RAMB - AGOSTO 2017

ale

urinary

incontinence

: A

rtificial

sphincter

ssoc

ras

2017; 63(8):664-680

671

radiation, and 25 patients had a secondary procedure

after failure of AUS or urinary incontinence surgery. Af-

ter a median of 32 months (minimum follow-up of two

years), the continence rate (0 to 1 pad/day) was 69.7%. A

total of 88% of patients reported satisfaction with the

AUS. Patients with primary implant due to irradiation

were no more prone to revision than non-irradiated pa-

tients. Erection preservation was reported in half of the

potent patients.

(C)

A before-and-after study included 18 patients who

had implanted AUS with dual cuff, being one or both

cuffs placed using the TC approach. Ten patients had a

distal cuff implanted transcorporally to complement a

proximal bulbar urethral cuff implanted using standard

technique. The main indication for this approach was

erosion or infection with prior AUS. None of the patients

had preoperative erectile function and median follow-up

was 26 months (IQR 14-30). Results of 16 patients were

analyzed, with continence rate (0 to 1 pad/day) at 38%

(one completely dry). In addition, five (31%) patients

needed 2 pads/day, and five (31%) used 3 pads/day. Before

the implantation of the dual TC cuff, the median daily

pad use was 5.0 (IQR 3.5-5). Complications included four

(22%) reoperations, one erosion and two infections.

(C)

Global evidence summary

The TC approach for cuff implantation may be indicated

for men with a history of urethroplasty, previous urethral

erosion, those treated with radiotherapy, with urethral

atrophy, and tissue involvement.

(B)

An important consideration regarding the use of a

transcorporal approach is the erectile function of patients.

They should be warned that this approach can lead to

erectile dysfunction.

(C)

5. P

erioperative

and

postoperative

care

The objective of this evaluation is to assess the best con-

duct in the perioperative and postoperative period of

artificial urinary sphincter implantation, considering

primary studies.

Clinical question

What conduct should be adopted in the perioperative and

postoperative period of the implantation of the artificial

urinary sphincter in order to reduce the risks of the proce-

dure? This question was answered based on the PICO

method, where P stands for patients with moderate to

severe urinary incontinence, I is the intervention implanta-

tion of the AUS model AMS800® and O is the periopera-

tive and postoperative conduct that can reduce the risks

of implantation. Based on the structured question, key-

words 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 V).

Results

For this issue, 1,764 studies were retrieved, 35 were selected

by title and 32 by summary, with reading of the full text in

the second case. After the analysis of the full texts, 29 studies

were included in our evaluation.

1,17,26,31,34,45,56-76

Absence to

respond to the PICOcriteria was themain reason of exclusion.

Evidence on perioperative antibiotic prophylaxis for

urinary prosthesis placement is variable, with data ex-

trapolated from meta-analyses on hernioplasty with the

use of mesh and orthopedic implant surgeries.

45,56,57

(A)

Thus, the adequate duration of postoperative antibiotics

after implantation remains unknown.

(D)

The rate of infection in contemporary studies is be-

tween 1 and 8%

(A)

34,59-61

(C)

, with rates < 2% in high-

-volume centers.

1,17,62

(C)

Gram-positive bacteria such as

Staphylococcus aureus

and

Staphylococcus epidermidis

represent

the majority of infections, with methicillin resistance

(MRSA) reported in 26% of the microorganisms.

(C)

Gram-negative infections account for 26% of infections.

(C)

Perioperative antibiotics are routinely administered;

however, there is no standardized antibiotic regimen, and

the choice depends on the surgeon’s preference. It is rec-

ommended to provide both Gram-positive and Gram-

-negative coverage, including coverage for methicillin-

resistant

Staphylococcus.

(D)

According to the guidelines

of the American Urological Association on antimicrobial

prophylaxis, this should consist of an aminoglycoside

and a first- or second-generation cephalosporin or van-

comycin, and should be administered within 60 minutes

before skin incision.

(D)

Perioperative antibiotic therapy and attention to me-

ticulous sterile techniques are the pillars of infection

prevention. Authors have reported that a group of patients

who rubbed the skin (five minutes rubbing the perineal

and abdominal skin twice a day during the 5-day period

immediately prior to AUS implantation) preoperatively

with 4% topical chlorhexidine were four times less likely

to suffer perineal colonization during surgery compared

to a group receiving normal hygiene procedures (water

and soap) [OR 0.23, p=0.003].

(B)

More recently, it has

been demonstrated in a randomized study that alcohol

chlorhexidine solution reduced the presence of coagulase-

-negative staphylococci at the surgical site better than

iodopovidone (topical PVP-I).

(A)