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Functional: Surgery for Male SUI: Difference between revisions

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


===== Transurethral bulking agents =====
===== Transurethral bulking agents =====
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** A trial of bulking agent may be appropriate in men with neurogenic SUI
** A trial of bulking agent may be appropriate in men with neurogenic SUI


==== Adjustable balloon devices (ProACT) ====
===== Adjustable balloon devices (ProACT) =====
*'''Disadvantages'''
*'''Disadvantages'''
** '''Increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
** '''Increased incidence of intraoperative complications and need for explanation within the first 2 years compared to the male sling and AUS'''
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===== Artificial Urinary Sphincter (AUS) =====
===== Artificial Urinary Sphincter (AUS) =====
* '''Gold standard (AMS 800) for the treatment of SUI in males'''
* '''<span style="color:#ff0000">Gold standard (AMS 800) for the treatment of SUI in males'''
* '''Advantages'''
* '''Advantages'''
** '''Long-term durability'''
** '''Long-term durability'''
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*#'''<span style="color:#ff0000">Control pump</span>'''
*#'''<span style="color:#ff0000">Control pump</span>'''
*#'''<span style="color:#ff0000">Pressure-regulating balloon (PRB)</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'''
*#'''<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.'''
*#*'''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 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.
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***Decreased success rates when undergoing male slings
***Decreased success rates when undergoing male slings


====== Contraindications (4) ======
====== Contraindications'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640149 §]''' ======


* '''Absolute'''
*'''<span style="color:#ff0000">Absolute (6):'''
# '''Poor manual dexterity'''
*#'''<span style="color:#ff0000">Lack of physical or mental dexterity to manipulate the pump'''
# '''Cognitive disability'''
*#'''<span style="color:#ff0000">Repetitive urinary tract infections'''
# '''Poor urethral tissue integrity'''
*# '''<span style="color:#ff0000">Urethral diverticula at the expected implant site/Poor urethral tissue integrity'''
# '''Active infection at surgical site'''
*# '''<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'''
* '''Relative'''
*#'''<span style="color:#ff0000">Active infection at surgical site'''
** '''Expected repeat transurethral instrumentation'''
*'''Relative (4):'''
***'''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'''
*#'''High-grade vesicoureteric reflux'''
**** A male sling will allow passage of a 24-Fr resectoscope
*#'''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 ======
====== Technique ======
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** '''<span style="color:#ff0000">Urethral injury</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.'''
*** '''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</span>'''
*** '''<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 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'''
****'''The defect should be repaired and a catheter inserted for 7 days'''
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** '''<span style="color:#ff0000">Infection</span>'''
** '''<span style="color:#ff0000">Infection</span>'''
*** '''Device infection occurs in <1-5% of cases'''
*** '''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'''
***'''Diagnosis and Evaluation'''
****'''Presents with pain at the site of the AUS, fever, scrotal warmth or erythema, or skin changes'''
****'''Rule out inadvertent cuff activation'''
***'''Management'''
*** '''Management'''
****'''Urgent AUS explantation'''
****'''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.'''
*****'''AUS should not be reimplanted until at least 3 months''' to allow the infection to clear and inflammation to subside.
***** '''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">Late Post-operative</span>'''
**'''<span style="color:#ff0000">Persistent leakage</span>'''
**'''<span style="color:#ff0000">Persistent leakage</span>'''
**'''<span style="color:#ff0000">Mechanical failure</span>'''
**'''<span style="color:#ff0000">Cuff erosion</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.
***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.
***'''Management:'''
***'''Risk factors'''
****'''AUS explant with the urethral catheter left in place for a few weeks to allow the urethral defect to heal'''
**** '''Campbell’s: radiation therapy, prior erosions with the need for removal of the device, prolonged catheterization and instrumentation, hypertension and other comorbidities'''
****'''AUS should not be re-implanted until at least 3 months'''
***** '''No increased risk of erosion with prior transobturator sling'''
** '''<span style="color:#ff0000">Decreased efficacy over time and reoperations are common</span>'''***'''The current version consists of''' a hydraulic system composed of '''3 separate parts:'''
**** 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'''.
***#'''A urethral cuff''' of varying sizes
***** '''No increased risk of erosion with increasing age, proximal or distal bulbar urethral placement of the AUS, or prior radical prostatectomy'''
***#'''A pressure regulating balloon reservoir''' with three available pressure profiles
***'''Management'''
***# '''A control pump'''
****'''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>]'''
****The device will fail if any of the 3 parts, the tubing, or connections suffer a micro-perforation with loss of fluid
*****Immediate removal of all the components of the AUS is imperative because they are assumed to be infected.
***The rate of device failure increases with time, with '''failure rates of'''
****'''AUS should not be re-implanted until at least 3 months''' and urethral healing is confirmed by urethrography
****'''≈24% at 5 years'''
** '''<span style="color:#ff0000">Urethral atrophy</span>'''
****'''≈ 50% at 10 years'''
*** '''Results from the chronic compression of the spongy tissue under the occlusive cuff'''
***'''An AUS might need to be replaced over time due to persistent or recurrent incontinence generally due to:'''
*** '''Most common cause of gradual return of incontinence and revision of the AUS'''
***#'''Urethral atrophy'''
*** '''Management'''
***# '''Improper cuff sizing'''
**** '''Options:'''
***#'''Partial fluid loss'''
***** '''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 =====
===== Bladder neck closure or diversion =====
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*'''May be required if inadequate tissue integrity at the bladder neck or urethra to accommodate a sling or AUS'''
*'''May be required if inadequate tissue integrity at the bladder neck or urethra to accommodate a sling or AUS'''


== AUS Complications ==
== Special Situations ==
 
=== Urinary retention ===
 
* Rare
* '''Rule out inadvertent cuff activation'''
* '''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.
* '''Late-onset urinary retention mandates endoscopic and urodynamic evaluation to rule out:'''
** '''Proximal urethral obstruction'''
** '''Erosion'''
** '''Detrusor failure'''
 
=== Device infection ===
 
* '''The rate of infection with initial AUS surgery is 1-3%'''
* '''Skin pathogens (staphylococcus epidermidis (most common) and staphylococcus aureus) are the most commonly cultured organisms'''
* '''Diagnosis and Evaluation'''
** '''Initial presentation of an early postoperative AUS infection is usually scrotal pain, although can be erythema, edema, and frank purulence'''
* '''Management'''
** '''Almost always require explantation'''
*** Implant infections are not amenable to antibiotic therapy
*** Traditional management includes device removal followed by a waiting period of several months with delayed reimplantation.
*** '''Immediate salvage of infected, noneroded AUS can be accomplished with complete device removal, antiseptic irrigation, and immediate reimplantation'''
**** '''Contraindications to salvage include sepsis, ketoacidosis, necrotizing infection, immunosuppression, and the finding of gross purulent material at the time of explantation'''
 
=== Urethral erosion ===
 
* Occurs in up to 5% of AUS implantations
** '''Introduction of narrow back modification of AUS has reduced the risk of erosion'''
* '''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'''
** '''Immediate removal of all the components of the AUS is imperative because they are assumed to be infected.'''
** '''The urethral injury is managed with urethral catheter drainage''' and/or suprapubic cystostomy
** Reimplantation is considered only after a delay of 3-6 months and urethral healing is confirmed by urethrography
 
=== Urethral atrophy ===
 
* '''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'''
 
=== Urethral stricture ===
 
* '''The safest approach for an initial stricture would be laser incision through a smaller caliber endoscope such as a ureteroscope.'''
** Although exploration of the AUS cuff with uncoupling of the cuff will allow safe endoscopic management of strictures and tumors with resectoscopes, this should be reserved for cases not amenable to simple laser incision with small caliber and scopes.
** Antegrade incision is feasible but offers less control than the retrograde approach.
** Open surgical reconstruction should be reserved for refractory cases.
 
=== Mechanical failure ===
 
* '''7-10-year device life for the AUS'''
* '''Management'''
** '''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.'''
 
=== Persistent incontinence ===


=== Persistent Incontinence after Surgery (AUS or sling) ===
* '''Causes'''
* '''Causes'''
*# '''Inadvertent deactivation'''
*# '''Inadvertent deactivation'''
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*** Connection to the existing device requires division of the existing cuff tubing and use of a metal Y connector. An additional 3 mL of fluid must be added to the system.
*** Connection to the existing device requires division of the existing cuff tubing and use of a metal Y connector. An additional 3 mL of fluid must be added to the system.
** '''However, in a relatively young patient, the cuff should be downsized rather than placing a second cuff to avoid using additional locations on the bulbar urethra, which will be necessary for future device replacements over time.'''
** '''However, in a relatively young patient, the cuff should be downsized rather than placing a second cuff to avoid using additional locations on the bulbar urethra, which will be necessary for future device replacements over time.'''
=== Urethral stricture ===
* '''The safest approach for an initial stricture would be laser incision through a smaller caliber endoscope such as a ureteroscope.'''
** Although exploration of the AUS cuff with uncoupling of the cuff will allow safe endoscopic management of strictures and tumors with resectoscopes, this should be reserved for cases not amenable to simple laser incision with small caliber and scopes.
** Antegrade incision is feasible but offers less control than the retrograde approach.
** Open surgical reconstruction should be reserved for refractory cases.
===Climacturia===
*'''In a patient with bothersome climacturia, treatment may be offered.'''


*'''As with post-prostatectomy SUI, for those with sexual arousal incontinence or climacturia, conservative management (emptying the bladder prior to sex, use of condoms to catch the urine, and PFME) should be the initial treatment'''
* '''Imipramine, a tricyclic antidepressant, has been used, but this medication is generally contraindicated in men age > 65 due to the risk of somnolence, falling down, and changes in cognition.'''
*'''Both the AUS and the trans-obturator male sling, when implanted for SUI, are associated with high rates of improvement in climacturia'''
===Concomitant IPT and erectile dysfunction===
*'''In patients with concomitant IPT and erectile dysfunction, a concomitant or staged procedure may be offered.'''
== Long-term results of AUS and slings ==
== Long-term results of AUS and slings ==


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* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 91
* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 91
*[https://pubmed.ncbi.nlm.nih.gov/31059663/ Sandhu, Jaspreet S., et al. "Incontinence after prostate treatment: AUA/SUFU guideline." ''The Journal of urology'' 202.2 (2019): 369-378.]
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