Billy H. Cordon

Is Risk of Artificial Urethral Sphincter Cuff Erosion Higher in Patients with Penile Prosthesis

INTRODUCTIONnFrequently encountered morbidities after prostatectomy include stress urinary incontinence and erectile dysfunction. Patients with severe disease may undergo placement of both a penile prosthesis (PP) and an artificial urethral sphincter (AUS).nnnAIMnWe hypothesized that concomitant PP may promote AUS cuff erosion by impaired corporal blood flow and/or direct pressure on the cuff. The aim of this study was to compare the rate of AUS cuff erosion in patients with and without a PP.nnnMETHODSnWe reviewed 366 AUS operations at our tertiary center between 2007 and 2015 with a mean follow-up of 41 months (range 6-104). Included in the analysis were first-time AUS cuff erosions. Patients with recurrent erosions, AUS revisions, and iatrogenic erosions were excluded. In a separate analysis, we analyzed AUS explantations for all causes. Cohorts were compared by demographic information, preoperative characteristics, and rates of erosion and explantation.nnnMAIN OUTCOME MEASURESnErosion confirmed by cystourethroscopy and explantation of the AUS for all causes.nnnRESULTSnAmong 366 AUS surgeries at a mean follow-up of 41 months, there were 248 (67.8%) AUS alone cases compared to 118 (32.2%) AUS and PP cases (AUS/PP). Sixty-two patients met exclusion criteria for first-time cuff erosion. Among 304 evaluable AUS patients, we found a significantly higher rate of erosion in the AUS/PP group (11/95, 11.6%) compared to the AUS alone group (9/209, 4.3%, Pxa0= .037). When examining explantations for all causes in the entire cohort (nxa0= 366), we observed a significantly higher rate of device removal, (20/118, 17%) in the AUS/PP group compared to the AUS group (23/248, 9.2%, Pxa0= .044).nnnCONCLUSIONnAUS/PP patients appear to have a higher risk of AUS cuff erosion and explantation compared to men with AUS alone.

Low Serum Testosterone Level Predisposes to Artificial Urinary Sphincter Cuff Erosion

OBJECTIVEnTo examine the association between decreased serum testosterone levels and artificial urinary sphincter (AUS) cuff erosion.nnnMATERIALS AND METHODSnWe evaluated serum testosterone levels in 53 consecutive patients. Low testosterone was defined as <280u2009ng/dL and found in 30/53 patients (56.6%). Chi-square and Student t tests, Kaplan-Meier analysis, binary logistic regression, and Cox regression analysis were used to determine statistical significance.nnnRESULTSnNearly all men with AUS cuff erosions had low serum testosterone (18/20, 90.0%) compared to those without erosions (12/33, 36.4%, Pu2009<u2009.001). Mean time to erosion was 1.70 years (0.83-6.86); mean follow-up was 2.76 years (0.34-7.92). Low testosterone had a hazard ratio of 7.15 for erosion in a Cox regression analysis (95% confidence interval 1.64-31.17, Pu2009=u2009.009) and Kaplan-Meier analysis demonstrated decreased erosion-free follow-up (log-rank Pu2009=u2009.002). Low testosterone was the sole independent risk factor for erosion in a multivariable model including coronary artery disease and radiation (odds ratio 15.78; 95% confidence interval 2.77-89.92, Pu2009=u2009.002). Notably, history of prior AUS, radiation, androgen ablation therapy, or concomitant penile implant did not confound risk of cuff erosion in men with low testosterone levels.nnnCONCLUSIONnMen with low testosterone levels are at a significantly higher risk to experience AUS cuff erosion. Appropriate counseling before AUS implantation is warranted and it is unclear whether testosterone resupplementation will mitigate this risk.

Pseudospongioplasty Using Periurethral Vascularized Tissue to Support Ventral Buccal Mucosa Grafts in the Distal Urethra

PURPOSEnFor ventral buccal mucosa graft onlay during bulbar urethroplasty, spongioplasty with advancement and closure of the corpus spongiosum is ordinarily performed to stabilize the graft. In the pendulous and distal bulbar urethra the spongiosum is often too thin to allow complete graft coverage. We describe the results of what to our knowledge is a novel technique for ventral graft coverage using periurethral vascularized tissue. We compared these results to those of conventional spongioplasty.nnnMATERIALS AND METHODSnWe retrospectively reviewed all urethroplasties performed by 2 surgeons at separate tertiary care facilities from July 2007 to July 2012. One-stage urethroplasties involving ventral buccal mucosa graft placement were selected for analysis. Conventional spongioplasty was performed when possible. When spongiosal tissue was inadequate for graft coverage, periurethral tissue flaps were mobilized bilaterally and sutured together in the midline as pseudospongioplasty to provide coverage. We compared the outcomes of the 2 techniques.nnnRESULTSnOf 637 urethroplasties performed during the 5-year study period 102xa0(16%) with a buccal mucosa graft onlay met study inclusion criteria. Pseudospongioplasty was performed in 46 of 102 cases (45%), predominantly in the pendulous urethra (34 of 46 or 74%), with success in 37 of 46 (80%) at a mean followup of 41 months. Conventional spongioplasty had a similar 84% success rate (47 of 56 cases) at a mean followup of 39 months (p = 0.645). For conventional spongioplasty mean stricture length was 4.7 cm compared to 5.8 cm for pseudospongioplasty (p = 0.028).nnnCONCLUSIONSnVentral buccal mucosa grafts can be applied reliably to various locations throughout the anterior urethra. For distal grafts, flaps of periurethral tissue provide a suitable host bed for revascularization with results equivalent toxa0those of conventional spongioplasty.

Preoperative Urine Culture Results Correlate Poorly With Bacteriology of Urologic Prosthetic Device Infections

INTRODUCTIONnAlthough preoperative negative urine culture results and treatment of urinary tract infections are generally advised before artificial urinary sphincter (AUS) and penile prosthesis (PP) surgery to prevent device infection, limited evidence exists to support this practice.nnnAIMnTo evaluate the relation between preoperative urine culture results and the bacteriology of prosthetic device infections.nnnMETHODSnMen undergoing AUS and/or PP placement at a tertiary referral center from 2007 through 2015 were analyzed. A total of 713 devices were implanted in 681 patients (337 AUSs in 314 patients and 376 PPs in 367 patients), of whom 259 (36%) did not have preoperative urine culture and were excluded. The remaining 454 patients received standard broad-spectrum perioperative antibiotics. Two patient groups were identified based on preoperative urine cultures: group 1 had negative urine culture results and group 2 had untreated asymptomatic positive urine culture results identified postoperatively.nnnMAIN OUTCOME MEASURESnDevice infection was diagnosed clinically and cultures obtained from the explanted device and tissue spaces were compared with preoperative urine culture results.nnnRESULTSnAlthough multivariate analysis showed that patients undergoing AUS placement had a 4.5-fold greater risk of positive urine culture results (114 of 250, 45%) compared with those undergoing PP placement (36 of 204, 18%; P < .001), infection rates between device types were similar (8 of 250 for AUSs [3%] and 7 of 204 for PPs [3%]; Pxa0= .89). At a median follow-up of 15 months, device infection occurred in 15 of 454 devices (3%) implanted and no differences in infection rates were noted between urine culture groups (10 of 337 in group 1 [3.3%] and 5 of 117 in group 2 [4.3%]; Pxa0= .28). Remarkably, only 1 of 15 device infections (7%) had the same organism present at preoperative urine culture.nnnCONCLUSIONSnDespite the finding that patients with AUS placement had a 4.5 times higher rate of positive urine culture results than patients with PP placement, preoperative urine culture results appeared to show little correlation with the bacteriology of prosthetic device infections.

Artificial urinary sphincters for male stress urinary incontinence: current perspectives

The artificial urinary sphincter (AUS), which has evolved over many years, has become a safe and reliable treatment for stress urinary incontinence and is currently the gold standard. After 4 decades of existence, there is substantial experience with the AUS. Today AUS is most commonly placed for postprostatectomy stress urinary incontinence. Only a small proportion of urologists routinely place AUS. In a survey in 2005, only 4% of urologists were considered high-volume AUS implanters, performing >20 per year. Globally, ~11,500 AUSs are placed annually. Over 400 articles have been published regarding the outcomes of AUS, with a wide variance in success rates ranging from 61% to 100%. Generally speaking, the AUS has good long-term outcomes, with social continence rates of ~79% and high patient satisfaction usually between 80% and 90%. Despite good outcomes, a substantial proportion of patients, generally ~25%, will require revision surgery, with the rate of revision increasing with time. Complications requiring revision include infection, urethral atrophy, erosion, and mechanical failure. Most infections are gram-positive skin flora. Urethral atrophy and erosion lie on a spectrum resulting from the same problem, constant urethral compression. However, these two complications are managed differently. Mechanical failure is usually a late complication occurring on average later than infection, atrophy, or erosions. Various techniques may be used during revisions, including cuff relocation, downsizing, transcorporal cuff placement, or tandem cuff placement. Patient satisfaction does not appear to be affected by the need for revision as long as continence is restored. Additionally, AUS following prior sling surgery has comparable outcomes to primary AUS placement. Several new inventions are on the horizon, although none have been approved for use in the US at this point.

Superior Cost Effectiveness of Penile Plication vs Intralesional Collagenase Injection for Treatment of Peyronie’s Disease Deformities

Introduction: In 2013 injection of collagenase clostridium histolyticum became the first nonsurgical FDA (Food and Drug Administration) approved treatment for Peyronies disease. We evaluated the cost effectiveness of collagenase injection compared to penile plication. Methods: A decision tree model using TreeAge Pro Healthcare (TreeAge Software, Inc., Williamstown, Massachusetts) was developed for cost analysis comparing collagenase clostridium histolyticum and penile plication. Treatment success was defined as penile curvature of 30 degrees or less. Data from IMPRESS (Investigation for Maximal Peyronies Reduction Efficacy and Safety Studies) I and II were used to calculate the probability of success, and stratified by severity of disease (moderate defined as 30 to 60 degrees and severe as 61 to 90 degrees). We assumed that 50% of injection failures proceeded to secondary plication. Material costs of medications, office visits, and facility and surgical fees, and predicted costs of complications were obtained from our billing department using real‐world patient data. For penile plication 90% success was assumed based on published series. All failed plications were assumed to undergo repeat plication. Results: The calculated probability of treatment success after injection was 49.5% for moderate curvature (30 to 60 degrees) and 12% for severe curvature (61 to 90 degrees). Per patient plication cost was

Improving Outcomes of Bulbomembranous Urethroplasty for Radiation-induced Urethral Strictures in Post-Urolume Era

3,039, while injection pathway was

Low Testosterone Levels Result in Decreased Periurethral Vascularity via an Androgen Receptor-mediated Process: Pilot Study in Urethral Stricture Tissue

25,856 for moderate disease and

Synchronous Ipsilateral High Submuscular Placement of Prosthetic Balloons and Reservoirs

26,375 for severe disease. One‐way sensitivity analyses revealed cost equivalence at

Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery

2,558 for injection. No increase in efficacy of collagenase injection accomplished cost equivalence at current pricing. Conclusions: Collagenase clostridium histolyticum treatment was at least 8 times more expensive than penile plication. Achieving cost equivalence would require a significant decrease in drug cost. Collagenase clostridium histolyticum appears to be most appropriate for men with moderate, as opposed to severe, penile deformities.