Caroline Helwick

November 02, 2017

SAN ANTONIO — For men who develop both erectile dysfunction and climacturia and/or mild urinary incontinence after radical prostatectomy, an add-on maneuver to penile prosthesis insertion can address both problems, according to an international study of the Andrianne mini-jupette graft.

The name "mini-jupette," which means "mini-skirt" in French, was coined by the surgeon who developed the procedure more than 10 years ago, Robert Andrianne, MD, from Liège, Belgium. Now, an international group of surgeons has collaborated to evaluate its efficacy and begin fine-tuning and standardizing the technique.

"The mini-jupette procedure is an excellent, safe, and easy technique that can be used for subsets of patients with postprostatectomy climacturia and/or minimal incontinence," said Faysal A. Yafi, MD, director of Men's Health at the University of California, Irvine, who presented the findings here at the Sexual Medicine Society of North America (SMSNA) Fall 2017 Scientific Meeting.

Many men who experience erectile dysfunction after radical prostatectomy opt for an inflatable penile prosthesis (IPP). Although this improves sexual function, at least 20% of men are bothered by another complication, climacturia, which is leakage of urine during orgasm.

"There are no good treatment options for these patients. We have put in slings, prescribed medications.... Some men just wear condoms.... There's a constriction band for the base of the penis, but none of these really work," Dr Yafi told Medscape Medical News.

How Mini-Jupette Works

However, climacturia and mild incontinence can be treated during IPP insertion by implanting a mesh that bridges the corpora. The mini-jupette approximates the medial aspects of bilateral corporotomies. Expansion of the cylinders on inflation compresses the urethra, which suppresses leakage.

"We put penile implants between the corpora, and then between them, like a hammock, we put the mesh. It's a sling that we attach. The idea is that when we inflate the implant, it will tighten on the urethra and this will stop the leaking during sex. It's pretty ingenious," Dr Yafi said in an interview.

Pilot Study in 37 Patients

The multicenter pilot study included 37 patients (mean age, 66 years) with erectile dysfunction after radical prostatectomy and who also had climacturia and/or mild urinary incontinence (≤2 pads/day). Patients underwent IPP insertion with concomitant placement of a mini-jupette graft; this maneuver adds only about 15 minutes to the surgical procedure time, the authors note.

Fourteen patients had postprostatectomy climacturia and 18 patients had incontinence. The prostheses included Coloplast Titan in 30 patients, AMS 700 LGX in four patients, and AMS 700 CX in three patients. Mean corporotomy size was 2.7 cm. The mean surface area of the graft was 10.2 cm2. More than half the patients received a tutoplast-human pericardium graft for their mini-jupette; a variety of other graft types were used on the others.

At a median follow-up of 3 months, subjective improvement in climacturia was reported by 93% of patients. At baseline, 82% of patients reported climacturia, which declined to 27% of patients at follow-up. Preoperatively, 48.5% of patients reported having climacturia frequently or always, but 0% reported this after surgery.

The effect on urinary incontinence was similar, with 89% of patients reporting subjective improvement. Mean pad usage per day was 1.3 before surgery and dropped to 0.2 pads after the implant. One day after surgery, 78% of patients required no pads, Dr Yafi reported.

Scores on the International Index of Erectile Function, as expected, also improved, from a mean of 8.2 before surgery to 23.7 after IPP insertion, a change of 15.5 points.

Five Postoperative Complications

There were five postoperative complications, four of which required explantation. Those explanted included one patient with psychiatric reasons; one patient with bleeding, hematoma formation, urinary obstruction, and device infection; one with persistent penile pain and urethral discharge, diagnosed with urethra-corporal fistula; and one patient with multiple comorbidities who developed postoperative urinary retention, urethral erosion, and device infection and who underwent urethroplasty and ultimately died from a pulmonary embolism judged to be unrelated to the mini-jupette procedure. A fifth patient developed significant postoperative operative pain but did not require surgical revision.

"We did have 5 post-op complications, but penile prosthetic surgery itself carries a risk for complications. Ours were not increased over those expected with penile implantation surgery alone," he said.

Refining the Technique

The surgeons are now discussing ways to standardize the mini-jupette and to evaluate it in a larger population. "The problem is we are heterogeneous in how we are doing this. We've now found some tricks to improve the mini-jupette, and our next step will be to use a standardized approach and study it further," he said.

"There is also debate as to the best graft. Obviously, the tutoplast is not made to be used straight on the urethra," Dr Yafi added.

Senior investigator Steven Wilson, MD, from the Institute of Urologica Excellence in La Quinta, California, said the researchers would like to identify a manufacturer who could provide an appropriate graft for this procedure. "Hopefully soon, we'll have something at a reasonable price and it will be the graft we all use," he said.

Ask About Climacturia

Brian Christine, MD, director of Urology Centers of Alabama in Birmingham, emphasized the need to address climacturia in men postprostatectomy. "I've been successfully treating men with postprostatectomy incontinence using the AdVance sling, and I've started to notice there are many men with climacturia," he said.

However, those men are not requiring IPP, he acknowledged. "What's interesting about this study is the fact that you can treat men for their erectile dysfunction and at the same time try to address climacturia, all in one setting.... We'll have to wait and see how well this works."

Dr Christine also advised his colleagues to ask their postprostatectomy patients about climacturia. "There are so many men who have it and don't talk about it. We know the surgeons who did their radical prostatectomy certainly didn't ask about it," he said. "We have to query out patients, because there are many men who can benefit from a sling, or perhaps this [mini-jupette] procedure."

Dr Yafi and Dr Christine both consult for Boston Scientific.

Sexual Medicine Society of North America (SMSNA) Fall 2017 Scientific Meeting: Abstract 024. Presented October 27, 2017.

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