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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.

Definitive radiation therapy with concurrent chemotherapy is curative for nonmetastatic squamous cell carcinoma of the anus (SCCA). However, the true effect of chemoradiation on long-term functional outcomes is poorly understood owing to limited follow-up and patient-reported outcomes (PROs).We conducted a cross-sectional survey of 248 patients with SCCA treated with definitive intensity modulated radiation and concurrent chemotherapy from 2010 to 2018 who were alive and without recurrence. PRO measures were collected, including Functional Assessment of Cancer Therapy-General (FACT-G7), Fecal Incontinence Quality of Life (FIQoL), Low Anterior Resection Syndrome (LARS), and International Consultation on Incontinence Questionnaires (ICIQ). Models were used to determine the association between demographic, tumor, treatment, and dosimetric data with PROs.One hundred twelve (45%) patients completed PROs. Median [interquartile range (IQR)] time from radiation completion to survey was 51 [37-85] months. The median scores [IQR] for FACT-G7, FIQoL, and LARS were 21 [15-24], 14 [11-16], and 32 [25-37], respectively. For men, median subscores [IQR] for ICIQ voiding and incontinence subscores were 5 [2-6] and 1 [1-3], respectively. For women, median subscores [IQR] for ICIQ voiding, incontinence, and filling were 1 [1-3], 5 [3-8], and 4 [2-5], respectively. Higher (better) FIQoL scores were associated with higher (better) FACT-G7 scores (β = 0.83; 95% confidence interval, 0.58-1.09; P.001), and higher (worse) LARS scores were associated with lower (worse) FACT-G7 scores (β = -0.22; 95% confidence interval, -0.31 to -0.13; P.001). A separate multivariable analysis revealed higher bowel bag D1% was associated with lower (worse) FIQoL (P = .001) and higher (worse) LARS (P = .003) scores. Higher bladder V40 Gy was associated with increased (worse) ICIQ voiding subscore (P = .001).Patients treated with modern chemoradiation for SCCA experience significant long-term bowel toxic effects with considerable effect on quality of life. Minimizing bowel hotspots and bladder V40 Gy may improve bowel and urinary function. Other interventions to reduce long-term toxic effects and improve quality of life are needed.

Introduction Concurrent urinary incontinence (UI) and erectile dysfunction (ED) can greatly damage a patient's quality of life. Owing to the intertwined anatomy, treatment options for one most certainly have implications on the other. Objective The aim of this review is to characterize and elucidate the treatment patients with postprostatectomy UI undergoing concurrent or subsequent treatment of ED. These principles can be extrapolated to all patients with UI and ED. Methods The literature on postprostatectomy UI treatment in the context of concurrent ED was reviewed through a Medline search. Original research using quantitative and qualitative methodologies was considered. Results The epidemiology, workup, and management of postprostatectomy UI being mindful of ongoing or future ED treatments are the main outcome measures. Owing to the intertwined anatomy, treatment options for UI and ED have implications on the other. It is essential for the surgeon to obtain an understanding of the patient's degree of bother for each process, personal preference on treatment options, and management of expectations. Surgical treatment options include a combination of the artificial urinary sphincter, sling, inflatable penile prosthesis, semi-rigid penile prosthesis, and new techniques such as the Mini-Jupette. The appropriate combinations will be determined by patient factors of dexterity, preference, degree of leakage, history of radiation, and so on. The decision of staged vs dual implant will be largely driven by the surgeons' preference, payor limitations, and comfort level. This issue is particularly challenging in redo cases where we advocate for cuff downsizing or tandem cuff before the transcorporal approach is used with the goal of preserving sexual function. Conclusion The concurrent treatment of ED and UI requires thoughtful workup, meticulous attention to detail, and an armamentarium of surgical skills. It is crucial for the surgeon to understand and manage patient expectations in treating these delicate and difficult pathologies. Ajay D, Mendez MH, Wang R, et al. Treatment of Urinary Incontinence in Patients With Erectile Dysfunction. Sex Med Rev 2021;9:593–604.

OBJECTIVE To evaluate the perioperative decision-making process, post-operative decision regret and reflection on the peri-operative experience of patients undergoing radical cystectomy and urinary diversion through patient interviews. METHODS Patients identified as having undergone radical cystectomy for malignancy were interviewed 6-24 months from the time of surgery and stratified by diversion type. Following written consent, interviews were conducted either in person or over the phone using a semi-structured script. Patients were asked 9 open-ended questions, with additional unscripted follow-up questions based on themes raised by the patient. The interviews were reviewed for common themes, preferences, and recommendations. RESULTS A total of 13 interviews were conducted. No patient expressed decision regret about their choice of urinary diversion. Ten out of 13 interviewees specifically stated that they had adequate information about diversion options pre-operatively, none felt they did not have adequate pre-operative counseling. One area identified as improvable was postoperative counseling- specifically, for ostomy appliances, catheters, or irrigation. The most striking recurrent theme was the desire for a “buddy system” in which patients could contact and maintain discussion about their surgical experience with an experienced patient. The overall impression was that this system would be most useful in the recovery/maintenance phase rather than in the pre-operative decision-making process. CONCLUSION This data furnishes a basis to develop more accessible and effective counseling and highlights the need to concentrate on post-surgical maintenance care, including management of urostomy appliances, catheters, and reinforcing irrigation technique.

The artificial urinary sphincter, known as AMS 800, has been the gold standard for treating moderate to severe stress urinary incontinence in males for 40 years. Yet, the number of sphincters done globally is quite small and the majority of urologists doing them are infrequent implanters. Estimates for 2019 showed half of implanters did only one implant that year and worldwide only around 13,000 implantations were performed. The traditional two-incision technique of perineal exposure for cuff placement and abdominal incision for pump and pressure regulating balloon persists as the most common technique to surgically place an artificial urinary sphincter. Present estimates are that upwards of 80% are done via the perineal approach and that approach is the highly favored incision of large volume centers. The scrotal one-incision approach was invented by Wilson 20 years ago and was aimed at making the implantation of a sphincter quicker, easier and safer for the occasional implanter. These physicians perform 1-2 devices per year, comprise 60% of implanters who perform the surgery yearly, and implant 22% of all implanted devices. Our article targets these infrequent inserters discussing the history of the two techniques and what the authors have learned about the advantages and hazards of the one scrotal incision procedure over the last two decades.

Radical cystectomy (RC) and urinary diversion in the treatment of muscle-invasive bladder cancer is associated with peri-operative complication rates as high as 60%. Ureteroenteric anastomotic stricture (UEAS) is a potential source significant morbidity often requiring secondary interventions. We sought to evaluate our experience with benign UEAS in our open ileal orthotopic neobladder (ON) population. After Internal Review Board (IRB) approval, we performed a retrospective review of patients who had RC and ON between 2000 and 2015 at MD Anderson Cancer Center and had at least 6 months of follow-up. Baseline demographics and treatment characteristics, peri-operative and post-operative outcomes, as well as information regarding anastomosis technique and suture types were evaluated. Patients with malignant ureteral obstruction were excluded from the analysis. 418 patients had ON creation and the mean age was 59 years (SD 9.4 years) and 90% were males. The mean follow-up was 57 months (6–183 months). 37 patients (8.9%) developed UEAS in 42 renal units and the mean time to diagnosis was 15.8 months (0.85–90 months). Anastomosis and suture type were not predictive of UEAS (p = 0.594, p = 0.586). Perioperative UTI within 30 days of surgery, and recurrent UTI were predictive of UEAS, HR 2.4 p = 0.03, HR 5.1 p

The objective of this review is to critically evaluate recent literature on the urinary complications following pelvic radiation for malignancy in women. Lower urinary tract symptoms (LUTS) manifest in a significant population of women post-radiation with confirmed objective findings on urodynamic evaluation. Other serious consequences such as fistula, hemorrhagic cystitis, and strictures are less common but can be significant. The sequelae of radiation on the female lower urinary tract can range from mild symptoms to those requiring major surgical intervention. Therefore, post-radiotherapy patients must be approached with vigilance in conjunction with thorough preoperative counseling.

Urinary incontinence after prostate treatment (IPT) is one of the few urologic diseases that is iatrogenic, and, therefore, predictable and perhaps preventable. Evaluation of the incontinent patient, risk factors for IPT, the assessment of the patient prior to intervention, and a stepwise approach to management are covered in this guideline. Algorithms for patient evaluation, surgical management, and device failure are also provided.This guideline was developed using a systematic review from the Mayo Clinic Evidence Based Practice Center with additional supplementation by the authors. A research librarian conducted searches from 2000 to December 21This guideline was developed by a multi-disciplinary panel to inform clinicians on the proper assessment of patients with IPT and the safe and effective management of the condition in both surgical and non-surgical contexts. Statements guiding the clinician on proper management of device failure are also included.Most patients who undergo radical prostatectomy (RP), and some patients who undergo radiation therapy (RT) or surgery for benign prostatic hyperplasia (BPH), will experience IPT. Although non-surgical options, such as pelvic floor muscle exercises (PFME), can hasten continence recovery, patients who remain incontinent at one-year post-procedure, or have severe incontinence at six months, may elect to undergo surgical treatment (e.g. artificial urinary sphincter). Prior to IPT surgery, the risks, benefits, alternatives, and additional likely procedures should be discussed with the patient.

Objective : To evaluate risks of peri-operative ureteral catheter placement in a consecutive patient-series. Methods : Patients who underwent peri-operative ureteral catheter placement at a single institution in 2018 were included. A retrospective review was conducted to evaluate patient and procedure related characteristics, including data on technique, perceived placement difficulty, operative details, and complications. Outcome Measurements and Statistical Analysis : Urologic complications within 30 days were evaluated using the Clavien-Dindo system. Statistical analysis for association was conducted using the X2 test or fisher's exact tests. Results : 413 patients were included. 50/413 (12.1%) cases had urologic complications within 30 days. 43 were Clavien-Dindo grade I-II. Six were grade III. 5/6 patients had oliguric, obstructive AKI. One had flank pain with hydronephrosis. Two patients each underwent placement of unilateral nephrostomy tube, bilateral double-J stent placement, and unilateral stent placement. One patient had a Grade V complication. They developed multi-system organ failure including renal failure with hydronephrosis.All patients who required re-intervention had bilateral peri-operative catheterization with use of a wire. Intraoperative difficulty with placement was associated with high-grade complication (p Conclusions : Rate of acute complication following ureteral catheter placement is 12%. 1.7% of patients develop post-operative ureteral obstruction requiring intervention within 30 days. Future studies are needed to determine patients most at risk for post-ureteral stent complication.

This chapter reviews the construction of orthotopic bladder substitution with tricks and tips as performed by the authors. Along with intraoperative photographs and surgical technique, we have outlined our routine postoperative management, workup, and treatment of commonly seen complications.

The artificial urinary sphincter, known as AMS 800, has been the gold standard for treating moderate to severe stress urinary incontinence in males for 40 years. Yet, the number of sphincters done globally is quite small and the majority of urologists doing them are infrequent implanters. Estimates for 2019 showed half of implanters did only one implant that year and worldwide only around 13,000 implantations were performed. The traditional two-incision technique of perineal exposure for cuff placement and abdominal incision for pump and pressure regulating balloon persists as the most common technique to surgically place an artificial urinary sphincter. Present estimates are that upwards of 80% are done via the perineal approach and that approach is the highly favored incision of large volume centers. The scrotal one-incision approach was invented by Wilson 20 years ago and was aimed at making the implantation of a sphincter quicker, easier and safer for the occasional implanter. These physicians perform 1-2 devices per year, comprise 60% of implanters who perform the surgery yearly, and implant 22% of all implanted devices. Our article targets these infrequent inserters discussing the history of the two techniques and what the authors have learned about the advantages and hazards of the one scrotal incision procedure over the last two decades.

Purpose We present a novel AUS implantation technique using a single perineal incision for single device placement or in combination with an inflatable penile prosthesis (IPP). Urinary and sexual dysfunction following the management of prostate cancer has a significant impact on the quality of life of our patients. While there are marginal changes in the prosthetic devices, we strive to reduce post-operative morbidity while maximizing efficacy. Materials and Methods We retrospectively reviewed the outcomes of 6 patients who underwent single perineal incision placement of a virgin AUS in 2014, 3 with simultaneous IPP placement. In all cases, the pressure regulating balloons (PRB) were placed in a high sub-muscular ectopic position and the pumps were placed into a sub-dartos pouch through the perineal incision, which was also validated using a cadaveric model. Results The mean patient age was 61 (SD, 7.5 years) with mean body mass index of 31 (SD, 5.9). The average pre-operative pad usage was 7.7 (SD 1.63) pads per day. The mean follow-up was 13.9 months (SD 9.45). Four out of the six patients reported utilizing ≤1 pad daily at follow-up. The one patient who was not initially dry required downsizing of his cuff to 3.5cm; the remaining patient was lost to follow-up. There were no identifiable perioperative or post-operative complications. Conclusions We present our initial report of using a single perineal incision for AUS implantation with a validated sub-dartos pump location, which is safe and effective for implantation of an AUS as a single or double implantation in well-selected patients.

Introduction Sacral chordoma is a rare malignant tumor arising from remnants of the notochord. Due to its propensity for recurrence, the treatment of choice is surgical resection. Orthopedic and neurosurgical literature describe bladder dysfunction as prevalent in these patients, specifically urinary incontinence, however urologic literature is lacking in the exact nature of this dysfunction. Thus far, Sacral Nerve Stimulation (SNS) has not been described as a treatment option for these patients. Presentation of Case: We describe a 36-year-old female who underwent midsacral resection (S3 and below) for a sacrococcygeal chordoma. She suffered from postoperative urinary incontinence and incomplete emptying requiring intermittent catheterization. Urodynamic evaluation showed detrusor hyporeflexia with nonobstructive urinary retention. She underwent InterStim® (Minneapolis, MN) placement resulting in return of spontaneous voiding and resolution of retention. Discussion SNS has been FDA approved for treatment of nonobstructive urinary retention since 1999. It has yet to be described as an effective treatment option in patients who have undergone sacral resection and suffer from prolonged postoperative nonobstructive urinary retention. Operative reports may not contain sufficient detail to confirm whether one or both S3 nerve roots are intact. Thus, it is mandatory to perform a bilateral nerve evaluation to verify integrity of the S3 nerve roots in this cohort of patients. This can present a technical challenge, as some of the usual landmarks are surgically absent. However, we have shown that the procedure is feasible and effective after partial sacral resection. Conclusion We are the first to report the successful use of SNS to treat nonobstructive urinary retention after partial sacral resection. Additional patients and long term follow-up will be required to support consistent usage of neuromodulation in this patient population.

Radical cystectomy (RC) and urinary diversion in the treatment of muscle-invasive bladder cancer is associated with peri-operative complication rates as high as 60%. Ureteroenteric anastomotic stricture (UEAS) is a potential source significant morbidity often requiring secondary interventions. We sought to evaluate our experience with benign UEAS in our open ileal orthotopic neobladder (ON) population.After Internal Review Board (IRB) approval, we performed a retrospective review of patients who had RC and ON between 2000 and 2015 at MD Anderson Cancer Center and had at least 6 months of follow-up. Baseline demographics and treatment characteristics, peri-operative and post-operative outcomes, as well as information regarding anastomosis technique and suture types were evaluated. Patients with malignant ureteral obstruction were excluded from the analysis.418 patients had ON creation and the mean age was 59 years (SD 9.4 years) and 90% were males. The mean follow-up was 57 months (6-183 months). 37 patients (8.9%) developed UEAS in 42 renal units and the mean time to diagnosis was 15.8 months (0.85-90 months). Anastomosis and suture type were not predictive of UEAS (p = 0.594, p = 0.586). Perioperative UTI within 30 days of surgery, and recurrent UTI were predictive of UEAS, HR 2.4 p = 0.03, HR 5.1 p 0.001, respectively.UEAS are associated with potentially significant morbidity following ON creation. UEAS may occur early following ON, but may occur as late as 7 years following surgery. Indeed, technical factors and surgeon experience contribute to the rates of UEAS, but perioperative UTI appears to herald future stricture development.

During the prostate-specific antigen (PSA) era, the prevalence of male stress urinary incontinence (SUI) continues to rise as more prostatectomies are performed. Treatment of male SUI is a multifactorial decision depending not only on bladder and sphincteric function, but also patient choice. Due to the economic burden and strain on quality of life, procedures and devices have been developed to help patients alleviate their symptoms. Mainstays of treatment include conservative management with biofeedback and Kegel exercises, periurethral bulking agents, or surgical procedures such as the male urethral sling or the artificial urinary sphincter. A proper evaluation is important as bladder dysfunction in the form of detrusor overactivity, detrusor underactivity, and poor bladder compliance can occur independently or coexist with intrinsic sphincter deficiency. Thus, it is important to clearly define patient symptomatology to optimize outcomes.

The elderly or older population segment has a heterogenous definition in the literature with the majority including patients aged between 60 and 80 years. Several studies have proven that a cystectomy can be performed safely in the elderly population. We sought out to review the literature identifying the specific complications and the considerations requiring attention when performing a urinary diversion on an elderly patient. A review of literature performed using PubMed revealed paucity of citations specifically looking at different urinary diversion techniques and the specific complications related in an elderly population. However, we extrapolated additional data from articles that studied cystectomy surgical cohorts with identifiable age stratification. Particular complications and areas deserving of additional attention included gastrointestinal, renal, uretero-enteric anastomotic technique, metabolic disorders, quality of life, and voiding dysfunction. Detailed history and proper counseling of the patient and family are central to the selection of the appropriate urinary diversion technique and help maintain realistic patient expectations with a higher satisfaction rate. It is of paramount importance when considering continent urinary diversions to address the feasibility of adhering to a higher level of maintenance and the patient’s ability to withstand diversion-related complications.

During an ileovesicostomy, urine is diverted to an abdominal stoma at low pressures, thereby avoiding the morbidity associated with cystectomy and allowing for the maintenance of native vesicoureteral junctions. This procedure gained popularity in the 1990s as an option for patients who were physically unable or unwilling to perform clean intermittent catheterization. Initial case series revealed fairly low morbidity with ileovesicostomy. However, subsequent larger case series revealed long-term complications that compromised the efficacy of ileovesicostomy, including recurrent urinary tract infections, bladder stones, upper urinary tract stones, urethral incontinence (persistent or de novo), fascial/stomal stenosis and ileal limb obstruction. Herein, we discuss the presentation, evaluation, and management of failed ileovesicostomy. In patients with an ileovesicostomy, recurrent urinary tract infections, urolithiasis, urinary incontinence and ileal limb obstruction should be evaluated with physical examination, fluoroscopic urodynamics and cystoscopy to determine the need for ileovesicostomy surgical revision, closure of the bladder outlet, repair of fistula or cystectomy with ileal conduit.

Objectives: To report the intermediate outcomes of a transcorporally placed artificial urinary sphincter. Methods: Medical records of 16 consecutive patients treated with transcorporal placement of artificial urinary sphincter from March 2003 to October 2008 were reviewed. The indications for surgery, operative logs, postoperative evaluations, complication rate and postoperative questionnaire assessment utilizing the International Continence Society short form for men were analyzed. Results: Eight patients each underwent primary transcorporal cuff placement and revision surgery. Complete data for analysis were available in 15 patients at a median follow up of 45 months (range 23−91 months). The success rate (defined as use of 0–1 pads per day) was 80% (12/15 patients). Average voiding score was 2/20 (standard deviation 1.88), average irritative score was 3/24 (standard deviation 4.92) and the mean Quality-of-Life score was 0.66 (standard deviation 1.04). Conclusions: Transcorporal placement of an artificial urinary sphincter is both safe and efficacious in patients with a small caliber or atrophic urethra, either as a primary or salvage procedure. Efficacy and level of satisfaction in this subset of patients is equivalent to those undergoing traditional artificial urinary sphincter cuff placement.

With favorable prognosis, radical therapy for pelvic malignancy no longer is just about oncological control, but is important in achieving the trifecta of oncological clearance with acceptable sexual function and urinary outcomes. As we face the prospect of escalating urogenital dysfunction following our radical interventions, we need to carefully assess these functional outcomes and their impact on the quality of life of our patients. In men, this includes urinary impairments with stress urinary incontinence, various types of voiding dysfunction, and sexual impairments (primarily erectile dysfunction and orgasmic dysfunction). Based on appropriate clinical and diagnostic assessments of severity of adverse outcomes depending on patient preference, combination surgery for treatment of erectile dysfunction and stress urinary incontinence is effective and durable and has an established, definitive role to address this not uncommon problem. This article reviews the prevalence of the problem, the available therapeutic options, and evidence of efficacy of these therapies in combination.

Pelvic ischemia can manifest as vascular-mediated erectile dysfunction (ED) and lower urinary tract symptoms (LUTS), and is associated with cardiac ischemia.We aimed to develop a dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) technique to measure pelvic perfusion in benign tissue.Nine men with coronary artery disease (CAD) were compared with nine without. Images were acquired at 3T with T1-weighted DCE-MRI for perfusion. Two-compartment pharmacokinetic modeling was employed to fit signal enhancement from prostate, corpus cavernosal, and spongiosal tissues.Perfusion parameters and validated pelvic symptom scores were compared.The mean International Index of Erectile Function (IIEF) total score was worse in CAD (41.3 +/- 19.7) vs. controls (59.4 +/- 14.9, P = 0.04). The IIEF erectile function domain score trended to worse in CAD (13.7 +/- 9.7) vs. controls (22.0 +/- 9.9, P = 0.09). The mean total International Prostate Symptom Score (IPSS) trended to worse in CAD patients (13.2) than controls (7.0) (P = 0.10). Magnetic resonance perfusion analysis demonstrated lower mean maximal percent enhancement to P0.0001 in the CAD group vs. controls for all the following comparisons: prostate in CAD (22.4 +/- 0.4) vs. controls (26.3 +/- 0.1); cavernosal tissue in CAD (9.3 +/- 0.2) vs. controls (16.6 +/- 0.8); and spongiosal tissue in CAD (20.6 +/- 1.2) vs. controls (24.0 +/- 0.6). Comparison of mean wash-in rates in the unit of 10(-3)/second was also highly significant (P0.0001 for all tissues): prostate in CAD (574.0 +/- 18.0) was lower than controls (1,035.0 +/- 29.0); slower wash-in rates were seen in CAD cavernosal (58.0 +/- 4.0 vs. 139.0 +/- 9.0 in controls) and spongiosal tissue (134.0 +/- 6.0 vs. 278.0 +/- 12.0 in controls).These initial data demonstrate that pelvic perfusion can be measured in noncancerous tissues, and that perfusion correlates with validated measures of ED and LUTS.

Priapism is defined as abnormal prolonged penile erection occurring beyond or unrelated to sexual interest. The disorder is enigmatic yet devastating because of its elusive etiology, irreversible erectile tissue damage, and resultant erectile dysfunction (ED). Current management strategies suffer from a poor understanding of the pathophysiology, especially at the molecular level. The traditional treatments are based more on empirical rather than evidence-based knowledge. The outcomes for restoration of normal erectile function are poor, especially for stuttering priapism. Therefore, it is critical to understand priapism from a molecular level, to formulate treatment strategies and to establish rational prevention strategies for high-risk populations, such as sickle cell disease (SCD) patients and cases of the stuttering variant. This review focuses on the recent advances at the molecular level in priapism and penile erection, and applies the recent knowledge to the treatment of stuttering priapism.

Urinary incontinence (UI) and erectile dysfunction (ED) are both very prevalent conditions. Insertion of an artificial urinary sphincter (AUS) and penile prosthesis (PP) is an effective and proven method of treatment for both conditions. With advancing age, as well as with increasing populations of patients radically treated for prostate cancer, the occurrence of both conditions found in the same patient is increasing. The purpose of this article was to analyze the available evidence for simultaneous surgical management of male ED and UI using prosthetic devices. The existing literature pertaining to dual implantation of AUS and PP was reviewed. The concomitant insertion of the PP with the male perineal sling was also considered. Concurrent ED and UI are increasingly seen in the post radical prostatectomy population, who are often younger and less willing to suffer with these conditions. Insertion of an AUS and PP, either simultaneously or as a two-stage procedure, appears to be a safe, efficacious and long-lasting method of treatment. The improvements in design of both the AUS and PP as well as the development of the single transverse scrotal incision have made simultaneous insertion of these prostheses possible. Dual implantation of the PP and male sling looks promising in a selected population. In conclusion, the insertion of the AUS and PP for the treatment of concurrent UI and ED is safe and effective. Simultaneous insertion of these prostheses in the same patient offers potential advantages in operative and recovery time and is associated with high patient satisfaction. Combination therapy should therefore be included in the arsenal of treatment of these conditions.

Radiation therapy for the treatment of prostate cancer has made tremendous advances in the past century but is still associated with significant urinary morbidities. These complications are divided into acute and late toxicities. Among the recognized acute toxicities are dysuria and urinary retention. Management differs from late toxicities, which may include urethral strictures, fistulas, and radiation-induced hemorrhagic cystitis. Although identical problems are seen in the absence of radiation, the management of these complications is altered by the additive effect of radiotherapy. This is likely due to progressive obliterative endarteritis triggered by radiation therapy. On the basis of the evolving tissue effects of radiotherapy, each treatment should be individualized and tailored to the patient, form and dosage of radiation, and the tissue quality.

Prostate cancer is the second leading cause of cancer deaths in the United States, and its treatment can be in the form of radiotherapy. Radiation therapy can be delivered in several different modalities, each offering its own unique morbidity profile. Radiation targeting the lower urinary tract tissue has both acute and long-term consequences. Depending on the modality of radiation and patient characteristics, the resultant voiding dysfunctions may include urinary obstruction, incontinence, strictures, and urodynamic changes. Voiding dysfunction after radiation therapy for prostate cancer is progressive by virtue of the insidious nature of obliterative endarteritis. Refinements in technique, such as intensity modulated radiation therapy and imaging guided brachytherapy, are geared toward improving cancer control while reducing complications. Treatment of the most severe complications are challenging due to poor tissue quality and limited blood supply. In the most extreme situations, urinary tract diversion may be necessary.

implant placements and the remaining 3,721 procedures (32.4%) were revision procedures. Of the primary placements, there were 6,705 (86.3%) inflatable penile prostheses and 1,060 (13.7%) malleable penile prostheses placed. There were no differences in type of implant placed based on age or race. There were no differences between type of surgery or numbers of surgeries per patient between races. As age increased there were fewer implant placements and more revision surgeries, as well as more implant removals without replacement (see chart below). CONCLUSIONS: In contrast to previously studied populations, age and race do not appear to play a role in the selection of malleable penile prostheses compared to inflatable penile prostheses in the veteran population. As veterans age, they are more likely to undergo revision surgery and more likely to have implants removed without replacement. Further studies are warranted to determine preoperative risk factors for eventual revision surgery.

OBJECTIVE To evaluate the insertion of a urethral sling at the time of radical prostatectomy (RP) in men at high risk of urinary incontinence after RP. PATIENTS AND METHODS Between 1998 and 2000, 49 of 871 men undergoing RP at The University of Texas M.D. Anderson Cancer Center, were identified as at risk of urinary incontinence after RP, based on their age (>65 years), previous transurethral resection of the prostate, previous radiation therapy, clinical stage, and obesity (body mass index of ≥ 30 kg/m2). These 49 men had a suburethral sling inserted at the time of RP, and incontinence after surgery was evaluated using pad counts and patient-completed questionnaires. Retrospectively, incontinence rates and complications in these men were compared with 122 men also at high risk of urinary incontinence after RP who did not have a sling inserted at the time of RP (control group). RESULTS In all, 29 of 49 men (59%) with a suburethral sling reported using either no pad or one pad per day for urinary leakage at 6 months after RP, compared with 83 of 118 (70%) in the control group. At 12 months after RP, 34 of 46 (74%) men with a suburethral sling reported using no or one pad, compared with 75 of 89 (84%) in the control group. Seventeen (35%) men were treated for urethral stricture in the sling group and 17 (14%) in the control group (P = 0.001). CONCLUSION The urethral sling modification concurrent with RP is feasible, but does not decrease incontinence compared with a similar group of high-risk patients who did not have the sling modification. In addition, the stricture rate in the sling group was unacceptably high. Currently, we do not recommend the use of a urethral sling at the time of RP.

Aims Detrusor sphincter dyssynergia (DSD) is defined as: “a detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle.” In neurogenic etiology, this usually refers to involuntary contraction of the external striated sphincter and has classically been termed detrusor-external sphincter dyssynergia (DESD). There is currently no consensus regarding diagnosis [specifics of electromyographic (EMG) or voiding cystourethrographic (VCUG) determination], and little data on how well these modalities correlate. We explore the diagnostic congruence for DESD between needle EMG and VCUG in the neurogenic population. Methods Consecutive studies performed by a single urodynamicist at a major neurologic center were reviewed. Presence of DESD was determined by increased wire needle EMG activity and/or by dilated bladder neck and proximal urethra during detrusor contraction, in the absence of valsalva or attempt to inhibit voiding. Minimal acceptable criterion for agreement between the two tests was set at 70%. Results Fourty nine patients were diagnosed with DESD, had a videourodynamic study available, and had no history of sphincterotomy or stent. Binomial testing demonstrated significant disagreement (P

Purpose: Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence.Materials and Methods: Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve.Results: A total of 28 patients 28 to 83 years old...

RESULTS: Of the 128 patients who underwent SPC, 105 patients (64 female, 41 male) fit the inclusion criteria and were sent the PGI-I questionnaire. Response rate was 44.8% (47/105). Mean age at the time of SPC placement was 54.9 years. Mean follow up was 25.1 months (1-120). Overall, 53 pts had MS, 26 had SCI, 4 had PD, 22 had other neurologic disorders (cerebrovascular accident, cerebral palsy, brain tumor, seizure disorder, transverse myelitis). Overall, success was seen in 41/47 patients (87.2%). Only 6.4% (3/47) patients reported a negative PGI-I (score 5-7/7). An early postoperative complication (within 30 days of surgery) was seen in 1/ 128 patients (0.08%) and consisted of bowel perforation requiring small bowel resection. CONCLUSIONS: SPC is an effective solution in many carefully selected patients with NGB conditions. Over 85% considered the SPC to have improved their urological quality of life with a mean follow-up of over 2 years. Adverse events are rare, though can be particularly serious in this group of neurologically impaired patients.

INTRODUCTION AND OBJECTIVES: Ureterointestinal stricture (UIS) is an infrequent but potentially severe complication after cystectomy with ileal conduit. We aimed to evaluate the safety of a conservative approach for this complication, based on a 10-year singleinstitution experience. METHODS: Between January 2001 and May 2011, 775 patients underwent a radical cystectomy at our institution. Patients who underwent orthotopic neobladder, continent diversion or who were followed elsewhere were excluded from further analysis. A total of 304 consecutive patients, who underwent a radical cystectomy with ileal conduit, remained in the analysis. Patient files and imaging were reviewed and data was retrospectively extracted. Specific details pertaining to UIS were collected: cause, laterality, location of stricture, date of stricture diagnosis, symptoms, treatment, renal function and survival. RESULTS: 29 UIS were diagnosed in 22/304 (6.6 %) patients, when a new-onset hydrouretero-nephrosis (HUN) or increase of the preexisting HUN was imaged by ultrasound or CT-scan. A loopogram was performed next to confirm the UIS. 11 Strictures were located at the left side, 6 on the right side and 6 were bilateral. The median time from cystectomy to stricture diagnosis was 11.2 months (146 months). A declining glomerular filtration rate (GFR), flank pain and (recurrent) febrile urinary tract infections were indications for active therapy. 7 Patients underwent antegrade DJ stent placement, 2 patients received percutaneous nephrostomy tubes (PCN) as a definitive treatment and 2 patients underwent ureterointestinal reimplantation. Asymptomatic patients with an UIS and a favorable GFR were conservatively managed. The mean GFR (ml/min/1.73m) at 60 months was 62 for the conservatively managed group, 48 for the DJ stents group and 60 for all patients with radical cystectomy and ileal conduit without an UIS. All conservatively managed patients remained asymptomatic during followup and no active treatment was as such performed, except in one patient with a transitional cell carcinoma (TCC) recurrence. CONCLUSIONS: According to our data, UIS can safely be left untreated in asymptomatic patients with a favorable GFR at time of UIS diagnosis. There was a good preservation of the GFR during follow-up, all patients remained asymptomatic and maximal patient comfort was preserved, which is why we recommend this approach in this selected population, although additional data are needed to support our findings.

Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak point pressure. In contrast, fascial slings are designed to achieve continence by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic bladder.From October 1994 until February 1999, 10 females and 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age was 14 years (range 8 to 18) and all were incontinent despite aggressive medical management. Urodynamic evaluation was performed preoperatively and postoperatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance was only compared in the 12 nonaugmented cases.With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in mean stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance was unchanged in the nonaugmented group (22.00 versus 26.78 ml/cm. H2O). Four patients (22.22%) remained wet after surgery, of whom 2 were successfully treated with a repeat sling procedure and 1 with collagen injection for an overall continence rate of 94.44%.Fascial slings can be effectively used in pediatric patients for neuropathic incontinence. Furthermore, stress urinary incontinence is corrected by increasing the Valsalva or stress leak point pressure with preservation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage.