Translational andrology and urology最新文献

Background and objective: 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.

Methods: 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.

Key content and findings: 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.

Conclusions: 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.

Iatrogenic stress urinary incontinence (SUI) is the most common complication of surgical treatment of prostate cancer, regardless of operative approach, and has a major impact on patients' quality of life. Although SUI can occur after surgical treatment of benign prostatic hyperplasia, specifically transurethral prostate resection, laser enucleation of the prostate, and simple open prostatectomy, these therapeutic modalities play a much less significant role in the etiology of SUI. Artificial urethral sphincter (AUS) implantation is considered the standard treatment modality providing high success rates, including durable efficacy, and optimal patient satisfaction for moderate to severe urinary incontinence resulting mainly from radical prostatectomy. However, although complication rates are generally acceptably low, revision and/or explantation may be required due to mechanical failure and non-mechanical problems, specifically urethral atrophy/cuff deficient occlusion, infection, and cuff erosion. Several risk factors for AUS failure associated with a fragile, compromised urethra have been identified and these play a critical role in device cuff erosion and subsequent removal of the device. Among others, apparently the most impacting factors are irradiation, urethral stent placement, a previous AUS placement, and importantly presence of urethral stricture or prior urethroplasty. Generally, any clinical situation leading to a diseased urethra or lack of urethral integrity is associated with impaired local blood perfusion, and consequently lower success rates. The present review aims to evaluate the impact of the presence of prior urethral strictures and urethroplasty on the outcomes of AUS implantation on one hand, and vice-versa, the influence of AUS placement on later urethral stricture surgery, particularly following cuff erosion.

Background: Urinary incontinence following prostate treatment (IPT) represents a significant complication that detrimentally impacts the quality of life for patients who have undergone prostate surgery. Presently, there is a scarcity of evidence regarding the preferred surgical techniques for IPT. We conducted a meta-analysis to compare the outcomes of the male sling and artificial urinary sphincter (AUS) in the treatment of IPT.

Methods: Data were extracted through electronic literature searches on PubMed, Web of Science, and Embase databases until September 2023. Eligible studies included patients who underwent AUS or male sling procedures for IPT and had a follow-up duration exceeding 12 months. The primary end point was the success rate, with the secondary outcome focusing on complication rates. A fixed-effects or random-effects models were used to calculate the pooled estimate and its 95% confidence interval (CI). The publication bias was assessed using funnel plots and Egger's regression test.

Results: The meta-analysis included nine studies, involving a total of 1,350 participants. No statistically significant difference in success rates was found between AUS and male sling [odds ratio (OR): 0.96, 95% CI: 0.91-1.01]. In terms of the complication rate, there was no significant disparity between the two procedures (OR: 0.87, 95% CI: 0.86-1.12).

Conclusions: The findings from this study indicated that male sling surgery yielded success and complication rates comparable to those of AUS. This suggests that male sling could serve as a viable alternative surgical option in the treatment of IPT.

Background: Cryptorchidism, the failure of testes to descend into the scrotum, exposes the testes to higher temperature and external pressure. Scholars from Razi University found through research conducted at different pressure gradients (0, 25, 50, and 100 mmHg) and time gradients (2 and 4 h) that high hydrostatic pressure may lead to sperm apoptosis. In this work, we investigated the effect of external pressure on spermatogonia, exploring a new mechanism of male infertility caused by cryptorchidism.

Methods: Various pressure gradients (0, 25, 50, and 100 mmHg) were applied to spermatogonia for different durations (0, 2, and 4 h) in the Cell Counting Kit-8 (CCK8) experiment. Morphological changes, cell ultrastructure, apoptosis rates, and the expression of apoptosis-related proteins (bax, bcl-2, caspase-3, and caspase-9) were assessed through immunofluorescence, electron microscopy, terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) assay, flow cytometry, immunohistochemistry, real-time quantitative polymerase chain reaction (qPCR), and western blot.

Results: The cell viability assay showed that higher external pressure had a greater negative time-dependent impact on cell viability. Immunofluorescence results indicated that external pressure stimuli altered the morphology of spermatogonia. The results of TUNEL assay and flow cytometry demonstrated that external pressure stimuli induced apoptosis in spermatogonia. Transmission electron microscopy (TEM) observations showed the generation of apoptotic bodies, mitochondrial swelling, vacuolization, and mitochondrial cristae fusion. The results of immunohistochemistry indicated that pressure induced the expression of caspase-3 and caspase-9 proteins. qPCR and western blot analyses revealed an increased ratio of bax/bcl-2 and expression of caspase-3 and caspase-9. Methazolamide (cytochrome C inhibitor) blocked the pressure-induced cell apoptosis and inhibited the activation of caspase-3 while Z-IETD-FMK (caspase-8 inhibitor) did not.

Conclusions: External pressure promotes spermatogonia apoptosis through the intrinsic apoptosis pathway, which may be one of the mechanisms of male infertility induced by cryptorchidism.

The modern AMS 800 artificial urinary sphincter (AUS) is often considered the standard of care for the treatment of moderate to severe stress urinary incontinence in male patients. Nonetheless, the AMS 800 device has several inherent limitations, and these factors can potentially impact its clinical utility and impede excellent clinical outcomes. The new Rigicon AUS devices such as ContiClassic and ContiReflex urinary sphincters are designed to overcome some of the existing issues pertaining to the AMS 800 device. The ContiClassic device is similar in terms of device design to the AMS 800 apart from the inclusion of a hydrophilic coating, has a greater range of cuff sizes with 0.25-cm diameter increments, and an Easy Clink Connectors which negates the need for an assembly tool. In contrast, The ContiReflex device differs from the ContiClassic model in that it features an extra stress relief balloon (SRB) to provide a safeguard on the urethral occlusive mechanism against any sudden increase in intra-abdominal pressure, and a larger pump system that is responsible to cycle fluid between the higher pressure two-balloon system and the sphincteric cuff. The following brief report evaluates the current device design and technology of the Rigicon ContiClassic and ContiReflex AUS devices.

Background and objective: In a patient who complains of both stress urinary incontinence (SUI) and erectile dysfunction (ED), prosthetic surgery with a urinary continence device and penile prosthesis implant can offer a definitive solution to address both problems. The AMS 800 artificial urinary sphincter (AUS) device is considered the standard of care to restore SUI while the inflatable penile prosthesis (IPP) device is thought to be superior to a malleable prosthesis to provide a more natural penile erection with higher patient satisfaction rates. The following article explores the current understanding of AMS 800 AUS surgery and IPP device in treating males with concurrent SUI and ED as well as evaluates the advantages and disadvantages of concurrent synchronous dual vs. delayed or staged device implantation.

Methods: The available literature on AUS and IPP implantation was reviewed on PubMed and Embase databases between 1 January 2000 and 1 December 2022. This narrative review evaluates relevant key features pertaining to prosthetic surgery with an emphasis on arguments for concurrent synchronous dual vs. delayed sequential surgery for AUS and IPP devices. Additionally, this paper provides a brief surgical description of the techniques and potential complications relating to both prosthetic procedures.

Key content and findings: While a great deal is known about the excellent outcomes of both AUS and IPP implantation, there is limited literature published on the outcomes of dual AUS and IPP surgery. The decision to proceed with concurrent synchronous dual vs. delayed sequential two-stage implants is likely determined by the patient's preference, the surgeon's expertise, and the availability of prostheses. In either situation, patients should be counselled regarding the advantages and disadvantages of undergoing synchronous concurrent vs. delayed sequential implants and associated surgical challenges are likely dependent on the patient's anatomy and the surgeon's preference.

Conclusions: For carefully selected patients with SUI and ED, dual implantation of AUS and IPP provides a definitive treatment to address both conditions at the same time. Patients should be counselled regarding the advantages and disadvantages of synchronous concurrent vs. sequentially delayed implants while technical considerations regarding the sequence of prosthetic device surgery are likely dependent on the patient's factors and the surgeon's preference and surgical expertise.

Background: At present, few articles on percutaneous nephrolithotomy (PCNL) for renal calculi and renal pelvic tumors detected by intraoperative biopsy exist, which has provided limited guidance for clinical practice. In this article, we aimed to further study the relationship between renal calculi and renal pelvic tumors.

Methods: We retrospectively analyzed the medical records of patients with abnormal mucosal biopsy results who underwent PCNL for kidney stones in the Urology Department of Peking University People's Hospital from January 2011 to November 2021.

Results: In total, 2,801 patients underwent PCNL for kidney stones, of whom 69 underwent intraoperative mucosal biopsy. Biopsy results indicated that 8 cases were malignant (11.60%), and 61 cases were benign (88.40%). All malignant cases were renal pelvic carcinoma. Seven were urothelial carcinoma, and one of these was urothelial carcinoma with squamous differentiation. Only one was squamous cell carcinoma. The preoperative information of patients with a malignant mucosa biopsy was analyzed. To provide clinical guidance, an early warning biopsy system was established based on the abnormal mucosa found during the operation. We found that PCNL should be considered if the following risk factors are associated with stones: advanced age, long history of kidney stones, severe hydronephrosis, urinary tract infection, multiple or staghorn stones.

Conclusions: Early warning information should be established for patients with kidney stones based on preoperative clinical characteristics and intraoperative mucous membrane observations. An early warning biopsy should be performed for patients with possible tumors to detect tumors in a timely manner and provide early treatment to improve patient prognosis.

Background: The lithotomy position (LP) may pose limitations and discomfort for elderly patients and those with a history of lower limb surgery, potentially leading to an increased risk of complications. And the LP is the conventional position during flexible ureteroscopic lithotomy for the treatment of ureteral calculi. However, it has some disadvantages, such as peripheral nerve injury and deep venous thrombosis in the lower limbs, etc. Therefore, we performed a new approach, which is named as modified dorsal recumbent position (MDRP). Currently, there is a lack of systematic analysis and standardization regarding the surgical positioning for flexible ureteroscopic lithotripsy. The objective of the study was to assess whether there were any disparities in the overall duration of the procedure when comparing the MDRP with the LP. The investigation of the optimal position for flexible ureteroscopic lithotomy is essential for enhancing patient safety and comfort.

Methods: This is a prospective, multicenter, randomized clinical trial. A total of 144 patients with renal or ureteral calculi from April 2021 to June 2022 were enrolled. Eligible patients were randomized to the MDRP group (n=72) or LP group (n=72). The patient's demographics, the placement of the surgical position (time of position placement, time of disinfection and towel laying, time of position return, degree of medical fatigue) and the operation safety (time of operation, time of ureteroscope from bladder neck to ureteral orifice, heart rate, blood pressure) of two groups were compared and analyzed.

Results: Between the two groups, the body positioning time (93.8±31.6 vs. 134.8±40.1 s, P=0.02), operation time (71.8±36.7 vs. 77.7±48.6 min, P=0.04), the time from the bladder neck to the ureteral orifice of the flexible ureteroscope spent by the doctors (3.4±4.7 vs. 10.3±14.7 s, P<0.001) and incidence rate of patient's lower limb soreness (19.4% vs. 49.7%, P=0.01) in the MDRP group were significantly shorter than those in the LP group. However, there was no significant difference in the stone removal rate (87.6% vs. 85.4%, P=0.09) or postoperative hospitalization days (4.3±1.4 vs. 4.1±1.6 d, P=0.08) between the two groups.

Conclusions: This trial showed that the MDRP could not only effectively shorten the operation time, shorten the time from the bladder neck to the ureteral orifice of the ureteroscopic lithotripsy, but also place the patient's body in a functional position, stabilize the blood pressure during the operation, improve the comfort of the patient.

Trial registration: Chinese Clinical Trial Registry (No. ChiCTR2100053416).

Background and objective: While the modern artificial urinary sphincter (AUS) has benefited from incremental innovation, which has improved both device efficacy and complication rates, the foundational technology in use in Boston Scientific's AMS800 can be traced back to the fundamental hydraulic tenets of the AS721. Research and development in adaptive technology and electronic integration stand to further improve AUS outcomes.

Methods: The Medline online retrieval system was queried using the MeSH terms "artificial urinary sphincter", "electronic", "complications", "history", and "development" in various combinations. Publications were reviewed if applicable, and their reference lists were used to collect additional articles as needed. Final article inclusion was based on senior author discretion.

Key content and findings: The AMS800 AUS is the gold standard for male stress incontinence implants. A 2015 consensus conference set out the goals for sphincter device development in the coming decades. A future ideal sphincter would adjust cuff pressure dynamically as well as function with minimal manipulation, or even via electronic control. Multiple new devices are in various states of development. During the next decade, artificial urinary sphincter technology is likely to include multiple Food and Drug Administration (FDA)-approved devices with varying features aimed at satisfying the 2015 consensus conference goal for an "ideal" AUS.

Conclusions: The future of stress incontinence therapy lies in both continued innovation for the AUS, as well as advances in regenerative medicine. Electronic and adaptive developments in AUS technology will increase device safety, efficacy, and longevity while improving the user and caregiver experience. For some, regenerative medicine may even make AUS technology obsolete.

Background and objective: First-line surgical management of stress urinary incontinence (SUI) currently involves implantation of an artificial urinary sphincter (AUS) in male patients and midurethral sling in female patients. Still, there is demand for a less invasive treatment option without the need to use a device during voiding. Since its first description in 2005, many clinics have implemented adjustable continence therapy balloons in male (ProACT^TM) and female patients (ACT^TM).

Methods: Publications on the use of ProACT/ACT^TM were reviewed from 2002 until September 2022, focusing on functional and safety outcomes, including predictors of treatment failure and complications.

Key content and findings: Most publications report the use of ProACT^TM in patients after prostate surgery, with approximately 60% experiencing a cure rate and 82% achieving over 50% improvement. Consistent functional outcome assessment in female and neurogenic lower urinary tract dysfunction (NLUTD) patients lacks. Few predictors of treatment failure were described, resulting in an advise to not use the balloons after male pelvic radiation therapy. High revision rates were observed in all patient groups, with balloon defects as one of the most common causes for revision.

Conclusions: Based on the current literature, ProACT^TM is safe and effective in male patients after prostate surgery, but the role of ProACT/ACT^TM in female and NLUTD patients is still unclear. There is need for research of higher level of evidence with uniform outcome assessments. Preferably, ProACT^TM is prospectively compared with AUS in a randomized setting. In addition, development of better-quality balloons should reduce mechanical failure and revision surgeries, resulting in improved functional and patient satisfaction outcomes.