Editing Functional: Surgery for Male SUI (section)

====== 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'''