RAMB - AGOSTO 2017

ruzzi

668

ssoc

ras

2017; 63(8):664-680

Results

In total, 1,757 studies were retrieved. Of these studies, 28

were selected by title and 20 by summary, with reading of

the full text in the second case. After the analysis of the full

texts, 17 studies were included in our evaluation.

16,18,24,36,38-44

The main reason for exclusion was lack of response to

the PICO.

The AUS should be offered to individuals with stress

urinary incontinence (SUI) due to intrinsic sphincter

deficiency (ISD) who have failed conservative treatment.

(A)

Patients must have sufficient cognitive ability and

function to operate the device.

(D)

There is a risk of

mechanical failure of the device after five years and this

may be related to other possible (non-mechanical) com-

plications such as infection and erosion or atrophy of the

urethra.

(B)

The rate of reoperation for all causes is 26%

(varying between 14.8 and 44.8%).

(A)

It is worth men-

tioning that irradiated patients may constitute a group

with a higher risk of complications.

38,41

(A)

This informa-

tion must be provided to the patient.

The pre-implantation evaluation includes a clinical

history and, occasionally, voiding diary (urine time and

volume, diaper use, urinary incontinence episodes), phys-

ical examination, pad test, urinalysis, and urodynamic

evaluation.

(B)

(A)

Cystoscopy and/or urethrocystography prior to AUS

implantation are advised when concomitant urethral ste-

nosis is suspected, which may complicate placement or put

the AUS at risk of subsequent damage. For example, it was

verified that up to 32% of patients presented urethrovesical

anastomotic stenosis in the cystoscopy after radical pros-

tatectomy (RP).

(C)

Urethrovesical anastomotic stenosis

should be stable prior to implantation.

Sphincter deficiency can be diagnosed by urodynam-

ic examination.

(B)

Less frequently, changes in bladder

compliance are described, as well as the occurrence of

detrusor overactivity.

(C)

All sites of infection, including the urinary tract,

should be treated prior to the procedure to protect the

operative field from bacterial contamination. Prophylac-

tic antibiotic therapy should be administered 60 minutes

before the incision; however, there is no standard antibi-

otic for this procedure.

(B)

Global evidence summary

The AUS is indicated in urinary incontinence due to in-

trinsic deficiency of the sphincter, after failure of the

conservative treatment.

(A)

Patients should have sufficient cognitive capacity and

function to operate the device.

(D)

They should be informed of the possible complica-

tions (mechanical or otherwise), as well as irradiated pa-

tients with greater risk.

(A)

Advise of the possibility of not remaining 100% dry.

(A)

The recommended evaluation includes a clinical his-

tory and physical examination. Urinary voiding and absor-

bent tests can be used but are not required. Urodynamics

enables the diagnosis of sphincter deficiency. Cystoscopy

and/or urethrocystography may be indicated in the analy-

sis of urethral stenosis or vesicourethral anastomosis when

these changes are suspected.

(A)

All infection sites, including the urinary tract, should

be treated prior to the procedure.

(B)

3. P

erineal

versus

scrotal

approach

The objective of this evaluation is to suggest the best ap-

proach for implantation of the artificial urinary sphincter,

considering primary studies.

Clinical question

What should be the surgical approach to artificial urinary

sphincter implantation? This question was answered

based on the PICO method, where P corresponds to pa-

tients with urinary incontinence due to sphincter defi-

ciency; I to intervention with implantation of an artificial

urinary sphincter via the scrotal method; C to comparison

with implantation via the perineal method; and O to the

outcome in relation to control of incontinence and com-

plications. Based on the structured question, keywords

were identified and constituted the basis of the search for

evidence in the databases. After applying the eligibility

criteria (inclusion and exclusion), articles were selected

in order to answer the clinical question (Annex III).

Results

1,757 studies were retrieved. Twenty were selected by title

and 15 by summary, with reading of the full text in the

second case. After the analysis of the full texts, eight stud-

ies aiming only to describe the surgical technique were

included in our evaluation.

7,8,31,46-50

Series of cases with a

small number of patients included (n < 20) and a narrative

review were the main reasons for exclusion.

A recent historical cohort study

(B)

including 27,096

adult male patients compared the perineal approach (N =

18,373) to the scrotal approach (N = 8,723) in primary

implantation of the AUS. The perineal incision reduced

the risk of infection by 1.0% (RRA = 1.0%, 95CI 0.006-0.014;

NNT = 100, 95CI 72-161), as well as the risk of cuff erosion

by 2% (RRA = 2%, 95CI 0.014-0.024; NNT = 53, 95CI 41-73).

There was also a reduction in the risk of explantation of