Matthew J. Ziegelmann

Long-term Outcomes Following Artificial Urinary Sphincter Placement: An Analysis of 1082 Cases at Mayo Clinic

OBJECTIVE To evaluate long-term device outcomes following primary artificial urinary sphincter (AUS) implantation. MATERIALS AND METHODS We identified 1802 male patients with stress urinary incontinence that underwent AUS placement from 1983 to 2011. Of these, 1082 (60%) were involving primary implantations and comprise the study cohort. Multiple clinical and surgical variables were evaluated for potential association with treatment failure, defined as any secondary surgery. Patient follow-up was obtained through office examination, operative report, and written or telephone correspondence. RESULTS Patients undergoing AUS implantation had a median age of 71 years (interquartile range 66-76) and median follow-up of 4.1 years (interquartile range 0.8-7.7). Overall, 338 of 1082 patients (31.2%) underwent secondary surgery, including 89 for device infection and/or erosion, 131 for device malfunction, 89 for urethral atrophy, and 29 for pump malposition or tubing complications. No patient-related risk factors were independently associated with an increased risk of secondary surgery on multivariable analysis. Secondary surgery-free survival was 90% at 1 year, 74% at 5 years, 57% at 10 years, and 41% at 15 years. CONCLUSION Primary AUS implantation is associated with acceptable long-term outcomes. Recognition of long-term success is important for preoperative patient counseling.

Perioperative Complications following Artificial Urinary Sphincter Placement.

PURPOSE We evaluated perioperative complications in patients undergoing primary artificial urinary sphincter placement and the potential impact of these complications on device outcomes. MATERIALS AND METHODS During the 2-year period from 2012 to 2014 we retrospectively evaluated the outcomes of 197 consecutive artificial urinary sphincter implantation procedures performed at our institution for post-prostatectomy incontinence. Of these cases 100 that were primary implantations comprise the study cohort. Perioperative complications, defined as those occurring within 6 weeks postoperatively, were classified by the Clavien-Dindo classification. After office evaluation at 6 weeks patients were followed for symptoms. Patient followup was obtained through office examination and telephone correspondence. RESULTS Patients undergoing primary artificial urinary sphincter implantation had a median age of 71.5 years (IQR 66, 76). The overall rate of any complication (Clavien I-V) within 6 weeks of surgery was 35%, including urinary retention in 31% of cases, cellulitis in 1%, device infection in 2% and urethral erosion in 2%. No significant differences in pertinent clinical comorbidities such as age (p = 0.69), hypertension (p = 0.95), coronary artery disease (p = 0.57), diabetes mellitus (p = 0.17), body mass index (p = 0.47), prior pelvic radiation therapy (p = 0.45), prior urethral sling placement (p = 0.91) or transcorporeal urethral cuff placement (p = 0.22) were found between patients with and without complications. Median followup was similar between those with and without postoperative urinary retention (p = 0.14). Postoperative urinary retention was associated with adverse 6-month device survival (76% vs 89%, p = 0.04). CONCLUSIONS The most common complication of artificial urinary sphincter placement is urinary retention. Serious adverse events following artificial urinary sphincter placement are rare. Postoperative urinary retention is associated with adverse short-term device survival rates.

Long-Term Quality of Life and Functional Outcomes among Primary and Secondary Artificial Urinary Sphincter Implantations in Men with Stress Urinary Incontinence

PURPOSE There remains a paucity of data regarding subjective and functional outcomes after artificial urinary sphincter implantation. Therefore, we evaluated long-term differences in quality of life after primary and secondary artificial urinary sphincter surgery. MATERIALS AND METHODS Men were invited to participate in a mail-in survey assessing artificial urinary sphincter status, patient satisfaction and urinary control. Patients with primary (467) and secondary (122) artificial urinary sphincter devices without an event were included in the study. Differences between the cohorts including quality of life (10-point scale, maximum 100) and functional outcomes were evaluated. RESULTS Overall 229 (49%) patients with primary and 49 (40%) with secondary artificial urinary sphincters completed the survey at a median of 8.3 years. Patients with primary and secondary artificial urinary sphincter devices reported similar artificial urinary sphincter quality of life (score 74 vs 74). There were no significant differences in urinary continence outcomes including use of 1 pad or less daily (56% vs 55%), frequency of leakage 1 time or more per day (81% vs 71%) or degree of minimal leakage related bother (64% vs 55%). At less than 5 vs 10 or more years there was a significant reduction in artificial urinary sphincter quality of life (86 vs 73, p=0.007). Urinary continence also declined with time, including perceived urinary control (85% vs 53%, p=0.004), minimal leakage related bother (76% vs 59%, p=0.05) and use of 1 pad or less daily (67% vs 55%, p=0.07). On univariate analysis no clinical variables, including secondary revision, were associated with satisfaction or continence outcomes. CONCLUSIONS We noted a high level of artificial urinary sphincter quality of life, acceptable urinary control and no difference in functional outcomes between men undergoing primary or secondary artificial urinary sphincter surgery. However, the time related decline in satisfaction and continence highlights the need for patient counseling regarding long-term artificial urinary sphincter functional outcomes.

Outcomes of artificial urinary sphincter placement in octogenarians

To evaluate the impact of patient age on device outcomes among patients undergoing primary artificial urinary sphincter.

Effect of minimally invasive radical prostatectomy in older men

BACKGROUND Minimally invasive radical prostatectomy (MIRP) has been rapidly adopted over the last decade, however, little is known about outcomes in older patients. OBJECTIVE To examine the outcomes of MIRP vs. open radical prostatectomy (OPRP) stratified by age. SUBJECTS AND METHODS We examined the Surveillance, End Results and Epidemiology-Medicare database between years 2004 and 2009 for men with nonmetastatic adenocarcinoma of the prostate. Our cohort (n = 12,092) was subdivided into 2 groups-MIRP vs. OPRP, and by patient age≥70 years (n = 6,660) vs. 66 to 69 years (n = 5,432). Multivariate analysis and multiple Cox proportional hazard models evaluated the influence of surgical approach and other variables on perioperative and postoperative complications in each age group. RESULTS The use of MIRP increased over the 6-year time span (14.8%-73.3%;<70y) and 15.1%-69.8%;≥70y). OPRP was associated with a higher risk of blood transfusion and postoperative respiratory or genitourinary (GU) complications. Patients who underwent MIRP were more likely to have a diagnosis of erectile dysfunction or urinary incontinence compared to OPRP (56.9% vs. 42.2% and 53.9% vs. 43.2%, respectively; P<0.0001). Patients who underwent MIRP were less likely to have an anastomotic stricture or require additional cancer therapy. Men aged≥70 years, who underwent MIRP had higher rates of transfusion, GU complications, length of stay, incontinence, and anastomotic stricture rates compared with those of men aged 66 to 69 years. However, older men undergoing MIRP had 10% lower rates of erectile dysfunction compared with that of men aged 66 to 69 years of age. CONCLUSIONS MIRP increased to>70% of all procedures performed in 2009. MIRP is associated with lower blood transfusion rates, postoperative respiratory or GU complications, anastomotic stricture diagnoses, and additional cancer therapies. This suggests that MIRP is a successful prostate cancer treatment for older patients.

Heavy Testosterone Use Among Bodybuilders: An Uncommon Cohort of Illicit Substance Users.

OBJECTIVE To identify and characterize patterns of use among a contemporary cohort of current anabolic-androgenic steroid (AAS) users. PATIENTS AND METHODS An anonymous, self-administered, 49-item questionnaire was posted on message boards of Internet websites popular among AAS users and administered via SurveyMonkey from February 1, 2015, to June 1, 2015. Thirty-seven questions were analyzed for this study. RESULTS A total of 231 male respondents met the inclusion criteria. Most were white, were older than 25 years, were employed with above average income, and had received a formal education beyond high school. Ninety-three percent began using AAS after the age of 18 years, and 81% reported using 400 mg or more of testosterone per week. Factors associated with longer duration of use (>5 years) included higher incomes (≥

The Impact of Diabetes Mellitus and Obesity on Artificial Urinary Sphincter Outcomes in Men

75,000, P=.003), increased testosterone dosages (>600 mg per week, P=.007), older age (≥35 years, P<.001), being married (P<.001), and being self-employed (P<.001). The Internet was the most common source of testosterone (53%). Ninety-three percent used at least one additional performance-enhancing drug. Seventy-seven percent had routine laboratory tests performed, and 38% reported laboratory abnormalities at some point. Nearly all experienced subjective adverse effects while using and not using testosterone. Fifty-three percent reported use of other illegal substances, most commonly (90%) beginning before AAS initiation. Ten percent had a criminal conviction, 91% of which preceded AAS use. Fifty percent were felonies. CONCLUSION The population of AAS users is disparate from that of other drugs of abuse. Laboratory test abnormalities and adverse effects are common and should be taken into account when counseling patients who may be using AASs.

Effects of Smoking Status on Device Survival Among Individuals Undergoing Artificial Urinary Sphincter Placement.

OBJECTIVE To evaluate the impact of diabetes and obesity on artificial urinary sphincter (AUS) outcomes. MATERIALS AND METHODS From 1987 to 2011, men with available diabetes and body mass index (BMI) information (568 of 954) undergoing primary AUS placement at our institution were evaluated. The incidence of all-cause reintervention, mechanical failure, atrophy, and erosion or infection was assessed using the Kaplan-Meier method. Multivariable analyses evaluated the association between clinical characteristics and AUS outcomes. RESULTS In total, 90 (16%) men had diabetes. Median follow-up among alive men without AUS event was 5.9 years. Diabetics had a greater 5-year incidence of erosion/infection (13% vs 8%; P = .025). On multivariable analysis, diabetes was independently associated with an increased risk of erosion/infection (hazard ratio [HR] = 2.26; P = .02); whereas greater BMI was associated with a reduced risk of erosion or infection (obese: HR = 0.39; P = .02; overweight: HR = 0.57; P = .07). Accordingly, in diabetics, greater average postoperative glucose level (176 mg/dL vs 153 mg/dL; P = .04) and use of nonantibiotic coated devices (13 of 62 vs 1 of 28; P = .035) was associated with a greater incidence of erosion or infection. There was no difference in social continence (≤1 pad/day) (45% vs 57%; P = .29) or high-level satisfaction (95% vs 90%; P = .43) among diabetics vs nondiabetics. However, with greater BMI (<25, 25 to <30, and ≥30), there was a decrease in ≤1 pad/day usage (62% vs 61% vs 49%; P = .02). CONCLUSION We found that the presence of diabetes was independently associated with a 2.3-fold increased risk of AUS erosion or infection. These findings warrant the consideration of additional periprocedural measures to reduce the risk of this devastating complication.

Urinary collecting system invasion is associated with poor survival in patients with clear-cell renal cell carcinoma.

Smoking is an established risk factor for wound complications. There is limited data on the impact of smoking on artificial urinary sphincter (AUS) outcomes. Thus, the aim of this study was to assess AUS device survival outcomes based on smoking status. From 1985 to 2014, 1,270 patients underwent AUS placement with 728 having smoking status available for review. Smoking status was categorized as never, prior, and active smokers. Kaplan−Meier analysis was performed to evaluate differences in survival, including overall device and erosion/infection−free survival. Hazard regression analysis was utilized to determine the association between smoking and device outcomes. Of the 728 patients in the study, 401 had a history of smoking with 41 active smokers and 360 never smokers at the time of AUS implant. When compared with nonsmokers, past smokers had a higher rate of hypertension and prior transient ischemic attack. Clinical comorbidities were similar between nonsmokers and active smokers. On univariate analysis, patient age, history of transient ischemic attack, diabetes, and coronary artery disease were significantly associated with infection/erosion rate, but prior or active smoking statuses were not. Likewise, when comparing smokers (past or active) with lifelong nonsmokers, there was no significant difference in 1- and 5-year overall device survival. There was no evidence for adverse AUS outcomes in current or past smokers compared with nonsmokers. Given the established risk of perioperative complications secondary to smoking, the recommendation should still be to counsel patients to quit prior to undergoing AUS placement. External validation of these findings is needed.

The impact of prior urethral sling on artificial urinary sphincter outcomes

To evaluate the prognostic significance of urinary collecting system invasion (UCSI) in a large series of patients with clear‐cell renal cell carcinoma (RCC).