Pandit Aroh, Chang Chrystal, Simhan Jay
Department of Urology, Fox Chase Cancer Center, Philadelphia, PA, USA.
Transl Androl Urol. 2024 Aug 31;13(8):1695-1708. doi: 10.21037/tau-22-798. Epub 2023 Jul 28.
Although the artificial urinary sphincter (AUS) has demonstrated successful outcomes in treating male stress urinary incontinence (SUI) for the past five decades, this procedure also carries inherent risks, including recurrent SUI, device malfunction, local tissue compromise, and infection/erosion, all of which may require revision surgery with or without device replacement. Patients that are at the highest risk for such untoward events often possess unhealthy urethral tissue (termed a "fragile urethra") that is compromised and unable to provide optimal cuff coaptation and continence. Accordingly, there are several techniques to address recalcitrant SUI in the setting of a fragile urethra to afford an improved chance of return to continence. Here, we review characteristics of patients that are at higher risk for an untoward outcome following AUS implantation and further define strategies to promote optimal success with device implantation. The aim of this paper is to review the available literature and describe surgical options for male SUI in patients with known or anticipated urethral tissue compromise.
A thorough literature review was completed by querying PubMed for relevant articles. Search terms included artificial urinary sphincter, failure, recalcitrant, urethral atrophy, fragile urethra, revision, radiation, cystectomy, incontinence, and/or urethroplasty published between 1975 and 2022.
Options for management of the fragile urethra include cuff relocation, cuff downsizing, tandem cuff placement, transcorporal cuff placement, pressure regulating balloon exchange with increased or decreased pressure, bulbospongiosus preservation, sub-cuff ventral capsulotomy, urethral wrapping with graft, and in select cases, urinary diversion, or complete device removal with a return to SUI. Proper patient selection is paramount to optimize outcomes. Advantages and disadvantages of each strategy are reviewed.
Numerous techniques are viable options for patients with recalcitrant SUI in the setting of a fragile urethra, but high-quality evidence with reproducible outcomes for many of these strategies remain limited. Proper patient selection as well as adequate counseling by experienced implant surgeons may help optimize outcomes. Further multi-institutional investigations with longer term outcomes are needed to improve patient selection and counseling with shared decision-making prior to any intervention.
尽管人工尿道括约肌（AUS）在过去五十年中已成功用于治疗男性压力性尿失禁（SUI），但该手术也存在固有风险，包括复发性SUI、装置故障、局部组织受损以及感染/侵蚀，所有这些情况可能需要进行翻修手术，可能还需要更换装置。发生此类不良事件风险最高的患者通常尿道组织不健康（称为“脆弱尿道”），这种组织受损且无法实现最佳的袖带贴合和控尿功能。因此，有多种技术可用于解决脆弱尿道情况下难治性SUI问题，以提高恢复控尿功能的几率。在此，我们回顾了AUS植入术后不良结局风险较高的患者的特征，并进一步确定了促进装置植入取得最佳成功效果的策略。本文旨在回顾现有文献，并描述已知或预期存在尿道组织受损的男性SUI患者的手术选择。
通过在PubMed上查询相关文章完成了全面的文献综述。检索词包括人工尿道括约肌、失败、难治性、尿道萎缩、脆弱尿道、翻修、放疗、膀胱切除术、尿失禁和/或尿道成形术，发表时间为1975年至2022年。
处理脆弱尿道的方法包括袖带重新定位、袖带缩小、串联袖带放置、经体部袖带放置、压力调节球囊压力增加或降低的更换、保留球海绵体肌、袖带下方腹侧包膜切开术、用移植物包裹尿道，在某些情况下，还包括尿流改道，或完全移除装置并恢复为SUI状态。正确选择患者对于优化结局至关重要。对每种策略的优缺点进行了综述。
对于脆弱尿道情况下难治性SUI患者，有多种技术是可行的选择，但其中许多策略的高质量、可重复结果的证据仍然有限。正确选择患者以及经验丰富的植入外科医生进行充分的咨询可能有助于优化结局。需要进一步开展多机构研究并获得长期结果，以改善患者选择，并在任何干预之前通过共同决策进行咨询。
