Alexander Friedl

Risk Factors for Failure of Male Slings and Artificial Urinary Sphincters: Results from a Large Middle European Cohort Study

Introduction: We analysed the impact of predefined risk factors: age, diabetes, history of pelvic irradiation, prior surgery for stress urinary incontinence (SUI), prior urethral stricture, additional procedure during SUI surgery, duration of incontinence, ASA-classification and cause for incontinence on failure and complications in male SUI surgery. Materials and Methods: We retrospectively identified 506 patients with an artificial urinary sphincter (AUS) and 513 patients with a male sling (MS) in a multicenter cohort study. Complication rates were correlated to the risk factors in univariate analysis. Subsequently, a multivariate logistic regression adjusted to the risk factors was performed. A p value <0.05 was considered statistically significant. Results: A history of pelvic irradiation was an independent risk factor for explantation in AUS (p < 0.001) and MS (p = 0.018). Moreover, prior urethral stricture (p = 0.036) and higher ASA-classification (p = 0.039) were positively correlated with explantation in univariate analysis for AUS. Urethral erosion was correlated with prior urethral stricture (p < 0.001) and a history of pelvic irradiation (p < 0.001) in AUS. Furthermore, infection was correlated with additional procedures during SUI surgery in univariate analysis (p = 0.037) in MS. Conclusions: We first identified the correlation of higher ASA-classification and explantation in AUS. Nevertheless, only a few novel risk factors had a significant influence on the failure of MS or AUS.

Antibiotic Coating of the Artificial Urinary Sphincter (AMS 800): Is it Worthwhile?

OBJECTIVE To investigate the impact of the antibiotic coating InhibiZone on the infection and explantation rates of the AMS 800 in comparison to the AMS 800 without InhibiZone. MATERIALS AND METHODS We retrospectively identified 305 patients with an AMS 800 in a multicenter cohort study. Patients were subsequently divided into InhibiZone and without InhibiZone-coated groups. Infection and explantation rates were analyzed by univariate and consecutively by multivariate logistic regression adjusted to variable risk factors. The infection-free interval was estimated by Kaplan-Meier plot and compared by the log-rank test. A P value below .05 was considered statistically significant. RESULTS We identified 47 patients with InhibiZone and 258 without InhibiZone coating. In univariate analysis, we could not identify a significant difference in infection (P = .932) or explantation (P = .715) rates between the groups. In multivariate analysis, impaired wound healing (P = .008) and urethral erosion (P < .001) were independent predictors for infection. The InhibiZone coating neither demonstrated significant influence on the infection rate (P = .534) nor on the explantation rate (P = .214). There was no significant difference in estimated infection-free survival between the groups (P = .265). CONCLUSION The antibiotic coating of the AMS 800 had no significant impact on infection or explantation rates in our cohort.

Complications and Short-Term Explantation Rate Following Artificial Urinary Sphincter Implantation: Results from a Large Middle European Multi-Institutional Case Series.

Background/Aims/Objectives: To analyze perioperative complication and short-term explantation rates after perineal or penoscrotal single-cuff and double-cuff artificial urinary sphincter (AUS) implantation in a large middle European multi-institutional patient cohort. Methods: 467 male patients with stress urinary incontinence underwent implantation of a perineal single-cuff (n = 152), penoscrotal single-cuff (n = 99), or perineal double-cuff (n = 216) AUS between 2010 and 2012. Postoperative complications and 6-month explantation rates were assessed. For statistical analysis, Fishers exact test and Kruskal-Wallis rank sum test, and a multiple logistic regression model were used (p < 0.05). Results: Compared to perineal single-cuff AUS, penoscrotal single-cuff implantation led to significantly increased short-term explantation rates (8.6% (perineal) vs. 19.2% (penoscrotal), p = 0.019). The postoperative infection rate was significantly higher after double-cuff compared to single-cuff implantation (6.0% (single-cuff) vs. 13.9% (double-cuff), p = 0.019). The short-term explantation rate after primary double-cuff placement was 6.5% (p = 0.543 vs. perineal single-cuff). In multivariate analysis, the penoscrotal approach (p = 0.004), intraoperative complications (p = 0.005), postoperative bleeding (p = 0.011), and perioperative infection (p < 0.001) were independent risk factors for short-term explantation. Conclusions: Providing data from a large contemporary multi-institutional patient cohort from high-volume and low-volume institutions, our results reflect the current standard of care in middle Europe. We indicate that the penoscrotal approach is an independent risk factor for increased short-term explantation rates.

Targeting Moderate and Severe Male Stress Urinary Incontinence With Adjustable Male Slings and the Perineal Artificial Urinary Sphincter: Focus on Perioperative Complications and Device Explantations

Purpose To analyze perioperative complications and postoperative explantation rates for selected readjustable male sling systems and the perineal single-cuff artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort. Methods Two hundred eighty-two male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in the study (n=127 adjustable male sling [n=95 Argus classic, n=32 Argus T], n=155 AUS). Perioperative characteristics and postoperative complications were analyzed. The explantation rates of the respective devices were assessed using the Fisher exact test and the Mann-Whitney U-test. A Kaplan-Meier curve was generated. Potential features associated with device explantation were analyzed using a multiple logistic regression model (P<0.05). Results We found significantly increased intraoperative complication rates after adjustable male sling implantation (15.9% [adjustable male sling] vs. 4.2% [AUS], P=0.003). The most frequent intraoperative complication was bladder perforation (n=17). Postoperative infection rates did not vary significantly between the respective devices (P=0.378). Device explantation rates were significantly higher after AUS implantation (9.7% [adjustable male sling] vs. 21.5% [AUS], P=0.030). In multivariate analysis, postoperative infection was a strong independent predictor of decreased device survival (odds ratio, 6.556; P=0.001). Conclusions Complication profiles vary between adjustable male slings and AUS. Explantation rates are lower after adjustable male sling implantation. Any kind of postoperative infections are independent predictors of decreased device survival. There is no significant effect of the experience of the implanting institution on device survival.

In-bore 3.0-T Magnetic Resonance Imaging-guided Transrectal Targeted Prostate Biopsy in a Repeat Biopsy Population: Diagnostic Performance, Complications, and Learning Curve

OBJECTIVE To evaluate the diagnostic performance and complication rate of the in-bore magnetic resonance imaging-guided transrectal targeted prostate biopsy (MRGB) in a repeat biopsy population on the basis of a nearly 4-year learning curve (2014-2017). MATERIALS AND METHODS A total of 142 consecutive males with previous biopsies and persistent suspicion of prostate cancer (PCa) due to high prostate-specific antigen level initially underwent MRGB in the case of prostate imaging reporting and data system (PI-RADS) 3-5 lesions. Cancer detection rate (CDR), number and length of cores, biopsy time, operator experience, complications, and prediction of clinically significant (cs) PCa (Gleason score ≥7) were investigated. RESULTS PCa was found in 57% of patients. CDR in PI-RADS 3, 4, and 5 lesions were 46%, 52%, and 74%, respectively. csPCa was found in 9%, 25%, and 48% of patients. In univariate analysis the PI-RADS score (P = .0067) was a significant predictor of csPCa. In the multivariate logistic regression, age (P = .0007), number of previous biopsies (P = .0236), and prostate-specific antigen density (P = .0250) were significant predictors of csPCa. Location and size of the index lesion, number and length of cores obtained, and operator experience did not affect CDR. Concerning learning curve, biopsy time and number of cores obtained improved significantly after 10 procedures. Complications requiring medical intervention were seen in 6% (infections 2%). CONCLUSION In a re-biopsy setting the MRGB showed sufficient diagnostic performance in detecting csPCa in PI-RADS 3-5 lesions, with low complication rate. The skill of performing biopsy is quickly acquired, and location of index lesion did not have an impact on CDR.

Prostate-specific Antigen Parameters and Prostate Health Index Enhance Prostate Cancer Prediction With the In-bore 3-T Magnetic Resonance Imaging-guided Transrectal Targeted Prostate Biopsy After Negative 12-Core Biopsy

OBJECTIVE To assess prostate cancer (PCa) detection and prediction by combining the in-bore magnetic resonance imaging-guided transrectal targeted prostate biopsy (MRGB) with prostate-specific antigen (PSA) parameters and the Prostate Health Index (PHI) in case of negative 12-core standard biopsy. MATERIALS AND METHODS A total of 112 men (2014-2016) underwent 3-T multiparametric magnetic resonance imaging and subsequent MRGB of Prostate Imaging-Reporting and Data System (PI-RADS) lesions 3-5. Ancillary PSA parameters (PSA ratio [%fPSA] and PSA density [PSAD]) and the PHI and PHI density (PHID) were recorded. With these parameters in combination with MRGB, PCa prediction was calculated. RESULTS The most common lesions biopsied were PI-RADS 4 (66%), located in the peripheral zone (64%), in the middle (58%) and anterior (65%) sections of the prostate, and 13 mm (IQR 10-15) in size. PCa was found in 62 (55%) patients (28% Gleason score ≥7). PSAD (0.15 vs 0.21; P = .0051), %fPSA (16 vs 13; P = .0191), PHI (45 vs 69; P < .0001), PHID (0.7 vs 1.5; P < .0001), and prostate volume (56 mL vs 45 mL; P = .0073) were significantly different in patients with PCa and those without PCa. PHI and PHID were the strongest predictors of PCa with areas under the curve of 0.79 and 0.77, respectively. Using optimal thresholds of 59 and 0.79, PHI and PHID were 69% and 84% sensitive and 82% and62% specific for PCa, respectively. CONCLUSION Following negative standard biopsy of the prostate, the MRGB achieved an overall PCa detection rate of 55% in patients with PI-RADS 3-5 lesions. By considering PHI and PHID, 82% and 62% of unnecessary biopsies could have been avoided, failing to detect 31% and 16% of cancers.

The AdVance and AdVanceXP male sling in urinary incontinence: is there a difference?

PurposeTo compare the efficacy and perioperative complications of the AdVanceXP with the original AdVance male sling.MethodsWe retrospectively enrolled 109 patients with an AdVance and 185 patients with an AdVanceXP male sling. The baseline characteristics and complication rates were analyzed retrospectively. Functional outcome and quality of life were evaluated prospectively by standardized, validated questionnaires. The Chi2-test for categorical and Mann–Whitney U test for continuous variables were performed to identify heterogeneity between the groups.ResultsRegarding operation time, there was no significant difference between the slings (p = 0.146). The complication rates were comparable in both groups except for postoperative urinary retention. This occurred significantly more often in patients with the AdVanceXP (p = 0.042). During follow-up, no differences could be identified regarding ICIQ-SF, PGI or I-QoL or number of pad usage.ConclusionsThe AdVance and AdVanceXP are safe and effective treatment options for male stress urinary incontinence. However, the innovations of the AdVanceXP sling did not demonstrate a superiority over the original AdVance sling regarding functional outcome.

Comparison of adjustable male slings and artificial urinary sphincter in the treatment of male urinary incontinence: a retrospective analysis of patient selection and postoperative continence status

AbstractPurpose To analyze and compare preoperative patient characteristics and postoperative results in men with stress urinary incontinence (SUI) selected for an adjustable male sling system or an artificial urinary sphincter (AUS) in a large, contemporary, multi-institutional patient cohort.Methods658 male patients who underwent implantation between 2010 and 2012 in 13 participating institutions were included in this study (n = 176 adjustable male sling; n = 482 AUS). Preoperative patient characteristics and postoperative outcomes were analyzed. For statistical analysis, the independent T test and Mann–Whitney U test were used.ResultsPatients undergoing adjustable male sling implantation were less likely to have a neurological disease (4.5% vs. 8.9%, p = 0.021), a history of urethral stricture (21.6% vs. 33.8%, p = 0.024) or a radiation therapy (22.7% vs. 29.9%, p = 0.020) compared to patients that underwent AUS implantation. Mean pad usage per day (6.87 vs. 5.82; p < 0.00) and the ratio of patients with a prior incontinence surgery were higher in patients selected for an AUS implantation (36.7% vs. 22.7%; p < 0.001). At maximum follow-up, patients that underwent an AUS implantation had a significantly lower mean pad usage during daytime (p < 0.001) and nighttime (p = 0.018). Furthermore, the patients’ perception of their continence status was better with a subjective complete dry rate of 57.3% vs. 22.0% (p < 0.001).ConclusionsPatients selected for an AUS implantation showed a more complex prior history and pathogenesis of urinary incontinence as well as a more severe grade of SUI. Postoperative results reflect a better continence status after AUS implantation, favoring the AUS despite the more complicated patient cohort.

Bladder cancer in nonagenarians: a multicentre study of 123 patients

To investigate the oncological outcome of nonagenarians with bladder cancer, as a substantial rise in bladder cancer in the old‐old age group in the upcoming decades is expected, due to demographic changes and the peak incidence around the age of 85 years. The paucity of data of nonagenarians prompted us to investigate the outcomes of such patients.

The TiLOOP® Male Sling: Did We Forejudge

Introduction: To evaluate the safety and efficacy of the TiLOOP® male sling (pfm medical, Cologne, Germany) used in the treatment for male stress urinary incontinence (SUI). Material and Methods: We retrospectively evaluated a total of 34 patients with a TiLOOP® male sling. Perioperative complication rates were assessed and validated questionnaires were prospectively evaluated to assess quality of life and satisfaction rate. Outcome and complication rates were analysed by using descriptive statistics. Correlation of continence outcome and risk factors was performed with the chi-square test. A p value below 0.05 was considered statistically significant. Results: The majority of patients (70.6%) were diagnosed with mild or moderate male SUI. During surgery, one instance (2.9%) of intraoperative urethral injury was observed. There were no immediate postoperative complications. The mean follow-up time was 44.6 months. An improvement of male SUI was reported by 61.9% of the patients and 38.1% reported no change according the Patient Global Impression of Improvement. The mean perineal pain score was 0.5 according to the international index of pain. Conclusions: The TiLOOP® is a safe treatment option for male SUI in our cohort with a low complication rate. However, the functional outcome of the TiLOOP® was inferior when compared to the outcome of the AdVance® male sling.