Ajuster la pression du réservoir d’un sphincter artificiel urinaire n’est pas sans risque

25 juin 2018

Auteurs : B. Peyronnet, X. Gamé, D.S. Elliott
Référence : Prog Urol, 2018, 7, 28, 359-360




 



Dear Editor ,


We read with great interest the article by Baron et al. entitled "AMS 800 Urethral pressure controlled balloon refilling or balloon change for artificial sphincter secondary procedure?" recently published in Progrès en Urologie Pelvi-Périnéologie [1].


Recurrent urinary incontinence due to non-mechanical failure is common after artificial urinary sphincter implantation [2] and is frequently attributed to urethral atrophy despite this concept has been recently challenged [3]. Several techniques for treating urethral cuff atrophy have been described for AUS revision in such as cuff replacement, cuff downsizing, cuff relocation, transcorporal cuff placement, tandem cuff placement and pressure-regulating balloon (PRB) replacement with a higher pressure rate. However, there is currently no consensus regarding the best management option in these patients due to the paucity of data available in the literature. In that regard, the study by Baron et al. is of value as they attempted to assess two revision strategies: PRB replacement with a higher pressure rate and PRB refilling with saline, which has previously not been reported in the literature [1].


In this series PRB replacement with a higher pressure rate (61-70cmH2 O to 71-80cmH2 O) was found to be associated with an acceptable safety profile (4.7% of postoperative erosion, 4.7% of balloon migration) [1]. However, we do not share the authors' conclusions that this is an effective option in view of the poor functional outcomes reported (subjective continence achieved in only 38% of patients).


The other treatment option assessed in this study raised serious concerns. With a 40% erosion rate postoperatively, PRB refilling appeared dangerous and poorly effective (subjective continence achieved in only 30% of patients). The series did include a wide proportion of « higher risk » urethras (38% of prior radiation therapy, 29% of prior urethrotomy [4]) that could partly explain these outcomes. However, we share the authors' conclusion that PRB repressiurizing should not be considered a suitable option for non-mechanical failure. The findings of this study fuels the debate regarding the adjustability for artificial urinary sphincter.


In the past few years, several adjustable artificial urinary sphincter have been assessed [5]. The adjustment is made by puncturing the device to inject or remove fluid. The two main adjustable sphincters described over the past decades, namely the Flowsecure® (Promedon, Argentina) and the Zephyr ZSI 375® (Mayor group, Villeurbanne, France) were found to be associated with high erosion and explantation rates (up to 28% [6] and 61.5% respectively [7]). The inability to alter the cuff pressure and to correct for delayed tissue atrophy without further surgery has often been regarded as a limitation of the AMS 800 device [5]. The findings reported by Baron et al reinforces the idea that adjusting artificial urinary sphincter pressure carries a high risk of complication, notably erosion due to excessive pressure from the cuff on the urethral wall, causing ischaemia of the underlying spongiosum.


Disclosure of interest


Dr Benoit Peyronnet and Pr Xavier Game are consultants for Boston Scientific.


Pr Daniel Elliot declares that he has no competing interest.



Appendix A. Supplementary data


(18 Ko)
  



References



Baron M.G., Auble A., et al. AMS 800 Urethral pressure controlled balloon refilling or balloon change for artificial sphincter secondary procedure? Prog Urol 2017 ; [in press].
Anusiowu I., Wright E.J. Indications for revision of artificial urinary sphincter and modifiable risk factors for device-related morbidity Neurourol Urodyn 2013 ;  32 : 63-65
Bugeja S., Ivaz S.L., Frost A., et al. Urethra l atrophy after implantation of an artificial urinary sphincter: fact or fiction? BJU Int 2016 ;  117 : 669-676 [cross-ref]
Pic G., Terrier J.E., Ozenne B., Morel-Journel N., Paparel P., Ruffion A. Impact of anastomotic strictures on treatment of post-prostatectomy stress incontinence by artificial urinary sphincter Prog Urol 2016 ;  26 (11-12) : 635-641 [inter-ref]
Chung E. Contemporary surgical devices for male stress urinary incontinence: a review of technological advances in current continence surgery Transl Androl Urol 2017 ;  6 (2) : S112-S121
Alonso Rodriguez D., Fes Ascanio E., Fernandez Barranco L., et al. One hundred FlowSecure artificial urinary sphincters (abstract) Eur Urol Suppl 2011 ;  10 : 309 [cross-ref]
Kretschmer A., Husch T., Thomsen F., et al. Efficacy and safety of the ZSI375 artificial urinary sphincter for male stress urinary incontinence: lessons learned World J Urol 2016 ;  34 : 1457-1463 [cross-ref]






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