Editing Functional: Surgery for Male SUI (section)

==== Options (5): ====
# '''<span style="color:#ff0000">Transurethral bulking agents'''
# '''<span style="color:#ff0000">Adjustable balloon devices (ProACT)''' 
# '''<span style="color:#ff0000">Bulbar urethral sling'''
# '''<span style="color:#ff0000">Artificial Urinary Sphincter (AUS)'''
# '''<span style="color:#ff0000">Bladder neck closure with diversion'''

===== Transurethral bulking agents =====
*'''Advantage'''
**'''Least invasive technique'''
*'''Disadvantage'''
**'''Least effective surgical technique'''
***Cure is rare
*'''<span style="color:#ff0000">Indication</span>'''
**'''<span style="color:#ff0000">Consider in patients who are unable to tolerate or refuse more invasive surgical therapy</span>'''
***'''Limited role after prostatectomy given the severity of incontinence''' and post-surgical scarring in the vesicourethral region
** A trial of bulking agent may be appropriate in men with neurogenic SUI

===== Adjustable balloon devices (ProACT) =====
*'''Disadvantages'''
** '''Increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
*'''<span style="color:#ff0000">Indication</span>'''
**'''<span style="color:#ff0000">Consider for mild SUI</span>'''
===== Bulbar Urethral Sling =====
*<span style="color:#ff0000">'''Indication'''</span>
**'''<span style="color:#ff0000">Consider for mild to moderate SUI</span>'''
*** '''Mild-to-moderate incontinence defined as a 24-hour pad weight < 150 g for mild UI and < 400 g for moderate UI'''
***'''<span style="color:#ff0000">Poor efficacy in comparison to an AUS in patients with severe incontinence.</span>'''
**Alternatives for those who refuse AUS from fear of infection, erosion, or mechanical failure, as well as those with limited physical or cognitive capacity
*'''<span style="color:#ff0000">Contraindications (3):</span>'''
*# '''<span style="color:#ff0000">Radiation</span>'''
*# '''<span style="color:#ff0000">Urethral erosion</span>'''
*# '''<span style="color:#ff0000">Severe gravitational urinary incontinence</span>'''
* '''Types (3)'''
*# '''InVance''' (AMS): '''mesh placed outside the bulbospongiosus muscle and anchored to the pubic rami'''
*#* '''No longer available in the US'''
*#* '''Mechanism of continence thought to be from compression of urethra'''
*# '''AdVance''' (AMS): '''transobturator fixation of mesh'''
*#* '''Mechanism of continence thought to be from enhanced rhabdosphincter function without significant compression; designed to reposition and lengthen the membranous urethra'''
*#* See [https://www.medgadget.com/2019/02/advance-xp-male-sling-system-for-urinary-incontinence-now-available-in-u-s.html Figure]
*# '''Virtue''' (Coloplast): '''combined prepubic and transobturator sling'''
*#* Four-armed mesh device (quadratic fixation) that provides a '''long segment of urethral compression''' against the urogenital diaphragm '''and a separate elevation component''' because of the prepubic and transobturator arms, respectively
*#* '''Limited data on efficacy and durability'''
* '''After urethral disruption due to pelvic fracture, neither the InVance or the AdVance slings are likely to reliably provide effective elevation, elongation, or compression because of distortion of the bony pelvic anatomy''' and high likelihood of rhabdosphincter damage
* '''Technique'''
**'''Determining the appropriate tension of the sling is the most critical portion of the operation'''
* '''Adverse events''' (generally low complication rate):
**'''Urinary retention'''
***Typically resolves within 1 week
**'''Pelvic and perineal pain and paresthesia'''
***Typically resolves within 12 weeks
**'''Anchoring complications from bone anchors'''
**'''Erosion or infection'''
***'''Both are exceedingly rare.'''
****If a male sling is thought to be infected or documented to be eroded on cystoscopy, the '''management is similar to management of an infected or eroded AUS (see below)'''

===== Artificial Urinary Sphincter (AUS) =====
* '''<span style="color:#ff0000">Gold standard (AMS 800) for the treatment of SUI in males'''
* '''Advantages'''
** '''Long-term durability'''
*** '''Revision rates:'''
**** 2 years: 16%
**** '''5 years: 28%'''
** '''Effective across the spectrum of moderate and severe degrees of urinary loss''' [[File:Blausen 0059 ArtificialUrinarySphincter.png|alt=3 parts of the Artificial Urinary Sphincter: Cuff, Balloon reservoir, Pump. Source: Wikipedia|thumb|3 parts of the Artificial Urinary Sphincter: Cuff, Balloon reservoir, Pump. Source: [[commons:File:Blausen_0059_ArtificialUrinarySphincter.png|Wikipedia]]]]
* '''<span style="color:#ff0000">Device consists of (3)</span>[https://medlineplus.gov/ency/article/003983.htm]'''
*#'''<span style="color:#ff0000">Control pump</span>'''
*#'''<span style="color:#ff0000">Pressure-regulating balloon (PRB)</span>'''
*#'''<span style="color:#ff0000">Fluid-filled cuff</span>''' '''placed around the bladder neck or bulbar urethra, of varying sizes'''
*#*'''Provides a 2-cm zone of circumferential compression.'''
*#** The degree of compression is determined by the compliance of the pressure-regulating balloon (PRB), with the pressure selected based on patient tissue characteristics and location of the cuff.
*#*** '''The standard PRB for bulbar AUS is 61-70 cm H2O''' and balances the need for occlusion with the risk for erosion. Lower pressures provide reduced continence rates but may be advisable if risk for erosion is considered excessive
[[File:Artificial urethral sphincter - CT axial 001.jpg|alt=Axial CT images demonstrating cuff (circled) in left panel, and balloon reservoir visible in right panel. Source: Wikipedia|thumb|Axial CT images demonstrating cuff (circled) in left panel, and balloon reservoir visible in right panel. Source: [[commons:File:Artificial_urethral_sphincter_-_CT_axial_001.jpg|Wikipedia]]]]
[[File:Artificial urethral sphincter - CT coronar 001.jpg|alt=Coronal CT images demonstrating cuff (square) and PRB visible (circled). Source: Wikipedia|thumb|Coronal CT images demonstrating cuff (square) and PRB visible (circled). Source: [[commons:File:Artificial_urethral_sphincter_-_CT_coronar_001.jpg|Wikipedia]]]]
======Indications======
*'''<span style="color:#ff0000">Consider for mild to severe SUI</span>''' 
*'''<span style="color:#ff0000">Preferred in patients with prior (3):</span>'''
**'''<span style="color:#ff0000">Radiation</span>'''
***Improved outcomes compared to male slings or adjustable balloons for treatment of patients with SUI after primary, adjuvant, or salvage radiotherapy
***'''Complication rates are higher'''
**'''<span style="color:#ff0000">Urethral reconstruction</span>'''
***Urethral strictures of the anterior urethra and urethral stenosis of the posterior urethra can arise after RP, RT, or treatment for IPT. Urethral reconstructive surgery is often used to treat narrowing in the urethra.
*** '''Male slings will not be effective given post-surgical changes related to most types of urethral reconstruction in the posterior and anterior urethra'''
***'''Complications rates are higher'''
**** Depending on the technique employed (urethra transecting or not) the blood supply to the urethra may be diminished and potentially decrease the life span of an AUS.
** '''<span style="color:#ff0000">Vesicourethral anastomotic stenosis or bladder neck contracture</span>'''
***Decreased success rates when undergoing male slings

====== Contraindications'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640149 §]''' ======

*'''<span style="color:#ff0000">Absolute (6):'''
*#'''<span style="color:#ff0000">Lack of physical or mental dexterity to manipulate the pump'''
*#'''<span style="color:#ff0000">Repetitive urinary tract infections'''
*# '''<span style="color:#ff0000">Urethral diverticula at the expected implant site/Poor urethral tissue integrity'''
*# '''<span style="color:#ff0000">Complex, unstable, or recurrent urethral stricture diseases'''
*#'''<span style="color:#ff0000">Small capacity and/or non-compliant bladder prior to definitive treatment'''
*#'''<span style="color:#ff0000">Active infection at surgical site'''
*'''Relative (4):'''
*#'''High-grade vesicoureteric reflux''' 
*#'''Recurrent intravesical or intraurethral diseases such as stones or tumors that are expected to require repeat transurethral instrumentation'''
*##'''Bulbar urethral placement of an AUS will not allow appropriate instrumentation and transurethral resection in patients with recurrent bladder tumors; in these patients, a male sling is preferred'''
*##* A male sling will allow passage of a 24-Fr resectoscope
*#'''Bladder neck contracture prior to treatment'''
*# '''Detrusor overactivity''' 
*Radiotherapy is not considered to be a contraindication for placement of the AUS in males'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640149 §]'''

====== Technique ======

*'''<span style="color:#ff0000">Cuff is most commonly placed around bulbar urethra via a perineal incision.</span> The aim is to place the cuff as proximal on the bulbar urethra as possible, proximal to the convergence of the corporeal bodies'''
**'''Single cuff perineal approach is preferred, superior outcomes compared to transverse scrotal incision[https://pubmed.ncbi.nlm.nih.gov/31059663/ ★]'''
* '''Summary of Steps'''
** After incision of the skin, Colles fascia, and bulbospongiosus muscle, the Buck fascia is incised as it reflects off the bulbar urethra onto the diverging corporeal bodies.
** Create a 2-cm wide tunnel under direct vision using sharp dissection, dorsal to the Buck fascia over the roof of the urethra.
** Pass a right-angle clamp through this tunnel.
** Measure the circumference of the urethra around the corpus spongiosum to guide selection of cuff size, '''most commonly 4 or 4.5 cm.'''
** Pass the tubing from the AUS cuff through the overlying bulbospongiosus muscle into the deep perineal space beneath the Colles fascia.
** '''Place the pressure-regulating balloon'''
***'''May be achieved through a scrotal, perineal, or abdominal incision, depending on prior surgical incisions, body habitus, and surgeon preference.'''
**** '''<span style="color:#ff0000">Contraindications to the scrotal/perineal approach:</span>'''
****# '''<span style="color:#ff0000">Mesh hernia repairs</span>'''
****# '''<span style="color:#ff0000">Radical cystectomy and other extensive abdominal surgery</span>'''
***** '''<span style="color:#ff0000">In such cases, the abdominal approach reduces the risk for bladder or intestinal injury</span>'''
** '''Place the pump assembly into the anterior scrotum''' '''from the inguinal, scrotal, or perineal incision.'''
** After completing the connections, the device is cycled several times through the activation and deactivation states.
** '''Verify adequate coaptation of the urethra via urethroscopy.''' 
***'''The closed cuff should cause slight blanching of the urethral tissue''', indicating adequate urethral coaptation, filling, and connection of the device.
* '''Bladder neck AUS'''
** '''Remains an optional, although more invasive, method of cuff placement in men with sphincteric UI in whom the prostate is without external surgical or traumatic disruption.'''
*** '''Thus, for cases of myelomeningocele and other neuropathic disorders, it should be considered as an alternative to bulbar AUS.'''
*** '''Contraindicated after radical prostatectomy'''
** '''Advantages include lower likelihood of erosion and cuff atrophy'''
** '''Requires higher PRB pressures to ensure coaptation'''
* '''Postoperative deactivation of the cuff for 4-6 weeks is essential for proper healing without erosion.'''

====== Adverse Events ======

* '''<span style="color:#ff0000">Intra-operative</span>'''
** '''<span style="color:#ff0000">Urethral injury</span>'''
*** '''Urethral injury during any implant surgery places the patient at risk for device infection due to the presence of colonizing bacteria in the urethra.'''
*** '''<span style="color:#ff0000">If identified during implantation, the defect should be repaired, procedure should be abandoned and subsequent implantation should be delayed[https://pubmed.ncbi.nlm.nih.gov/31059663/ ★]</span>'''
****'''The risk of devastating device infection outweighs any benefit and thus the procedure should be aborted.''' 
****'''The defect should be repaired and a catheter inserted for 7 days'''
* '''<span style="color:#ff0000">Early Post-operative</span>'''
** '''<span style="color:#ff0000">Infection</span>'''
*** '''Device infection occurs in <1-5% of cases'''
***'''Skin pathogens (staphylococcus epidermidis (most common) and staphylococcus aureus) are the most commonly cultured organisms'''
***'''<span style="color:#ff0000">Diagnosis and Evaluation</span>'''
****'''<span style="color:#ff0000">Presents with pain at the site of the AUS/scrotal pain, fever, scrotal warmth, erythema, edema, or skin changes, or frank purulence</span>'''
***'''<span style="color:#ff0000">Management</span>'''
****'''<span style="color:#ff0000">Urgent AUS explantation[https://pubmed.ncbi.nlm.nih.gov/31059663/ ★]</span>'''
*****Implant infections are not amenable to antibiotic therapy
***** Traditional management includes device removal followed by a waiting period of several months with delayed reimplantation.
****'''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.'''[https://pubmed.ncbi.nlm.nih.gov/31059663/ ★]'''
**'''<span style="color:#ff0000">Urinary Retention</span>'''
***'''Diagnosis and Evaluation'''
****'''Rule out inadvertent cuff activation'''
*** '''Management'''
****'''In the immediate postoperative period, should be managed by with a small (10 or 12 Fr) catheter for 24-48 hours. Cuff deactivation must be confirmed before catheterization.'''
***** '''Instructions to deactivate AUS (pdf)''' '''(video)'''
**** '''If the patient fails a voiding trial at 48 hours, suprapubic cystostomy drainage is recommended to reduce the risk for urethral erosion'''
**** '''Retention persisting beyond several weeks implies undersizing of the cuff; in such cases, reoperation and cuff replacement may be required.''' Correlation with preoperative urodynamic findings is advised in such cases.
* '''<span style="color:#ff0000">Late Post-operative</span>'''
**'''<span style="color:#ff0000">Persistent leakage</span>'''
**'''<span style="color:#ff0000">Cuff erosion</span>'''
***Occurs in up to 5% of AUS implantations
**** '''Introduction of narrow back modification of AUS has reduced the risk of erosion'''
***Can be due to unrecognized urethral injury at the time of initial surgery or more likely due to subsequent instrumentation of the urethra including catheterization.
***'''Risk factors'''
**** '''Campbell’s: radiation therapy, prior erosions with the need for removal of the device, prolonged catheterization and instrumentation, hypertension and other comorbidities'''
***** '''No increased risk of erosion with prior transobturator sling'''
**** SASP 2016: '''radiation therapy, prior erosions''' or infection in a previous AUS, a '''prior urethroplasty''', '''multiple endoscopic treatments for bladder neck contracture or urethral stricture, or prior urethral stent placement'''. There is also a much lower but still significant increased risk of erosion with a '''prolonged postoperative catheterization interval''' (> 48 hours), '''or use of either a 3.5 cm or transcorporal cuff compared to a standard 4 cm cuff'''.
***** '''No increased risk of erosion with increasing age, proximal or distal bulbar urethral placement of the AUS, or prior radical prostatectomy'''
***'''Management'''
****'''AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal[https://pubmed.ncbi.nlm.nih.gov/31059663/ <span style="color:#ff0000">★</span>]'''
*****Immediate removal of all the components of the AUS is imperative because they are assumed to be infected.
****'''AUS should not be re-implanted until at least 3 months''' and urethral healing is confirmed by urethrography
** '''<span style="color:#ff0000">Urethral atrophy</span>'''
*** '''Results from the chronic compression of the spongy tissue under the occlusive cuff'''
*** '''Most common cause of gradual return of incontinence and revision of the AUS'''
*** '''Management'''
**** '''Options:'''
***** '''Cuff downsizing'''
***** '''Movement of the cuff to a more proximal or distal location where the urethra may be thicker'''
***** '''Placement of a second cuff in tandem'''
**'''<span style="color:#ff0000">Mechanical failure</span>'''
***'''7-10-year device life for the AUS'''
****Rate of device failure increases with time, with '''failure rates of'''
*****'''≈24% at 5 years'''
*****'''≈ 50% at 10 years'''
***'''Causes'''
****'''Failure in any of the 3 parts (cuff, balloon reservoir, or pump), the tubing, or connections suffer a micro-perforation with loss of fluid'''
*** '''Management'''
**** '''An AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to:'''
****#'''Urethral atrophy'''
****# '''Improper cuff sizing'''
****#'''Partial fluid loss'''
****'''In the absence of infection or erosion, replacement of an isolated malfunctioning component may be feasible if the revision occurs within 3 years of implantation.'''
***** However, a slow leak from the PRB may be difficult to diagnose intraoperatively, and, if in doubt, total device replacement is prudent.
**** '''Devices older than 3 years old should be replaced in entirety.'''
**'''<span style="color:#ff0000">Urinary Retention</span>'''
***'''Late-onset urinary retention mandates endoscopic and urodynamic evaluation to rule out:'''
**** '''Proximal urethral obstruction'''
**** '''Erosion'''
**** '''Detrusor failure'''

===== Bladder neck closure or diversion =====
*'''Can be considered in appropriately motivated and counseled patients who are unable to obtain adequate long-term quality of life'''
**'''If bladder preservation is feasible, conversion to a Mitrofanoff (e.g. Appendix, Monti), incontinent ileovesicostomy, or suprapubic tube with bladder neck closure may confer an improved QoL.'''
**'''In the event of the “hostile” bladder, cystectomy in combination with either an ileal conduit or continent catheterizable pouch''' would best manage incontinence while protecting the upper tracts.
*'''May be required if inadequate tissue integrity at the bladder neck or urethra to accommodate a sling or AUS'''