RAMB - AGOSTO 2017

ale

urinary

incontinence

: A

rtificial

sphincter

ssoc

ras

2017; 63(8):664-680

669

5.7% (ARR = 5.7%, 95CI 0.048-0.066; NNT = 18, 95CI 15-21)

and risk of revision of 2% (ARR = 2%, 95CI 0.12-0.028; NNT

= 50, 95CI 36-83). There was no difference between the

groups regarding the risk of atrophy.

(C)

Another historical cohort

(B)

included data from

84 patients with stress urinary incontinence after prostate

surgery, monitored for an average of 39.7 months and

submitted to AUS implantation (5% primary). In a sub-

group analysis, perineal access (N = 24) compared to scro-

tal access (N = 60) reduced the risk of erosion by 20% (ARR

= 20%, 95CI 0.099-0.301; NNT = 5, 95CI 3-10). There were

no significant differences between the groups in the num-

ber of irradiated and/or anticoagulated patients, nor in

the number of patients submitted to double-cuff place-

ment (p=0.44, 0.22 and 0.76, respectively).

(B)

Also, a

recent historical cohort

(B)

compared perineal (N = 152)

and penoscrotal access (N = 99) in the single cuff implan-

tation. The comparison of the two groups showed that

the perineal route reduced the risk of explantation by 10.6%,

in the 6-month follow-up (RRA = 10.6%, 95CI 0.017-0.195;

NNT = 9, 95CI 5-61).

(B)

A historical cohort study compared the scrotal to the

perineal approach in a total of 126 artificial urinary sphinc-

ter cuffs (120 procedures, including double cuff placement

in six), implanted in 94 patients, 63 of which were placed via

the penoscrotal approach and 63 via the perineal approach.

In the subgroup analysis with patients undergoing a

primary or revision procedure with a single cuff, the num-

ber of patients “completely dry” (without using pads) was

higher in the “perineal” group (ARA = 28%, 95CI -0.48 to

-0.07; NNH = 4, 95CI 2-14). Furthermore, perineal access

also showed a greater number of “completely dry” patients

(ARA = 28.7, 95CI -0.53 to -0.03; NNH = 3, 95CI 2-27).

The number of patients in the trans-scrotal group and in

the perineal group who required double cuff implantation

due to incontinence was 18 and 3%, respectively (p=0.6,

without statistical significance).

(B)

A before-and-after study (N = 30)

(C)

reported excel-

lent results with an improved technique using a single

scrotal incision, allowing a more proximal placement of

the cuff and the attainment of a continence rate similar

to those obtained with the perineal approach found in

the literature.

(C)

Another before-and-after study

(C)

evaluated 83

highrisk patients (69% prostatectomy only and 31% with

radiotherapy and/or cryotherapy) who underwent AUS

implantation with a single transverse scrotal incision. In an

average follow-up of 18.8 (14.6) months, the number of

pads per day decreased from a mean of 6.7 in the preopera-

tive period to 1.1 in the postoperative period. Overall, 83%

of the patients (79% of the irradiated ones and 85% of the

nonirradiated ones) used ≤ 1 pad/day after surgery.

(C)

Authors have evaluated the implantation of AUS and

inflatable penile prosthesis simultaneously through a

single trans-scrotal incision. They included 22 patients

with urinary incontinence and erectile dysfunction result-

ing from radical prostatectomy in 21 patients and radical

cystectomy in one. The average follow-up time was 17

(12-36) months. The total revision rate was 14%, due to

urethral erosion in two patients and migration of the

reservoir in one. All patients reported improvement in

urinary loss, requiring ≤ 1 pad/day. No patient suffered

prosthesis infection in the postoperative period.

(C)

A consensus of the International Continence Society

(ICS) recommends that the penoscrotal approach be reserved

for reoperation; patients with conditions that prevent place-

ment in the lithotomy position (morbid obesity, spine or

limb deformities, neuromotor conditions); and patients who

will undergo the AUS implantation and inflatable penile

prosthesis through a single penoscrotal incision.

(D)

Global evidence summary

The implantation of the AUS via the penoscrotal route can

increase the risk of erosion, infection and explantation.

(B)

The penoscrotal technique may not provide an ad-

vantage in relation to efficacy, and is associated with a

lower continence rate than the perineal approach.

(B)

The penoscrotal approach can be reserved for cases

of reoperation; patients with conditions that impede

placement in the lithotomy position (morbid obesity,

spine or limb deformities, neuromotor conditions); pa-

tients who will undergo AUS implantation and inflatable

penile prosthesis through a single penoscrotal incision;

and patients with a previously implanted sling.

(D)

The perineal approach should be the usual one.

(B)

4. T

ranscorporal

approach

for

cuff

placement

The aim of our evaluation is, based on primary studies,

to compare the transcorporal placement of the cuff with

the “standard” placement (directly around the urethra),

regarding efficacy and safety.

Clinical question

What is the best approach for cuff placement in artificial

urinary sphincter implant surgery? This question was

answered based on the PICO method, in which P stands

for patients with moderate to severe urinary incontinence;

I is the intervention with transcorporal cuff implantation;

C is the comparison with “standard” cuff implantation;