McGeady James B, McAninch Jack W, Truesdale Mathew D, Blaschko Sarah D, Kenfield Stacey, Breyer Benjamin N
Department of Urology, University of California, San Francisco, San Francisco, California; Urologic Specialists of Oklahoma, Tulsa, Oklahoma.
Department of Urology, University of California, San Francisco, San Francisco, California.
J Urol. 2014 Dec;192(6):1756-61. doi: 10.1016/j.juro.2014.06.088. Epub 2014 Jul 9.
Although long-term outcomes after initial placement of artificial urinary sphincters are established, limited data exist comparing sphincter survival in patients with compromised urethras (prior radiation, artificial urinary sphincter placement or urethroplasty). We evaluated artificial urinary sphincter failure in patients with compromised and noncompromised urethras.
We performed a retrospective analysis of 86 sphincters placed at a single institution between December 1997 and September 2012. We assessed patient demographic, comorbid disease and surgical characteristics. All nonfunctioning, eroded or infected devices were considered failures.
Of the 86 patients reviewed 67 (78%) had compromised urethras and had higher failure rates than the noncompromised group (34% vs 21%, p=0.02). Compared to the noncompromised group, cases of prior radiation therapy (HR 4.78; 95% CI 1.27, 18.04), urethroplasty (HR 8.61; 95% CI 1.27, 58.51) and previous artificial urinary sphincter placement (HR 8.14; 95% CI 1.71, 38.82) had a significantly increased risk of failure. The risk of artificial urinary sphincter failure increased with more prior procedures. An increased risk of failure was observed after 3.5 cm cuff placement (HR 8.62; 95% CI 2.82, 26.36) but not transcorporal placement (HR 1.21; 95% CI 0.49, 2.99).
Artificial urinary sphincter placement in patients with compromised urethras from prior artificial urinary sphincter placement, radiation or urethroplasty had a statistically significant higher risk of failure than placement in patients with noncompromised urethras. Urethral mobilization and transection performed during posterior urethroplasty surgeries likely compromise urethral blood supply, predisposing patients to failure. Patients with severely compromised urethras from multiple prior procedures may have improved outcomes with transcorporal cuff placement rather than a 3.5 cm cuff.
虽然人工尿道括约肌初次植入后的长期疗效已明确，但关于尿道功能受损患者（既往接受过放疗、人工尿道括约肌植入或尿道成形术）的括约肌存活率的比较数据有限。我们评估了尿道功能受损和未受损患者的人工尿道括约肌失效情况。
我们对1997年12月至2012年9月间在单一机构植入的86个括约肌进行了回顾性分析。我们评估了患者的人口统计学特征、合并疾病和手术特征。所有无法正常工作、发生侵蚀或感染的装置均视为失效。
在86例接受评估的患者中，67例（78%）尿道功能受损，其失败率高于未受损组（34%对21%，p = 0.02）。与未受损组相比，既往接受过放疗（风险比4.78；95%置信区间1.27，18.04）、尿道成形术（风险比8.61；95%置信区间1.27，58.51）和既往人工尿道括约肌植入（风险比8.14；95%置信区间1.71，38.82）的病例失败风险显著增加。人工尿道括约肌失效风险随既往手术次数增加而增加。放置3.5厘米袖带后观察到失败风险增加（风险比8.62；95%置信区间2.82，26.36），但经会阴放置则未观察到（风险比1.21；95%置信区间0.49，2.99）。
对于因既往人工尿道括约肌植入、放疗或尿道成形术导致尿道功能受损的患者，人工尿道括约肌植入的失败风险在统计学上显著高于尿道功能未受损的患者。后尿道成形术期间进行的尿道游离和横断可能会损害尿道血供，使患者易于出现失败情况。对于因多次既往手术导致尿道严重受损的患者，经会阴袖带放置可能比3.5厘米袖带放置能取得更好的疗效。
