Jerilyn M. Latini

Long-term durability and functional outcomes among patients with artificial urinary sphincters: a 10-year retrospective review from the University of Michigan.

PURPOSE The artificial urinary sphincter continues to be one of the most effective and commonly used surgical treatments for severe urinary incontinence. The long-term durability and functional outcome remains unclear. This study sought to report the artificial urinary sphincter complication rates, associated risk factors with complications, and long-term quality of life and durability. MATERIALS AND METHODS This single institution study reports the outcomes of 124 consecutive index cases of artificial urinary sphincter from 1996 to 2006 for complications (infection, erosion, and mechanical failure). Bivariate statistics and multivariable logistic models were used to identify patient and artificial urinary sphincter characteristics associated with complications. Functional outcomes and long-term durability were assessed using a cross sectional analysis of a validated health related quality of life survey and a product limit estimates, respectively. RESULTS Among the 124 male patients median followup was 6.8 years. The overall complication rate for patients undergoing an artificial urinary sphincter was 37.0%, with mechanical failure the most common cause (29), followed by erosion (10) and then infection (7). Significant differences between complications and specific patient and artificial urinary sphincter characteristics risk factors were not found. Functional outcomes appeared stable with similar mild-moderate urinary incontinence severity and 0 to 1 daily pad use at intervals of 0 to 4 years, 4 to 8 years and more than 8 years. Long-term durability was notable with 36% having complications (requiring surgical revision or removal) within 10 years and most events occurring within the first 48 months. CONCLUSIONS Long-term durability and functional outcomes are achievable for the AMS 800, but there are appreciable complication rates for erosion, mechanical failure and infection in the first 48 months from implantation.

Long-term outcomes after primary failures of artificial urinary sphincter implantation

OBJECTIVES To assess our institutional outcomes after primary artificial urinary sphincter (AUS) failures. METHODS From 1985 to 2010, a total of 149 patients underwent 318 primary and additional AUS procedures. We classified additional procedures as revisions, replacements, or explantations. RESULTS At a median of 52 months (range, 6-250 months), 53% of patients had required at least 1 additional procedure beyond their initial implantation. These included 106 (63%) revisions, 42 (24.9%) explantations, and 21 (12.4%) replacements. The most common revision was reservoir upsizing (37/106). Reasons for first revision included recurrent incontinence (56.7%), mechanical malfunction (22%), and infection or erosion (18.6%). Explantations were performed primarily for infection and erosion (64.3%). Median time to first revision was 20.1 months (range, 0.1-173 months) after implantation, with a median of 9.5 months (range, 1-102 months) between revisions. Explantation occurred at a median of 22 months (range, 1-221 months) after implant, and subsequent replacement at a median of 33.6 months (range, 2-138 months). At 5 years, 28/83 (33.7%) patients had undergone no additional procedures. Patients with previous radiation were more likely to experience infection (P = .03; OR 3.99; 95% CI 1.03-15.42). Patients with previous myocardial infarction were more likely to experience erosion (P = .04; OR 2.29; 95% CI 1.05-5.02), and obese patients were more likely to experience mechanical malfunction (P = .04; OR 2.62; 95% CI 1.07-6.4). CONCLUSIONS More than half of patients with an AUS will require additional procedures, most likely revision. Radiation, previous myocardial infarction, and obesity are linked to complications. Median time to first revision or explantation is slightly less than 2 years, indicating that long-term follow-up is required after initial implantation.

Combination Drug Therapy Improves Compliance of the Neurogenic Bladder

PURPOSE Typical management of increased bladder storage pressures and decreased compliance related to neurogenic bladder dysfunction consists of antimuscarinic therapy with or without clean intermittent catheterization. However, these measures are often unsuccessful. In this patient group we commonly use combination therapy consisting of antimuscarinics combined with imipramine and/or an alpha-blocker. MATERIALS AND METHODS A retrospective chart review was performed identifying all patients with neurogenic bladder dysfunction who were initially on no drug therapy or antimuscarinic therapy alone and were later switched to 2 or 3 drug therapy. RESULTS In the group initially on no therapy and subsequently on 2 drugs (22) mean bladder pressure at capacity decreased 52% and mean compliance increased 5.0-fold. Similarly in the group starting without therapy but ending up on 3 drugs (28) bladder pressure decreased 67% and compliance increased 9.7-fold. In the group initially on an antimuscarinic agent alone (27) triple drug therapy decreased bladder pressure 60% and compliance increased 3.0-fold (all p <0.01). There were also improvements in incontinence, vesicoureteral reflux, detrusor overactivity and detrusor sphincter dyssynergia. CONCLUSIONS In this highly selected group of patients with neurogenic bladder dysfunction and poor bladder compliance combination medical therapy with 2 or 3 drugs improved compliance, decreased bladder pressures at capacity and improved clinical outcomes. Combination therapy requires further study of the side effect profile but these results suggest that it should be considered for patients in whom antimuscarinic agents alone fail.

Risk Factors and Quality of Life for Post-prostatectomy Vesicourethral Anastomotic Stenoses

OBJECTIVE To evaluate the difference in vesicourethral anastomotic stenosis (VUAS) rates after open radical retropubic prostatectomy (RRP) vs robot-assisted radical prostatectomy (RARP), and to analyze associated factors and effect on quality of life. METHODS From 2001 to 2009, a total of 1038 patients underwent RARP and 707 patients underwent open RRP. Perioperative factors and Expanded Prostate Cancer Index Composite (EPIC) quality of life scores were compared between patients who did and did not develop a VUAS. Independent significant predictors of VUAS development were identified using multivariable modeling. RESULTS The incidence of VUAS in open RRP cases was higher (53/707, 7.5%) than for RARP (22/1038, 2.1%) (P<.0001). Intervention consisted of dilation in 34 of 75 cases (45.3%), internal urethrotomy in 8 of 75 (10.7%), and multiple procedures in 30 of 75 (40%). Open technique (P<.0001, odds ratio [OR]=3.0, 95% confidence interval [CI]=1.8-5.2), prostate-specific antigen (PSA) recurrence (P=.02, OR=2.2, 95% CI=1.2-4.1), postoperative hematuria (P=.02, OR=3.7, 95% CI=1.2-11.3), urinary leak (P=.002, OR=6.0, 95% CI=1.9-19.2), and urinary retention (P=.004, OR=3.5, 95% CI=1.5-8.7) were significant independent predictors of VUAS development. EPIC incontinence scores were similar between VUAS and non-VUAS patients, whereas irritative voiding scores were worse initially with VUAS but became similar by 12 months. CONCLUSION There is a higher rate of VUAS after open RRP vs RARP. Most cases of VUAS require endoscopic intervention. Predictors include open surgery, PSA recurrence, and postoperative hematuria, urinary leak, and retention. There is no diminution of quality of life scores at 12 months.

SIU/ICUD Consultation on Urethral Strictures: Epidemiology, Etiology, Anatomy, and Nomenclature of Urethral Stenoses, Strictures, and Pelvic Fracture Urethral Disruption Injuries

This committee reviewed and evaluated published data, and recommended standardized terminology relating to the epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, urethral strictures, and pelvic fracture urethral disruption injuries, as well as their surgical management. A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), Embase, online acronym databases, and abstracts from scientific meetings was performed from 1980-2010. Articles were evaluated using the Levels of Evidence adapted by the International Consultation on Urological Diseases (ICUD) from the Oxford Centre for Evidence-Based Medicine. Recommendations were based on the level of evidence and discussed among the committee to reach a consensus. There is expert opinion to support standards regarding the epidemiology, anatomy, and nomenclature of urethral stenoses, urethral strictures, and pelvic fracture urethral disruption injuries. There is level 3 evidence regarding the epidemiology and etiology of urethral stenoses, urethral strictures, and pelvic fracture urethral injuries. The literature regarding the epidemiology, anatomy, and nomenclature of urethral stenoses, urethral strictures, and pelvic fracture urethral disruption injuries are sparse and generally of a low level of evidence. The proposed ICUD system does not readily apply to these areas. Further research is needed so that stronger levels of evidence can be developed leading to recommendations regarding the accuracy of the data. To improve future research and promote effective scientific progress and communication, a standardized nomenclature and anatomy regarding the urethra and urethral surgery is detailed herein.

Simple cystectomy: outcomes of a new operative technique.

OBJECTIVE To present an efficient technique for simple cystectomy. Urinary diversion for benign indications is a relatively rare procedure. However, diversion alone without accompanying cystectomy results in a significant risk of complications, such as pyocystis, hematuria, pain, and secondary carcinoma. METHODS We retrospectively reviewed our institutional experience with this simple cystectomy technique, which included 23 patients from 2007-2010 performed by 3 surgeons. There were 14 females and 9 males. All patients had exhausted all other possible conservative therapies. Indication for the procedure included neurogenic bladder and resulting complications in 9 patients, complications from prostate radiation therapy in 5 patients, refractory interstitial cystitis in 5 patients, and refractory incontinence in 4 patients. RESULTS The average patient was 63.3 years old and had undergone 2.7 prior abdominal or pelvic surgeries and 3.6 prior urinary operations. The average operative time was 27.5 minutes for the simple cystectomy portion of the case (recorded in 19 cases) and average blood loss was 46.7 mL (recorded in 12 cases). For the entire procedure, including diversion with bowel segment, the average blood loss was 231.5 mL. The mean entire operative time was 318.5 minutes. There were no complications noted intraoperatively or postoperatively specifically attributed to the cystectomy portion. All pathology specimens revealed no evidence of malignancy. Mean follow-up was 8 months (range 1-33). CONCLUSION This simple cystectomy technique, in most cases of urinary diversion for benign indications, can be performed quickly with minimal blood loss and complications.

The Impact of Urethroplasty on Voiding Symptoms and Sexual Function

OBJECTIVE To determine the effect of urethroplasty for urethral stricture disease on both voiding symptoms and sexual function through the use of validated patient questionnaires. METHODS Pre- and post-operative scores for the American Urological Association Symptom Index (AUASI), Incontinence Symptom Index (ISI), and Sexual Health Inventory for Men (SHIM) were obtained and compared for adult male patients undergoing urethroplasty. Score differences were then stratified by age. Relevant clinical and demographic characteristics were also examined. RESULTS Over the 15-year study period, 183 patients underwent 222 urethroplasties. Median age at the time of surgery was 45 years. Urethroplasties were performed for 207 anterior and 15 posterior urethral strictures. The most common approaches were primary anastomotic (36.5%), staged (23.9%), and buccal graft augmented (21.6%). Overall, 63% of men had a clinically meaningful (≥4 point) improvement in AUASI total score and 69% had improvement in their quality of life (QOL) score after urethroplasty. In aggregate, AUASI total scores improved by 7 points (P<.001), and QOL scores improved by 2 points (P<.001). There was no significant difference in ISI or SHIM scores before and after urethroplasty. AUASI total scores improved more dramatically in younger patients. Half of patients with improved AUASI QOL scores did not have a corollary improvement in their total score. CONCLUSIONS As measured by validated questionnaires, patients of all ages can expect a meaningful improvement in bothersome voiding symptoms after urethroplasty for urethral stricture disease, with minimal impact on continence or erectile function.

Functional and anatomical differences between continent and incontinent men post radical prostatectomy on urodynamics and 3T MRI: a pilot study.

There are competing hypotheses about the etiology of post prostatectomy incontinence (PPI). The purpose of this study was to determine the anatomical and functional differences between men with and without PPI.

Dynamic MRI evaluation of urethral hypermobility post‐radical prostatectomy

One postulated cause of post‐prostatectomy incontinence is urethral and bladder neck hypermobility. The objective of this study was to determine the magnitude of anatomical differences of urethral and bladder neck position at rest and with valsalva in continent and incontinent men post‐prostatectomy based on dynamic MRI.

Civilian gunshot wounds to the genitourinary tract: incidence, anatomic distribution, associated injuries, and outcomes

OBJECTIVES Gunshot wounds (GSW) affecting the genitourinary (GU) system in civilians are uncommon. This study describes the incidence, anatomic distribution, demographics, associated injuries, management, and outcomes after civilian GU GSW. METHODS A Level 1 Trauma Center Registry was used to retrospectively identify all patients who sustained GU GSW (January 1997-December 2008). Patient information was abstracted from the Registry, medical, and autopsy records. Multivariate regression detected significant factors associated with mortality. RESULTS Of 2941 civilian GSW patients, 309 (10.5%) sustained GU injury with/without associated injuries. Mean age was 30.4 ± 11.9 years (range 6.6-80.6 years); 289 patients (93.5%) were male. Mean Injury Severity Score (ISS) 22.2 ± 15.4 (1-75). Incidence of GU GSW increased during the study period. GSW affected the kidneys (55%), scrotum (21%), bladder (19%), testicle (12%), penis (8%), some patients having more than 1 GU organ injured. A total of 284 patients (92%) experienced at least 1 other organ injury. Most GU GSW were managed surgically (mean 2.2 ± 2.0; 0-13 surgeries/patient). There was a 27% (n = 84) overall mortality, with 16% (n = 50) dead on arrival. Mortality and ISS were correlated (P = 0.002; hazard ratio = 3.0; 95% confidence interval 3.0-3.0CI). Large vessel, head/neck, kidney, vascular, heart, lung, spine, and spinal cord injury were statistically significant risk factors for death. CONCLUSIONS GU injury occurred in 10.5% of 2941 civilian GSW patients. Associated injuries were very common, with many cases involving multiple organs. Most injuries (90%) were managed surgically. Mortality is usually the result of associated nongenitourinary injuries. A high index of suspicion for injuries affecting other organs is necessary in managing GU GSW trauma patients.