. Patients who underwent TOS placement were identified using our patient data portal (DEDUCE). Demographic, urodynamic, and follow-up data were extracted by chart review. Post-operative success was defined by the use of 0 or 1 security pad, a negative stress test on exam, or pad weight of less than 8 g per 24 h. Cox and linear regression models were performed., Results: 290 patients were included. All patients underwent a radical prostatectomy for prostate cancer and presented with PPUI. Mean age at surgery was 66.3 (± 7.4) years and 84% were Caucasian. Median time to follow-up was 5 months (IQR 1-15). A linear regression model shows an inverse prediction curve for sling failure versus VLPP (p = 0.02). The hazard ratio for failure with a VLPP of ≤ 70 cm H 2 O compared with a VLPP of > 70 cm H 2 O, adjusted for pelvic radiation and 24-h pad weight was 0.5 (95% CI 0.2-0.98)., Conclusion: Patient selection is imperative in the success of the male TOS for patients with PPUI. In our cohort of patients with PPUI, those with a pre-procedural VLPP of > 70 cm H 2 O were 50% less likely to fail after TOS placement versus those with a VLPP ≤ 70 cm H 2 O. In our practice, we use these data to support the use of VLPP cut off of 70 cm H 2 O as an indicator for success to help in the evaluation and counseling of patients., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Aims: Measuring the urethral circumference accurately during artificial urethral sphincter (AUS) placement is an important technical aspect to optimize the selection of cuff size. Differing methods exist for this step with some experts recommending measurement with no urethral catheter in place. In this prospective observational trial, we compared urethral measurements with and without an indwelling catheter to determine if the presence of a catheter affects the circumferential measurement., Methods: With IRB approval, we prospectively collected data on consecutive cases of transperineal male AUS implantation. Urethral circumference was measured with no urethral catheter (0 French [Fr]), 12Fr, and 16Fr Foley catheters in the urethra. The final measurements and cuff size chosen were recorded. A comparison was made between each measurement using Spearman's correlation coefficient., Results: A total of 54 patients were included, the majority of whom (92.6%) underwent AUS placement for postprostatectomy incontinence. The three urethral circumference measurements were highly correlated (0Fr vs 12Fr, ρ = 0.96, P < .001, mean difference 1 mm) (0Fr vs 16Fr, ρ = 0.94, P < .001, mean difference 2 mm) (12Fr vs 16Fr, ρ = 0.96, P < .001, mean difference 1 mm). Patients with a history of radiation had a lower mean urethral circumference than those who had never been radiated (4.78 cm vs 5.3 cm, P = .01)., Conclusions: Urethral circumference measurement during AUS implantation is not influenced by the presence of a 12 or 16Fr Foley catheter when compared to no catheter in the urethra. Measurement of the urethral circumference can, therefore, be accurately performed with or without a catheter in place, depending on the surgeon's preference., (© 2020 Wiley Periodicals LLC.)

Objective: To compare the length of the membranous (functional) urethra in male patients who underwent the male transobturator sling (TOS) for postradical prostatectomy urinary incontinence (PPI). The TOS is in established use for treatment of PPI; however, the precise mechanism of action is unknown., Materials and Methods: This is a prospective case-controlled study on men undergoing male TOS surgery from 2008 to 2014. The comparison arm included patients without incontinence after radical prostatectomy. All participants underwent dynamic magnetic resonance imaging (MRI) at baseline and this was repeated after TOS placement for those who underwent the procedure. Three standardized points were measured using MRI and compared in both groups in addition to clinical measures., Results: Thirty-nine patients were enrolled and 31 patients completed the protocols. The controls (N = 14) had a longer vesicourethral anastomosis to urethra measured at the penile bulb (functional urethral length) distance compared to the pre-TOS group at rest (1.92 cm controls vs 1.27 cm pre-TOS, P = .0018) and at Valsalva (2.13 cm controls vs 1.72 cm pre-TOS, P = .0371). Placement of the sling (N = 17) increased the functional urethral length distance at rest (1.92 cm control vs 1.53 cm post-TOS, P = .09) and at Valsalva (1.94 cm post-TOS vs 2.13 cm control, P = .61), so that the difference was no longer statistically significant., Conclusion: We identified that one possible mechanism in improvement in stress urinary incontinence post-TOS placement is the lengthening of the vesicourethral anastomosis to bulbar-urethra distance. This is the first such study utilizing dynamics MRI in post prostatectomy controls, incontinent pre-TOS, and post-TOS to assess and show these findings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims: To analyze the rates of incontinence procedures after radical prostatectomy, and define the variables associated with them., Methods: We conducted an IRB approved retrospective review of patients with prostate cancer who underwent radical prostatectomy at a single institute from January 1998 to December 2012. Logistic regression and time to event analyses were performed to ascertain variables associated with receipt of incontinence procedure after prostatectomy., Results: Four thousand four hundred one men underwent radical prostatectomy (69.8% open, 30.1% laparoscopic or robotic) of whom 74.3% were white Caucasian and 22.1% were African-American. Overall, 165 (3.7%) patients underwent a total of 191 procedures for male urethral sling or artificial urinary sphincter placement. African-American men received fewer incontinence procedures than white Caucasian men (2.1% versus 4.3%, P = 0.001); and with a longer delay after prostatectomy than white Caucasian men (28.3 months versus 19.9 months, P = 0.029). Men who had a laparoscopic or robotic prostatectomy received an incontinence procedure earlier than men who had an open prostatectomy (17.6 months versus 24.4 months, P = 0.0001). On multivariate analysis, age at prostatectomy, diagnosis of incontinence, and race were independently associated with receiving an incontinence procedure., Conclusions: The overall rate of incontinence surgery after radical prostatectomy is low at 3.7%. African-American men receive incontinence procedures at a lower rate and with a longer delay after prostatectomy than white Caucasian men. Further studies are needed to define the reasons for this racial disparity in urinary incontinence surgery in the prostate cancer survivor. Neurourol. Urodynam. 35:733-737, 2016. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Purpose: While the AMS 800 artificial urinary sphincter improves continence in up to 90% of patients, revision surgery may be needed in up to 50%. We determined whether an ohmmeter could accurately assess the site of fluid leak from individual components of the artificial urinary sphincter at the time of revision surgery., Materials and Methods: We retrospectively reviewed the records of patients who underwent artificial urinary sphincter revision surgery between 1996 and 2013. Patients in whom fluid loss was identified preoperatively by plain film radiography and who subsequently underwent revision surgery using the ohmmeter were assessed for outcomes., Results: The ohmmeter was used intraoperatively in a total of 20 surgeries in 19 patients and it correctly identified the location of fluid loss in 18 of 20 (90%). Fluid leakage was found from the pressure regulating balloon in 13 cases, from the cuff in 4 and from the tubing to the pressure regulating balloon in 1. None had fluid loss from the pump. In the 17 cases in which only the malfunctioning component was replaced a satisfactory postoperative outcome with a fully functional device was documented in all. Repeat surgery was performed in 5 of 17 cases (29.4%) at a median of 17 months (range 2 to 39). No patient underwent repeat surgery due to failure to accurately diagnose a component leak., Conclusions: In cases of suspected fluid loss as a cause of artificial urinary sphincter malfunction an ohmmeter can identify the site of fluid loss during component revision surgery., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Aims: The reported incidence of urinary incontinence (UI) after radical prostatectomy (RP) ranges from 2.5 to 87%. We reviewed data from the Center for Prostate Disease Research (CPDR) to determine the incidence of patient reported UI after RP (postRPUI) and establish risk factors for postRPUI., Methods: We obtained IRB approval to query the CPDR database on all patients undergoing RP between 1990 and 2007. We assessed patient age, nerve sparing status, blood loss, margin status, stage, and patient self-reported incontinence status as entered into the database. Patients were counted as having UI only if the database showed patient reported UI in every follow-up encounter. Patients were counted as permanently dry if at any time in the follow-up they answered that they had no UI., Results: Four thousand three hundred seventy four patients underwent RP without radiation therapy or hormonal ablation between 1990 and 2007. Complete data were available for 1,616 (37%) and 1,459 (90.3%) reported UI more than 1 year after RP with a median follow-up of 50.7 months. Older age is an independent risk factor for UI (OR = 1.021, P ≤ 0.0003). Nerve sparing, blood loss, stage of cancer, and margin status were not predictive for UI., Conclusions: Our data indicate that patient reported post-RPUI is higher than expected but is not related to the nerve sparing technique, stage of cancer nor blood loss at the time of surgery., (Copyright © 2011 Wiley Periodicals, Inc.)

Since its introduction in 1973, the artificial urinary sphincter (AUS) has become widely accepted therapy, particularly for male incontinence. In this article, the authors review their experience with more than 600 artificial urinary sphincter (AUS) devices and discuss practical points concerning surgery and revisions. Their routine surgical approach as a means of reporting on technical lessons learned is also described., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: Artificial urinary sphincter urethral cuff erosion occurs in up to 5.0% of cases, presenting a complex management problem. We examine our experience with the eroded AUS, relating to preoperative risk factors, operative management and outcomes., Materials and Methods: We reviewed the medical records of 637 patients undergoing bulbar urethral AUS implantation from 1990 to 2003 for demographic and surgical variables., Results: Of the 637 records reviewed, 46 patients underwent 54 explantations of the AUS device for erosions, including 13 who had the primary implant performed at our institution and 33 being referred for management of erosion after implantation elsewhere. Our institution erosion rate was 2.2%. Mean followup after AUS reimplant following erosion was 27.8 months (range 1 to 180). Comorbidities were more prevalent in patients with erosions included hypertension (p = 0.006), coronary artery disease (p = 0.03), prior radiation therapy (p = 0.006) and prior AUS revisions (p = 0.0001). A majority of patients had persistent mild incontinence (0 to 1 pad daily in 29 or 56.8%), moderate (1 to 3 pads daily in 9 or 17.4%) and severe (more than 3 pads daily in 6 or 11.8%) incontinence after secondary AUS implantation. Patients who underwent reimplantation after AUS cuff erosions have a significantly higher rate of second erosions (in 16, 34.8%) within an average of 6.7 months (range 3 to 24), including our own 11.8% institutional rate (in 4)., Conclusions: Our study suggests that patients with comorbidities including hypertension, coronary artery disease, prior radiation therapy and prior AUS revisions are more likely to have erosions of their AUS. Nevertheless, continence can still be salvaged using various strategies which optimize use of the remaining healthy urethral tissue.

ObjectiveTo determine whether ejaculatory dysfunction (EjD) and post-void dribbling (PVD) after urethroplasty are associated, providing evidence for a common etiology.MethodsWe reviewed a prospectively maintained database for first-time, anterior urethroplasties. One item from the Male Sexual Health Questionnaire (MSHQ) assessed EjD: "How would you rate the strength or force of your ejaculation". One item from the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) assessed PVD: "How often have you had slight wetting of your pants after you had finished urinating?". The frequency of symptoms was compared after penile vs. bulbar repairs, and anastomotic versus augmentation bulbar repairs. Associations were assessed with chi-square.ResultsA total of 728 men were included. Overall, postoperative EjD and PVD were common; 67% and 66%, respectively. There was a significant association between EjD and PVD for the whole cohort (p

Purpose: For male cancer survivors, the combination of stress urinary incontinence and recurrent bladder neck contracture presents a management dilemma with poor consensus. Our objective was to assess the impact of artificial urinary sphincter placement on bladder neck contracture recurrence among prostate cancer survivors with stress urinary incontinence and bladder neck contracture. Materials and Methods: Men electing artificial urinary sphincter placement at our institution undergo synchronous bladder neck contracture treatment if indicated. An institutional database was queried for men with stress urinary incontinence and ≥1 intervention for bladder neck contracture. Records were divided according to whether an artificial urinary sphincter was ever placed. The impact of artificial urinary sphincter placement on bladder neck contracture recurrence was assessed using a multivariable conditional survival analysis, with survival defined as the recurrence-free interval following bladder neck contracture intervention. The proportional hazards assumption was assessed on the basis of Schoenfeld residuals. Results: The analytic cohort consisted of 118 in the artificial urinary sphincter group and 88 in the non-artificial urinary sphincter group. Patients in both groups underwent a median of 2 (range 1-8) bladder neck contracture interventions over the entire course of their care, encompassing 445 total bladder neck contracture interventions. The artificial urinary sphincter group was on average 2.6 years younger (P = .02) and had a higher pack-year smoking history (P < .01). The presence of an artificial urinary sphincter was associated with a 61% lower bladder neck contracture re-intervention rate (HR 0.39, P < .01, CI 0.30-0.50) at any time when accounting for number of prior bladder neck contracture interventions and bladder neck contracture risk factors. Conclusions: Artificial urinary sphincter placement is associated with a lower rate of bladder neck contracture re-intervention. Artificial urinary sphincter placement should not be delayed or avoided due to the presence of bladder neck contracture. [ABSTRACT FROM AUTHOR]

Objective: To describe the distribution of post-void residual (PVR) volumes across patients with and without lower urinary tract symptoms (LUTS) and examine relationships between self-reported voiding symptoms, storage symptoms, and PVR.Methods: PVR and demographic data were obtained from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) observational cohort study. Self-reported symptoms were collected using the American Urological Association Symptom Index and the LUTS Tool. PVR values were obtained from 2 other cohorts: living kidney donors with unknown LUTS from the Renal and Lung Living Donors Evaluation Study (RELIVE), and continent women in the Establishing the Prevalence of Incontinence (EPI) study, a population-based study of racial differences in urinary incontinence prevalence.Results: Across the 3 studies, median PVRs were similar: 26 mL in LURN (n = 880, range 0-932 mL), 20 mL in EPI (n = 166, range 0-400 mL), and 14 mL in RELIVE (n = 191, range 0-352 mL). In LURN, males had 3.6 times higher odds of having PVR > 200 mL (95% CI = 1.72-7.48). In RELIVE, median PVR was significantly higher for males (20 mL vs 0 mL, P= .004). Among women, only the intermittency severity rating was associated with a probability of an elevated PVR. Among men, incomplete emptying and burning severity rating were associated with a higher odds of elevated PVR, but urgency severity ratings were associated with lower odds of elevated PVR.Conclusion: Care-seeking patients have PVRs similar to those in people with unknown history of LUTS (RELIVE) and without self-reported LUTS (EPI). Although PVR was correlated with voiding symptoms, the mean differences only explain ∼2% of the variance. [ABSTRACT FROM AUTHOR]

Purpose We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling. Materials and Methods 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. Results 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). Conclusion 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. [ABSTRACT FROM AUTHOR]

The article focuses on urinary incontinence in prostate cancer survivors who were treated with surgery and/or radiotherapy following an appropriate period of healing from the therapy. It cites an algorithm developed for all patients presenting with the complaint of incontinence to parse through the complex nature of urinary incontinence. It indicates that the diagnosis and treatment of men with urinary incontinence following prostate cancer treatment can necessitate a systematic evaluation.

Objective: To evaluate the functional and surgical impact of CIC protocols in men with a bulbar AUS in place. Stress urinary incontinence (SUI) and poor bladder emptying are both sequelae of prostate cancer treatment, though there is sparse data to guide concomitant management. The safety of intermittent catheterization (CIC) in men with an artificial urinary sphincter (AUS) at the bulbar urethra remains unclear.Methods: We performed a retrospective review of all bulbar urethral AUS procedures at our institution. Inclusion criteria were patients with a history of prostate cancer treatment, AUS placement for SUI, and a history of CIC before and/or after AUS placement. All eligible cases were retrospectively reviewed. Surgical and continence outcomes were analyzed.Results: 57 patients were identified with a history of CIC and AUS placement under the care of two surgeons. Eighteen continued to perform CIC or first initiated CIC after AUS placement and 39 discontinued CIC protocol prior to AUS placement. The incidence of erosion was no different amongst patients who continued or discontinued CIC after AUS placement (17.9% vs 22.2%, p=0.79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, p=0.41). Both groups experienced improvement in urinary incontinence after placement of an AUS.Conclusion: Bulbar AUS placement in the setting of continuous intermittent catheterization can be considered in patients who are not surgical candidates for definitive treatment of their outlet obstruction. [ABSTRACT FROM AUTHOR]