2100
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
Surgery Insight: Surgical Management of Postprostatectomy Incontinence—The Artificial Urinary Sphincter and Male Sling C. V. Comiter, Department of Urology, Stanford University, Stanford, California Nat Clin Pract Urol 2007; 4: 615– 624. Permission to Publish Abstract Not Granted Editorial Comment: A nicely done article, by one of the early adopters and subsequent developers of the sling technique, on the advantages and disadvantages and patient selection variables for the artificial urinary sphincter (AUS) and male sling. Comiter states his preferences for using the AUS in patients who have had a previous sphincter or male sling surgery, and in patients who have received primary radiation therapy for prostate cancer, those with detrusor underactivity and those with “severe or total urinary incontinence.” The male sling is recommended as the preferred treatment in patients with poor manual dexterity or mental facilities insufficient to cycle the sphincter, and in those who desire the ability to void spontaneously without the need to manipulate a scrotal pump, and he offers as his opinion that the male sling is preferred for patients with mild stress incontinence and good detrusor contractility “owing to a lower complication rate and lower revision rate than with AUS.” The data for both procedures are fairly presented, and the author closes by concluding that the AUS is effective for all degrees of sphincteric incontinence, with a success rate generally greater than 80%, an infection rate of 1% to 5%, an erosion rate of 1% to 5% and a revision rate of 20% to 25% at 5 years using the narrow back cuff. He cites figures for the male sling as including a 2 to 4-year success rate of 75% to 80%, an infection rate of 2% to 6%, an erosion rate of 2% and a revision rate of less than 5%. Alan J. Wein, M.D., Ph.D. (Hon.)
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION A Prospective Study Evaluating the Efficacy of the Artificial Sphincter AMS 800 for the Treatment of Postradical Prostatectomy Urinary Incontinence and the Correlation Between Preoperative Urodynamic and Surgical Outcomes F. Trigo Rocha, C. M. Gomes, A. I. Mitre, S. Arap and M. Srougi, Division of Urology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil Urology 2008; 71: 85– 89. Objectives: We have evaluated prospectively the long-term efficacy of the artificial urinary sphincter (AUS) AMS 800 for the treatment postradical prostatectomy urinary incontinence (PRPUI) patients. We also evaluated the correlation between preoperative urodynamic findings and surgical outcomes. Methods: From May 1997 to April 2003, 40 consecutive patients with PRPUI caused by intrinsic sphincter deficiency (ISD) were treated with the AMS 800. Mean age was 68.3 ⫹/⫺ 6.3 years. Continence status was evaluated on the basis of pad count, impact of urinary incontinence on the quality of life, complications, and surgical revisions. Preoperative urodynamic findings were correlated with surgical outcomes. Results: Follow-up ranged from 27 to 132 months (mean ⫽ 53.4 ⫹/⫺ 21.4 months). There was a significant reduction in pad count from 4.0 ⫹/⫺ 0.9 to 0.62 ⫹/⫺ 1.07 diapers per day (P ⬍0.001) leading to continence in 90%. There was a significant reduction on the impact of incontinence decreasing from 5.0 ⫹/⫺ 0.7 to 1.4 ⫹/⫺ 0.93 (P ⬍0.001) in a visual analogue scale (VAS). Surgical revision rate was 20%. Preoperative urodynamics was useful to identify sphincter deficiency. Except by a tendency of worse results in patients with reduced bladder compliance (RBC), other urodynamic parameters did not correlate with a worse surgical outcome. Conclusions: The AMS 800 offers good long-term continence to most PRPUI patients. Preoperative findings like detrusor hyperactivity (DH), impaired detrusor contraction (IDC), low Valsalva leak point pressure, bladder outlet obstruction (BOO), and mild RBC were not associated with worse surgical outcomes. Editorial Comment: This is a well written article from a referral center in Sao Paolo, Brazil, summarizing the influence of preoperative urodynamics on outcomes of AUS procedures. De-
BENIGN PROSTATIC HYPERPLASIA
2101
trusor hyperactivity was noted in 25% of these patients following prostatectomy. Interestingly, continence rates were similar in patients with and without DH, thus supporting the concept that in mixed incontinence the initial approach should be treatment of the sphincteric deficiency, followed as necessary by anticholinergics. For that matter other preoperative urodynamic parameters such as ISD, low Valsalva leak point pressure, BOO and bladder compliance did not correlate with worse surgical outcome. Although the authors conclude that these investigations were “mandatory,” it would have been interesting if they had reported the costs associated with these unhelpful studies. I, for one, view these laborious evaluations as wasteful and unnecessary in the vast majority of AUS candidates. Allen F. Morey, M.D.
Long-Term Follow-Up of Single Versus Double Cuff Artificial Urinary Sphincter Insertion for the Treatment of Severe Postprostatectomy Stress Urinary Incontinence R. C. O’Connor, M. B. Lyon, M. L. Guralnick and G. T. Bales, Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin Urology 2008; 71: 90 –93. Objectives: To assess the long-term effectiveness and complications associated with single and double cuff artificial urinary sphincter (AUS) implantation for the treatment of severe postprostatectomy stress urinary incontinence (SUI). Methods: We updated the outcomes of 56 men with postprostatectomy SUI who underwent single (28 patients) or double (28 patients) cuff AUS placement. Originally patients in each cohort were matched according to preoperative pad usage, risk factors for complications, and age. Continence, quality of life, and complications were assessed according to the Incontinence Impact Questionnaire Short Form (IIQ-7), postoperative pad usage, chart review, and patient/family interview. Results: Updated data were available for 47 men (25 single cuff and 22 double cuff patients). Mean pre-AUS implant age was 67 years for each group. Average follow-up was 74.1 months and 58.0 months for single and double cuff patients, respectively. No statistically significant difference in continence improvement was noted between the two groups according to daily pad usage and overall dry rate. IIQ-7 scores improved from 14.8 to 4.1 after single cuff implants and from 16.3 to 6.4 after double cuff placement (P ⫽ 0.34). Men receiving a single cuff AUS reported seven complications requiring further operative intervention. Double cuff patients underwent 12 additional surgeries secondary to complications. Conclusions: Despite our earlier findings, no significant difference in dry rate, overall continence, or quality of life was seen with long-term follow-up of single versus double cuff AUS patients. Furthermore, men receiving double cuff implants may be at higher risk of complications requiring additional surgery. Editorial Comment: This is a nice comparison of single versus double cuff AUS outcomes in 56 patients. Double cuff cases had a higher complication rate, although overall continence and quality of life were similar. Significantly, the double cuff did not provide an improvement in “complete dryness.” I have abandoned double cuff AUS procedures for this reason. Outcomes of the AUS procedure are often determined by cuff fit, which in turn is a function of patient anatomy and cuff location. When the 4.0 cm cuff is loose adding a second loose cuff distally will not improve continence. Double cuff placement may risk compromising spongiosal and urethral blood flow without increasing coaptation. One proximally placed cuff usually gives the best AUS outcomes. Allen F. Morey, M.D.
BENIGN PROSTATIC HYPERPLASIA Natural Course of Lower Urinary Tract Symptoms Following Discontinuation of alpha-1-Adrenergic Blockers in Patients With Benign Prostatic Hyperplasia T. Yokoyama, T. Watanabe, T. Saika, Y. Nasu, H. Kumon, Y. Miyaji and A. Nagai, Department of Urology, Kawasaki Medical School, Okayama, Japan Int J Urol 2007; 14: 598 – 601.